Columbia  ©nitJer^ftj) 

CoIIesE  of  ^f)?2!idang  anb  ^urgeong 


W-     YC  \aJU.s^ 


Ji}^mU>mu^' 


THE    PRINCIPLES    AND 
PRACTICE  OF  MEDICINE 


Digitized  by  tine  Internet  Arciiive 

in  2010  witii  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/principlespracti1920osle 


THE  PRINCIPLES  AND 
PRACTICE  OF  MEDICINE 

DESIGNED  FOR  THE  USE  OF  PRACTITIONERS  AND 
STUDENTS  OF  MEDICINE 


BY 

THE  LATE  SIR  WILLIAM  OSLER,  BT.,  M.D.,  F.R.S. 

FELLOW    OF    THE    ROYAL    COLLEGE    OF    PHYSICIANS,    LONDON;     REGIUS    PROFESSOR    OF    MEDICINE, 

OXFORD  university;    honorary  PROFESSOR  OF  MEDICINE,  JOHNS   HOPKINS  UNIVERSITY, 

BALTIMORE;     FORMERLY    PROFESSOR    OP    THE    INSTITUTES    OF   MEDICINE,    McGILL 

UNIVERSITY,    MONTREAL,    AND   PROFESSOR    OF    CLINICAL   MEDICINE    IN 

THE    UNIVERSITY     OF     PENNSYLVANIA,     PHILADELPHIA 

AND 

THOMAS   McCRAE,  M.D. 

FELLOW  OF  THE  ROYAL    COLLEGE  OF  PHYSICIANS,  LONDON;    PROFESSOR  OF  MEDICINE,  JEFFERSON 
MEDICAL    COLLEGE,    PHILADELPHIA;      PHYSICIAN    TO    THE    JEFFERSON   AND    PENNSYL- 
VANIA   HOSPITALS,    PHILADELPHIA;     FORMERLY"    ASSOCIATE    PROFESSOR 
OF     MEDICINE,     JOHNS     HOPKINS     UNIVERSITY 


NINTH   THOROUGHLY  REVISED    EDITION 


--^^isr^/?^ 


I^<2^^<^-r-, 


NEW  YORK  AND  LONDON 

D.  APPLETON  AND   COMPANY 

1920 


Copyright,  1892,  1895,  1898,  1901,  1902,  1903,  1904,  1905,  1909,  1912,  1916,  1920, 
By  D.  APPLETON  AND   COMPANY 


3  0 


^Ci^ 


\^a  0 


PRINTED  IN  THE  UNITED  STATES  OF  AMERICA 


TO  THE 

/iRemorg  ot  ^bree  Zcucbeve  ot  MUHam  ©slers 
WILLIAM   ARTHUR   JOHNSON 

PRIEST   OF    THE    PARISH   OP   WESTON;    ONTARIO 

JAMES  BOVELL 

OF   THE   TORONTO   SCHOOL   OF   MEDICINE,  AND   OF   THE 
UNIVERSITY   OF   TRINITY    COLLEGE,    TORONTO 

ROBERT   PALMER   HOWARD 

DEAN   OF   THE   MEDICAL   FACULTY   AND   PROFESSOR   OF   MEDICINE, 
MCGILL   UNIVERSITY,    MONTREAL 


PREFACE 

The  death  of  Sir  William  Osier  takes  from  medicine — and  from  medical 
literature — one  of  its  greatest  masters.  A  prolific  writer,  he  never  wrote  for 
the  mere  sake  of  writing  but  because  he  had  something  worthy  of  being  written. 
With  the  art  of  extracting  and  condensing  the  essentials  of  a  subject  went 
the  ability  to  present  them  clearly.  His  use  of  the  telling  phrase  often  drove 
home  a  point  more  strongly  than  a  long  description  could  do.  To  promote 
sound  knowledge  was  one  of  his  ambitions  and  that  he  succeeded  there  is  no 
question.  It  is  doubtful  if  any  man  of  his  generation  exercised  a  greater 
influence.  From  all  who  knew  him  has  come  the  tribute  to  the  man  even 
more  than  to  his  learning. 

This  Text  Boole  of  Medicine  was  one  of  the  great  interests  in  his  life; 
as  he  said;,  it  brought  him  "mind  to  mind"  with  members  of  the  profession 
in  many  parts  of  the  world.  It  was  interesting  to  find  the  number  of  letters 
concerning  it  which  he  had  kept.  He  regretted  greatly  the  interruption  in 
the  usual  triennial  appearance  of  a  new  edition  caused  by  the  war.  At  its 
ending  he  turned  actively  to  work  on  his  part  of  the  revision  for  this  edition 
and  had  practically  completed  it  at  the  onset  of  his  last  illness.  It  is  a  grim 
coincidence  that  at  the  time  of  my  association  as  assistant  author  in  1912  he 
planned  to  give  up  active  participation  in  the  revision  when  he  reached 
seventy  years  of  age. 

My  association  with  the  book  began  as  a  student  in  1892  when  the  first 
edition  was  used  as  my  text-book  of  medicine.  In  my  copy  of  this  edition 
are  many  additions  picked  up  in  the  wards  of  the  Johns  Hopkins  Hospital 
from  the  author  himself.  A  study  of  successive  editions  represents  a  record 
of  the  advance  of  medicine  during  a  period  of  nearly  thirty  years. 

In  this  edition  many  changes  have  been  made  throughout  the  whole  book, 
which  has  been  recast.  Many  parts  have  been  re-written.  New  sections 
have  been  added  on  Paratyphoid  Fever,  Focal  Infection,  Trench  Fever,  Gas 
Poisoning,  Brass  Poisoning,  Acidosis,  Diverticulitis,  Infectious  Jaundice, 
Torsion  of  the  Omentum,  Foreign  Bodies  in  the  Bronchi,  Hsemothorax,  Med- 
iastinitis,  and  Diseases  of  the  Diaphragm.  x4.dditions  have  been  made  to  the 
discussion  of  Diseases  of  the  Circulation,  with  a  new  section  on  Aortitis.  In 
the  section  on  the  Xervous  System,  certain  familial  and  hereditary  diseases, 
have  been  grouped  together.  Epidemic  Encephalitis  represents  new  material 
and  the  section  on  Cerebral  Arterio-sclerosis  is  entirely  rewritten.  The  de- 
scription of  the  Sympathetic  Xervous  System  and  the  discussion  of  Cervical 
Rib,  the  Pineal  and  Sex  Glands,  Lipodystrophia,  Osteomalacia  and  Chondro- 
dysplasia represent  added  material. 

One  problem  is  ever  present  in  a  text-book — the  matter  of  arrangement. 
Should  poliomyelitis,  for  example,  be  placed  with  the  acute  infectious  dis- 
eases or  in  the  section  on  Diseases  of  the  Xervous  System?    Should  syphilis 


viii  PEEFACE 

in  all  its  aspects  be  discussed  together  or  some  parts,  for  example,  the  nervous 
system  features,  be  separated  and  taken  up  with  the  other  diseases  of  that 
system  ?  There  are  points  for  and  against  any  rigid  plan  and  it  is  difficult  to  be 
consistent.  The  effort  has  been  made  to  consider  the  student  and  make  such 
arrangement  as  seems  to  be  most  helpful  for  him. 

Thanks  are  due  to  many  friends  for  suggestions  and  aid  in  various  ways. 
Dr.  H.  M.  Thomas  of  Baltimore  has  given  valuable  assistance  in  the  section 
dealing  with  diseases  of  the  nervous  system  in  every  edition  and  not  least 
with  this  one.  To  my  associates.  Dr.  Eoss  V.  Patterson,  Dr.  E.  H.  Funk  and 
Dr.  M.  H.  Eehfuss,  I  am  under  many  obligations,  and  Dr.  A.  Malloch  helped 
in  many  ways.  To  practitioners  and  students  in  many  lands  thanks  are  due 
for  criticism  and  suggestions. 

Thomas  McCrae. 


CONTENTS 


SECTION  I 
Specific  Infectious  Diseases 

PAGE 

A.      Bacterial  Diseases 1 

I.     Typhoid  Fever 1 

II.     Paratyphoid  Fever .43 

^III.     Colon  Bacillus  Infections 45 

IV.     Typhus  Fever 47 

t^.    The  Pyogenic  Infections 51 

1.  Local  Infections  with  the  Development  of  Toxins      .        .51 

2.  Septicsemia 52 

3.  Septico-pysemia 53 

4.  Focal  Infection 56 

^             5.     Terminal  Infections  .       . 57 

^"Vl.    Erysipelas .       .       .58 

VII.     Diphtheria 61 

VIII.    The  Pneumonias  and  Pneumococcic  Infections      ....  78 

A.  Lobar  Pneumonia 78 

B.  Broncho-pneumonia 104 

C.  Other  Pneumococcic  Infections 110 

IX.     Cerebro-spinal  Fever   ,       .       . 110 

*X.     Influenza ' 118 

XL    Whooping  Cough 122 

i/XII.     Gonococcus  Infection  .       .       .    ■ 125 

^XIII.    Bacillary  Dysentery    .       .       .  ■ 128 

I.    Acute  Dysentery 131 

II.     Chronic  Dysentery 132 

XIV.     Malta  Fever 132 

^V.     Cholera  Asiatica 134 

^VI.    The  Plague 139 

■'XVII.    Tetanus 143 

^XVIII.     Glanders 147 

uXIX.    Anthrax 149 

•/XX.    Leprosy 152 

XXI.     Tuberculosis : 155 

I.     General  Etiology  and  Morbid  Anatomy        .       .       .  155 

11.    Acute  Miliary  Tuberculosis 168 


X  CONTENTS 

PAGE 

III.  Tuberculosis  of  the  Lymphatic  System  ....  174 

1.  Tuberculosis  of  the  Ljinph-glands       .       .       .  174 

2.  Tuberculosis  of  the  Serous  Membranes       .        .178 

IV.  Pulmonary  Tuberculosis 182 

,                          1.     Acute  Pneumonic  Tuberculosis  of  the  Lungs     .  183 

2.  •  Chronic  Llcerative  Tuberculosis  of  the  Lungs  .  187 

3.  Fibroid  Tuberculosis 202 

Complications  of  Pulmonary  Tuberculosis    .       .       .  202 

Diagnosis  of  Pulmonary  Tuberculosis     ....  206 
Concurrent  Infections  and  Diseases  Associated  -R-ith 

Pulmonary  Tuberculosis 209 

Peculiarities  of  Puhnonarj^  Tuberculosis  at  the  Ex- 
tremes of  Life 210 

Modes  of  Death  in  Pulmonary  Tuberculosis   .       .       .  210 
V.     Tuberculosis  of  the  Alimentary"  Canal    .       .       .       .211 

"VT;.     Tuberculosis  of  the  Liver 214 

VII.     Tuberculosis  of  the  Brain  and  Cord        .       .       .        .  214 

VIII.     Tuberculosis  of  the  Genito-urinary  System   .        .        .  215 

IX.     Tuberculosis  of  the  Manmiary  Gland     ....  220 

X.    Tuberculosis  of  the  Circulatory  System         .       ,       .221 

*              XL     The  Prognosis  in  Tuberculosis 221 

XII.     Prophylaxis  in  Tuberculosis 222 

XIII.     Treatment  of  Tuberculosis 223 

^B.      Non-Bacterial  Fimgus  Infections — The  Mycoses 231 

I.     Actinomycosis 231 

II.     The  Sporotrichoses .  233 

III.  Nocardiosis 234 

IV.  Oidiomycosis 235 

V.    Mycetoma 235 

VI.    Aspergillosis .  236 

C.      Protozoan  Infections 236 

I.    Psorospermiasis 236 

II.     Amoebiasis 237 

III.  Malarial  Fever 242 

IV.  Trypanosomiasis  .        .       , 257 

V.    Leishmaniasis 259 

VI.    Relapsing  Fever 260 

VII.    YeUow  Fever 263 

--VIIl.    Syphihs 268 

I.    History,  Etiology,  and  Morbid  Anatomy  ....  268 

II.    Acquired  Syphilis 271 

III.  Congenital  Syphilis .  273 

IV.  Visceral  SyphiUs 276 

1.  Cerebro-spinal  Syphilis 276 

2.  Syphilis  of  the  Respiratory  Organs         .       .       .  278 

3.  Sychilis  of  the  Liver  ........  279 


CONTENTS 


XI 


IX. 


PAGE 

4.  Syphilis  of  the  Digestive  Tract        ....  281 

5.  Circulatory  System 281 

6.  Syphilis  of  the  Urinary  Tract 282 

7.  Syphilitic  Orchitis 283 

V.     Diagnosis,  Treatment,  Etc 283 

Diseases  Due  to  Parasitic  Infusoria 288 


^"D.      Diseases  Due  to  Metazoan  Parasites .  289 

I.     Diseases  Due  to  Flukes — Distomiasis 289 

II.     Diseases  Caused  by  Cestodes — -Tseniasis 291 

1.  Intestinal  Cestodes;  Tapeworms 291 

2.  Somatic  Tseniasis ^    .  294 

III.  Diseases  Caused  by  Nematodes 301 

1.  Ascariasis 301 

2.  Trichiniasis 302 

3.  Uncinariasis 307 

4.  Filariasis 311 

5.  Dracontiasis 313 

6.  Other  Nematodes 314 

IV.  Parasitic  Arachnida  and  Ticks  .        .        .        .       .       .        .       .315 

V.     Parasitic  Insects 317 

VI.     Parasitic  Fhes 318 

E.      Infectious  Diseases  of  Doubtful  or  Unknown  Etiology 320 

^  I.     Small-pox       .        . 320 

~II.    Vaccinia  (Cow-pox) — -Vaccination 331 

-III.     Varicella  (Chicken-pox)       .        .        . 336 

-  IV.     Scarlet  Fever 337 

'V.     Measles 348 

—  VI.     Rubella  (German  Measles) 353 

—VII.     Epidemic  Parotitis  (Mumps) 354 

^III.     Dengue 356 

-IX.     Hydrophobia 358 

X.     Rheumatic  Fever 361 

^I.    Acute  Tonsillitis 369 

i-XII.     Acute  Catarrhal  Fever 371 

XIII.  Febricula— Ephemeral  Fever 372 

XIV.  Infectious  Jaundice 373 

yXV.     Milk-sickness 374 

yXYI.     Glandular  Fever .375 

'^VII.     Miliary  Fever  (Sweating  Sickness) 375 

'■^  XVIII.     Foot  and  Mouth  Disease — Epidemic  Stomatitis — ^Aphthous  Fever  376 

^XIX.     Psittacosis 377 

i/XX.     Rocky  Mountain  Spotted  Fever;  Tick  Fever 377 

^XXl.    SwineFever 377 

XXII.     Rat-bite  Fever 378 

.  XXIII.     French  Fever 378 

''XXIV.    Acute  Ulcerative  Conjunctivitis  Transmitted  from  Rabbits      .  379 

^XXV,    Six  (Seven)  Day  Fever 379 


xii  CONTENTS 

PAGE 

SECTION  II 

Diseases  Due  to  Physical  Agents 

I.     Sunstroke;  Heat  Exhaustion •.  380 

II.     Caisson  Disease 383 

III.  Mountain  Sickness 384 

IV.  Gas  Poisoning 385 

SECTION  III 

The  Intoxications 

I.    Alcoholism 387 

II.     Morphia  Habit 391 

III.  Lead  Poisoning 392 

IV.  Brass  Poisoning .  397 

V.     Arsenical  Poisoning 397 

VI.    Food  Poisoning 399 

SECTION  IV  ^ 
Deficiency  Diseases 

I.     Pellagra 403 

II.     Beri-beri        .        .        .        .        .       . 406 

III.     Scurvj^    .        .        .        .        , .  408 

Infantile  scurvy 411 

SECTION  V 

Diseases  of  Metabolism 

I.    Gout 413 

II.    Diabetes  MeUitus 421 

III.  Diabetes  Insipidus 434 

IV.  Rickets  (Rhachitis) ■ 436 

V.    Obesity 440 

VI.     The  Lipomatoses 442 

VII.     Heemochromatosis r       .  444 

VIII.     Ochronosis 444 

IX.    Acidosis 445 

SECTION  VI 

Diseases  of  the  Digestive  System 

A.  Diseases  of  the  Mouth 448 

Stomatitis 448 

B.  Diseases  of  the  Salivary  Glands .        .       .  454 

C.  Diseases  of  the  Pharynx      ,       .       .       ,       ,       .       .       .       .       .       .  456 


CONTENTS  xiii 

PAGE 

(/D.      Diseases  of  the  Tonsils 458 

I.     Suppurative  Tonsillitis 458 

II.     Chronic  Tonsillitis 459 

E.  Diseases  of  the  (Esophagus 463 

I.     Acute  (Esophagitis 463 

II.     Spasm  of  the  Qilsophagus 465 

III.  Stricture  of  the  Oesophagus 465 

IV.  Cancer  of  the  (Esophagus 466 

V.     Rupture  of  the  (Esophagus 467 

YL.     Dilatations  and  Diverticula 467 

F.  Diseases  of  the  Stomach 468 

I.    Acute  Gastritis 468 

II.     Chronic  Gastritis 471 

III.  Cirrhosis  Yentriculi 477 

IV.  Dilatation  of  the  Stomach 477 

V.     The  Peptic  Ulcer,  Gastric  and  Duodenal 481 

VI.     Cancer  of  the  Stomach 489 

VII.     Hypertrophic  Stenosis  of  the  Pylorus 496 

VIII.     Hsemorrhage  from  the  Stomach .  497 

IX.     Neuroses  of  the  Stomach 499 

G.  Diseases  of  the  Intestines 506 

I.     Diseases  of  the  Intestines  Associated  with  Diarrhcea    .        .       .  506 

Catarrhal  Enteritis;  Diarrhcea 506 

Diphtheroid  or  Croupous  Enteritis 510 

Phlegmonous  Enteritis    . 510 

Ulcerative  Enteritis ■.       .        .       .511 

II.     Diarrhoeal  Diseases  in  Children         .        .       .       .       .       .        .  514 

III.    Appendicitis 521 

rV.    Intestinal  Obstruction 528 

V.     Constipation 535 

VI.    Enteroptosis 538 

VII.     Miscellaneous  Affections 540 

I.     Mucous  Colitis 540 

II.     Dilatation  of  the  Colon 541 

III.  Intestinal  Sand 542 

IV.  Diverticulitis — Perisigmoiditis 543 

V.     Affections  of  the  Mesentery 543 

VI.     Dilatation  of  the  Duodenum 545 

H.      Diseases  of  the  Liver    , 545 

I.     Jaundice 545 

I.     Obstructive  Jaundice 545 

II.     Toxic  and  Hsemolytic  Jaundice 547 

III.     Hereditary  Icterus 548 

II.     Icterus  Neonatorum 549 

III.  Acute  Yellow  Atrophy 549 

IV.  Affections  of  the  Blood-vessels  of  the  Liver 552 

V.     Diseases  of  the  Bile-passages  and  Gall-bladder      ....  553 

I.    Acute  Catarrh  of  the  Bile-ducts 553 


XIV  CONTENTS 

PAGE 

II.     Chronic  Catarrhal  Angiochohtis        ...               .  555 

III.  Suppurative  and  Ulcerative  Angiocholitis        .       .       .  555 

IV.  Acute  Infectious  Cholecystitis    .       .       .       .       .       .  556 

V.     Chronic  Cholecystitis 557 

VI.     Cancer  of  the  Bile-passages 558 

VII.     Stenosis  and  Obstruction  of  the  Bile-ducts      .        .       .  559 

VI.     Cholelithiasis 560 

VII.     The  Cirrhoses  of  the  Liver 567 

I.     Portal  Cirrhosis 568 

II.     Hypertrophic  Biliary  Cirrhosis    .        .        .        .        .        .571 

III.  Syphilitic  Cirrhosis 572 

IV.  Capsular  Cirrhosis — Perihepatitis 573 

VIII.     Abscess  of  the  Liver 574 

IX.     New  Growths  in  the  Liver 578 

X.    Fatty  Liver 580 

XL     Amyloid  Liver 581 

XII.     Anomalies  in  Form  and  Position  of  the  Liver         ....  582 

I.       Diseases  of  the  Pancreas 583 

I.     Pancreatic  Insufficiency 583 

11.     Pancreatic  Necrosis 584 

HI.     Haemorrhage 584 

IV.     Acute  Pancreatitis 585 

V.     Chronic  Pancreatitis 587 

VI.     Pancreatic  Cysts .       .       .  588 

VII.     Tumors  of  the  Pancreas 590 

VIII.     Pancreatic  Calcuh 591 

J.       Diseases  of  the  Peritoneum         .        .        .        .        .•      .    •   .        .       .        .591 

I.     Acute  General  Peritonitis 591 

II.     Peritonitis  in  Infants 595 

III.  Localized  Peritonitis 595 

IV.  Chronic  Peritonitis 597 

V.     New  Growths  in  the  Peritoneum 599 

VI.     Ascites 600 

K.      Diseases  of  the  Omentum 602 

SECTION  VII 
Diseases  of  the  Respiratory  System 

A.  Diseases  of  the  Nose 604 

I.     Epistaxis 604 

B.  Diseases  of  the  Larynx 605 

I.    Acute  Catarrhal  Laryngitis 605 

11.     Chronic  Laryngitis •       •       •  606 

III.  (Edematous  Laryngitis 606 

IV.  Spasmodic  Laryngitis 607 

V.    Tuberculous  Laryngitis       . •  60S 

VI.    Syphilitic  Laryngitis 609 


CONTENTS  XV 

PAGE 

C.  Diseases  of  the  Bronchi 610 

I.     Acute  Tracheo-Bronchitis  .        .        .        „ 610 

II.     Chronic  Bronchitis       .        .        .        ,       „        .    '    .       .       .       .  613 

III.  Bronchiectasis 615 

IV.  Hay  Fever  and  Bronchial  Astlima 618 

V.     Fibrinous  Bronchitis 624 

VI.     Foreign  Bodies  in  the  Bronchi 626 

D.  Diseases  of  the  Lungs 627 

I.     Circulatorj^Disturbances  in  the  Lungs 627 

II.     Chromc_Interstitial  Pneumonia 633 

III.  Pneumoconiosis 636 

IV.  Emphysema 638 

I.  Compensatory 638 

II.  Hypertrophic 639 

III.  Atrophic .  643 

IV.  Acute  Vesicular 643 

V.  Interstitial 643 

V.     Gangrene  of  the  Lung 643 

VI.     Abscess  of  the  Lung 645 

VII.     New  Growths  in  the  Lungs        .       .       .       .       .       .       ,       .  646 

E.  Diseases  of  the  Pleura 647 

I.     Acute  Pleurisy 647 

I.    Fibrinous  or  Plastic  Pleurisy 647 

II.     Sero-fibrinous  Pleurisy 648 

III.  Purulent  Pleurisy  (Empyema) 653 

IV.  Tuberculous  Pleurisy 655 

.  "\'".     Other  Varieties  of  Pleurisy 655 

II.     Chronic  Pleurisy 660 

III.  Hj^drothorax 661 

IV.  Hsemothorax         .       .' 662 

V.  Pneumothorax .  663 

VI.     Affections  of  the  Mediastinum 666 

F.  Diseases  of  the  Diaphragm 670 

SECTION  VIII 
Diseases  of  the  Kidneys 

I,     Malformations 671 

II.     Movable  Kidney 672 

III.  Circulatory  Disturbances 674 

IV.  Anomalies  of  the  Urinary  Secretion 675 

I.    Anuria 675 

II.  Hsematuria 676 

III.  Hsemoglobinuria 677 

IV.  Albuminuria        .        . 679 

V.    Bacteriuria 682 

VI.  Pyuria 682 

VII.     Chyluria— Non-parasitic 683 


CONTENTS 

PAGE 

VIII.    Lithuria       ....„„....  684 

IX.    Oxaluria       ..........  684 

X.     Cystinuria    ..........  685 

XI.    Phosphaturia      .       .       .       .       .       .       .       .       .  685 

XII.     Indicanuria 686 

XIII.  Melanuria 687 

XIV.  Alkaptonuria 687 

XV.    Pneumaturia 687 

XVI.     Other  Substances 688 

V.    Uraemia 688 

VI.    Acute  Nephritis 692 

VII.     Chronic  Nephritis        .       .       .       .       .       .       .       •.       .       .697 

1.  Chronic  Parenchymatous  Nephritis 697 

2.  Chronic  Interstitial  Nephritis 700 

VIII.    Amyloid  Disease  .       .       .       .       ,       ,       .       .       .       ,       .  707 

IX.    Pyelitis .  708 

X.    Hydronephrosis • 711 

XI.    NephroHthiasis 713 

XII.    Tumors  of  the  Kidney 717 

XIII.  Cystic  Disease  of  the  Kidney     .  ■ ,       .  719 

XIV.  Perinephric  Abscess 720 

SECTION   IX 
Diseases  of  the  Blood-forming  Organs 

I.    Anaemia 722 

Local  Anaemia 722 

General  Anaemia — Classification 722 

Primary  or  Essential  Anaemia 725 

1.  Chlorosis 725 

2.  Pernicious  or  Addisonian  Anaemia 727 

II.    Leukaemia .  733 

III.  Hodgkin's  Disease 738 

IV.  Purpura 742 

V.    Haemophilia .       .  747 

VI.    Erythraemia 750 

VII.    Enterogenous  Cyanosis 751 

SECTION  X 

Diseases  of  the  Circulatory  System 

Diseases  of  the  Pericardium 753 

I.     Pericarditis    .   • .       .       .       .       .  753 

Acute  Fibrinous  Pericarditis 754 

Pericarditis  with  Effusion 756 

Chronic  Adhesive  Pericarditis       . 760 


CONTENTS                                 .  xvii 

PAGE 

II.    Other  Affections  of  the  Pericardium         ......  762 

B.  Diseases  of  the  Heart ' 763 

I.    Symptomatic  and  Mechanical  Disorders 763 

I.    Symptomatic  Disorders 763 

1.  Heart  Consciousness 763 

2.  Cardiac  Pain 763 

3.  "Effort  Syndrome"  .       ........  764 

4.  Palpitation         .       ,       . 765 

II.     Mechanical  Disorders"of  the  Heart  Beat          ....  766 

A.  Disturbances  of  Rate 767 

1.  Tachycardia 767 

2.  Bradycardia 767 

B.  Disturbances  of  Rhythm  and  Force 768 

1.  Sinus  Arrhythmia 768 

2.  Extra  Systole  (Premature  Contraction)   .        .        .  768 

3.  Paroxysmal  Tachycardia 770 

4.  Auricular  Flutter 771 

5.  Auricular  Fibrillation 772 

6.  Heart  Block  .       .       .       ...       .       .       .773 

7.  Alternation  of  the  Heart 776 

II.    Affections  of  the  Myocardium 777 

I.    Hypertrophy 777 

II.    Dilatation 779 

III.     Cardiac  InsulSiciency 781 

III.  Endocarditis 792 

Acute  Endocarditis .  792 

Chronic  Endocarditis 799 

IV.  Chronic  Valvular  Disease   . 800 

General  Introduction 800 

Aortic  Insufficiency 802 

Aortic  Stenosis 808 

Mitral  Insufficiency 810 

Mitral  Stenosis 813 

Tricuspid  Valve  Disease 817 

Pulmonary  Valve  Disease 818 

V.    Special  Pathological  Conditions 822 

I.    Aneurism  of  the  Heart 822 

II.    Rupture  of  the  Heart    .       .       . 823 

III.  New  Growths  and  Parasites 823 

IV.  Wounds  and  Foreign  Bodies 823 

VI.     Congenital  Affections  of  the  Heart 824 

VII.    Angina  Pectoris 828 

C.  Diseases  of  the  Arteries 833 

I.    Arteriosclerosis 833 

II.    Aortitis 839 

III.    Aneurism 841 

I.    Aneurism  of  the  Aorta 843 


CONTENTS 


A.  Aneurism  of  the  Thoracic  Aorta     . 

B.  Aneurism  of  the  Abdominal  Aorta 

C.  Dissecting  Aneurism 

II.     Aneurism  of  the  Branches  of  the  Abdominal  Aorta 

III.     Arteriovenous  Aneurism       ...... 


PAGE 

843 
850 
852 
853 
853 


SECTION  XI 

Diseases  of  the  Ductless  Glands 

I.     Diseases  of  the  Suprarenal  Bodies 855 

I.  Addison's  Disease 856 

II.  Other  Affections  of  the  Suprarenal  Glands         .       .       .  859 
II.     Diseases  of  the  Thjinus  Gland 860 

I.  H3T)ertrophy  of  the  ThjTnus 860 

II.  Atrophy  of  the  Thymus .  861 

III.  Status  ThjTnico-ljTuphaticus       .     ■ 861 

III.     Diseases  of  the  ThjToid  Gland 862 

I.     Congestion 862 

II.  Th}Toiditis 863 

III.  Tumors  of  the  ThjTcid 863 

IV.  Aberrant  and  Accessory  ThjToids 863 

V.     Goitre .864 

VI.     Hj^pothjToidism  (Cretinism  and  jMyxcedema)         .       .  865 

VII.     Hyperthyroidism;  Exophthalmic  Goitre  ....  869 

•  IV.     Diseases  of  the  Parathyroid  Glands 872 

Tetany 873 

\.     Diseases  of  the  Pituitary  Body 875 

Acromegaly 877 

VI.     Diseases  of  the  Pineal  Gland 878 

VII.    Diseases  of  the  Sex  Glands 879 

VIII.    InfantiHsm 879 

IX.    Diseases  of  the  Spleen 880 

I.     General  Remarks 880 

II.    Movable  Spleen .       .881 

III.  Rupture  of  the  Spleen 881 

IV.  Infarct,  Cysts  and  Tuberculosis  of  the  Spleen         .        .  882 

V.  Primary  Splenomegaly  with  Ansemia         ....  882 


SECTION  XII 
Diseases  of  the  Nervous  System 

A.  General  Introduction 886 

B.  System  Diseases •       •  905 

I.     Introduction 905 

II.    Diseases  of  the  Afferent  or  Sensory  System 906 


CONTENTS  xix 

PAGE 

I.  Tabes  Dorsalis         .        .       " .906 

II.  General  Paresis  and  Tabo-paralysis 914 

III.     Diseases  of  the  Efferent  or  Motor  Tract 918 

I.     Progressive  (Central)  Muscular  Atrophy  ....  918 

II.  Spastic  Paralysis  of  Adults 922 

III.  Secondary  Spastic  Paralj^sis 923 

C.  Plereditary  and  Familial  Diseases 924 

I.     The  Muscular  Dystrophies 924 

II.     Familial  Spinal  Muscular  Atrophy 926 

III.  Progressive  Neural  Muscular  Atrophy 926 

IV.  Progressive  Interstitial  Hypertrophic  Neuritis        ....  927 
Y.     Hereditary  Ataxia 927 

VI.     Hereditary  Cerebellar  Ataxia 929 

VII.     Hereditary  Spastic  Paraplegia   . 929 

VIII.     Chronic  Hereditary  Chorea 929 

IX.     Progressive  Lenticular  Degeneration 930 

X.     Periodic  Paralysis 931 

XI.     Amaurotic  Familj''  Idiocy 932 

XII.     Myoclonic  Epilepsy 932 

D.  Diseases  of  the  Meninges 933 

I.     Diseases  of  the  Dura  Mater 933 

II.     Diseases  of  the  Pia  Mater 936 

E.  Meningo-Myelo-Encephalitis .  938 

I.     Acute  Poliomyehtis  _ 938 

II.     Epidemic  Encephalitis 943 

F.  Myelitis 946 

I.     Acute  Myelitis 946 

II.     Acute  Ascending  (Landry's)  Paratysis 948 

III.  Degenerative  Myelitis 949 

I.  Combined  Postero-lateral  Sclerosis 949 

II.     Senile  Spastic  Paralj'sis 951 

IV.  Compression  of  the  Spinal  Cord 951 

G.  Diffuse  Scleroses 954 

Multiple  Sclerosis         . 954 

H.      Diffuse  and  Focal  Diseases  of  the  Spinal  Cord 957 

I.     Topical  Diagnosis 957 

II.    Affections  of  the  Blood-vessels 960 

I.     Congestion 960 

II.  Ansmia 960 

IIT.     Embolism  and  Thrombosis 960 

IV.  Endarteritis 960 

V.    Haemorrhage  into  the  Spinal  Membranes;  Hsematorachis  961 

VI.    Haemorrhage  into  the  Spinal  Cord  ;Ha?matomyelia  .       .  962 
III.     Tumors  of  the  Spinal  Cord  and  Its  Membranes     .       .       .       .963 

I.     Syringomyelia 963 

II.     Tumors  of  the  Meninges 964 

I.        Diffuse  and  Focal  Diseases  of  the  Brain 965 

I.     Topical  Diagnosis 965 


XX  CONTENTS 

PAGE 

II.    Aphasia 973 

III.  Affections  of  the  Blood-vessels 978 

I.  Arteriosclerosis — Cerebral  Features         ....     978 

II.     Hyper semia  and  Ansemia 980 

III.  CEdema  of  the  Brain ,       .        .981 

IV.  Cerebral  Haemorrhage 982 

V.  Embolism  and  Thrombosis       ...'...     992 

VI.     Aneurism  of  the  Cerebral  Arteries 997 

VII.     Thrombosis  of  the  Cerebral  Sinuses  and  Veins      .        .  998 

VIII.     Cerebral  Palsies'^of  Children 1000 

IV.  Tumors,  Infections,  Granulomata  and  Cysts  of  the  Brain    .        .  1003 
V.     Inflammation  of  the  Brain 1009 

I.    Acute  Encephalitis 1C09 

II.    Abscess  of  the  Brain 1C09 

VI.     Hydrocephalus 1012 

J.       Diseases  of  the  Peripheral  Nerves      .       .       ..        .       ,       .       .       .1014 

I.     Neuritis ,       .        .  1014 

II.     Nem-omata 1020 

III.     Diseases  of  the  Cerebral  Nerves 1021 

Olfactory  Nerves  and  Tracts 1021 

Optic  Nerve  and  Tract 1022 

1.  Lesions  of  the  Retina 1022 

2.  Lesions  of  the  Optic  Nerve 1024 

3.  Affections  of  the  Chiasma  and  Tract 1025 

4     Affections  of  the  Tract  and  Centers 1C25 

Motor  Nerves  of  the  Eyeball 1028 

Fifth  Nerve 1032 

Facial  Nerve 1034 

Auditory  Nerve 1038 

The  Cochlear  Nerve 1038 

The  Vestibular  Nerve      . '.       .  1040 

Glosso-pharyngeal  Nerve 1042 

Pnemnogastric  Nerve 1043 

Spinal  Accessory  Nerve 1045 

Hypoglossal  Nerve 1048 

Combined  Paralysis  of  the  Last  Three  and  Four  Cranial  Nerves   .   1049 

TV.    Diseases  of  the  Spinal  Nerves 1049 

Cervical  Plexus 1049 

Brachial  Plexus .       .       .       .       •  1051 

Lumbar  and  Sacral  Plexuses 1055 

Sciatica  • 1056 

V.    Herpes  Zoster 1058 

K.      General  and  Functional  Diseases       .       .       .       .       .       .       •       •       •  1059 

I.    Paralysis  Agitans 1059 

Other  Forms  of  Tremor  .' 1062 

11.    Acute  Chorea 1062 

III.  Habits  Spasms  and  Tics " •       •  1069 

IV.  Infantile  Convulsions •       •       •       .1071 


CONTENTS  xxi 

PAGE 

V.  EpUepsy 1073 

VI.  Migraine 1080 

VII.  Neuralgia 1082 

VIII.  Professional  Spasms;  Occupation  Neuroses 1086 

IX.  Hysteria 1087 

X.  Neurasthenia 1100 

XI.  The  Traumatic  Neuroses .       .       .  1108 

L.      Vasomotor  and  Trophic  Disorders 1111 

I.  Raynaud's  Disease 1111 

II.  Erythromelalgia 1114 

III.  Angioneurotic  Oedema 1115 

IV.  Persistent  Hereditary  Gdema  of  the  Legs      .       .       .               .1116 
V.  Facial  Hemiatrophy 1116 

VI.    Scleroderma  ...-,...,...  1117 

VII.     Ainhum  .       .       .'      .       . .  1118 

VIII.    Lipodystrophia  Progressiva        .       .       .       .       .       .       .       .1118 

SECTION  XIII 
Diseases  of  the  Locomotoe  System 

A.  Diseases  of  the  Muscles 1119 

I.  Myositis ....  1119 

II.  Myositis  Ossificans  Progressiva         .......  1120 

III.  Fibrositis '      .       .  1120 

IV.  Myotonia 1122 

V.  Paramyoclonus  Multiplex 1123 

VI.    Myasthenia  Gravis 1124 

VII.    Amyotonia  Congenita   , 1124 

B.  Diseases  of  the  Joints 1125 

I.     Arthritis  Deformans 1125 

II.    Intermittent  Hydrarthrosis 1133 

C.  Diseases  of  the  Bones 1134 

I.  Hypertrophic  Pulmonary  Arthropathy 1134 

II.  Osteitis  Deformans ....  1135 

III.  Leontiasis  Ossea 1136 

IV.  Osteogenesis  Imperfecta 1136 

V.  Osteomalacia 1137 

VI.    Achondroplasia 1137 

VII.     Hereditary  Deforming  Chondrodysplasia 1138 

VIII.    Oxycephaly ' 1138 


CHARTS  AND  ILLUSTRATIONS 


CHART  PAGE 

I.    Typhoid  Fever  with  Relapses 15 

II.     Typhoid  Fever.     Hsemorrhage  from  the  Bowels 21 

III.  Typhus  Fever  (Murchison) 49 

IV.  Blood  Count  in  Pneumonia  and  Comparative  Mortality         ...  90 
V.     Chronic  Tuberculosis 198 

Via.     Double  Tertian  Infection.     Quotidian  Fever 249 

VIb.     Quartan  Fever 249 

Vic.    ^stivo-autumnal  Fever.     Quotidian  Paroxysms 250 

VId.    Ji]stivo-autumnal  Infection.     Remittent  Fever 250 

VII.     Malaria  Cases  Among  the  Employees  of  the  Isthmian  Canal  Com- 
mission, 1906-1910 256 

VIII.     Relapsing  Fever  (Murchison) 262 

IX.    Small-pox  (Strumpell) 323 

X.    Scarlet  Fever    .       . .341 

XI.     Measles ,        .350 

XII.     Caseof  Sunstroke  Treated  by  the  Ice-bath;  Recovery       ....  382 

XIII.  Uric  Acid  and  Phosphoric  Acid  Output  in  Case  of  Acute  Gout  .       .       .  415 

XIV.  Diabetic  Food  Tables 433 

XV.    Pernicious  Anaemia  .        . 731 

XVI.     Blood  Chart  of  Anaemia  in  Purpura  Hsemorrhagica 745 

FIGURE 

1.  Premature  Contractions  of  Ventricular  Origin 769 

2.  Auricular  Flutter 771 

3.  Auricular  Fibrillation 772 

4.  Auricular  Fibrillation 773 

5.  Diagram  Showing  the  Sino-auricular  Node  and  the  Auricular  Bundle        .  774 

6.  Partial  Heart-Block  with  2:1  Ratio 775 

7.  Complete  Heart-Block 775 

8.  Combined  Alternation  of  Pulse  and  Premature  Contractions        .       .       .  770 

9.  Diagrams  after  Martius,  Showing  Schematically  the  Power  of  the  Heart 

Muscle .801 

10.  Pulse  Tracing  in  Aorticlnsufl&ciency;  Extra-systole 807 

11.  Pulse  Tracing  in  Aortic  Stenosis 809 

12.  Diagram  of  Motor  Path  from  Left  Brain  (van  Gehuchten)   .       .'     .       .  888 

13.  Diagram  of  Motor  Path  from  Each  Hemisphere  (van  Gehuchten)  .        .       .  889 

14.  Diagrams  of  Cerebral  Locahzation 893 


CHARTS  AND  ILLUSTRATIONS 


FIGURE 

15.  Diagram  of  3,Iotor  and  Sensory'  Representation  in  the  Internal  Capsule 

16.  Diagram  of  :\Iotor  and  Sensory  Paths  in  Crura 

17.  Diagi-am  of  Cross-section  of  the  Spinal  Cord    . 
IS.  Anterior  Aspect  of  the  Segmental  Skin-fields  of  the  Body 

19.  Posterior  Aspect  of  the  Segmental  Skin-fields  of  the  Body 

20.  Diagram  of  3»Iotor  Path  from  Left  Brain  .... 

21.  Diagram  of  Visual  Paths  (Violet) 


PAGE 

894 
895 
895 
898 
899 
987 
1027 


THE 

PRINCIPLES  AND  PRACTICE 

OF  MEDICINE 

SECTION  I 

SPECIFIC  INFECTIOUS  DISEASES 

A.    BACTERIAL  DISEASES 
I.     TYPHOID  FEVER 

Definition. — A  general  infection  caused  by  the  Bacillus  typhosus,  charac- 
terized anatomically  by  hyperplasia  and  ulceration  of  the  intestinal  lymph- 
follicles,  swelling  of  the  mesenteric  glands  and  spleen,  and  parenchymatous 
changes  in  the  other  organs.  There  are  cases  in  which  the  local  changes  are 
slight  or  absent,  and  there  are  others  with  intense  localization  in  the  lungs, 
spleen,  kidneys,  or  cerebro-spinal  system.  Clinically  the  disease  is  marked 
by  fever,  rose-colored  eruption,  abdominal  tenderness,  tympanites,  and  enlarge- 
ment of  the  spleen;  but  these  symptoms  are  extremely  inconstant,  and  even 
the  fever  varies  in  its  character. 

Historical  Note. — Huxham,  in  his  remarkable  Essay  on  Fevers,  had  "taken 
notice  of  the  very  great  difference  there  is  between  the  putrid  malignant  and 
the  slow  nervous  fever."  In  1813  Pierre  Bretonneau,  of  Tours,  distinguished 
"dothienenterite"  as  a  separate  disease ;  and  Petit  and  Serres  described  entero- 
mesenteric  fever.  In  1829  Louis'  great  work  appeared,  in  which  the  name 
"typhoid"  was  given  to  the  fever.  At  this  period  typhoid  fever  alone  pre- 
vailed in  Paris  and  many  European  cities,  and  it  was  universally  believed 
to  be  identical  with  the  continued  fever  of  Great  Britain,  where  in  reality 
typhoid  and  typhus  coexisted.  The  intestinal  lesion  was  regarded  as  an  ac- 
cidental occurrence  in  the  course  of  ordinary  typhus.  Louis'  students,  return- 
ing to  their  homes  in  different  countries,  had  opportunities  for  studying  the 
prevalent  fevers  in  the  thorough  and  systematic  manner  of  their  master. 
Among  these  were  certain  young  American  physicians,  to  one  of  whom,  Ger- 
hard, of  Philadelphia,  is  due  the  great  honor  of  having  first  clearly  laid  down 
the  differences  between  the  two  diseases.  His  papers  in  the  American  Jour- 
Jial  of  the  ^ledical  Sciences,  1837,  are  the  first  which  give  a  full  and  satis- 
factory account  of  their  clinical  and  anatomical  distinctions.  The  studies  of 
James  Jackson,  Sr.  and  Jr.,  of  Enoch  Hale  anrl  of  George  C.  Shattuck,  of 

1 


2  SPECIFIC  INFECTIOUS  DISEASES 

Boston,  and  of  Alfred  Stille  and  Austin  Flint  made  the  subject  very  familiar 
in  American  medicine.  In  1842  Elislia  Bartlett's  work  appeared,  in  which, 
for  the  first  time  in  a  systematic  treatise,  typhoid  and  typhus  fever  were  sep- 
arately considered  with  admirable  clearness.  In  Great  Britain  the  recognition 
of  the  difference  between  the  two  diseases  was  slow,  and  due  largely  to  A.  P. 
Stewart,  and  to  the  studies  of  Jenner  between  1849  and  1850. 

Etiology. — General  Prevalence. — Typhoid  fever  prevails  especially  in 
temperate  climates,  in  which  it  constitutes  the  most  common  continued  fever. 
Widely  distributed  throughout  all  parts  of  the  world,  it  probably  presents 
everywhere  the  same  essential  characteristics,  and  is  everywhere  an  index  of 
the  sanitary  intelligence  of  a  community.  Imperfect  sewerage  and  contami- 
nated water-supply  are  two  special  conditions  favoring  the  distribution  of  the 
bacilli;  filtli,  overcroivding,  and  tad  ventilation  are  accessories  in  lowering  the 
resistance  of  the  individuals  exposed.  While  from  an  infected  person  the 
disease  may  be  spread  by  -fingers,  food  and  fiies. 

In  England  and  Wales  in  1916  the  disease  was  fatal  to  1,122  persons,  a 
mortality  of  30  per  million  of  living  persons.  It  destroys  more  lives  in  pro- 
portion to  population  in  towns  than  in  the  country.  The  rate  was  lower  in 
1916  than  in  any  year  since  1869.  In  India  the  disease  is  very  prevalent;  no 
race  or  creed  is  exempt,  and  80  per  cent,  of  the  cases  of  continued  fever  lasting 
three  weeks  prove  to  be  typhoid  fever  (L.  Eogers). 

In  the  United  States  there  has  been  a  marked  decrease  in  the  last  twenty 
years.  The  death  rate  per  100,000  population  in  the  registration  areas  has 
fallen  from  35.9  in  1900  to  13.4  in  1917.  In  1919  the  death  rate  in  the  sixty 
largest  cities  was  4.2  per  100,000.  It  is  more  prevalent  in  country  districts 
than  in  cities,  and,  as  Fulton  showed,  the  propagation  is  largely  from  the 
countrj'^to  the  town.  What  is  needed  both  in  Canada  and  the  United  States 
is  a  realization  by  the  public  that  certain  primary  laws  of  health  must  be 
obeyed. 

T5^phoid  fever  has  been  one  of  the  great  scourges  of  armies,  and  killed 
and  maimed  more  than  powder  and  shot.  The  recent  war  shows  the  results 
of  preventive  inoculation  in  a  striking  way.  In  the  Spanish-American  War 
the  report  of  the  Commission  (Eeed,  Vaughan,  and  Shakespeare)  showed  that 
in  the  national  encampments  among  107,973  men  there  were  20,738  cases  of 
typhoid  fever  with  1,580  deaths.  In  90  per  cent,  of  the  volunteer  regiments 
the  disease  broke  out  within  eight  weeks  after  going  into  camp.  In  the 
opinion  of  the  Commission  the  most  important  factors  were  camp  pollution, 
flies  as  carriers  of  contagion,  and  the  contamination  through  the  air  in  the 
form  of  dust.  In  the  South  African  War  the  British  army,  557,653  officers 
and  men,  had  57,684  cases  of  typhoid  fever,  with  8,225  deaths  (Simpson), 
while  only  7,582  men  died  of  wounds  received  in  battle.  The  disease  was 
essentially  one  of  the  standing  camps;  troops  constantly  on  the  move  were 
rarely  jnuch  affected.  While  contaminated  water  was  no  doubt  an  important 
factor,  as  it  always  is  in  camp  pollution,  yet  certain  of  the  conditions  in 
Africa  were  peculiar.  Faecal  and  urinary  contamination  must  have  been  very 
common,  as  in  the  cooking,  performed  in  the  open  air,  sand  "entered  largely 
into  every  article  of  food.'^  As  there  was  a  perfect  plague  of  flies,  they  were 
without  doubt  a  very  important  factor  in  the  infection  of  both  food  and  drink. 

On  the  other  hand,  the  Japanese  and  Eussiau  War  demonstrated  the  re- 


TYPHOID  FEYEE  3 

markable  efficiency  of  modern  hygiene,  if  carried  out  in  an  intelligent  manner. 
In  the  great  European  war  typhoid  fever  did  not  prevail  to  any  extent  in  the 
Western  armies.  The  efficacy  of  inoculation  has  been  demonstrated.  The 
large  proportion  of  paratyphoid  cases  is  remarkable. 

Season.-r^ Almost  without  exception  the  disease  is  everywhere  more  preva- 
lent in  the  autumn,  hence  the  old  popular  name  autumnal  fever.  The  exhaus- 
tive study  of  this  question  by  Sedgwick  and  Winslow  shows  everywhere  a  strik- 
ing parallelism  between  the  monthly  variations  in  temperature  and  the  preva- 
lence of  the  disease.  In  a  few  cities  the  curves  are  irregular,  showing,  in 
addition  to  the  usual  summer  rise,  two  secondary  maxima  in  the  winter  and 
spring,  and  these  authors  suggest  that  epidemics  at  these  seasons  are  character- 
istic of  cities  whose  water-supply  is  most  subject  to  pollution.  In  their  opin- 
ion "the  most  reasonable  explanation  of  the  seasonal  variations  of  typhoid 
fever  is  a  direct  effect  of  the  temperature  upon  the  persistence  in  nature  of 
the  germs  which  proceed  from  previous  victims  of  the  disease." 

Of  1,500  cases  at  the  Johns  Hopkins , Hospital  (upon  the  study  of  which 
this  section  is  based),  840  were  in  August,  September,  and  October. 

Sex. — Males  and  females  are  equally  liable  to  the  disease,  but  males  are 
much  more  frequently  admitted  into  hospitals,  2.4  to  1  in  our  series. 

Age. — Typhoid  fever  is  a  disease  of  youth  and  early  adult  life.  The  great- 
est susceptibility  is  between  the  ages  of  fifteen  and  twenty-five.  Of  1,500 
cases  treated  in  the  Johns  Hopkins  Hospital  there  Avere  under  fifteen  years  of 
age,  231;  between  fifteen  and  twenty,  253;  between  twenty  and  thirty,  680; 
between  thirty  and  forty,  227;  between  forty  and  fifty,  88;  between  fifty  and 
sixty,  8;  above  sixty,  11;  age  not  given,  1.  Cases  in  advanced  life  are  not 
uncommon,  but  as  the  course  is  often  atypical  the  diagnosis  may  be  uncertain 
and  the  disease  not  recognized  until  autopsy.  It  is  not  very  infrequent  in 
childhood,  but  infants  are  rarely  attacked.  Murchison  saw  a  case  at  the  sixth 
month. 

Immunity. — Not  all  exposed  to  the  infection  take  the  disease.  Some  fam- 
ilies seem  more  susceptible  than  others.  One  attack  usually  protects.  Two 
attacks  have  been  described  within  a  year.  In  500  of  our  cases  in  which  special 
inquiry  was  made  as  to  a  previous  attack,  it  was  found  to  have  occurred  in 
11  (2.2  per  cent.)  but  some  of  those  were  probably  paratyphoid  fever.  The 
interval  varied  from  nine  months  to  thirty  years.  It  is  well  known  that  usually 
within  a  short  time  after  recovery  the  immune  substances  disappear  from  the 
blood,  yet  in  most  cases  the  immunity  lasts  a  long  time,  frequently  for  life. 
An  experimental  explanation  for  this  fact  has  been  given  in  the  demonstra- 
tion that  animals  which  have  once  reacted  to  the  typhoid  infection,  react  in 
throwing  out  immune  substances  more  quickly  and  in  larger  amounts  when 
danger  again  threatens   (Cole). 

Bacillus  typhosus. —  (a)  General  Characters. — It  is  a  rather  short, 
thick,  flagellated,  motile  bacillus,  with  rounded  ends,  in  one  of  Mdiich,  some- 
times in  both  (particularly  in  cultures),  there  can  be  seen  a  glistening  round 
body,  at  one  time  believed  to  be  a  spore ;  but  these  polar  structures  are  prob- 
ably only  areas  of  degenerated  protoplasm.  There  are  various  strains  which 
show  antigenic  differences.  This  organism  fulfills  all  the  requirements  of 
Koch's  law — it  is  constantly  present,  and  grows  outside  the  l)ody  in  a  specific 
manner;  the  third  requirement,  the  production  of  the  disease  experimentally, 


4  SPECIFIC  I^TpECTIOITS  DISEASES 

has  been  successfully  met  by  its  conveyance  to  chimpanzees.  The  bacilli  or 
their  toxins  inoculated  in  large  quantities  into  the  blood  of  rabbits  are  patho- 
genic, and  in  some  instances  ulcerative  and  necrotic  lesions  in  the  intestine 
may  be  produced.  But  similar  intestinal  lesions  may  be  caused  by  other 
bacteria,  including  Bacillus  coK. 

Cultures  are  killed  within  ten  minutes  by  a  temperature  of  60°  C.  They 
may  live  for  eighteen  weeks  at  — 5°  C,  although  most  die  within  two  weeks, 
and  all  within  twenty-two  weeks  (Park).  The  typhoid  bacillus  resists  ordi- 
nary drying  for  months,  unless  in  very  thin  layers,  when  it  is  killed  in  five 
to  fifteen  days.  The  direct  rays  of  the  sun  completely  destroy  them  in  from 
four  to  ten  hours'  exposure.  Bouillon  cultures  are  destroyed  by  carbolic  acid, 
I  to  200,  and  by  corrosive  sublimate,  1  to  2,500. 

(&)  Distribution  in  the  Body. — Our  ideas  in  regard  to  this  have  been 
much  modified,  owing  to  the  demonstration  that  in  practically  all  cases  the 
bacilli  enter  the  circulating  blood  and  are  carried  throughout  the  body.  During 
life  they  may  be  demonstrated  in  the  circulating  blood  in  a  large  proportion  of 
cases,  in  75  per  cent,  of  604  collected  cases  (Coleman  and  Buxton).  They 
occur  in  the  urine  in  from  25  to  30  per  cent,  of  the  cases.  They  may  be 
isolated  from  the  stools  in  practically  all  cases  at  some  stage.  They  are 
probably  always  present  in  the  rose  spots.  They  are  reported  to  have  been 
cultivated  from  the  sweat,  and  occur  with  considerable  frequency  in  the  spu- 
tum (Eichardson,  Eau,  and  others).  They  have  been  found  in  the  milk  of 
nursing  women.  At  autopsy  they  are  found  widely  distributed,  most  numer- 
ous and  constant  usually  in  the  mesenteric  glands,  spleen,  and  gall-bladder, 
but  are  found  in  almost  all  organs,  even  the  muscles,  uterus,  and  lungs 
(von  Drigalski).  Cultures  made  from  the  intestines  at  autopsy  (according  to 
von  Jiirgens,  and  von  Drigalski)  show  that  they  are  very  numerous  in  the 
duodenum  and  jejunum,  and  practically  constant  in  cultures  made  from  the 
mucous  membrane  of  the  stomach.  They  are  present  in  the  oesophagus  and 
frequently  on  the  tongue  and  tonsils.  From  endocardial  vegetations,  from 
meningeal  and  pleural  exudates  and  from  foci  of  suppuration  in  various 
parts  of  the  body,  the  bacilli  have  been  isolated.  A  most  important  fact  is  that 
at  times  they  may  be  present  in  the  stools  of  persons  who  show  no  symptoms  of 
typhoid  fever,  but  who  have  lived  in  very  close  association  with  typhoid-fever 
patients.     This  is  especially  true  of  children. 

(c)  The  Bacilli  outside  the  Body. — In  sterile  water  the  bacilli  retain 
their  vitality  for  weeks,  but  under  ordinary  conditions,  in  competition  with 
saprophytes,  disappear  within  a  few  days.  The  question  of  the  longevity  of 
the  typhoid  bacillus  in  water  is  of  great  importance,  and  was  much  discussed 
in  connection  with  the  supposed  pollution  of  the  water  of  the  Mississippi  by 
the  Chicago  drainage  canal.  The  experiments  of  E.  0.  Jordan  would  indicate 
that  the  vitality  was  retained  as  a  rule  not  longer  than  three  days  after  infec- 
tion. Whether  an  increase  can  occur  in  water  is  not  finally  settled.  Their 
detection  in  water  is  difficult,  and  although  they  undoubtedly  have  been  found, 
many  such  discoveries  are  not  certain  on  account  of  the  inaccurate  differentia- 
tion of  the  typhoid  bacillus  and  varieties  of  intestinal  bacilli  closely  resembling 
it.    Both  Prudden  and  Ernst  found  it  in  water  filters. 

There  are  cities  deriving  their  ice  snpply  from  polluted  streams  with  low 
death  rates  from  typhoid  fever.     Sedgwick  and  Winslow  conclude  from  their 


TYPHOID  FEVEE  5 

careful  study  that  very  few  typhoid  germs  survive  in  ice.  The  Ogdeusburg 
epidemic  in  1902-'03  was  apparently  due  to  infection  from  ice.  Typhoid 
bacilli  were  grown  from  frozen  material  in  it  (Hutchins  and  Wheeler). 

In  milk  the  bacilli  undergo  rapid  development  without  changing  its  ap- 
pearance. They  may  persist  for  three  months  in  sour  milk,  and  may  live  for 
several  days  in  butter  made  from  infected  cream. 

Eobertson  has  shown  that  under  entirely  natural  conditions  typhoid  bacilli 
may  live  in  the  upper  layers  of  the  soil  for  eleven  months.  Yon  Drigalski  says 
if  stools  which  contain  typhoid  bacilli  are  kept  at  room  temperature  the  B. 
typJiosus  disappears  in  a  few  days. 

The  direct  infection  of  exposed  food-stuffs  by  dust  is  very  probable.  The 
bacilli  retain  their  vitality  for  many  weeks;  in  garden  earth  21  days,  in  filter- 
sand  82  days,  in  street  dust  30  days,  on  linen  60  to  70  days,  on  wood  32  days, 
on  thread  kept  under  suitable  conditions  for  a  year. 

Modes  of  Convftance. —  (a)  Contagion. — Direct  aerial  transmission  does 
not  seem  probable.  Each  case  should  be  regarded  as  a  possible  source  of 
infection,  and  in  houses,  hospitals,  schools,  and  barracks  a  widespread  epi- 
demic may  arise  from  it.  Fingers,  food,  and  flies  are  the  chief  means  of 
local  propagation.  It  is  impossible  for  a  nurse  to  avoid  finger  contamination, 
and  without  scri^pulous  care  the  germs  may  be  widely  distributed  in  a  ward 
or  throughout  i  house.  Cotton  or  rubber  gloves  are  used  in  some  institu- 
tions. Even  With  special  precautions  and  an  unusually  large  proportion  of 
nurses  to  patimts,  it  was  not  possible  to  avoid  "house"  infection  at  the  Johns 
Hopkins  Hospital.  T.  B.  Futcher  analyzed  the  31  cases  contracted  in  the 
hospital  amon^  the  first  1,500  cases;  physicians,  5*  among  a  total  of 
288 ;  nurses,  1)  of  a  total  of  407 ;  patients,  8  out  of  a  total  of  47,956  admis- 
sions; 4  of  these  occurred  in  a  small  ward  epidemic.  Two  orderlies  were 
infected  while  caring  for  typhoid  patients,  and  one  Avoman  in  charge  of  a 
supply  room,  yhere  she  handled  clean  linen  only.  Kewman  concluded  from 
his  study  of  ty)hoid  fever  in  London  that  direct  personal  infection  and  infec- 
tion through  ftod  are  the  two  common  channels  for  its  propagation. 

(6)  Infectim  of  water  is  the  most  common  source  of  widespread  epidemics, 
many  of  which  lave  originated  in  the  contamination  of  a  well  or  a  spring.  A 
striking  one  ocCirred  at  Plymouth,  Pa.,  in  1885.  The  town,  with  a  population 
of  8,000,  was  ii  part  supplied  Avith  drinking-water  from  a  reservoir  fed  by 
a  mountain  strem.  During  January,  February,  and  March,  in  a  cottage  by 
the  side  of  and  it  a  distance  of  from  60  to  80  feet  from  this  stream,  a  man 
was  ill  with  tyjioid  fever.  The  attendants  were  in  the  habit  at  night  of 
throwing  out  thi;  evacuations  on  the  ground  toward  the  stream.  During  these 
months  the  grouni  was  frozen  and  covered  with  snow.  In  the  latter  part  of 
March  and  early  in  \pril  there  was  considerable  rainfall  and  a  thaw,  in  which 
a  large  part  of  the  tiree  months'  accumulation  of  discharges  was  washed  into 
a  brook,  not  60  feet  ditaut.  At  the  time  of  this  thaw  the  patient  had  numer- 
ous and  copious  dischai,-es.  About  the  10th  of  April  cases  of  typhoid  fever 
broke  out  in  the  town,  a^earing  for  a  time  at  the  rate  of  50  a  day.  In  all 
about  1,200  people  wereXttacked.     An  immense  majority  of  all  the  cases 


*  Only  three  of  these  were  a  atu^tij^j^c^,  on  typhoid  cases.     Two  of  the  five  died.— 
Oppenheimer  and  Ochsner. 


6  SPECIFIC  IXFECTIOUS  DISEASES 

were  in  the  part  of  the  to^^ai  which  received  water  from  the  infected  reservoir. 

The  experience  of  Maidstone  in  1897  illustrates  the  widespread  and  serious 
character  of  an  epidemic  when  the  water-supply  becomes  badly  contaminated. 
The  outbreak  began  about  the  middle  of  September,  and  within  the  first  two 
weeks  509  cases  were  reported.  By  October  27th  there  were  1,748  cases,  and 
by  November  17th  1,818'  cases.  In  all,  in  a  population  o:'  35,000,  about  1,900 
persons  were  attacked. 

(c)  Typhoid  Carriers. — The  bacilli  may  persist  for  years  in  the  bile  pas- 
sages and  intestines  of  persons  in  good  health.  They  bave  been  found  in  the 
urinary  bladder  and  in  the  gall-liladder,  ten  and  twenty  years  after  the  fever, 
and  there  have  been  cases  of  typhoid  bone  lesion  from  which  ths  bacilli  were 
isolated  many  years  after  the  primary  attack.  Tiie  work  of  Strassburg  ob- 
servers called  attention  to  a  group  of  chronic  typhoid  carriers  of  the  first 
importance  in  the  spread  of  the  disease.  The  majority  oi  carriers  are  females. 
One  woman,  a  baker,  had  typhoid  fever  ten  years  predously.  The  bacilli 
were  found  in  large  numbers  in  her  stools.  Every  new  employee  in  the  bakery 
sooner  or  later  became  ill  with  typhoid-like  symptoms,  md  in  two  persons 
the  disease  proved  fatal.  Many  localized  epidemics  have  ken  traced  to  car- 
riers. Soper  reported  an  mstance  in  which  a  cook,  apparently  in  perfect 
health,  but  in  whose  stools  bacilli  were  present  in  large  ni.mbers,  had  been 
responsible  for  the  occurrence  of  typhoid  in  seven  househoHs  in  five  years. 
Apparently  there  is  no  limit  to  the  length  of  time  in  which  the  bacilli  may 
persist.  One  carrier  had  the  attack  of  typhoid  fever  forty-sevei  years  before. 
The  paratyphoid  bacillus  may  be  carried  in  the  same  way.  An  epidemic  of  19 
cases  in  a  French  barrack  was  traced  to  a  cook. 

{d)  Infection-  of  Food. — Milk  may  be  the  source  of  infection.  One  of  the 
most  thoroughly  studied  epidemics  due  to  this  cause  was  flat  investigated 
by  Ballard  in  Islington.  The  milk  may  be  contaminated  by  the  infected  water 
used  in  cleaning  the  cans.  The  milk  epidemics  have  been  colbcted  by  Ernest 
Hart  and  by  Kober.  The  germs  may  be  conveyed  in  ice,  s.lads  of  various 
sorts,  spaghetti,  etc.  The  danger  of  eating  celery  and  other  mcooked  vegeta- 
bles, which  have  grown  in  soil  on  which  infected  material  h»  been  used  as  a 
fertilizer,  must  not  be  forgotten. 

Much  attention  has  been  paid  to  the  oyster  as  a  source  jf  infection.  In 
several  epidemics,  such  as  that  in  Middletown.  reported  ly  Conn,  that  in 
Xaples,  1)y  Lavis,  and  the  outbreak  which  occurred  at  AYinchester,  the 
chain  of  circumstantial  evidence  seems  complete.  Most  s^gestive  sporadic 
cases  have  been  recorded  by  Broadl^ent  and  others.  Foote  s'owed  that  oysters 
taken  from  the  feeding-grounds  in  rivers  contain  a  larger  rumber  of  micro- 
organisms of  all  sorts  than  those  from  the  sea.  Chanten^sse  found  typhoid 
bacilli  in  oysters  which  had  lain  in  infected  sea-water,  eve^  afte;  they  had  been 
transferred  to  and  kept  in  fresh  water  for  a  time.  y^^^J,  in  his  report  to 
the  French  Government  (1900).  admits  the  possibi-ty  of  oysier  infection, 
but  thinks  that  the  oyster  plays  a  very  small  role  in  elation  to  tho  total  mor- 
bidity of  the  disease.  Mussels  have  been  found  ''ntaminated  wi^li  tj^jhoid 
bacilli,  and  it  is  stated  that  dried  fish  have  carried  ^^e  infection. 

{e)  FZie^.— The  importance  of  flies  in  the  t^^ismission  of  the  disease  was 
brought  out  very  strongly  in  the  Spanish- Ad- "^'^^^  ^^ar  in  1898.  The  ffeport 
of  the  Commission  states  that  '-'flies  wer^  undoubedly  the  most  active  agents 


TYPHOID  FEYEE  7 

in  the  spread  of  typhoid  fever.  Plies  alternately  visited  and  fed  on  the  in- 
fected ffecal  matter  and  the  food  in  the  mess-tent.  .  .  .  Typhoid  fever  Avas 
much  less  frecpient  among  members  of  the  messes  who  had  their  mess-tents 
screened  than  it  was  among  those  who  took  no  such  precautions."'  In  the 
South  African  AYar  there  was  a  perfect  plague  of  flies,  particularly  in  the 
typhoid  fever  tents,  and  among  the  army  surgeons  the  opinion  was  universal 
that  they  had  a  great  deal  to  do  with  the  dissemination  of  the  disease.  Pirth 
and  Horrocks  demonstrated  the  readiness  with  which  flies,  after  feeding  on 
typhoid  stools  or  fresh  cultures  of  typhoid  bacilli,  could  infect  sterile  media. 
One  of  the  most  interesting  studies  on  the  question  was  made  in  the  Chicago 
epidemic  of  1902  by  Alice  Hamilton.  Plies  caught  in  two  undrained  privies, 
on  the  fences  of  two  yards,  on  the  walls  of  two  houses,  and  in  the  room  of  a 
typhoid  fever  patient,  were  used  to  inoculate  eighteen  tubes,  and  from  five  of 
these  tubes  typhoid  bacilli  were  isolated. 

(/)  Contamination  of  the  Soil. — Filth,  bad  sewers,  or  cesspools  can  not 
in  themselves  cause  typhoid  fever,  but  they  furnish  the  conditions  suitable  for 
the  preservation  of  the  bacillus,  and  possibly  for  its  propagation. 

Dust  may  be  an  important  factor,  though  it  has  been  shown  that  the  bacilli 
die  very  quickly  when  desiccated.  Possibly,  as  Barringer  suggested,  the  dust 
on  the  railway  tracks  may  become  contaminated.  Men  working  on  the  tracks 
are  very  liable  to  infection. 

Types  of  Ixfectiox. — We  may  recognize  the  following  groups:  (a) 
Ordinary  typhoid  fever  with  marked  enteric  lesions.  An  immense  majority 
of  all  cases  are  of  this  character;  and  while  the  spleen  and  mesenteric  glands 
are  involved  the  lymphatic  apparatus  of  the  intestinal  walls  bears  the  brunt 
of  the  attack.  (&)  Cases  in  which  the  intestinal  lesions  are  very  slight,  and 
may  be  found  only  after  a  very  careful  search.  In  reviewing  the  cases  of 
"tvphoid  fever  without  intestinal  lesions/'  Opie  and  Bassett  call  attention  to 
the  fact  that  in  many  negative  cases  slight  lesions  really  did  exist,  while  in 
others  death  occurred  so  late  that  the  lesions  might  have  healed.  In  some 
cases  the  disease  is  a  general  septicaemia  with  symptoms  of  severe  intoxication 
and  high  fever  and  delirium.  In  others  the  main  lesions  may  be  in  organs — 
liver,  gall-bladder,  pleura,  meninges,  or  even  the  endocardium,  (c)  Cases  in 
which  the  typhoid  bacillus  enters  the  body  wiihout  causing  any  lesion  of  the 
intestine.  In  a  number  of  the  earlier  cases  reported  as  such  the  demonstra- 
tion of  the  typhoid  bacillus  was  inconclusive.  In  others  the  intestine  showed 
tuberculous  ulcers,  through  which  the  organisms  may  have  entered.  But  after 
excluding  all  these,  a  few  cases  remain  in  which  the  demonstration  of  the 
typhoid  bacillus  was  conclusive,  cases  in  which  death  occurred  early,  and  yet 
after  a  very  careful  search  no  intestinal  lesions  could  1)e  found.  There  were 
4  cases  in  this  series.  Undoubtedly  the  intestinal  lesions  may  be  so  slight  as 
not  to  be  recognizable  at  autopsy,  (d)  Mixed  infections.  It  is  well  to  dis- 
tinguish, as  Dreschfeld  pointed  out,  between  double  infections,  as  with  bacillus 
tuberculosis,  the  diphtheria  bacillus,  and  the  plasmodia  of  Laveran,  in  which 
two  different  diseases  are  present  and  can  be  distinguished,  and  the  true  mixed 
or  secondary  infections,  in  which  the  conditions  induced  by  one  organism 
favor  the  growth  of  other  pathogenic  forms;  thus  in  ordinary  typhoid  fever 
secondary  infection  with  the  colon  bacillus,  the  streptococcus,  staphylococcus, 
or  the  pneumococcus,  may  occur,      (e)   Paratyphoid  infections.      (Page  43.) 


8  SPECIFIC  IXFECTIOUS  DISEASES 

(/)  Local  infections.  The  typhoid  bacillus  may  cause  a  local  abscess,  cystitis, 
or  cholecystitis  without  evidence  of  a  general  infection,  {g)  Terminal 
typhoid  infections.  In  rare  instances  the  bacillus  causes  a  fatal  infection 
towards  the  end  of  other  diseases.  The  subjects  may,  of  course,  be  typhoid 
carriers.  In  two  cases  of  malignant  disease  at  the  Johns  Hopkins  Hospital 
the  bacilli  were  isolated  from  the  blood,  and  there  were  no  intestinal  lesions. 

Products  of  the  Growth  of  the  Bacilli. — According  to  Pfeiffer,  the  chief 
poison  belongs  to  the  intracellular  group  of  toxins.  Sidney  Martin  isolated 
a  poison  which  is  in  the  nature  of  a  secretion,  but  does  not  differ  from  that 
contained  within  the  bacterial  cell.  Injected  into  animals  it  causes  lowering 
of  temperature,  diarrhoea,  loss  of  weight,  and  degeneration  of  the  myocardium. 
Its  chemical  nature  is  not  known.  Similar,  but  weaker,  jDoisons  may  be  iso- 
lated from  cultures  of  Bacillus  coli  and  other  members  of  this  group.  Xo 
toxins  have  been  isolated  which  cause  changes  in  animals  at  all  comparable 
to  typhoid  fever  in  human  beings. 

Morbid  Anatomy. — Intestixes. — A  catarrhal  condition  exists  throughout 
the  small  and  large  bowel.  Specific  changes  occur  in  the  lymphoid  elements, 
chiefly  at  the  lower  end  of  the  ileum.  The  alterations  which  occur  are  most 
conveniently  described  in  four  stages: 

{a)  Hyperplasia,  which  involves  the  glands  of  Peyer  in  the  jejunum  and 
ileum,  and  to  a  variable  extent  those  in  the  large  intestine.  The  follicles 
are  swollen,  grayish-white,  and  the  patches  may  project  3  to  5  mm.,  or  may  be 
still  more  prominent.  The  solitary  glands,  which  range  in  size  from  a  pin's 
head  to  a  pea,  are  usually  deeply  imbedded  in  the  submucosa,  but  project  to  a 
variable  extent.  Occasionally  they  are  very  prominent,  and  may  be  almost 
pedunculated.  Microscopic  examination  shows  at  the  outset  a  condition  of 
hypersemia  of  the  follicles.  Later  there  is  a  great  increase  and  accumula- 
tion of  cells  of  the  lymph-tissue  which  may  even  infiltrate  the  adjacent  mucosa 
and  the  muscularis ;  and  the  blood-vessels  are  more  or  less  compressed,  which 
gives  the  whitish,  ansemic  appearance  to  the  follicles.  The  cells  have  all 
the  characters  of  ordinary  lymph-corpuscles,  but  some  are  larger,  epithelioid, 
and  contain  several  nuclei.  Occasionally  cells  containing  red  blood-corpuscles 
are  seen.  This  so-called  medullary  infiltration,  always  more  intense  toward 
the  lower  end  of  the  ileum,  reaches  its  height  from  the  eighth  to  the  tenth 
day  and  then  undergoes  one  of  two  changes,  resolution  or  necrosis.  Death 
very  rarely  takes  jolace  at  this  stage.  Eesolution  is  accomplished  by  a  fatty 
and  granular  change  in  the  cells,  which  are  destroyed  and  absorbed.  A  curious 
condition  of  the  patches  is  produced  at  this  stage,  in  which  they  have  a  reticu- 
lated appearance.  The  swollen  follicles  in  the  patch  undergo  resolution  and 
shrink  more  rapidly  than  the  surrounding  framework,  or  what  is  more  probable 
the  follicles  alone,  owing  to  the  intense  hyperplasia,  become  necrotic  and  dis- 
integrate, leaving  the  little  pits.  In  this  process  superficial  haemorrhages  may 
result,  and  small  ulcers  may  originate  by  the  fusion  of  these  superficial  losses 
of  substance. 

Except  histologically  there  is  nothing  distinctive  in  the  hyperplasia  of  the 
lymph-follicles ;  but  apart  from  typhoid  fever  we  rarely  see  in  adults  a  marked 
affection  of  these  glands  with  fever.  In  children,  however,  it  is  not  uncom- 
mon when  death  has  occurred  from  intestinal  affections,  and  it  is  also  met 
with  in  measles,  diphtheria,  and  scarlet  fever. 


TYPHOID  FEYEE  9 

(&)  Necrosis  and  Slougliiug. — When  the  hyperplasia  of  the  l}Tnph-follicles 
reaches  a  certain  grade,  resolution  is  no  longer  possible.  The  blood-vessels 
become  choked,  there  is  a  condition  of  anaemic  necrosis,  and  sloughs  form 
■which  must  be  separated  and  thrown  off.  The  necrosis  is  probably  due  in 
great  part  to  the  direct  action  of  the  bacilli.  According  to  Mallory,  there 
occurs  a  proliferation  of  endothelial  cells  due  to  the  action  of  a  toxin.  These 
cells  are  phagocytic  in  character,  and  the  swelling  of  the  intestinal  lymphoid 
tissue  is  due  almost  entirely  to  their  formation.  The  necrosis,  he  thinks, 
is  due  to  the  occlusion  of  the  veins  and  capillaries  by  fibrinous  thrombi,  which 
owe  their  origin  to  degeneration  of  phagocytic  cells  beneath  the  lining  endo- 
thelium of  the  vessels.  The  process  may  be  superficial,  affecting  only  th-e 
upper  part  of  the  mucous  coat,  or  it  may  extend  to  and  involve  the  submu- 
cosa.  The  "^slough"  may  sometimes  lie  upon  the  Peyer's  patch,  scarcely 
involving  more  than  the  epithelium  (]\Iarchand).  It  is  always  more  intense 
toward  the  ileo-cascal  valve,  and  in  very  severe  cases  the  greater  part  of  the 
mucosa  of  the  last  foot  of  the  ileum  may  be  converted  into  a  brownish-black 
eschar.  The  necrotic  area  in  the  solitary  glands  forms  a  yellowish  cap  which 
often  involves  only  the  most  prominent  point  of  a  follicle.  The  extent  of  the 
necrosis  is  very  variable.  It'  may  pass  deep  into  the  muscular  coat,  reaching  to 
or  even  perforating  the  peritoneum. 

(c)  Ulceration. — The  separation  of  the  necrotic  tissue — the  sloughing — 
is  gradually  effected  from  the  edges  inward,  and  results  in  the  formation  of 
an  ulcer,  the  size  and  extent  of  which  are  directly  proportionate  to  the 
amount  of  necrosis.  If  this  be  superficial,  the  entire  thickness  of  the  mucosa 
may  not  be  involved  and  the  loss  of  substance  may  be  small  and  shallow.  More 
commonly  the  slough  in  separating  exposes  the  snbmucosa  and  muscularis, 
particularly  the  latter,  which  forms  the  floor  of  a  majority  of  all  typhoid  ulcers. 
It  is  not  common  for  an  entire  Peyer's  patch  to  slough  away,  and  a  perfectly 
ovoid  ulcer  opposite  to  the  mesentery  is  rarely  seen.  Irregularly  oval  and 
rounded  forms  are  most  common.  A  large  patch  may  present  three  or  four 
ulcers  divided  by  septa  of  mucous  membrane.  The  terminal  6  or  8 
inches  of  the  mucous  membrane  of  the  ileum  may  form  a  large  ulcer,  in  which 
are  here  and  there  islands  of  mucosa.  The  edges  of  the  ulcer  are  usually 
swollen,  soft,  sometimes  congested,  and  often  undermined.  The  base  of  a 
typhoid  ulcer  is  smooth  and  clean,  being  usually  formed  of  the  submucosa  or 
of  the  muscularis. 

(d)  Healing. — This  begins  with  the  development  of  a  thin  granulation 
tissue  which  covers  the  base.  Occasionally  an  appearance  is  seen  as  if  an 
ulcer  had  healed  in  one  place  and  was  extending  in  another.  The  mucosa 
gradually  extends  from  the  edge,  and  a  new  growth  of  epithelium  is  formed. 
The  glandular  elements  are  reformed ;  the  healed  ulcer  is  somewhat  depressed 
and  is  usually  pigmented.  In  death  during  relapse  healing  ulcers  may  be 
seen  in  some  patches  with  fresh  ulcers  in  others. 

We  may  say,  indeed,  that  healing  begins  with  the  separation  of  the  sloughs, 
as,  when  resolution  is  impossible,  the  removal  of  the  necrosed  part  is  the  first 
step  in  the  process  of  repair.  In  fatal  cases,  we  seldom  meet  with  evidences 
of  cicatrization,  as  the  majority  of  deaths  occur  before  this  stage  is  reached. 
It  is  remarkable  that  no  matter  how  extensive  the  ulceration  has  been,  healing 
is  never  associated  with  stricture,  and  typhoid  fover  docs  not  appear  as  one  of 


10  SPECIFIC  INFECTIOUS  DISEASES 

the  causes  of  intestinal  obstruction.  Within  a  very  short  time  all  traces  of  the 
old  ulcers  disappear. 

Lauge  Intestine. — The  caecum  and  colon  are  affected  in  about  one-third 
of  the  cases.  Sometimes  the  solitary  glands  are  greatly  enlarged.  The  ulcers 
are  usually  larger  in  the  csecum  than  in  the  colon. 

Perfoeation  of  the  Bowel. — Incidence  at  Atdopsy. — J.  A.  Scott's  fig- 
ures, embracing  9,713  cases,  give  351  deaths  from  perforation  among  1,037 
deaths  from  all  causes,  a  percentage  of  33.8  of  the  deaths  and  3.6  of  the  cases. 
The  German  statistics  give  a  much  lower  proportion  of  deaths  from  perfora- 
tion; Munich  in  2,000  autopsies,  5.7  per  cent,  from  perforation;  Basle  in  2,000 
autopsies,  1.3  per  cent,  from  perforation;  Hamburg  in  3,686  autopsies,  1.2 
per  cent,  from  perforation  (Hector  Mackenzie,  Lancet,  1903).  At  the  Johns 
Hopkins  Hospital  among  1,500  cases  of  typhoid  fever  there  were  43  with  per- 
foration. Twenty  of  these  were  operated  upon,  with  7  recoveries.  One  died 
of  toxaemia  on  the  eighth  day  after  operation.  At  the  Pennsylvania  Hospital 
there  were  139  cases  of  perforation  among  5,891  cases.  Chomel  remarks  that 
"the  accident  is  sometimes  the  result  of  ulceration,  sometimes  of  a  true  eschar, 
and  sometimes  it  is  produced  by  the  distention  of  the  intestine,  causing  the 
rupture  of  tissues  weakened  by  disease."  x\s  a  rule,  sloughs  are  adherent 
about  the  site  of  perforation.  The  site  is  usually  in  the  ileum,  232  times  in 
Hector  Mackenzie's  collection  of  264  cases;  the  jejunum  twice,  the  large 
intestine  22  times,  and  the  appendix  9  times  in  his  series.  As  a  rule,  the 
perforation  occurs  within  twelve  inches  of  the  ileo-caecal  valve.  There  may 
be  two  or  three  separate  perforations.  J.  A.  Scott  described  two  distinct 
varieties :  first,  the  more  common  single,  circular,  pin-point  in  size,  due  to 
the  extension  of  a  necrotic  process  through  the  base  of  a  small  ulcer.  The 
second  variety,  produced  by  a  large  area  of  tissue  becoming  necrotic,  ranges 
in  size  from  the  finger-tip  to  3  cm.  in  diameter. 

Death  from  hcemorrliage  occurred  in  99  of  the  Munich  cases,  and  in  12 
of  137  deaths  in  our  1,500  cases.  The  bleeding  seems  to  result  directly  from 
the  separation  of  the  sloughs.  It  is  unusual  to  find  the  bleeding  vessel.  In 
one  case  only  a  single  patch  had  sloughed,  and  a  firm  clot  Avas  adherent  to  it. 
The  bleeding  may  come  from  the  soft  swollen  edges  of  the  patch. 

The  mesenteric  glands  show  hyperaemia  and  subsequently  become  greatly 
swollen.  Spots  of  necrosis  are  common.  In  several  of  our  cases  suppuration 
had  occurred,  and  in  one  a  large  abscess  of  the  mesentery  was  present.  The 
rupture  of  a  softened  or  suppurating  mesenteric  gland,  of  which  there  are  only 
a  few  cases  in  the  literature,  may  cause  either  fatal  haeniorrhage  or  peritonitis. 
Le  Conte  has  successfully  operated  upon  the  latter  condition.  The  bunch  of 
glands  in  the  mesentery,  at  the  lower  end  of  the  ileum,  is  especially  involved. 
The  retroperitoneal  glands  are  also  swollen. 

The  spleen  is  invariably  enlarged  in  the  early  stages  of  the  disease.     In 

11  of  our  series  it  exceeded  20  ounces  (600  grams)  in  weight,  in  one  900 
grams.  The  tissue  is  soft,  even  diffluent.  Infarction  is  not  infrequent.  Eup- 
ture  may  occur  spontaneously  or  as  a  result  of  injury.  In  the  Munich  autop- 
sies there  were  5  instances  of  rupture  of  the  spleen,  one  of  which  resulted 
from  a  gangrenous  abscess. 

The  bone-marroiv  shows  changes  very  similar  to  those  in  the  lymphoid 
tissues,  and  there  may  be  foci  of  necrosis  (Longcope). 


TYPHOID  FEVER  11 

The  liver  shows  signs  of  parenchymatous  degeneration.  Early  in  the 
disease  it  is  hypergemic,  and  in  a  majority  of  instances  it  is  swollen,  some- 
what pale,  on  section  turbid,  and  microscopically  the  cells  are  very  granular 
and  loaded  with  fat.  Nodular  areas  (microscopic)  occur  in  many  cases. 
Some  of  the  nodules  are  lymphoid,  others  are  necrotic.  In  12  of  the  Munich 
autopsies  liver  abscess  was  found,  and  in  3,  acute  yellow  atrophy.  In  3  of  this 
series  liver  abscess  occurred.  Pylephlebitis  may  follow  abscess  of  the  mesen- 
tery or  perforation  of  the  appendix.  Affections  of  the  gall-bladder  are  not 
uncommon,  and  are  described  under  the  clinical  features. 

Kidneys. — Cloudy  swelling,  with  granular  degeneration  of  the  cells  of 
the  convoluted  tubules,  less  commonly  an  acute  nephritis,  may  be  present. 
Eayer,  Wagner,  and  others  described  the  occurrence  of  numerous  small  areas 
infiltrated  with,  round  cells,  which  may  have  the  appearance  of  lymphomata, 
or  may  pass  on  to  softening  and  suppuration,  producing  the  so-called  miliary 
abscesses,  of  which  there  were  7  cases  in  this  series.  The  typhoid  bacilli  have 
been  found  in  these  areas.  The  kidneys  in  cases  of  typhoid  bacilluria  may 
show  no  changes  other  than  cloudy  swelling.  Diphtheritic  inflammation  of 
the  pelvis  of  the  kidney  may  occur.  It  was  present  in  3  of  our  cases,  in  one 
of  which  the  tips  of  the  papillae  were  also  affected.  Catarrh  of  the  bladder  is 
not  uncommon.  Diphtheritic  inflammation  of  this  viscus  may  also  occur. 
Orchitis  is  occasionally  met  with. 

Respiratoey  Organs. — Ulceration  of  the  larynx  occurs  in  a  certain  num- 
ber of  cases;  in  the  Munich  series  it  was  noted  107  times.  It  may  come  on 
at  the  same  time  as  the  ulceration  in  the  ileum.  It  occurs  in  the  posterior 
wall,  at  the  insertion  of  the  cords,  at  the  base  of  the  epiglottis,  and  on  the 
ary-epiglottidean  folds.  The  cartilages  are  very  apt  to  become  involved.  In 
the  later  periods  ulcers  may  be  present. 

'vEdema  of  the  glottis  was  present  in  20  of  the  Munich  cases,  in  8  of  which 
tracheotomy  was  performed.  Diphtheritis  of  the  pharynx  and  larynx  is  not 
very  uncommon.  It  occurred  in  a  most  extensive  form  in  2  of  our  cases. 
Lobar  pneumonia  may  be  found  early  (see  Pneumo-typhus),  or  it  may  be  a 
late  event.  Hypostatic  congestion  and  the  condition  of  the  lung  spoken  of  as 
splenization  occur.  Gangrene  of  the  lung  occurred  in  -10  cases  in  the  Munich 
series;  abscess  of  the  lung  in  l-i;  hemorrhagic  infarction  in  129.  Pleurisy 
is  not  a  common  event.  Fibrinous  pleurisy  occurred  in  about  G  per  cent,  of 
the  Munich  cases,  and  empyema  in  nearly  2  per  cent. 

Changes  in  the  Circulatory  System. — Heart  Lesions. — Endocarditis, 
while  not  common,  is  probably  more  frequent  than  is  generally  supposed.  It 
was  present  without  being  suspected  in  3  out  of  105  autopsies  in  this  series, 
while  in  3  other  cases  the  clinical  symptoms  suggested  its  presence.  Typhoid 
bacilli  have  been  found  in  the  vegetations.  Pericarditis  was  jDresent  in  11  cases 
of  the  Munich  autopsies.  Myocarditis  is  not  very  infrequent.  In  protracted 
cases  the  muscle-fibre  is  usually  soft,  flabby,  and  of  a  pale  yellowish-brown 
color.  The  softening  may  be  extreme,  though  rarely  of  the  grade  described  by 
Stokes  in  typhus  fever,  in  which,  when  held  apex  up  by  the  vessels,  the 
organ  collapsed  over  the  hand,  forming  a  mushroom-like  cap.  Microscopically, 
the  fibres  may  show  little  or  no  change,  even  when  the  impulse  of  the  heart 
has  been  extremely  feeble.     A  granular  parenchymatous  degeneration  is  com- 


12  SPECIFIC  IXFECTIOUS  DISEASES 

mon.  Fatt}^  degeneration  may  be  present,  particularly  in  long-standing  cases 
with  anaemia.     The  hyaline  change  is  not  common. 

Lesions  of  the  Blood-vessels. — Changes  in  the  arteries  are  not  infrequent. 
In  21  of  52  cases  in  our  series,  in  which  there  were  notes  on  the  state  of  the 
aorta,  fresh  endarteritis  was  present,  and  in  13  of  62  cases  in  which  the 
condition  of  the  coronary  arteries  was  noted  similar  changes  were  found 
(Thayer).  Arteritis  of  a  peripheral  vessel  with  thrombus  formation  is  not 
uncommon.  Bacilli  have  been  found  in  the  thrombi.  The  artery  may  be 
blocked  by  a  thrombus  of  cardiac  origin — ^an  embolus — but  in  the  great  major- 
ity of  instances  they  are  autochthonous  and  due  to  arteritis,  obliterating  or 
partial.  Thrombosis  in  the  veins  is  very  much  more  frequent  than  in  the 
arteries,  but  is  not  such  a  serious  event.  It  is  most  frequent  in  the  femoral, 
and  in  the  left  more  often  than  the  right. 

Nervous  System. — There  are  very  few  obvious  changes  met  with.  3Ien- 
ingitis  is  rare  and  occurred  in  only  11  of  the  2,000  Munich  cases.  The  exu- 
dation may  be  either  serous,  sero-fibrinous,  or  purulent,  and  typhoid  bacilli 
have  been  isolated.  Five  cases  of  serous  and  one  of  purulent  meningitis  oc- 
curred in  our  series  (Cole).  Optic  neuritis,  which  occurs  sometimes  in 
typhoid  fever,  has  not  been  described  in  connection  with  the  meningitis.  The 
anatomical  lesion  of  the  aphasia — seen  not  infrequently  in  children — is  not 
known,  possibly  it  is  an  encephalitis.  Parenchymatous  changes  have  been  met 
with  in  the  periphereal  nerves,  and  appear  to  be  not  very  uncommon,  even  when 
there  have  been  no  symptoms  of  neuritis. 

The  voluntary  muscles  show,  in  certain  instances,  the  changes  described 
by  Zenker,  which  occur  in  all  long-standing  febrile  affections,  and  are  not 
peculiar  to  typhoid  fever.  The  muscle  substance  undergoes  either  a  granular 
degeneration  or  a  hyaline  transformation.  The  abdominal  muscles,  the  ad- 
ductors of  the  thighs,  and  the  pectorals  are  most  commonly  involved.  Eupture 
of  a  rectus  abdominis  has  been  found  post  mortem.  Haemorrhage  may  occur. 
Abscesses  may  develop  in  the  muscles  during  convalescence. 

Symptoms. — In  a  disease  so  complex  as  typhoid  fever  it  will  be  well  first 
to  give  a  general  description,  and  then  to  study  more  fully  the  symptoms, 
complications,  and  sequelae  according  to  the  individual  organs. 

General  Description. — The  period  of  incubation  lasts  from  "eight  to 
fourteen  days,  sometimes  twenty-three"  (Clinical  Society),  during  which 
there  are  feelings  of  lassitude  and  inaptitude  for  work.  The  average  is  about 
ten  days.  The  onset  is  rarely  abrupt.  In  the  1,500  cases  chills  occurred  at 
onset  in  334,  headache  in  1,117,  anorexia  in  825,  diarrhoea  (without  purga- 
tion) in  516,  epistaxis  in  323,  abdominal  pain  in  443,  constipation  in  249, 
pain  in  right  iliac  fossa  in  10.  The  patient  at  last  takes  to  his  bed,  from  which 
event,  in  a  majority  of  cases,  the  definite  onset  may  be  dated.  During  the 
first  week  there  is,  in  some  cases  (but  by  no  means  in  all,  as  has  long  been 
taught),  a  steady  rise  in  the  fever,  the  evening  record  rising  a  degree  or  a 
degree  and  a  half  higher  each  day,  reaching  103°  or  104°.  The  pulse  is  not 
rapid  when  compared  with  the  temperature,  full  in  volume,  but  of  low  tension 
and  often  dicrotic;  the  tongue  is  coated  and  white;  the  abdomen  is  slightly 
distended  and  tender.  Unless  the  fever  is  high  there  is  no  delirium,  but 
the  patient  complains  of  headache,  and  there  may  be  mental  confusion  at 
night.     The  bowels  may  be  constipated  or  there  may  be  loose  movements. 


TYPHOID  FEVER  13 

Toward  the  eud  of  the  week  the  spleen  becomes  enlarged  and  the  rash  appears 
in  the  form  of  rose-colored  spots,  seen  first  on  the  skin  of  the  abdomen.  Cough 
and  bronchitic  symptoms  are  not  uncommon  at  the  outset. 

In  the  second  lueek,  in  cases  of  moderate  severity,  the  symptoms  become 
aggravated;  the  fever  remains  high  and  the  morning  remission  is  slight. 
The  pulse  is  rapid  and  loses  its  dicrotic  character.  There  is  no  longer  head- 
ache, but  there  are  mental  torpor  and  dullness.  The  face  looks  heavy;  the 
lips  are  dry;  the  tongue,  in  severe  cases,  becomes  dry  also.  The  abdominal 
symptoms,  if  present — diarrhcea,  tympanites,  and  tenderness — become  aggra- 
vated. Death  may  occur  during  this  week,  with  jDronounced  nervous  symp- 
toms, or,  toward  the  end  of  it,  from  hsemorrhage  or  perforation.  In  mild 
cases  the  temperature  declines,  and  by  the  fourteenth  day  may  be  normal. 

lu  the  third  week,  in  cases  of  moderate  severity,  the  pulse  ranges  from 
110  to  130;  the  temperature  shows  marked  morning  remissions,  and  there 
is  a  gradual  decline  in  the  fever.  The  loss  of  flesh  is  more  noticeable,  and 
the  weakness  pronounced.  Diarrhoea  and  meteorism  may  occur  for  the  first 
time.  Unfavorable  symptoms  at  this  stage  are  the  pulmonary  complications, 
increasing  feebleness  of  the  heart,  and  pronounced  delirium  with  muscular 
tremor.     Special  dangers  are  perforation  and  haemorrhage. 

With  the  fourth  iveclc,  in  a  majority  of  instances,  convalescence  begins. 
The  temperature  gradually  reaches  the  normal  point,  the  diarrhoea  stops,  the 
tongue  cleans,  and  the  desire  for  food  returns.  In  severe  cases  the  fourth 
and  even  the  fifth  week  may  present  an  aggravated  picture  of  the  third;  the 
])atient  grows  weaker,  the  pulse  is  more  rapid  and  feeble,  the  tongue  dry, 
and  the  abdomen  distended.  He  lies  in  a  condition  of  profound  stupor,  with 
low  muttering  delirium  and  subsultus  tendinum,  and  passes  the  faeces  and 
urine  involuntarily.  Failure  of  the  circulation  and  secondary  complications 
are  the  chief  dangers  of  this  period. 

In  the  fifth  and  sixth  weeks  protracted  cases  may  still  show  irregular 
fever,  and  convalescence  may  not  set  in  until  after  the  fortieth  day.  In  this 
]:ieriod  we  meet  with  relapses  in  the  milder  forms  or  slight  recrudescence  of 
the  fever.     At  this  time,  too,  occur  many  of  the  complications  and  sequelae. 

Special  Features  axd  Symptoms. — Mode  of  Onset. — As  a  rule,  the 
symptoms  come  on  insidiously,  and  the  patient  is  unable  to  fix  definitely  the 
time  at  which  he  began  to  feel  ill.  The  following  are  the  most  important 
deviations  from  this  common  course : 

{a)  Onset  with  Pronounced,  Sometimes  Sudden,  Nervous  Manifestations. 
— Headache,  of  a  severe  and  intractal)le  nature,  is  by  no  means  an  infrequent 
initial  symptom.  Again,  a  severe  facial  neuralgia  may  for  a  few  days  put 
the  practitioner  off  his  guard.  In  cases  in  which  the  patients  have  kept 
about  and,  as  they  say,  fought  the  disease,  the  very  first  manifestation  may  be 
pronounced  delirium.  Such  patients  may  even  leave  home  and  wander  about 
for  days.  In  rare  cases  the  disease  sets  in  with  the  most  intense  cerebro- 
spinal symptoms,  simulating  meningitis — severe  headache,  photophobia,  re- 
traction of  the  head,  twitching  of  the  muscles,  and  even  convulsions.  Occa- 
sionally drowsiness,  stupor,  and  signs  of  basilar  meningitis  may  exist  for  ten 
days  or  more  before  the  characteristic  symptoms  develop ;  the  onset  may  be 
with  mania  and  marked  mental  symptoms. 

[h)    With  rro/iounccd  ruimoiiari/  Siiinptoins. — The   initial  1)ronrlual   ca- 


14  SPECIFIC  II^FECTIOUS  DISEASES 

tarrh  may  be  of  great  severity  and  obscure  the  other  features  of  the  disease. 
More  striking  still  are  those  cases  in  which  the  disease  sets  in  with  a  single 
chill,  with  pain  in  the  side  and  all  the  characteristic  features  of  lobar  pneu- 
monia or  of  acute  pleuris}';  or  tuberculosis  is  suspected. 

(c)  With  Intense  Gast 7-0 -intestinal  Sympto7ns. — The  incessant  vomiting 
and  pain  may  lead  to  a  suspicion  of  poisoning,  or  the  patient  may  be  sent 
to  the  surgical  wards  for  appendicitis. 

(d)  With  symptoms  of  an  acute  nephritis,  smoky  or  bloody  urine,  with 
much  albumin  and  tube-casts. 

(e)  Ambulatory  Form. — Deserving  of  especial  mention  are  those  cases 
in  which  the  patient  keeps  about  and  attempts  to  work,  or  perhaps  takes  a 
long  journey  to  his  home.  He  niay  come  under  observation  for  the  first  time 
with  a  temperature  of  104°  or  105°,  and  the  rash  well  out.  Many  of  these 
cases  run  a  severe  course,  and  in  general  hospitals  contribute  largely  to  the 
mortality.  Finally,  there  are  rare  instances  in  which  typhoid  is  unsuspected 
until  perforation  or  a  profuse  hsemorrhage  from  the  bowels  occurs. 

Facial  Aspect. — Early  in  the  disease  the  cheeks  are  flushed  and  the 
eyes  bright.  Toward  the  end  of  the  first  week  the  expression  becomes  more 
listless,  and  when  the  disease  is  Avell  established  the  patient  has  a  dull  and 
heavy  look.  There  is  never  the  rapid  angemia  of  malarial  fever,  and  the  color 
of  the  lips  and  cheeks  may  be  retained  even  to  the  third  week. 

Fever. —  (a.)  Regular  Course.  (Chart  I.) — In  the  stage  of  invasion  the 
fever  rises  steadily  during  the  first  five  or  six  days.  The  evening  tempera- 
ture is  about  a  degree  or  a  degree  and  a  half  higher  than  the  morning  remis- 
sion, so  that  a  temperature  of  104°  or  105°  is  not  uncommon  by  the  end 
of  the  first  week.  Having  reached  the  fastigiiim  or  height,  the  fever  then 
persists  with  very  slight  daily  remissions.  The  fever  may  be  singularly  per- 
sistent and  but  little  influenced  by  bathing  or  other  measures.  At  the  end 
of  the  second  and  throughout  the  third  week  the  temperature  becomes  more 
distinctly  remittent.  The  difference  between  the  morning  or  evening  record 
may  be  3°  or  4°,  and  the  morning  temperature  may  even  be  normal.  It  falls 
by  lysis,  and  the  temperature  is  not  considered  normal  until  the  evening 
record  is  at  98.4°. 

(&)  Variations  from  the  typical  temperature  curve  are  common.  AA'e  do 
not  always  see  the  gradual  step-like  ascent  in  the  early  stage;  the  patients 
do  not  often  come  under  observation  at  this  time.  When  the  disease  sets  in 
with  a  chill,  or  in  children  with  a  convulsion,  the  temperature  may  rise  at  once 
to  103°  or  104°.  In  many  cases  defervescence  occurs  at  the  end  of  the  second 
week  and  the  temperature  may  fall  rapidly,  reaching  the  normal  within  twelve 
or  twenty  hours.  An  inverse  type  of  temperature,  high  in  the  morning  and 
low  in  the  evening,  is  occasionally  seen,  but  has  no  especial  significance. 

Sudden  falls  in  the  temperature  may  occur,  thus,  as  shown  in  Chart  II, 
a  drop  of  6.4°  may  follow  an  intestinal  haemorrhage,  and  the  fall  may  be 
apparent  before  the  blood  has  appeared  in  the  stools.  Sometimes  during 
the  anaemia  which  follows  a  severe  hgemorrhage  from  the  bowels  there  are 
remarkable  oscillations  in  the  temperature.  Hyperpyrexia  is  rare.  In  only 
58  of  1,500  cases  did  the  fever  rise  above  106°.  Before  death  the  fever  may 
rise;  the  highest  we  have  known  was  109.5°. 

(c)  Post-typhoid  Variations. —  (1)   Becrudescences. — x\fter  a  normal  tern- 


TYPHOID  FEYER 


15 


.    »       iH        icg       o 


«5     S;' 


C^ 


^ 


^1 


t/:i 


o^ 


EZSZZZEZZSEZZEEZZZZEZZEEi^ 

znzizzxEEZzzzn :.-=^ 

:^zzzx:xnzzzzxizzzzz:^ 

:n:knzhEE:\zEzzz:Zz 

EEZZEZZZEEEEZXZZZE-'-^ 
ZEXZEXuXeZXe  Z  ..  -== 

:l:;;Lb;tbl:iX.;:H: .<;: 

ZZZZZEZEZZ/(EZZZEZi:XEZZK.\ 

...I..L.*l<!0-----^--------'------^---^--- 

EEZXZSZZZZEZZZZZZEZZZZZ^ZZZMZZZ 

Si,i:.i:i:t:i:.i.:ti:l:i:ii.d 

_p?=*  i     i    i     i     i    i    i     i    i    i*^    :s;    • 
^^p.,..,..,...........^.,..,..,......              .....^ 

i     :     i     i     i     i     •     i     i     i     i     i     i"/-^     iS!     1 

■v'r"'i'''T'V'r'i'i"i"i"i%:^7§r'' 

:     i     i     i     i     i     i     i     i     i     i     i     i*/-     iSi     i 

'■rT-|-i-r'r'r"i"'r'VT"i"i^'"ign 
••r-r-i--ri-'i--i--T-T-T-i"i":^"Tg;-i 

- 

— 

5 

~ 

- 

g 

— 

— 

^ 

- 

— 

'^ 

— 

— 

o 

— 

- 

§ 



- 

§ 

— 

- 

1- 

- 

- 

o 

- 

- 

^ 

- 

- 

3 

XXXC.:iri'.I.J'^l^--r-X'H3Ci 

■  JX>»  i     i     i     i     i"i    i     :•%!     -Si     i 

- 

- 

g 

- 

- 

g 

- 

— 

S 

!!I'I!l'j^irrXCCQ"4'^~:!?Ei 
ZEXZ\XiZXyiXZZXXZXEX'ZZ^[ZMZ'\ 

ZZEZX^^^XXZ^ZbEXEZXZ?XZMZ 

.         ■..■........:. .,..;.......:...;...|...;...p.^^..||;...; 

r::c.^^p^r'ix:^;j:;.Mj^i:j 

r=i=-!»i"i"i":":";"i'"i'"i"T";^""iW:"i 

- 

- 

§ 

- 

- 

§ 

- 

- 

g? 

— 

- 

^ 

'-' 

- 

§? 

- 

— 

- 

- 

s 

- 

— 

s? 

- 

— 

?! 

- 

- 

« 

— 

— 

S 

- 

- 

OJ 

:   i  i   M   i   i   i   i   i   i   i   i^   iSi   i 
■"^tii^  i  i  i   i   i   i  i   i  i   i'^y  is;  i 

-xxQX''Ci!j'"r'.i!!'ci"i^"iiii; 

r  ;■'■;■  '■■'i"''i':':'-r-i--:4'':S!''i 

■i'T'i   iiT'i';VVV;";^""i3i"i 
si-*  ;■■;  ■V:"i'i'T"i"  i   i   :   i-%   isi   i 

,..;..^..^...,......,..,..^...,..;.......;..,^,...^_.^ 

-!     i     i     i     i     i     i     i     i     i     i     i     i''!^     [SSi     i 

■■•■•■:i1-i-i-r-;t:  ■■••■r-^-'sr'i 

■■■i:r"i  ^  i'ii   i   i'i  "i"'i^'isi'''i 
■'•"r''':i'^'-'i'r  ^'  ■■;''^'i§i"; 
■'i'i'i  Ti   i   ri'i'i'  rT''i^''iiT'"; 
'^i  :■;'■':■■■  ■i'ii;'ri'^''-si'''; 
■■■■■"r'TTi'rTMMM-rri^  ••:  =  ;••: 

■■■•■■r:'ri'r---v-'r-ri--i^"ri;"T 
.,^.. ...^.. ....... ^... ............... ^...p..^^..^^^.. 

■  i ■■rT"i"r"i'"v"i"i'  i"i  \"^  :si  • 

■■T'i'^'i^'T'T"''^   •■"^■■T'i^"isir"'i 

...;..^.    .........   ^..  ,..,....,...    ..p.    ,^,..;^,... 

......... ...^   i"V:";"r:":"VM'i^"isi'  • 

■■!::i'T':'":'i  ■■■'•'■■■■:  ■■■^■■■;gt"' 
■   :-vM-;    :••;■■■:•-::■;■■;  ■■;--;(^--:5r- 

.....^..,...  :..... p....  ;,..,. ^... ...... ^,...^:.... 

i"i'"i  '  "i    i  'i"i"i"i  ■i"i";^"i5i" 

ZZZEEEEXZZZZZZEXZmMZ 

-x-rxHm-Hxm-4- 

r-*Ti"i"i"i"i":";'i"i'i"i*)^"isi'' 

— 

— 

CO 

- 

- 

t- 

- 

- 

o 

- 

- 

in 

- 

- 

- 

— 

eo 

- 

- 

UJ 

— 

- 

;:! 

- 

- 

o 

- 

— 

OS 

— 

- 

30 

- 

- 

t- 

- 

- 

o 

~ 

— 

lO 

- 

- 

■* 

^ 

- 

'^S 

o,   dS 


.a  °§ 


2    .^  b 


16  SPECIFIC  INFECTIOUS  DISEASES 

perature  of  perhaps  five  or  sis  daya^  the  fever  may  rise  suddenly  to  102°  or 
103°,  without  constitutional  disturbance,  furring  of  the  tongue,  or  abdomi- 
nal symptoms.  After  persisting  for  from  two  to  four  days  the  temperature 
falls.  Of  1,500  cases,  92  presented  these  elevations,  notes  of  which  are  given 
in  the  Studies  on  Typhoid  Fever  (Johns  Hopkins  Hospital  Eeports).  Con- 
stipation, errors  in  diet,  or  excitement  may  cause  them.  These  attacks  are  a 
frequent  source  of  anxiety;  they  are  common,  and  it  is  not  always  possible 
to  say  upon  what  they  depend.  In  some  cases  typhoid  or  colon  bacilli  are 
found  in  the  blood.  As  a  rule,  if  the  rise  in  temperature  is  the  result  of  a  com- 
plication, such  as  thrombosis,  there  is  an  increase  in  the  leucocytes.  Natur- 
ally one  suspects  a  relapse,  but  there  is  an  absence  of  the  step-like  ascent,  and, 
as  a  rule,  the  fever  falls  after  a  few  days. 

(2)  The  Sub-febrile  Stage  of  Convalescence. — In  children,  in  very  ner- 
vous patients,  and  in  cases  of  angemia,  the  evening  temperature  may  keep 
up  for  weeks  after  the  tongue  has  cleaned  and  the  appetite  has  returned. 
This  may  usually  be  disregarded,  and  is  often  best  treated  by  allowing  the 
patient  to  get  up,  and  by  stopping  the  use  of  the  thermometer.  Of  course, 
it  is  important  not  to  overlook  any  latent  complications. 

(3)  Hypothermia. — Low  temperatures  in  typhoid  fever  are  common, 
following  baths,  or  spontaneously  in  the  third  and  fourth  week  in  the  periods 
of  marked  remissions,  and  following  heemorrhage.  An  interesting  form  is 
the  persistent  hypothermia  of  convalescence.  For  ten  days  or  more,  particu- 
larly in  the  protracted  cases  with  great  emaciation,  the  temperature  may  be 
96.5°  or  97°.     It  is  of  no  special  significance. 

{d)  The  Fever  of  the  Belapse. — This  is  a  repetition  in  many  instances 
of  the  original  fever,  a  gradual  ascent  and  maintenance  for  a  few  days  at  a  cer- 
tain height  and  then  a  decline.  It  is  usually  shorter  than  the  original  pyrexia, 
and  rarely  continues  more  than  two  or  three  weeks.      (Chart  I.) 

(e)  Afebrile  Typhoid. — The  occurrence  of  this  is  doubtful  and  the  cases 
so  termed  are  probably  mild  attacks  with  slight  fever  for  a  few  days. 

(/)  Chills  occur  (1)  sometimes  with  the  fever  of  onset;  (2)  occasionally 
at  intervals  througholit  the  course,  and  followed  by  sweats  (so-called  sudoral 
form)  ;  (3)  with  the  advent  of  complications,  pleurisy,  pneumonia,  otitis 
media,  phlebitis,  etc.;  (4)  with  active  antipyretic  treatment  by  the  coal-tar 
remedies;  (5)  occasionally  during  the  period  of  defervescence  without  rela- 
tion to  any  complication,  sometimes  due  to  a  septic  infection;  (6)  after  the 
injection  of  vaccines  or  serum;  (7)  according  to  Herringham,  chills  may 
result  from  constipation.  There  are  cases  in  which  throughout  the  latter 
half  of  the  disease  chills  recur  with  great  severity.  (See  Chills  in  Typhoid 
Fever,  Studies  II.) 

Skin". — The  characteristic  rash  consists  of  hyperasmic  spots,  which  appear 
from  the  seventh  to  the  tenth  day,  usually  at  first  upon  the  abdomen.  They 
are  slightly  raised,  flattened  papules,  w^hich  can  be  felt  distinctly,  of  a  rose- 
red  color,  disappearing  on  pressure,  and  ranging  in  diameter  from  2  to  4  mm. 
They  were  present  in  93.2  per  cent.-  of  the  white  patients  and  20.6  per  cent, 
of  the  colored.  They  come  out  in  successive  crops,  and  after  persisting  for 
two  or  three  days  they  disappear,  occasionally  leaving  a  brownish  stain.  The 
spots  may  be  present  upon  the  back,  and  not  upon  the  abdomen.  The  erup- 
tion may  be  very  abundant  over  tlie  whole  skin  of  the  trunk,  and  on  the 


TYPHOID  FEVER  17 

extremities.  There  were  81  in  which  they  occurred  on  the  arms,  17  on  the 
forearms,  13  on  the  thighs,  legs  15,  face  5,  hands  3.  The  cases  with  very 
abmidant  eruption  are  not  necessarily  more  severe.  Typhoid  bacilli  have 
been  found  in  the  spots.  Of  variations  in  the  rash,  frequently  the  spots  are 
capped  by  small  vesicles.  A  profuse  miliary  or  sudaminal  rash  is  not  un- 
common. In  38  cases  in  our  series  there  were  purpuric  spots.  Three  of 
the  cases  were  true  ha^morrhagic  typhoid  fever.  The  rash  may  not  appear 
until  the  relapse.  In  21  cases  in  our  series  the  rose  spots  came  out  after 
the  patient  was  afebrile. 

A  branny  desquamation  is  not  rare  in  children,  and  common  in  adults 
after  hydrotherapy.  Occasionally  the  skin  peels  off  in  large  Hakes.  A  yellow 
color  of  the  palms  of  the  hands  and  soles  of  the  feet  is  not  imcommon. 

Among  other  skin  lesions  the  following  may  be  mentioned: 

Erythema. — It  is  not  very  uncommon  in  the  first  week  of  the  disease  to 
find  a  diffuse  erythematous  blush — E.  typhosum.  Sometimes  the  skin  may 
have  a  peculiar  mottled  pink  and  white  appearance.  E.  exudativum,  E.  nodo- 
sum, and  urticaria  may  be  present. 

Herpes. — Herpes  is  rare  in  typhoid  fever  in  comparison  with  its  great 
frequency  in  malarial  fever  and  in  pneumonia.  It  was  noted  in  20  of  our 
1,500  cases,  usually  on  the  lips. 

Tlie  Tdches  hJeudtres — Peliomata — Maculce  cerulece. — These  are  pale-blue 
or  steel-gray  spots,  subcuticular,  from  1  to  10  mm.  in  diameter,  and  of  irregu- 
lar outline.     They  are  due  to  lice  (see  Pediculosis). 

Skin  Gangrene. — Areas  of  superficial  gangrene  may  follow  the  prolonged 
use  of  an  ice-bag.  In  children  noma  may  occur;  as  reported  by  McFarland 
in  the  Philadelphia  epidemic  of  1898,  there  were  many  cases  with  multiple 
areas  of  gangrene  of  the  skin.     The  nose,  ears,  and  genitals  may  be  attacked. 

Sweats. — At  -the  height  of  the  fever  the  skin  is  usually  dry.  Profuse 
sweating  is  rare,  but  it  is  not  very  uncommon  to  see  the  abdomen  or  chest 
moist  with  perspiration,  particularly,  in  the  reaction  which  follows  the  bath. 
Sweats  in  some  instances  constitute  a  striking  feature  and  may  be  associated 
with  chilly  sensations  or  actual  chills.  In  this  sudoral  form  of  typhoid  fever 
there  may  be  recurring  paroxysms  of  chill,  fever,  and  sweats'  (even  several  in 
twenty-four  hours),  and  the  ease  may. be  mistaken  for  one  of  malarial  fever. 
Profuse  sweats  may  occur  with  hasmorrhage  or  perforation. 

CEdema  of  the  skin  occurs:  (1)  As  the  result  of  vascular  obstruction, 
most  commonly  of  a  vein,  as  in  femoral  thrombosis.  (2)  In  connection  with 
nephritis,  very  rarely.  (3)  In  association  with  the  anemia  and  cachexia. 
The  hair  falls  out  after  the  attack,  but  complete  baldness  is  rare.  •  The  nutri- 
tion of  the  nails  suffers,  and  during  and  after  convalescence  transverse  ridges 
may  occur.  A  peculiar  odor  is  exhaled  from  the  skin  in  some  cases.  Whether 
due  to  a  cutaneous  exhalation  or  not,  there  is  a  very  distinctive  smell  con- 
nected M'ith  many  patients.  jSTathan  Smith  described  it  as  of  a  "semi-cadaver- 
ous, musty  character." 

Linece  atrophica^. — Lines  of  atrophy  may  appear  on  the  skin  of  the  abdo- 
men, lateral  aspects  of  the  thighs  and  about  the  knees,  similar  to  those  seen 
after  pregnancy.  They  have  been  attributed  to  neuritis,  and  Duckworth  has 
reported  a  case  in  which  the  skin  adjacent  to  them  was  hyperaesthetic. 

Bed-sores  are  not  uncomnKju    in   protractcil   ca^cs.  with  groat  emaciation. 


18  SPECIFIC  INFECTIOUS  DISEASES 

In  some  eases  the  necrosis  begins  in  the  deeper  structures  but,  as  a  rule,  they 
result  from  pressure  and  are  seen  upon  the  sacrum,  more  rarely  the  ilia,  the 
shoulders,  and  the  heels.  These  are  less  common  since  the  introduction,  of 
hydrotherapy  and  scrupulous  care  does  much  for  their  prevention,  but  in 
cases  with  profound  involvement  of  the  nerve  centres  acute  bed-sores  of  the 
back  and  heels  may  occur  with  very  slight  pressure,  and  with  astonishing 
rapidity. 

Boils  and  superficial  abscesses  constitute  a  common  and  troublesome  sequel. 

Circulatory  System. — The  Mood  presents  important  changes.  The  fol- 
lowing statements  are  based -on  studies  made  by  W.  S.  Thayer  (Studies  I  and 
III)  :  During  the  first  two  weeks  there  may  be  little  or  no  change  in  the 
blood.  Profuse  sweats  or  copious  diarrhoea  may  cause  the  corpuscles — as  in 
the  collapse  stage  of  cholera — to  rise  above  normal.  In  the  third  week  a  fall 
usually  takes  place  in  corpuscles  and  hggmoglobin,  and  the  number  may  sink 
rapidly  even  to  1,300,000  per  c.  mm.,  gradually  rising  to  normal  during  con- 
valescence. When  the  patient  first  gets  up,  there  may  be  a  slight  fall  in  the 
corpuscles.     The  average  maximum  loss  is  about  1,000,000  to  the  c.  mm. 

The  amount  of  hemoglobin  is  always  reduced,  and  usually  in  a  greater 
relative  proportion  than  the  red  corpuscles,  and  during  recovery  the  normal 
color  standard  is  reached  at  a  later  period.  Leucopenia  is  present  throughout 
the  course.  Cold  baths  increase  temporarily  the  number  of  leucocytes  in  the 
peripheral  circulation.  The  absence  of  leucocytosis  is  of  value  in  distin- 
guishing typhoid  fever  from  various  septic  fevers  and  acute  inflammatory 
processes.  The  large  mononuclears  are  relatively  increased.  When  an  acute 
inflammatory  process  occurs  in  typhoid  fever  the  leucocytes  show  an  increase 
in  the  polynuclear  forms,  and  this  may  be  of  great  diagnostic  moment. 

The  post-typhoid  ansemia  may  reach  an  extreme  grade.  In  one  of  our 
patients  the  blood-corpuscles  sank  to  1,300,000  per  c.  mm.  and  the  haemoglobin 
to  about  20  per  cent,  but  these  severe  grades  of  anaemia  are  not  common. 
In  the  Munich  statistics  there  were  54  cases  with  general  and  extreme  anaemia. 
Of  changes  in  the  blood  plasma  very  little  is  known. 

The  pulse  presents  no  special  characters.  It  is  increased  in  rapidity,  but 
not  always  in  proportion  to  the  fever,  and  this  may  be  a  special  feature  in 
the  early  stages.  There  is  no  acute  disease  with  which,  in  the  early  stage,  a 
dicrotic  pulse  is  so  frequently  associated.  Even  with  high  fever  the  pulse 
may  not  be  greatly  accelerated.  iVs  the  disease  progresses  the  pulse  becomes 
more  rapid,  feebler,  and  small.  In  15  per  cent,  of  our  cases  the  pulse  rate 
rose  above  140.  In  the  extreme  prostration  of  severe  cases  it  may  reach  150 
or  more,  and  is  a  mere  undulation — the  so-called  running  pulse.  The  lowered 
arterial  pressure  is  manifest  in  the  dusky  lividity  of  the  skin  and  coldness  of 
the  hands  and  feet. 

During  convalescence  the  pulse  gradually  returns  to  normal,  and  occasion- 
ally becomes  very  slow.  After  no  other  acute  fever  do  we  so  frequently  meet 
with  bradycardia.  The  pulse  may  be  as  low  as  30,  and  instances  are  on 
record  of  still  fewer  beats  to  the  minute.  Some  of  these  are  probably  due  to 
temporary  heart-block.  Tachycardia,  while  less  common,  may  be  a  very 
troublesome  and  persistent  feature  of  convalescence. 

Blood  Pressure. — There  is  a  gradual  fall  during  the  course  to  about  100- 
110  mm.  Hg  at  the  beginning  of  apyrexia,     In  two  or  three  weeks  later  the 


TYPHOID  FEVER  19 

pressure  has  usually  returned  to  normal.  Hfemorrhage  usually  produces  a 
marked  fall  both  in  the  systolic  and  diastolic  pressure.  In  some  cases  of 
perforation  there  may  be  a  sharp  rise  in  systolic  pressure.  Tubs  and  ice 
sponges  usually  cause  a  rise  of  10-20  mm.  Hg. 

The  heart-sounds  may  be  normal  throughout.  In  severe  cases,  the  first 
sound  becomes  fee'ble  and  there  is  often  heard,  at  the  apex  and  along  the  left 
sternal  margin,  a  soft  systolic  murmur,  which  was  present  in  22  per  cent, 
of  our  cases.  Absence  of  the  first  sound  is  rare.  Gallop  rhythm  is  not  un- 
common. In  the  extreme  feebleness  of  the  graver  forms,  the  first  and  second 
sounds  become  similar,  and  the  long  pause  is  shortened   (embryocardia). 

Pericarditis  is  rare  and  has  been  met  with  chiefly  in  children  and  in  asso- 
ciation with  pneumonia.  It  was  present  in  3  of  our  series  and  occurred  in 
only  14  of  the  2,000  Munich  post  mortems.  Endocarditis  was  found  post 
mortem  in  3  cases,  and  the  physical  signs  suggested  its  presence  in  3  other 
cases  in  the  series.  Myocarditis  is  more  common,  and  is  indicated  by  a  pro- 
gressive weakening  of  the  heart-sounds  and  enfeeblement  of  the  action  of  the 
organ. 

Complications  in  the  Arteries. — Arteritis  with  thrombus  formation  oc- 
curred in  four  cases  in  the  series,  one  in  the  branches  of  the  middle  cerebral, 
two  in  the  femoral,  and  one  in  the  brachial.  In  one  case  gangrene  of  the  leg 
followed.  In  a  similar  case  seen  with  Eoddick,  in  Montreal,  obliteration  of 
the  left  femoral  artery  occurred  on  the  sixteenth  day,  and  of  the  vessel  on 
the  right  side  on  the  twentieth  day,  with  gangrene  of  both  feet.  Pain,  tender- 
ness and  swelling  occur  over  the  artery,  with  diminution  or  disappearance  of  the 
pulsations  and  coldness  and  blueness  of  the  extremity.  In  two  of  the  cases 
these  symptoms  gradually  disappeared,  and  the  pulsation  returned  not  only 
in  the  peripheral,  but  in  the  affected  vessels  (Thayer).  Keen  refers  to  46 
cases  of  arterial  gangrene,  of  which  8  were  bilateral,  19  on  the  right  side,  and 
19  on  the  left. 

Thromlji  in  the  Veins. — In  our  series  there  were  43  instances,  distributed 
in  the  following  veins :  femoral  23,  popliteal  5,  iliac  5,  veins  of  the  calf  5, 
internal  saphenous  3,  pulmonary  artery  and  common  iliac  1,  axillary  vein  1 
(Thayer).  In  one  case  it  occurred  in  the  right  circumflex  iliac  vein.  Fem- 
oral thrombosis  is  the  most  common,  and  almost  invariably  in  the  left 
vessel,  due  probably  to  the  fact  that  the  left  iliac  vein  is  crossed 
by  the  right  iliac  artery,  and  the  blood  flow  is  not  so  free.  The 
symptoms  are  very  definite — the  fever  may  increase  or  recur.  Chills 
occurred  in  11  of  the  cases.  Pain  and  swelling  at  the  site  are  constantly 
present,  and  the  thrombotic  mass  can  be  felt,  not  always  at  first,  nor  is  it  well 
to  feel  for  it.  Swelling  of  the  leg  follows  as  a  rule,  but  it  is  rarely  so  extreme, 
and  not  so  painful  as  in  the  puerperal  cases.  In  iliac  thrombosis  the  pain 
may  be  severe  and  lead  to  the  suspicion  of  perforation,  as  in  one  of  our  cases. 
Leucocytosis  is  usually  present;  in  12  cases  it  rose  above  10,000.  Five  of  the 
43  patients  died,  2  only  as  a  result  of  the  thrombus;  in  the  case  of  axillary 
thrombosis  from  pulmonary  embolism,  in  one  from  embolism  of  the  inferior 
cava  and  right  auricle  from  the  dislocation  of  a  piece,  of  thrombus  from  the 
left  iliac  vein.  Thayer  examined  16  of  the  patients  at  varying  periods  after 
convalescence,  and  found  in  every  case  more  or  less  disability  from  the  varices 
and  persistent  swelling.     In  gome  cases,  however,  the   recovery   is   complete. 


20  SPECIFIC  INFECTIOUS  DISEASES 

Conner  has  emphasized  the  frequency  of  thrombosis  in  the  small  veins  of  the 
legs  and  feet  and  suggests  that  pulmonary  embolism  of  slight  extent  is  a 
common  result. 

Digestive  System. — Loss  of  appetite  is  early,  and,  as  a  rule,  the  relish 
for  food  is  not  regained  until  convalescence.  The  tongue  presents  the  changes 
inevitable  in  a  prolonged  fever.  Early  in  the  disease  it  is  moist,  swollen,  and 
coated  with  a  thin  white  fur,  which,  as  the  fever  progresses,  becomes  denser. 
It  may  remain  moist  throughout.  In  severe  cases,  particularly  those  with 
delirium,  the  tongue  becomes  very  dry,  partly  owing  to  the  fact  that  such 
patients  breathe  with  the  mouth  open.  It  may  be  covered  with  a  brown  or 
brownish-black  fur,  or  with  crusts  between  which  are  cracks  and  fissures. 
In  these  cases  the  teeth  and  lips  may  be  covered  with  a  dark  brownish  matter 
called  sordes — a  mixture  of  food,  epithelial  debris,  and  micro-organisms.  By 
keeping  the  mouth  and  tongue  clean  from  the  outset,  the  fissures  may  be 
prevented.  Acute  glossitis  occurred  in  one  case  at  the  onset  of  the  relapse. 
During  convalescence  the  tongue  gradually  becomes  clean,  and  the  fur  is 
thrown  off,  almost  imperceptibly  or  occasionally  in  flakes. 

The  secretion  of  saliva  is  often  diminished;  salivation  is  rare. 

Parotitis  was  present  in  45  of  the  2,000  Munich  cases.  It  occurred  in  14 
cases  in  our  series;  of  these,  5  died.  It  is  most  frequent  in  the  third  week 
in  very  severe  cases.  Extensive  sloughing  may  follow  in  the  tissues  of  the  neck. 
Usually  unilateral,  and  in  a  majority  of  cases  going  on  to  suppuration,  it  is 
regarded  as  a  very  fatal  complication,  but  recovery  followed  in  nine  of  our 
cases.  It  may  arise  from  extension  of  inflammation  along  Steno's  duct. 
This  is  probably  not  so  serious  a  form  as  when  it  arises  from  metastatic  in- 
flammation. In  four  cases  the  submaxillary  glands  were  involved  alone,  in 
one  a  cellulitis  of  the  neck  extended  from  the  gland  and  proved  fatal.  Paro- 
titis may  occur  after  the  fever  has  subsided.  A  remarkable  localized  sweating 
in  the  parotid  region  is  an  occasional  sequel. 

The  pharynx  may  be  the  seat  of  catarrh  or  ulceration.  Sometimes  the 
fauces  are  deeply  congested.  Membranous  pharyngitis,  a  serious  and  fatal 
complication,  may  come  on  in  the  third  week.  Difficulty  in  swallowing  may 
result  from  ulcers  of  the  oesophagus,  and  in  one  of  our  cases  stricture  followed. 
The  thyroid  gland  is  often  enlarged  in  the  acute  stages.  Thyroiditis  may 
occur  with  abscess  formation  years  after  the  attack  of  typhoid  fever.  Typhoid 
bacilli  have  been  found  in  the  pus. 

The  gastric  symptoms  are  extremely  variable.  Nausea  and  vomiting  are 
not  common.  There  are  instances,  however,  in  which  vomiting,  resisting  all 
measures,  is  a  marked  feature  from  the  outset,  and  may  directly  cause  death 
from  exhaustion.  Vomiting  does  not  often  occur  in  the  second  and  third 
weeks,  unless  associated  with  some  serious  complication.  Ulcers  have  been 
found  in  the  stomach.     Hamatemesis  occurred  in  4  of  our  cases. 

Intestinal  Symptoms. — Diarrhoea  is  a  very  variable  symptom,  occurring 
in  from  20  to  30  per  cent,  of  the  cases.  Of  1,500  cases,  516  had  diarrhoea 
Ijefore  entering,  260  during  their  stay  in  hospital.  It  frequently  follows  the 
giving  of  purgatives  and  the  small  percentage  in  the  hospital  may  be  due  to 
the  fact  that  we  used  no  purges  or  intestinal  antiseptics.  Its  absence  must 
not  be  taken  as  an  indication  that  the  intestinal  lesions,  are  of  slight  extent. 
The  most  extensive  infiltration  and  ulceration  of  the  small  intestine  may  be 


TYPHOID  FEVER 


21 


seen  with  the  colon  fUled  with  solid  fseces.  The  diarrhnoa  is  caused  less  hv 
the  ulcers  than  by  the  associated  catarrh,  and,  as  in  tuberculosis,  it  is  probable 
that  when  this  is  in  the  large  intestine  the  discharges  are  more  frequent.  It 
is  most  common  toward  the  end  of  the  first  and  throughout  the  second  week, 
but  it  may  not  occur  until  the  third  or  even  the:  fourth  week.     The  number  of 


2o 


5 

- 

- 

|.J.aL|si...i.... 

•»:..j.sl..I..;... 
LjMLXsLI.. 

l..iS.-...iSL-..;... 

\U..iML.i.l-. 
L.M..;.!:...;... 

■^     "^     *        *■        '       ^  0  JO  H  vi 
i  O      en                            ins  H 

s^  "^  ■    ■      /'V^"^ 

-D  C                                        <7  30    iM 
•      :^-<     -0     ♦        •        -^     •lAY-AX:        •         •        •         • 

•  -■     -S  •     •     •  \-  /ip-m:     '     •     •     • 

O                                >6I>M 

•  *       c5                     *jAM 

^>^i  e  al 

'          *          *          *          ■     _..^  7  P*  M      * 

SijJ   T"^""!,--*'''''^  '           lA-M    stool  without  hiood 

X^-'Sa^M      .          ,          ^1  15  A  M    ^threehemoiThapcsat 
jPll-^?C                                       mtenalsof  Ijmmutes 

*;*iS5pil 2  So  P  ir    stooUontainW  lil^ 

^Sw4.stfpai 

■    ^»14&30"'P4i 1    '         *         •         ■ 

/ysopM 
•."^ISii 

•  '      "     XV^i 

/IPM 

VPM.    \ 

X*      'Vofpir 

•  '     •      •      •     ^^^si 

>8  A  M 

»rrA.ir 

pKP.sr 

/tpm 
<V2-ii 

'          '         '         *         '         47  JOl  M 

\     "   fl'-SUI'M       'Daik'tatry'stool'' 
>•  0  45  P  M            Clay  i,oloreil  stool 

- 

- 

s 

- 

— 

- 

- 

- 

- 

- 

- 

r^ 

- 

^ 

- 

- 

:..;.^...ii;...-... 
l?.'...:xxJ.J.... 

f   i°:    iS:    ; 
\..}M:..:MLL. 

i.sL..isL.|...i... 

- 

- 

- 

CO 

S 

- 

- 

- 

- 

i..jsi..ig.:..i... 
ls!..i2i..i..;.... 

i..;2:.JSlJ... 

r  jgj  jgrjX 

:"Yg""!s:  ":"" 

:    ;g:    :8i    i 
:8i    igl    i    1 

um:mj:.: 

Y'TirtsTT' 
raf"i?i"":"r'" 
;  ;i:  ;"s:  i 

;:XH^|i?^jX 
liXXIXII 

:E";II.''XX! 

- 

- 

- 

- 

— 

- 

- 

- 

5 

- 

- 

— 

-• 

- 

- 

8 

- 

- 

— 

- 

*o 

- 

- 

- 

- 

IS 

- 

CO 

- 

- 

L.i.?J.„;l.;...L. 

;";8i"Tg'": "" 
igV'vsi-y:- 

I  "tKl^'fJii  ■■■■■■■ 
isVigfV":  ■' 
r  isi  ;ii  :  •■ 

- 

— 

- 

- 

i^AM 

M 

- 

i:f 

8     S     S 

" 

►0 
c 

3          0          000000000000 

-doSoSSoCToSoSoSgg 

V 

Chart  II. — Hemorrhage  from  the  Bowels.     Rapid  Fall  op  Temperature. 

discharges  ranges  from  3  to  8  or  10  in  the  twenty-four  hours.  They  are 
usually  abundant,  thin,  grayish-yellow,  granular,  of  the  consistency  and  ap- 
pearance of  pea-soup,  and  resemble,  as  Addison  remarked,  the  normal  con- 
tents of  the  small  bowel.  Blood  may  be  in  small  amount  and  only  recognized 
by  the  microscope.  Sloughs  of  the  Peyer's  glands  occur  as  grayish-yellow 
fragments  or  occasionally  as  ovoid  masses,  an  inch  or  more  in  length,  in  which 


23  SPECIFIC  INFECTIOUS  DISEASES 

portions  of  bowel  tissue  may  be  found.  The  bacilli  are  not  found  in  the 
stools  until  the  end  of  the  first  or  the  middle  of  the  second  week.  Constipa- 
tion was  present  in  51  per  cent,  of  this  series. 

Hamorrliage  from  the  boAvels  is  a  serious  complication,  occurring  in  about 
7  per  cent,  of  all  cases.  It  had  occurred  in  99  of  the  2,000  fatal  Munich 
cases.  In  1,500  cases  of  our  series  haemorrhage  occurred  in  118,  and  in  13 
death  followed  the  hgemorrhage.  It  occurred  in  1,641  (7  per  cent.)  of 
23,721  collected  cases.  There  may  be  only  a  slight  trace  of  blood  in  the  stools, 
but  often  it  is  a  profuse,  free  hsemorrhage.  It  occurs  most  commonly  be- 
tween the  end  of  the  second  and  the  beginning  of  the  fourth  week,  the  time  of 
the  separation  of  the  sloughs.  Occasionally,  early  in  the  course,  it  results 
simply  from  the  intense  hypersemia.  It  usually  comes  on  without  warning. 
A  sensation  of  sinking  or  collajjse  is  experienced  by  the  patient,  the  tempera- 
ture falls,  and  may,  as  in  the  annexed  chart,  drop  6°  or  7°  in  a  few  hours. 
Fatal  collapse  may  supervene  before  the  blood  appears  in  the  stool.  Haemor- 
rhage usually  occurs  in  cases  of  considerable  severity,  but  Graves  and  Trous- 
seau held  that  it  was  not  a  very  dangerous  symptom. 

It  must  not  be  forgotten  that  melsena  may  also  be  part  of  a  general  hsem- 
orrhagic  tendency  (to  be  referred  to  later),  in  which  cases  it  is  associated  with 
petechia  and  hematuria.  There  may  be  a  special  family  predisposition  to 
intestinal  hsemorrhages  in  typhoid  fever. 

Meteorism,  a  frequent  symptom,  is  not  serious  if  of  moderate  grade,  but 
when  excessive  is  usually  of  ill  omen.  Owing  to  defective  tone  in  the  walls, 
in  severe  cases  to  their  infiltration  with  serum,  gas  accumulates  in  the  stom- 
ach, small  and  large  bowel,  particularly  in  the  last.  Pushing  up  the  dia- 
phragm, it  interferes  very  much  with  the  action  of  the  heart  and  lungs,  and 
may  also  favor  perforation.  Gurgling  in  the  right  iliac  fossa  exists  in  a  large 
pro^Dortion  of  the  cases,  and  indicates  simply  the  presence  of  gas  and  fluid 
faeces  in  the  colon  and  caecum. 

Ahdommal  pain  and  tenderness  were  present  in  three-fifths  of  a  series  of 
500  cases  studied  with  special  reference  to  the  point  (McCrae).  In  some  it 
was  only  present  at  the  onset.  Pain  occurred  during  the  course  in  about 
one-third  of  the  cases.  This  is  due  in.  some  instances  to  conditions 
apart  from  the  bowel  lesions,  such  as  pleurisy,  distention  of  the  bladder,  and 
phlebitis.  It  may  be  associated  with  diarrhoea,  severe  constipation,  peri- 
splenitis, or  acute  abdominal  complications.  Pain  occurs  with  some  cases  of 
hgemorrhage,  but  is  most  constantly  present  with  perforation.  In  a  large 
group  no  cause  could  be  found  for  the  pain,  and  if  other  symptoms  be  asso- 
ciated the  condition  may  lead  to  error  in  diagnosis.  Operation  for  appendi- 
citis has  been  performed  in  the  early  stage  of  typhoid  fever,  owing  to  the 
combination  of  pain  in  the  right  iliac  fossa,  fever  and  constipation. 

Perforation. — From  one-fourth  to  one-third  of  the  deaths  are  due  to 
perforation.  Among  34,916  collected  cases  perforation  occurred  in  3.1  per 
cent.  While  it  may  occur  as  early  as  the  first  week,  in  the  great  majority  it 
is  at  the  height  of  the  disease  in  the  third  week,  and  much  more  frequently  in 
the  severe  cases,  particularly  those  associated  with  tympanites,  diarrhoea,  and 
haemorrhage.  It  may  occur,  however,  in  very  mild  attacks  and  with  great 
suddenness,  when  the  patient  is  apparently  progressing  favorably. 

Symptoms  of  Perforation. — By  far  the  most  important  single  indication  is 


TYPHOID  FEVER  23 

a  sudden,  sharp  pain  of  increasing  severity,  often  paroxysmal  in  character.  It 
is  rarely  absent,  except  in  the  small  group  of  cases  with  profound  toxsemia. 
The  situation  is  most  frequent  in  the  hypogastric  region  and  to  the  right  of 
the  middle  line.  Tenderness  on  pressure  is  present  in  the  great  majority  of 
cases,  usually  in  the  hypogastric  and  right  iliac  regions,  sometimes  diffuse; 
it  may  only  be  brought  out  on  deep  pressure.  As  LeConte  points  out,  Avhen 
the  perforation  happens  to  be  in  contact  with  the  parietal  peritoneum  the 
local  features  on  palpation  are  much  more  marked  than  when  the  perforated 
ulcer  is  next  to  a  coil  or  to  the  mesentery.  There  may  be  early  irritability 
of  the  bladder,  with  frequent  micturition,  and  pain  extending  toward  the 
penis.  A  third  important  sign  is  muscle  rigidity,  increased  tension,  and 
spasm  on  any  attempt  to  palpate.  The  temperature  may  rise  for  a  few  hours 
to  fall  later  or  may  drop  at  once.  The  pulse  and  respiration  rate  are  usually 
increased.  Following  these  features  in  a  few  hours  there  is  usually  a  reaction, 
and  then  the  features  of  general  peritonitis  become  manifest  to  a  more  or  less 
marked  degree.  Among  the  general  features,  the  facies  of  the  patient  shows 
changes;  there  is  increased  pallor,  a  pinched  expression,  and  as  the  symptoms 
progress  and  toward  the  end  a  marked  Hippocratic  facies,  a  dusky  suffusion, 
and  the  forehead  bathed  in  a  clammy  perspiration.  The  temperature  rises 
with  the  increase  of  the  peritonitis.  The  pulse  quickens,  is  running  and 
thready,  the  heart's  action  becomes  more  feeble,  and  there  is  an  increase  in  the 
respiration  rate.  Vomiting  is  a  variable  feature;  it  is  present  in  a  majority  of 
the  cases.    Hiccough  is  common  and  may  occur  early,  but  more  frequently  late. 

The  local  abdominal  features  are  often  more  important  than  the  general, 
as  it  is  surprising  to  notice  how  excellent  the  condition  of  a  patient  may  be 
with  perforative  peritonitis.  Limitation  of  the  respiratory  movements  is  usu- 
ally present,  perhaps  confined  to  the  hypogastric  area.  Increasing  distention 
is  the  rule,  but  perforation  and  peritonitis  may  occur,  it  is  to  be  remembered, 
with  an  abdomen  flat  or  even  scaphoid.  Increasing  pain  on  pressure,  increas- 
ing muscle  spasm  and  tension  of  thp  wall  are  important  signs.  Percussion 
may  reveal  a  flat  note  in  the  flanks,  due  to  exudate.  A  friction  may  be  present 
within  a  few  hours  of  the  onset  of  the  perforation.  Obliteration  of  the  liver 
flatness  in  the  nipple  line  may  be  caused  by  excessive  tympany,  but  rapid 
obliteration  of  liver  flatness  in  a  flat,  or  a  not  much  distended  abdomen,  is  a 
valuable  sign.  Examination  of  the  rectum  may  show  fullness  or  tenderness 
in  the  pelvis.     Advance  in  the  abdominal  signs  is  an  important  point. 

In  some  cases  there  is  a  rise  in  the  leucocytes,  and  when  present  may  be  a 
valuable  help,  but  it  is  not  constant.  Increase  in  the  blood  pressure  is  not 
constant. 

General  peritonitis,  without  perforation  of  the  bowel,  may  occur  by  exten- 
sion from  an  ulcer,  or  by  rupture  of  a  softened  mesenteric  gland,  or,  as  in 
one  case  in  our  series,  from  inflammation  of  the  Fallopian  tubes.  It  was  pres- 
ent in  2.2  per  cent,  of  the  Munich  autopsies. 

Perforation  is  almost  invariably  fatal  without  operation.  In  a  few  cases 
healing  takes  place  spontaneously  or  the  orifice  may  be  closed  by  a  tag  of 
omentum.  There  is  a  group  of  cases  in  which  haemorrhage  complicates  the 
perforation  and  adds  to  the  difficulty  in  diagnosis.  In  7  of  our  43  cases 
haemorrhage  accompanied  the  perforation;  in  3  others  the  haemorrhage  had 
occurred  some  days  before. 


24  SPECIFIC  I^^FECTIOUS  DISEASES 

The  diagnosis  of  perforation,  easy  enough  at  times,  is  not  without  serious 
difficulties.  The  conditions  for  which  it  was  mistaken  in  our  series  were": 
appendicitis,  occurring  during  the  course  of  the  typhoid  fever,  phlebitis  of  the 
iliac  vein  with  great  pain,  heemorrhage,  and  in  one  case  a  local  peritonitis  with- 
out perforation,  for  which  no  cause  was  found.  Eecovery  followed  the  ex- 
ploratory operation  in  all  but  one  (hemorrhage  case)  of  the  cases.  Explora- 
tion is  justifiable  and  better  than  delay  in  suspicious  cases. 

Ascites  occurs  in  rare  instances  (McPhedran). 

The  SPLEEN  is  usually  enlarged,  and  the  edge  was  felt  below  the  costal 
margin  in  71.6  per  cent,  of  our  cases.  Percussion  is  uncertain,  as,  owing  to 
distention  of  the  stoma'ch  and  colon,  even  the  normal  area  of  dulness  may  not 
be  obtainable.  Enlargement  is  often  not  marked  in  elderly  patients.  Eupture 
of  the  spleen  occurs  occasionally. 

Liver. — Symptoms  on  the  part  of  this  organ  are  rare. 

(a)  Jaundice  of  marked  grade  was  present  in  only  8  cases  of  our  series, 
but  slight  icterus  is  not  uncommon.  Catarrh  of  the  ducts,  toxsemia,  abscess, 
and  occasionally  gall-stones  are  the  usual  causes. 

(&)  Ahscess. — Solitary  abscess  is  exceedingly  rare  and  occurred  in  but  3 
cases  in  our  series.  It  may  occur  early  in  the  disease,  but  most  frequently  is  a 
sequel.  Eberts  collected  30  cases,  in  9  of  which  the  typhoid  bacillus  was 
isolated  from  the  pus.  In  about  half  the  cases  the  right  lobe  was  affected. 
Eighteen  of  the  patients  recovered.  Abscess  may  folloAv  the  intestinal  lesion 
or  a  complication  as  parotitis.  Suppurative  pylephlebitis  may  follow  perfora- 
tion of  the  appendix.     Suppurative  cholangitis  has  been  described. 

(c)  Cliolecystitis  occurred  in  19  cases  of  the  series.  Pain  in  the  region 
of  the  gall-bladder  is  the  most  constant  symptom.  Tenderness,  muscle  spasm 
with  rigidity,  and  a  gall-bladder  tumor  are  present  in  a  majority  of  the  cases. 
Jaundice  is  inconstant.  Leucocytosis  usually  occurs.  With  perforation  there 
may  be  a  marked  drop  in  the  fever  and  the  onset  of  signs  of  peritonitis.  In 
simple  cholecystitis  the  urgency  of  the  symptoms  may  abate,  and  recovery  fol- 
low. Suppuration  may  occur  with  infection  of  the  bile  passages.  Months 
or  years  later  the  bacilli  may  cause  cholecystitis  or  gall-stones.  Typhoid 
bacilli  have  been  found  in  the  gall-bladder  in  patients  who  never  had  typhoid 
fever. 

{d)  Gall-stones. — Bernheim  called  attention  to  the  frequency  of  chole- 
lithiasis after  typhoid  fever.  It  is  probably  associated  with  the  presence  of 
typhoid  bacilli  in  the  gall-bladder  (see  under  Gall-Stones). 

Panckeas.^ — Hagmorrhagic  pancreatitis  has  occurred  rarely. 

Eespieatory  System. — Epistaxis,  an  early  symptom,  precedes  typhoid 
fever  more  commonly  than  any  other  febrile  affection.  It  is  occasionally 
profuse  and  serious  and  may  occur  during  the  course. 

Laryngitis  is  not  very  common  and  oedema,  apart  from  ulceration,  is  rare. 
In  the  United  States  the  laryngeal  complications  of  typhoid  fever  seem  much 
less  frequent  than  on  the  Continent.  We  have  twice  seen  severe  perichondritis ; 
both  of  the  patients  recovered,  one  after  the  expectoration  of  large  portions  of 
the  thyroid  cartilage.  Keen  and  Liining  collected  221  cases  of  serious  surgical 
complications  of  the  larynx.  General  emphysema  may  follow  the  perforation 
of  an  ulcer.  Stenosis  is  a  very  serious  sequence.  It  would  appear  that  paraly- 
sis of  the  laryngeal  muscles  is  more  common  than  we  have  supposed.     Przed- 


TYPHOID  FEVER  25 

borski  (Volkmann's  Sammlung,  No.  182)  examined  the  larynx  in  100 
consecutive  cases  and  found  25  with  paralysis.  This  is  nearly  always  due  to 
neuritis,  sometimes  in  connection  with  affections  of  other  nerves. 

Bronchitis  is  one  of  the  most  frequent  initial  symptoms.  It  is  indicated 
by  the  presence  of  sibilant  rales.  The  sputum  is  usually  scanty.  The  smaller 
tubes  may  be  involved,  producing  urgent  cough  and  even  slight  cyanosis.  Col- 
lapse and  lobular  pneumonia  may  also  occur. 

Lobar  pneumonia  is  met  with  under  two  conditions : 

(a)  At  the  outset,  the  pneumo -typhus  of  the  Germans.  This  occurred  in 
three  of  our  cases.  After  an  indisposition  of  a  day  or  so,  the  patient  is  seized 
with  a  chill,  has  high  fever,  pain  in  the  side,  and  within  forty-eight  hours 
there  are  signs  of  consolidation  and  the  evidences  of  an  ordinary  lobar  pneu- 
monia. The  intestinal  symptoms  may  not  occur  until  toward  the  end  of  the 
first  week  or  later;  the  pulmonary  symptoms  persist,  crisis  does  not  occur; 
the  aspect  of  the  patient  changes,  and  by  the  end  of  the  second  week  the 
clinical  picture  is  that  of  typhoid  fever.  Spots  may  then  be  present  and 
doubts  as  to  the  nature  of  the  case  are  solved.  In  other  instances,  in  the 
absence  of  a  characteristic  eruption,  the  case  remains  doubtful,  and  it  is 
impossible  to  say  whether  the  disease  has  been  pneumonia,  in  which  the  so- 
called  typhoid  symptoms  have  developed,  or  whether  it  was  typhoid  fever 
with  early  implication  of  the  lungs.  This  condition  may  depend  upon  an 
early  localization  of  the  typhoid  bacillus  in  the  lung. 

(&)  Lobar  pneumonia  forms  a  serious  and  not  infrequent  complication  of 
the  second  or  third  week — in  19  of  our  cases.  It  was  present  in  over  8  per 
cent,  of  the  Munich  cases.  The  symptoms  are  usually  not  marked.  There 
may  be  no  rusty  sputum,  and,  unless  sought  for,  the  condition  is  frequently 
overlooked.  The  etiological  agent  is  still  in  dispute.  Typhoid  bacilli  have 
been  isolated  from  the  sputum  and  also  from  the  consolidated  lungs  at  autopsy, 
but  in  such  cases  the  pneumococci  may  have  been  originally  present,  and  the 
typhoid  bacilli  secondary  invaders.  In  all  cases  of  pneumonia  during  typhoid 
fever  in  the  Johns  Hopkins  Hospital  and  coming  to  autopsy,  the  pneumococcus 
could  be  demonstrated  in  the  consolidated  lung.  Infarction,  abscess,  and 
gangrene  are  occasionally  pulmonary  complications. 

Hypostatic  congestion  of  the  lungs  and  oedema,  due  to  enfeebled  circula- 
tion, occur  in  the  later  periods.  The  physical  signs  are  defective  resonance  at 
the  bases,  feeble  breatli  sounds,  and  moist  rales  on  deep  inspiration.  Dulness 
at  the  right  base  is  not  uncommon. 

Hcemoptysis  may  occur.    Creagh  reports  a  case  in  which  it  caused  death. 

Pleurisy  was  present  in  about  8  per  cent,  of  the  Munich  autopsies.  It  oc- 
curred in  2  per  cent,  of  our  series.  It  may  occur  at  the  outset — pleuro-typhoid 
— or  slowly  during  convalescence,  in  which  case  it  is  almost  always  purulent 
and  due  to  the  typhoid  bacillus. 

Pneumothorax  is  rare.  Hale  White  has  reported  two  cases,  in  both  of 
which  pleurisy  existed.  After  death,  no  lesions  of  the  lungs  or  bronchi  were 
discovered.  The  condition  may  be  due  to  straining,  or  to  the  rupture  of  a 
small  pysemic  abscess.     It  may  occur  also  during  convalescence. 

Nervous  System. — Cerebrospinal  Form. — The  disease  may  set  in  with 
intense  and  persistent  headache,  or  an  aggravated  form  of  neuralgia.  Ivernig's 
sign  is  often  present  without  any  evidence  of  meningeal  reaction.     There  are 


26  SPECIFIC  IXFECTIOUS  DISEASES 

cases  in  which  the  effect  of  the  poison  is  manifested  on  the  nervous  system 
early  and  with,  the  greatest*  intensity.  There  are  headache,  photophobia,  re- 
traction of  the  neck,  marked  twitchings  of  the  muscles,  rigidity,,  and  even 
convulsions.  In  such  cases  the  diagnosis  of  meningitis  is  invariably  made. 
The  cases  showing  marked  meningeal  features  during  the  course  may  be 
divided  into  three  groups.  First,  those  with  symptoms  suggestive  of  menin- 
gitis, but  without  localizing  features  and  without  the  anatomical  lesions  of 
meningitis  at  post  mortem  (meningism).  In  every  series  of  cases  numerous 
such  examples  occur.  Secondly,  the  cases  of  so-called  sero-w^smeningitis.  There 
is  a  localization  of  typhoid  bacilli  in  the  cerebro-spinal  fluid  and  a  mild 
inflammatory  reaction,  but  without  suppurative  meningitis.  Cole  in  1904 
collected  13  such  cases,  5  of  them  occurring  in  our  series,  and  Bayne- Jones 
has  collected  17  cases  from  the  literature  since  1904.  Probably  more  frequent 
lumbar  punctures  vtdll  show  that  this  occurs  not  infrequently.  Thirdly,  true 
typhoid  suppurative  meningitis  due  to  B.  typhosus.  Only  one  such  case 
occurred  in  our  series,  and  Cole  collected  13  from  the  literature.  Bayne-Jones 
has  collected  18  additional  cases.  Meningitis  in  typhoid  fever  is  occasionally 
due  to  other  organisms,  as  the  tubercle  bacillus,  or  the  meningococcus.  Marked 
convulsive  movements,  local  or  general,  with  coma  and  delirium,  are  seen 
also  in  thrombosis  of  the  cerebral  veins  and  sinuses. 

Delirium,  usually  present  in  very  severe  cases,  is  much  less  frequent  under 
a  rigid  plan  of  hydrotherapy.  It  may  exist  from  the  outset,  but  usually  does 
not  occur  until  the  second  and  sometimes  not  until  the  third  week.  It  may  be 
slight  and  only  nocturnal.  It  is,  as  a  rule,  a  quiet  delirium,  though  there  are 
cases  in  which  the  patient  is  very  noisy  and  constantly  tries  to  get  out  of  bed, 
and,  unless  carefully  watched,  may  escape.  The  patient  does  not  often  become 
maniacal.  In  heavy  drinkers  the  delirium  may  have  the  character  of  delirium 
tremens.  Even  in  patients  who  have  no  positive  delirium,  the  mental  processes 
are  usually  dulled  and  the  aspect  is  listless  and  apathetic.  In  severe  cases 
the  patient  passes  into  a  condition  of  unconsciousness.  The  eyes  may  be  open, 
but  he  is  oblivious  to  all  surrounding'  circumstances  and  neither  knows  nor  can 
indicate  his  wants.  The  urine  and  fseces  are  passed  involuntarily.  In  this 
pseudo- wakeful  state,  or  coma  vigil,  as  it  is  called,  the  eyes  are  open  and.  the 
patient  is  constantly  muttering.  The  lips  and  tongue  are  tremulous;  there 
are  twitchings  of  the  fingers  and  wrists — siibsultus  tendinum  and  carphologia. 
He  picks  at  the  bedclothes  or  grasps  at  invisible  objects.  These  are  among 
the  most  serious  symptoms  of  the  disease  and  always  indicate  danger. 

Convulsions'  are  rare.  There  were  7  instances  in  our  series,  with  3  deaths. 
They  occur :  first,  at  the  onset,  particularly  in  children ;  secondly,  as  a  mani- 
festation of  the  toxsemia;  and  thirdly,  as  a  result  of  severe  cerebral  com- 
plications— thrombosis,  meningitis,  or  acute  encephalitis.  Occasionally  in 
convalescence  convulsions  may  occur  from  unknown  causes. 

Neuritis,  which  is  not  uncommon — 11  cases  in  the  series — ^may  be  multiple 
or  local.  Multiple  neuritis  comes  on  usually  during  convalescence.  The  legs 
may  be  affected,  or  the  four  extremities.  The  cases  are  often  difficult  to 
differentiate  from  those  with  subacute  poliomyelitis.    Eecovery  is  the  rule. 

Local  Neuritis. — This  may  occur  during  the  height  of  the  fever  or  after 
convalescence  is  established.  It  may  set  in  with  agonizing  pain,  and  with 
sensitiveness  of  the  affected  nerve  trunks.     The  local  neuritis  may  affect  tiie 


TYPHOID  FEVER  27 

nerves  of  an  arm  or  of  a  leg,  and  involve  chiefly  the  extensors,  so  that  there 
is  wrist-drop  or  foot-drop.  The  arm  or  leg  may  he  much  swollen  and  the 
skin  over  it  erythemat»us.  A  curious  condition,  probably  a  local  neuritis  in 
some  but  in  others  due  to  phlebitis,  is  that  described  by  Handford  as  tender 
toes.  The  tips  and  pads  of  the  toes,  rarely  the  pads  at  their  bases,  become 
exquisitely  sensitive,  so  that  the  patient  can  not  bear  the  weight  of  the  bed- 
clothes. There  is  no  discoloration  or  swelling,  and  the  pain  disappears  usually 
within  a  week  or  ten  days. 

Poliomyelitis  may  occur  with  the  symptoms  of  acute  ascending  paralysis 
and  prove  fatal  in  a  few  days.  More  frequently  it  is  less  acute,  and  causes 
either  a  paraplegia  or  a  limited  atrophic  paralysis  of  one  arm  or  leg. 

Hemiplegia  is  a  rare  complication.  Smithies  (1907)  collected  40  cases  in 
26  of  which  aphasia  occurred  and  in  10  the  hemiplegia  was  preceded  by  con- 
vulsions. In  21  cases  the  paralysis  was  on  the  right  side.  The  lesion  is  usually 
thrombosis  of  the  arteries,  less  often  a  meningo-encephalitis.  The  aphasia 
usually  disappears.  Aphasia,  apart  from  hemiplegia,  occurs  rarely  and  usually 
in  children.     The  prognosis  is  good. 

The  superficial  abdominal  reflexes  may  disappear  early  in  the  course  and 
not  return  until  convalescence,  but  this  is  not  constant  and  can  not  be  regarded 
as  important  in  diagnosis. 

True  tetany  occurs  sometimes,  and  has  been  reported  in  connection  with 
certain  epidemics.    It  may  set  in  during  the  height  of  the  disease. 

Typhoid  Psychoses. — There  are  three  groups  of  cases:  first,  an  initial 
delirium,  which  may  be  serious,  and  cause  the  patient  to  wander  away  from 
his  home,  or  he  may  even  become  maniacal;  secondly,  the  psychosis  associated 
directly  with  the  pyrexia  and  the  tox£emia ;  in  a  few  cases  this  outlasts  the 
disappearance  of  the  fever  for  months  or  even  years;  and,  lastly,  the  asthenic 
psychosis  of  convalescence,  more  common  after  typhoid  than  after  any  other 
fever.  The  prognosis  is  usually  good.  Edsall  studied  the  condition  in 
children,  finding  69  cases,  of  which  43  recovered. 

There  is  a  distressing  post-typhoid  neurasthenia,  in  which  for  months  or 
even  for  years  the  patient  is  unable  to  get  into  harmony  with  his  surroundings. 

Special  Sexses. — Eye: — Conjunctivitis,  simple  or  phlyctenular,  some- 
times with  keratitis  and  iritis,  may  develop.  Panophthalmitis  has  been  re- 
ported in  one  case  in  association  with  haemorrhage  (Finlay).  Loss  of  accom- 
modation may  occur,  usually  in  the  asthenia  of  convalescence.  Oculo-motor 
paralysis  has  been  seen,  due  probably  to  neuritis.  Eetinal  hssmorrhages  may 
occur  alone  or  in  association  with  other  haemorrhagic  features.  Double  optic 
neuritis  has  been  described  and  may  be  independent  of  meningitis.  Atrophy 
may  follow,  but  these  complications  are  excessively  rare.  Cataract  may  follow 
inflammation  of  the  uveal  tract.  Other  rare  complications  are  thrombosis  of 
the  orbital  veins  and  orbital  haemorrhage.  (See  de  Schweinitz  in  Keen's 
monograph  for  full  consideration  of  the  subject.) 

Ear. — Deafness  is  common  during  the  course  but  usually  is  not  permanent. 
Otitis  media  is  not  infrequent,  2.5  per  cent,  in  Hengst's  collected  cases.  We 
never  found  the  typhoid  bacillus  in  the  discharge.  Serious  results  are  rare; 
only  one  case  of  mastoid  disease  occurred  in  our  series*  The  otitis  may  set  in 
with  a  chill  and  an  aggravation  of  the  fever. 

Renal  System. — Retention  of  urine  is  an  early  symptom  and  may  be  the 


28  SPECIFIC  INFECTIOUS  DISEASES 

cause  of  alDclominal  pain.  It  may  recur  throughout  the  attack.  Suppression 
of  wine  is  rare.  The  urine  is  usually  diminished  at  first,  has  the  ordinary 
febrile  characters,  and  the  pigments  are  increased.  Polyuria  is  not  very  un- 
common. While  most  common  during  -convalescence,  the  increase  may  be 
sudden  in  the  second  week  at  the  height  of  the  fever.  The  amount  of  urine 
depends  very  much  on  the  fluid  taken.  Patients  treated  by  what  is  known 
as  the  washing-out  method,  in  which  large  quantities  of  water  are  taken,  may 
pass  enormous  amounts,  18  or  19  litres.  One  of  our  patients  passed  33  litres 
in  one  day ! 

Bacilluria  caused  by  the  typhoid  bacilli  occurs  in  about  one-third  of  the 
cases.  The  urine  may  be  turbid  from  their  presence  and  in  the  test-tube  give 
a  peculiar  shimmer.  There  may  be  millions  of  bacilli  to  the  cubic  millimetre 
"wdthout  pyuria  or  any  symptoms  of  renal  or  bladder  trouble.  The  routine 
administration  of  hexamine  diminishes  the  occurrence  of  typhoid  bacilluria. 
The  bacilli  may  be  present  in  the  urine  for  years  after  the  attack  (see  Gwyn, 
Studies  III). 

The  renal  complications  in  typhoid  fever  may  be  thus  grouped: 

(«■)  Febrile  albuminuria  is  common  and  of  no  special  significance.  It 
was  present  in  999  of  1,500  cases,  &Q  per  cent.  Tube  casts  were  present  in 
568  cases,  37.8  per  cent.     Hcemoglohinuria  occurred  in  one  case. 

(&)  Acute  nepliritis  at  the  onset  or  during  the  height  of  the  disease — 
the  nephro-ti/phu.s  of  the  Germans,  the  fievre  typhoid  a  forme  renale  of  the 
French — may  set  in,  masking  in  many  instances  the  true  nature  of  the  malady. 
After  an  indisposition  of  a  few  days  there  may  be-  fever,  pain  in  the  back, 
and  the  passage  of  a  small  amount  of  bloody  urine. 

(c)  Nephritis  during  convalescence  is  rare,  and  is  usually  associated  with 
anaemia  and  oedema.     Chronic  nephritis  is  a  most  exceptional  sequel. 

(d)  The  lymphomatous  nephritis,  described  by  E.  Wagner,  and  referred 
j;p  in  the  section  on  morbid  anatomy,  produces,  as  sc  rule,  no  symptoms. 

(e)  Pyuridj  a  not  uncommon  complication,  may  be  associated  with  the 
typhoid  or  the  colon  bacillus,  less  often  "with  staphylococci.  It  disappears 
during  convalescence.  It  is  usually  due  to  a  simple  catarrh  of  the  bladder, 
rarely  to  an  intense  cvstitig,  sometimes  to  pyelitis.- 

(/)  Post-typhaid  Pyelitis. — One  or  both  kidneys  may  be  involved,  either 
at  the  height  of  the  disease  or  during>  convalescence.  There  may  be  blood 
and  pus  at  first,  later  pus  alone,  varying  in  amount..  A  severe  pyelonephritis 
may  follow.  The  colon  bacillus  is  often  the  organism;  present.  Perinephric 
abscess  i&  a  rare  sequel. 

Generative  System. — Orchitis  i»  occasionally  met  with.  Kinnicutt  col- 
lected 53  cases  in  the  literature.  It  may  be  associated  with  a  catarrhal 
urethritis.  Induration  or  atrophy  may  occur,  and  more  rarely  suppuration. 
It  was  present  in  4  cases  of  our  series.  In  1  case  double  hydrocele  developed 
suddenly  on  the  nineteenth  day  (DunlapJ.    Prostatitis  occurs  rarely. 

Aciite  mastitis,  which  may  go  on  to  suppuration,  is  rare.  It  was  present 
in  3  cases  of  our  series  during  the  fever  and  in  one  late  in  convalescence. 

Osseous  System. — Among  the  most  troublesome  of  the  sequelae  are  the 
hon^  lesions  which  in  a  few  cases  occur  at  the  height  of  the  disease  or  even 
earlier.  Of  237  cases  collected  by  Keen  there  was  periostitis  in  110,  necrosis 
in  85,  and  caries  in  13.     They  are  much  more  frequent  than  the  figures  in- 


TYPHOID  FEVER  29 

(licate.  Six  cases  came  under  personal  notice  in  the  course  of  a  year, 
and  formed  the  basis  of  Parsons'  paper  (Studies  II).  The  legs  are  chiefly 
involved.  In  Keen's  series  the  tibia  was  affected  in  91  cases,  the  ribs  in  -10. 
The  typhoid  bone  lesion  is  apt  to  form  what  the  old  writers  called  a  cold 
abscess.  Only  a  few  of  the  cases  are  acute.  Chronicity,  indolence,  and  a 
remarkable  tendency  to  recurrence  are  perhaps  the  three  most  striking  features. 
A  bony  node  may  be  left  by  the  typhoid  periostitis. 

Arthritis  was  present  in  8  cases  of  our  series.  Keen  collected  84  cases 
from  the  literature.  It  may  be  monarticular  or  polyarticular.  One  of  the 
most  important  points  relating  to  it  is  the  frequency  with  which  spontaneous 
dislocations  occur,  particularly  of  the  hip. 

Typhoid  'Spine  (Gibney). — During  the  disease  but  more  often  during 
convalescence,  the  patient  complains  of  pain  in  the  lumbar  and  sacral  regions, 
perhaps  after  a  slight  jar  or  shock.  Stiffness  of  the  back,  pain  on  movement, 
sometimes  radiating,  and  tenderness  on  pressure  are  the  chief  features,  but 
there  are  in  addition  marked  nervous  manifestations.  There  is  rigidity  and 
fixation  of  the  spine,  usually  in  the  lower  part.  Kyphosis  occurs  in  some  cases. 
The  X-ray  plates  may  show  definite  bony  change.  There  is  usually  spondylitis 
or  perispondylitis.     The  duration  is  weeks  or  months,  but  the  outlook  is  good. 

The  muscles  may  be  the  seat  of  degeneration  but  it  rarely  causes  any 
symptoms.  HEemorrhage  occasionally  occurs  into  the  muscles,  and  late  in 
protracted  cases  abscesses  may  follow.  Eupture  of  a  muscle,  usually  the  rectus 
abdominis,  may  occur,  possibly  associated  with  acute  hsemorrhagic  myositis,. 
Painful  muscles  are  not  uncommon,  particularly  in  the  calves  (Studies  III). 
Painful  cramps  may  also  occur.  In  some  of  the  cases  of  painful  legs  the 
condition  is  a  myositis ;  in  others  the  swelling  and  pain  may  be  due  to  throm- 
bosis in  the  deeper  veins. 

Post-typhoid  Septicasmia  and  Pyaemia. — In  very  protracted  cases  after 
defervescence  a  slight  fever  (100°-101°  F.)  may  recur  with  sweats,  which  is 
possibly  septic.  In  other  cases  for  iwo  or  three  weeks  there  are  recurring 
chills,  often  of  great  severity.  They  are  usually  of  no  moment  in  the  absence 
of  signs  of  complication.     (See  Studies  II  and  III.) 

Typhoid  pysemia  is  not  common,  (a)  Extensive  furunculosis  may  be 
associated  with  irregular  fever  and  leucocytosis.  (&)  Following  the  fever 
there  may  be  multiple  subcutaneous  "cold"  abscesses,  often  with  a  dark,  thin 
bloody  pus.  A  score  or  more  of  these  may  appear  in  different  parts.  Pratt 
isolated  the  bacillus  in  pure  culture  from  the  subcutaneous  abscesses,  (c)  A 
crural  thrombus  may  suppurate  and  cause  a  widespread  pyaemia,  (d)  In  rare 
instances  suppuration  of  the  mesenteric  glands,  of  a  splenic  infarct,  a  slough- 
ing parotid  bubo,  a  perinephric  or  perirectal  abscess,  acute  necrosis  of  the 
bones,  or  a  multiple  suppurative  arthritis  may  cause  pyemia.  In  other  cases 
following  bed-sores  or  a  furunculosis  a  general  infection  with  pyogenic 
organisms  occurs  with  fatal  result.  In  three  such  cases  in  our  series  sta- 
phylococci were  cultivated  from  the  blood.  In  one  case  with  many  chills 
late  in  the  disease,  and  the  general  condition  excellent,  typhoid  bacilli  were 
cultivated  from  the  blood.  The  colon  bacillus  may  also  be  found  in  blood 
cultures. 

Associatian  of  Other  Diseases. — Erysipelas  is  a  rare  complication,  most 
commonly  met  with  during  convalescence.     Measles  or  scarlet  fever  may  do- 


30  SPECIFIC  INFECTIOUS  DISEASES 

velop  during  the  fever  or  in  convalescence.  Chicken-pox  and  noma  have 
been  reported  in  children.  Pseudo-membranous  inflammations  may  occur  in 
the  pharynx,  larynx,  or  genitals. 

Malarial  and  typhoid  fevers  may  be  associated,  but  a  majority  of  the  cases 
of  so-called  typho-malarial  fever  are  either  remittent  malarial  fever  or  true 
typhoid.  It  is  interesting  to  note  that  among  1,500  cases  of  typhoid  fever 
Plasmodia  were  found  in  the  blood  in  only  3  cases.  (See  Lyon,  Studies  III.) 
Many  of  the  typhoid  fever  patients  came  from  malarious  regions. 

The  symptoms  of  influenza  may  precede  the  typhoid  fever,  or  the  two 
diseases  may  run  ^concurrently.  There  are  cases  of  chronic  influenza  which 
simulate  typhoid  fever  very  closely. 

Typhoid  Fever  and  Tuberculosis. —  (a)  The  diseases  may  coexist.  A  per- 
son with  chronic  tuberculosis  may  contract  the  fever.  Of  105  autopsies  in 
typhoid  fever,  7  presented  marked  tuberculous  lesions.  Miliary  tuberculosis 
and  typhoid  fever  may  occur  together.  (&)  Cases  of  typhoid  fever  with  pul- 
monary and  pleuritic  symptoms  may  suggest  tuberculosis  at  the  onset,  (c) 
There  are  types  of  tuberculosis  infection  which  may  simulate  typhoid  fever : 
the  acute  miliary  form;  the  acute  septica3mic  form;  tuberculous  meningitis; 
tuberculous  peritonitis ;  the  acute  toxsemia  of  certain  local  lesions ;  and  forms 
of  ordinary  pulmonary  tuberculosis.  And,  lastly,  pulmonary  tuberculosis  may 
follow  typhoid.  In  a  large  majority  of  such  cases  from  the  onset  the  disease 
has  been  tuberculosis,  which  has  begun  Avith  a  low  fever  and  features  sug- 
gestive of  typhoid  fever. 

In  epilepsy  and  in  chronic  chorea  the  fits  and  movements  usually  cease 
during  an  attack,  and  in  typhoid  fever  in  a  diabetic  subject  the  sugar  may 
be  absent  during  the  height  of  the  disease. 

Varieties^ — Typhoid  fever  presents  an  extremely  complex  symptomatology. 
Many  forms  have  been  described,  some  of  which  present  exaggeration  of  com- 
mon symptoms,  others  modification  in  the  course,  others  again  greater  in- 
tensity of  action  of  the  poison  on  certain  organs.  When  the  nervous  system 
is  specially  involved,  it  has  been  called  the  cerebro-spinal  form;  when  the 
kidneys  are  early  and  severely  affected,  nephro-typhoid ;  when  the  disease 
begins  with  pulmonary  symptoms,  pneumo-typhoid ;  with  pleurisy,  pleuro- 
typhoid;  when  characterized  throughout  by  profuse  sweats,  the  sudoral  form 
of  the  disease.  It  is  enough  to  remember  that  typhoid  has  no  fixed  and  con- 
stant course,  that  it  may  set  in  occasionally  with  symptoms  localized  in  certain 
organs,  and  that  many  of  its  symptoms  are  extremely  variable — in  one  epi- 
demic uniform  and  text-book-like,  in  another  slight  or  not  met  with.  This 
diversified  symptomatology  has  led  to  many  clinical  errors,  and  in  the  absence 
of  the  salutary  lessons  of  morbid  anatomy  it  is  not  surprising  that  practi- 
tioners have  so  often  been  led  astray.  We  may  recognize  the  following 
varieties : 

(a)  The  mild  and  abortive  forms.  Much  attention  has  been  paid  to  the 
milder  varieties — the  typhus  levissimus  of  Griesinger.  Woodruff  called  special 
attention  to  the  great  danger  of  neglecting  these  mild  forms,  which  are  often 
spoken  of  as  mountain  fever  and  malarial  fever,  "acclimation,"  "ground,"  and 
"miasmatic"  fevers.  During  an  epidemic  there  may  be  cases  sa  mild  that 
the  patient  does  not  go  to  bed.  The  onset  may  be  sudden,  particularly  in 
children.    The  general  symptoms  are  slight,  the  pulse  rate  not  high,  the  fever 


TYPHOID  FEYEE  31 

rarely  above  103°.  Eose  spots  are  usually  present,  with  splenic  enlargement. 
Diarrha?a  is  rare.  The  Widal  reaction  is  present  in  a  majority  of  the  patients. 
There  may  be  a  marked  tendency  to  relapse.  While  infrequent,  characteristic 
complications  and  sequelae  may  give  the  first  positive  clue  to  the  nature  of 
the  trouble.  Briggs  studied  M  of  these  mild  cases  from  our  series  in  which 
the  fever  lasted  li  days  or  less.  Eose  spots  were  present  in  24,  and  the  Widal 
reaction  in  26.  There  were  three  relapses.  It  can  not  be  too  forcibly  impressed 
upon  the  profession  that  it  is  just  by  these  mild  cases,  to  which  so  little  atten- 
tion is  paid,  that  the  disease  may  be  kept  up  in  a  community. 

(&)  The  grave  form  is  usually  characterized  by  high  fever  and  pronounced 
nervous  symptoms.  In  this  category  come  the  very  severe  cases,  setting  in 
with  pneumonia  and  nephritis,  and  with  the  very  intense  gastro-intestinal 
or  cerebro-spinal  symptoms. 

(c)  The  latent  or  amhulatorij  form  is  particularly  common  in  hospital 
practice.  The  symptoms  are  usually  slight,  and  the  patient  scarcely  feels  ill 
enough  to  go  to  bed.  He  has  languor,  perhaj)s  slight  diarrhoea,  but  keeps 
about  and?  may  even  attend  to  his  work  throughout  the  entire  attack.  In  other 
instances  delirium  sets  in.  The  worst  cases  of  this  form  are  seen  in  sailors, 
who  keep  up  and  about,  though  feeling  ill  and  feverish.  When  brought  to  the 
hospital  they  often  have  symptoms  of  a  most  severe  type.  Hsemorrhage  or 
perforation  may  be  the  first  marked  symptom  of  this  ambulatory  type.  Sir 
W.  Jenner  called  attention  to  the  dangers  of  this  form,  and  particularly  to 
the  grave  prognosis  in  the  case  of  persons  who  have  travelled  far  with  the 
disease  in  progress. 

{d)  Hcemorrhagic  TypJioid  Fever. — This  is  excessively  rare.  Among 
Ouskow's  6,513  cases  there  were  4  fatal  cases  with  general  hemorrhagic  fea- 
tures. Only  three  instances  were  present  in  our  series.  Hemorrhages  may 
be  marked  from  the  outset,  but  more  commonly  they  come  on  during  the 
course.  The  condition  is  not  necessarily  fatal.     (See  Hamburger,  Studies  III.) 

(e)  An  afehrile  typhoid  fever  is  recognized  by  some  authors,  but  there  is 
usually  slight  fever.  The  patients  presented  lassitude,  depression,  headache, 
furred  tongue,  loss  of  appetite,  slow  pulse,  and  even  the  spots  and  enlarged 
spleen. 

Typhoid  Fever  in  Children.— Grifiith  collected  a  series  of  325  cases  in 
children  under  two  and  a  half  years;  111  of  these  were  in  the  first  year.  Out 
of  a  total  of  278  cases  in  which  the  result  was  recorded,  142  died.  The  cases 
are  not  very  uncommon.  The  high  mortality  in  Griffith's  series  was  probably 
due  to  the  fact  that  only  the  more  serious  cases  are  reported.  The  abdominal 
symptoms  are  usually  mild ;  fatal  hemorrhage  and  perforation  are  rare. 
Among  sequelae,  aphasia,  noma,  and  bone  lesions  are  stated  to  be  more  com- 
mon in  children  than  in  adults.     Two  of  our  cases  were  under  one  year  of  age. 

Typhoid  Fever  in  the  Aged. — After  the  sixtieth  year  the  disease  runs 
a  less  favorable  course,  and  the  mortality  is  high.  The  fever  is  less,  but 
complications  are  more  common,  particularly  pneumonia  and  heart-failure. 

Typhoid  Fever  in  Pkegxancy. — Pregnancy  affords  no  immunity  against 
typhoid.  In  1,500  of  our  cases,  438  of  which  were  females,  there  were  6 
cases.  Goltdammer  noted  26  pregnancies  in  600  cases  of  typhoid  fever  in 
the  female.  It  is  more  commonly  seen  in  the  first  half  of  pregnancy.  The 
pregnancy  is  interrupted  in  about  65  per  cent,  of  the  cases,  usually  in  the 


32  SPECIFIC  IXFECTIOUS  DISEASES 

second  week  of  the  disease.  In  the  obstetrical  department  of  tlie  Johns  Hop- 
kins Hospital  (J.  W.  Williams)  there  were  (to  January,  1905)  three  cases 
of  puerperal  infection  with  bacillus  typhosus.  One  showed  a  localized  lesion 
of  the  chorion,  from  which  bacilli  were  obtained  (Little). 

Typhoid  Feyer  ix  the  Fetus. — The  typhoid  bacillus  may  pass  through 
the  placenta  to  the  child,  causing  a  typhoid  septicaemia,  without  intestinal 
lesions.  Lynch  collected  16  such  cases.  Infection  of  the  fetus  does  not  neces- 
sarily follow,  but  when  infected  the  child  dies,  either  in  utero  or  shortly  after 
birth.  The  Widal  reaction  has  been  obtained  with  fetal  blood.  Its  presence 
does  not  indicate  that  the  child  has  survived  infection,  as  the  agglutinating 
substances  may  filter  through  the  placenta.  They  may  also  be  transmitted 
to  the  nursling  through  the  milk,  and  cause  a  transient  reaction.  The  reaction 
could  not  be  obtained  with  fetal  blood  from  which  typhoid  bacilli  were  cul- 
tivated (Lynch). 

Eelapse. — Eelapses  vary  in  frequency  in  different  epidemics,  and,  it  would 
appear,  in  different  places.  The  percentages  of  different  authors  range  from 
3  to  15  or  18  per  cent.  In  1,500  cases  there  were  173  relapses,  11.-4  per  cent. 
Among  28,057  collected  cases  8.8  per  cent,  had  a  relapse.  "We  may  recognize 
the  ordinary,  the  intercurrent,  and  the  spurious  relapse. 

The  ordinary  relapse  sets  in  after  complete  defervescence.  The  average 
duration  of  the  interval  of  normal  temperature  is  five  or  six  days.  In  one  of 
our  cases  there  was  complete  apyrexia  for  twenty-three  days,  followed  by  a 
relapse  of  forty-one  days'  duration ;  then  apyrexia  for  forty-two  days,  followed 
by  a  second  relapse  of  two  weeks'  duration.  As  a  rule,  two  of  the  three 
important  symptoms — step-like  temperature  at  onset,  roseola,  an  enlarged 
spleen — should  be  present  to  justify  the  diagnosis  of  a  relapse.  The  intestinal 
symptoms  are  variable.  The  onset  may  be  abruptly  with  a  chill,  or  the 
temperature  may  have  a  typical  ascent.  The  number  of  relapses  ranges  from 
1  to  5.  In  a  case  at  the  Pennsylvania  Hospital  in  1904  the  disease  lasted 
eleYen  months  and  four  days,  during  which  there  were  six  relapses.  The 
relapse  is  usually  less  severe,  of  shorter  duration  and  the  mortality  is  low. 

The  intercurrent  relapse  is  common,  often  most  severe,  and  is  responsible 
for  a  great  many  of  the  most  protracted  cases.  The  temperature  drops  and 
the  patient  improves;  but  after  remaining  between  100°  and  103°  for  a  few 
days,  the  fever  again  rises  and  the  patient  enters  upon  another  attack,  which 
may  be  more  protracted,  and  of  much  greater  intensity  than  the  original  one. 

Spurious  relapses  are  very  common.  They  have  already  been  mentioned 
as  post-typhoid  elevations  of  temperature.  They  are  recrudescences  of  the 
fever  due  to  a  number  of  causes.  It  is  not  always  easy  to  determine  whether 
a  relapse  is  present,  particularly  in  cases  in  which  the  fever  persists  for  only 
five  or  seven  days  without  rose-spots  and  without  enlargement  of  the  spleen. 

Undoubtedly  a  reinfection  from  within,  yet  of  the  conditions  favoring  the 
occurrence  of  relapse  we  know  little.  Durham  advanced  an  interesting  theory : 
Every  typhoid  infection  is  a  complex  phenomenon  caused  by  groups  of  bacilli 
alike  in  species  but  not  identical,  as  ^hown  by  their  serum  reactions.  The 
antibodies  formed  in  the  blood  during  the  primary  attack  neutralize  only  one 
(or  several)  groups,  the  remaining  groups  still  preserving  their  pathogenic 
power.  From  some  cause  these  latter  groups  may  multiply  sufficiently  to 
cause  a  reinfection.     Multiple  relapses  may  be  similarly  explained. 


TYrHUlD  FEYEK  33. 

Diagnosis. — There  are  several  points  to  note.  In  the  first  place,  typhoid 
fever  is  the  most  common  of  all  continued  fevers.  Secondly,  it  is  extraordi- 
narily variable  in  its  manifestations.  Thirdly,  there  is  no  such  hybrid  malady 
as  t}9ho-malarial  fever.  Fourthly,  errors  in  diagnosis  are  inevitable,  even 
under  the  most  favorable  conditions. 

Data  for  Diagnosis. —  (a)  General. — Xo  single  symptom  or  feature  is 
characteristic.  The  onset  is  often  suggestive,  particularly  the  occurrence  of 
epistaxis,  and  (if  seen  from  the  start)  the  ascending  fever.  The  steadiness  of 
the  fever  for  a  week  or  longer  after  reaching  the  fastigium  is  an  important 
point.  The  irregular  remittent  character  in  the  third  week,  and  the  intermit- 
tent features  with  chills,  are  common  sources  of  errors.  While  there  is  nothing 
characteristic  in  the  pulse,  dicrotism  is  so  much  more  common  early  in  typhoid 
fever  that  its  presence  is  always  suggestive.  The  rash  is  the  most  valuable 
single  sign,  and  with  the  fever  usually  clinches  the  diagnosis.  The  enlarged 
spleen  is  of  less  importance,  since  it  occurs  in  all  febrile  conditions,  but  with 
the  fever  and  the  rash  it  completes  a  diagnostic  triad.  The  absence  of  leucocy- 
tosis  is  a  valuable  accessory  sign.  Typhoid  should  be  .suspected  in  every 
doubtful  fever. 

(6)  Specific. —  (1)  Isolation  of  Typhoid  Bacilli  from  the  Blood. — This 
is  especially  useful  early  in  the  disease,  in  doubtful  cases  and  in  the  acute 
septic  forms. 

(2)  Isolation  of  Typhoid  Bacilli  from  the  Stools. — Cultures  from  the 
stools  are  of  diagTiostic  value  at  all  stages. 

(3)  Isolation  of  Typhoid  Bacilli  from  the  Urine. — In  some  cases  positive 
cultures  may  be  obtained  before  the  Widal  test  is  positive.  Eoutine  cultures 
are  frequently  of  diagnostic  value, 

(4)  Isolation  of  Typhoid  Bacilli  from  the  Rose^spots. — This  may  be  done 
but  as  the  procedure  causes  considerable  discomfort  it  can  not  be  used  as  a 
routine  method. 

(5)  The  Agglutination  Test.^ln  1894  Pfeiffer  showed  that  cholera  spi- 
rilla, when  introduced  into  the  peritoneum  of  an  immunized  animal,  or  when 
mixed  with  the  serum  of  immunized  animals,  lose  their  motion  and  break  up. 
This  "Pfeiffer's  phenomenon"'  was  thoroughly  studied  by  Durham  and  the 
specificity  of  the  reaction  demonstrated.  A.  S.  Griinbaum  and  Widal  made 
the  method  available  in  clinical  work. 

Macroscopic  Method. — This  may  be  done  with  living  or  dead  organisms 
and  has  the  advantage  of  use  away  from  a  laboratory.  The  diluted  serum 
and  organisms  are  mixed  in  a  tube  of  small  calibre  (dilution  1  to  50  or  1  to 
100).  With  a  positive  reaction  there  should  be  complete  precipitation  leaving 
a  clear  fluid  above  in  twenty-four  hours. 

Microscopic  Method. — If  the  reaction  is  positive  the  bacilli  lose  their 
motility  and  collect  in  clumps.  Witir  Dreyer's  method  of  standard  cultures 
of  constant  and  known  sensitiveness  it  is  possible  to  follow  the  patient's  serum 
changes  in  typhoid  or  paratyphoid  infection.  Whatever  be  the  infection  the 
agglutination  for  that  bacillus  will  show  (a)  a  marked  rise  in  an  early  stage 
and  (&)  a  marked  fall  later  in  the  infection.  If  the  patient's  serum  already 
contains  ac^crlutinins  for  one  or  more  of  the  bacilli  (owing  to  inoculation),  the 
following  phenomena  will  be  noted  {a)  there  is  no  change  in  the  inoculation 
agglutinins  or  (h)  a  slirrht  rise  occurs,  followed  by  a  slight  fall — an  alteration 


34  SPECIFIC  INFECTIOUS  DISEASES 

which  may  be  caused  by  a  number  of  non-specific  stimuli.  A  well  marked  rise 
OT  fall  of  the  titre  is  the  only  jjositive  evidence  of  active  infection  that  can  be 
obtained  with  the  agglutination  test  and  is  probably  the  best  evidence  afforded 
by  any  test  except  a  successful  blood  culture. 

On  the  whole  the  serum  reaction  is  of  great  value,  in  spite  of  certain 
difficulties  and  objections,  and  with  the  newer  methods  the  reactions  of  equal 
importance  in  inoculated  and  uninoculated  persons  and  in  the  paratyphoids. 
(6)  Ophthalmo-Reaction. — A  solution  of  one-third  to  one-half  of  a  milli- 
gram of  "typho-protein^'  derived  from  many  different  strains  of  typhoid 
bacilli  is  instilled  into  the  conjunctival  sac.  A  typical  reaction  is  marked  by 
deep  congestion  of  the  conjunctiva  of  the  lower  lid  and  the  caruncle.  It 
reaches  its  maximum  in  six  hours.  A  positive  reaction  is  obtained  most  often 
during  the  febrile  period,  frequently  before  the  agglutination  reaction  is 
given.  The  simplicity  of  the  method  and  the  absence  of  discomfort  are 
valuable  features.    A  cutaneous  method  has  also  been  employed. 

(c)  Atropine  Test  (Marris). — The  patient  should  remain  as  quiet  as  pos- 
sible during  the  test,  which  should  not  be  done  until  at  least  an  hour  after 
the  last  feeding.  The  pulse  rate  is  counted  until  it  is  found  to  be  steady. 
Atropine  gr.  1/33  (0.002  gm.)  is  given  hypodermically,  and  25  minutes  later 
the  pulse  is  counted  each  minute  until  any  rise  which  follows  the  injection  has 
begun  to  pass  off.  The  difference  between  the  average  pulse  rate  before  the 
injection  and  the  maximum  after  it  gives  the  acceleration  due  to  the  atrojjine. 
The  highest  average  count  is  usually  about  thirty  minutes  after  the  injection. 
If  the  "escape"  is  l-I  or  less,  the  diagnosis  is  probably  typhoid  or  para-typhoid 
fever;  if  15  or  more  the  reaction  is  negative.  Three  negative  reactions  within 
the  first  fortnight  of  a  febrile  illness  exclude  the  typhoid  group.  A  negative 
reaction  after  the  end  of  the  second  week  or  when  the  fever  has  fallen  may  be 
unreliable.  This  test  is  most  useful  from  the  fifth  to  the  fourteenth  day,  but 
a  series  of  negative  reactions  later  than  the  fourteenth  day  may  be  generally 
taken  as  evidence  against  typhoid  infection.  A  positive  reaction  may  be  ob- 
tained in  those  over  fifty  years  of  age,  especially  if  arteriosclerotic.  In  patients 
with  a  pulse  rate  of  100  or  over,  a  positive  reaction  has  to  be  taken  with  caution 
and  the  test  repeated ;  a  negative  reaction  in  patients  who  are  very  toxic  is  not 
necessarily  conclusive. 

Common  Sources  op  Error  in  Diagnosis. — An  early  and  intense  localiza- 
tion of  the  infection  in  certain  organs  may  give  rise  to  doubt  at  first. 

Cases  coming  on  with  severe  headache,  photophobia,  delirium^,  twitching 
of  the  muscles  and  retraction  of  the  head  are  almost  invariably  regarded  as 
cerehro-spinal  meningitis.  Under  such  circumstances  it  may  for  a  few  days 
be  impossible  to  make  a  satisfactory  diagnosis.  The  senior  author  has  per- 
formed autopsies  on  cases  of  this  kind  in  which  no  suspicion  of  typhoid  fever 
had  been  present,  the  intense  cerebro-spinal  manifestations  having  dominated 
the  scene.  Until  the  appearance  of  abdominal  symptoms,  or  the  rash,  it  may 
be  quite  impossible  to  determine  the  nature  of  the  case.  Cerebro-spinal  menin- 
gitis is^  however,  a  rare  disease;  typhoid  fever  a  very  common  one,  and  the 
onset  with  severe  nervous  symptoms  is  by  no  means  infrequent.  The  lumbar 
puncture  is  a  great  help. 

The  misleading  pulmonary  symptoms,  which  occasionally  occur  at  the 
very  outset  of  the  disease,  have  been  mentioned.     The  bronchitis  rarely  causes 


TYPHOID  FEVER  35 

error,  though  it  may  be  intense  and  attract  the  chief  attention.  More  difficult 
are  the  cases  setting  in  with  chill  and  followed  rapidly  by  piieumonia.  Such  a 
case  may  be  shown  to  a  class  one  week  as  typical  pneumonia,  and  a  fortnight 
later  as  typhoid  fever.  There  is  less  danger  of  mistaking  the  pneumonia 
which  occurs  at  the  height  of  the  disease,  and  yet  this  is  possible,  as  in  the 
case  of  a  man  aged  seventy,  insensible,  with  a  dry  tongue,  tremor,  ecch}anoses 
upon  the  wrists  and  ankles,  no  rose-spots,  enlargement  of  the  spleen,  and  con- 
solidation of  the  right  lower  lobe.  It  was  very  natural,  particularly  since 
there  was  no  history,  to  regard  such  a  case  as  senile  pneumonia  with  profound 
constitutional  disturbance,  but  the  autopsy  showed  the  characteristic  lesions 
of  typhoid  fever.  Early  involvement  of  the  pleura  or  the  kidneys  may  for  a 
time  obscure  the  diagnosis. 

Of  diseases  with  which  typhoid  fever  may  be  confounded,  malaria,  certain 
forms  of  pyaemia,  acute  tuberculosis,  and  tuberculous  peritonitis  are  the  most 
important. 

From  malarial  fewer,  typhoid  is,  as  a  rule,  readily  recognized.  There  is 
no  such  disease  as  typho-malarial  fever — that  is,  a  separate  and  distinct  mal- 
ady. Typhoid  fever  and  malarial  fever  may  coexist  in  the  same  patient  but 
this  is  rare.  The  term  typho-malarial  fever  should  be  abandoned.  The 
autumnal  type  of  malarial  fever  may  present  a  striking  similarity  to  typhoid 
fever  and  differentiation  may  be  made  only  by  the  blood  examination.  There 
may  be  no  chills,  the  remissions  may  be  extremely  slight,  there  is  a  history 
perhaps  of  malaise,  weakness,  diarrhoea,  and  sometimes  vomiting.  The  tongue 
is  furred  and  white,  the  cheeks  flushed,  the  spleen  slightly  enlarged,  and  the 
temperature  continuous,  or  with  very  slight  remissions.  The  sestivo-autumnal 
variety  of  the  malarial  parasite  may  not  be  present  in  the  circulating  blood 
for  several  days.  Every  year  in  Baltimore  we  had  one  or  two  cases  in  which 
the  diagnosis  was  in  doubt  for  a  few  days. 

Pycemia. — The  long-continued  fever  of  obscure,  deep-seated  suppuration, 
without  chills  or  sweats,  may  simulate  typhoid.  The  more  chronic  cases  of 
ulcerative  endocarditis  are  usually  diagnosed  typhoid  fever.  The  presence  or 
absence  of  leucocytosis  is  an  important  aid.  The  Widal  reaction  and  the 
blood  cultures  offer  valuable  help. 

Acute  miliary  tuberculosis  is  not  infrequently  mistaken  for  typhoid  fever. 
The  points  in  differential  diagnosis  will  be  discussed  under  that  disease. 
Tuberculous  peritonitis  in  certain  of  its  forms  may  closely  simulate  typhoid 
fever,  and  will  be  referred  to  in  another  section. 

The  early  abdominal  pain,  etc.,  may  lead  to  the  diagnosis  of  appendicitis. 

The  mild  endemic  form  of  typhus  fever  described  by  Brill  may  be  re- 
garded as  typhoid  fever,  but  the  character  of  the  rash,  the  absence  of  the 
agglutination  reaction,  negative  results  of  blood  cultures  and  the  course  are 
against  this.     The  majority  of  cases  are  probably  diagnosed  as  typhoid  fever. 

Prognosis.— (a)  Death-rate. — The  mortality  is  very  variable,  ranging  in 
private  practice  from  5  to  12  and  in  hospital  practice  from  7  to  20  per  cent. 
In  some  large  epidemics  the  rleath-rate  has  been  very  low.  In  the  Maidstone 
epidemic  it  was  between  7  and  8  per  cent.  In  recent  years  the  mortality  from 
typhoid  fever  has  diminished,  and  hydrotherapy  has  reduced  the  death-rate 
in  a  remarkable  manner,  even  as  low  as  5  or  G  per  cent.  Of  the  1,500  cases 
in  our  series,  9.1  per  cent,  died. 


36  SPECIFIC  INFECTIOUS  DISEASES 

(&)  Special  Features. — Unfavorable  symptoms  are  high  fever,  toxic 
symptoms  with  delirium,  meteorism,  and  haemorrhage.  Perforation  renders 
the  outlook  hopeless  unless  operation  is  done  early.  Fat  subjects  stand  typhoid 
fever  badly.  The  mortality  in  women  is  greater  than  in  men.  The  complica- 
tions and  dangers  are  more  serious  in  the  ambulatory  form  in  which  the 
patient  has  kept  about  for  a  Aveek  or  ten  days.  Early  involvement  of  the 
nervous  system  is  a  bad  indication;  and  the  low,  muttering  delirium  with 
tremor  means  a  close  fight  for  life.  Prognostic  signs  from  the  fever  alone 
are  deceptive.  A  temperature  above  10J:°  may  be  well  borne  if  the  nervous 
system  is  not  involved.  The  degree  of  bacteraemia  is  of  value;  the  greater 
this  is  the  worse  the  prognosis. 

(c)  Sudden  Death. — It  is  difficult  in  many  cases  to  explain  this  most 
lamentable  of  accidents.  There  are  cases  in  which  neither  cerebral,  renal,  nor 
cardiac  changes  have  been  found;  there  are  instances  too  in  which  it  does 
not  seem  likely  that  there  could  have  been  a  special  localisation  of  the  toxins 
in  the  pneumogastric  centres.  Fibrillation  of  the  ventricle  may  be  the  cause 
in  some  cases.  Under  conditions  of  abnormal  nutrition  a  state  of  delirium 
cordis  is  sometimes  induced,  which  may  occur  spontaneously,  or,  in  the  case 
of  animals,  on  slight  irritation  of  the  heart,  with  the  result  of  extreme  irregu- 
larity and  finally  failure  of  action.  Sudden  death  occurs  more  frequently  in 
Hien  than  in  women,  according  to  Dewevre's  statistics,  in  a  proportion  of  114 
to  26.  It  may  occur  at  the  height  of  the  fever,  and,  as  pointed  out  by  Graves, 
also  during  convalescence.     There  were  four  cases  in  our  series. 

Prophylaxis. — In  cities  the  preAalence  of  typhoid  fever  is  directly  propor- 
tionate to  the  inefficiency  of  the  drainage  and  the  water-supply.  With  their 
improvement  the  incidence  has  been  reduced  materially.  Fulton  has  shown 
that  in  the  United  States,  at  least,  the  disease  exists  to  a  proportionately 
greater  extent  in  the  country  than  it  does  in  the  city,  and  that  the  propaga- 
tion is  in  general  from  the  country  to  the  town.  In  the  water-supply  of  the 
latter  the  chances  for  dilution  of  the  contaminating  fluids  are  much  greater 
than  in  the  comitry,  where  the  privy  vault  is  often  in  close  proximity  to 
the  well. 

But  it  is  not  only  through  water  that  the  disease  is  transmitted.  Other 
methods  play  an  important  though  not  so  frequent  role.  The  bacilli  may  be 
carried  by  milk,  oysters,  uncooked  vegetables,  etc.  Flies  play  an  important 
part  in  the  spread  of  the  disease.  Many  cases  undoubtedly  arise  by  direct 
infection.  But  through  whatever  channel  the  infection  occurs,  for  new  cases 
to  arise  the  bacilli  must  be  obtained  from  another  patient.  Under  ordinary 
circumstances  the  bacilli  do  not  live  and  thrive  long  outside  the  body.  To 
stamp  out  typhoid  fever  requires  (1)  the  recognition  of  all  cases,  including 
the  typhoid  carriers  and  (2)  the  destruction  of  all  typhoid  bacilli  as  they  leave 
the  patient.  It  is  as  much  a  part  of  the  physician's  duty  to  look  after  these 
points  as  to  take  care  of  the  patient.  Mild  cases  of  fever  are  to  be  regarded 
with  suspicion. 

From  the  standpoint  of  prophylaxis,  the  question  practically  narrows  down 
to  disinfection  of  the  urine,  stools,  sputum  (in  the  few  cases  where  bacilli  are 
present),  and  of  objects  which  may  be  contaminated  accidentally  by  these 
excretions.  The  nurse  or  attendant  should  be  taught  to  regard  every  specimen 
of  urine  as  a  pure  culture  of  typhoid  bacilli,  and  to  exercise  the  greatest  care 


TYPHOID  FEARER  37 

in  preventing  the  scattering  of  drops  of  urine  over  the  patient,  bedding  or 
floor,  or  over  the  hands  of  the  attendant. 

To  disinfect  the  urine  the  best  solutions  are  carbolic  acid,  1-20,  in  an 
amount  equal  to  that  of  the  urine,  or  bichloride  of  mercury,  1-1,000,  in  an 
amount  one-fifth  that  of  the  fluid  to  be  sterilized.  These  mixtures  with 
the  urine  should  stand  at  least  two  hours.  Hexamine  causes  disappearance 
of  the  bacilli  from  the  urine  when  bacilluria  is  present,  but  under  no  cir- 
cumstances should  its  administration  permit  the  disinfection  of  the  urine 
to  be  neglected.  For  the  stools,  heat  is  the  most  efficient  and  can  be  employed 
in  hospitals  by  special  hoppers  in  which  steam  is  used.  Of  solutions,  carbolic 
acid  or  freshly  prepared  milk  of  lime  is  most  useful.  The  stool  should  be 
mixed  with  at  least  thrice  its  volume  of  these  solutions  and  allowed  to  stand 
for  several  hours.  For  the  disinfection  of  the  bath  water  chloride  of  lime 
is  the  best  and  even  when  the  water  contains  coarse  fascal  matter,  250  gm, 
(one-half  pound)  of  chloride  of  lime  will  render  the  ordinary  bath  of  200 
litres  sterile  in  one-half  hour. 

If  there  be  any  expectoration,  the  sputum  should  receive  the  same  care  as 
in  tuberculosis.    It  is  best  to  collect  it  in  small  cloths,  which  may  be  burned. 

All  the  linen  from  the  patient's  bed  or  person  should  be  soaked  for  two 
hours  in  1-20  carbolic  acid  solution  or  1-2000  bichloride  solution,  and  then 
sent  to  the  laundry,  where  it  should  be  boiled.  All  dishes  should  be  boiled  be- 
fore leaving  the  patient's  room. 

The  nurse  should  wear  a  rubber  apron  when  giving  tubs  or  working  over 
a  typhoid  patient,  and  this  should  be  washed  frequently  with  a  carbolic  acid 
or  bichloride  of  mercury  solution.  The  nurse  should  wear  rubber  gloves  when 
giving  tubs,  or  else  soak  her  hands  thoroughly  in  1-1,000  bichloride  solution 
after  she  has  finished. 

It  is  impossible  here  to  deal  with  all  the  possible  modes  of  spread  of  the 
infection.  Keeping  in  mind  that  everything  leaving  the  patient  should  be 
sterilized,  a  nurse  of  ordinary  intelligence,  even  one  of  the  family,  can  carry 
out  very  satisfactory  prophylaxis.  Those  nursing  the  patient  should  not  handle 
food  for  others. 

Should  the  typhoid  fever  patient  be  isolated?  To  prevent  direct  infection 
of  others  a  moderate  degree  of  isolation  should  be  carried  out,  though  this 
need  not  be  absolute  as  in  the  exanthemata.  The  windows  should  have  fly 
screens  in  summer.    After  recovery  the  room  should  be  disinfected. 

An  important  question  is  as  to  tlie  necessity  for  the  isolation  of  typhoid 
patients  in  special  wards  in  hospitals.  At  present  this  is  not  generally  done 
in  the  United  States.  When,  however,  in  a  hospital  with  as  good  sanitary 
arrangements  as  the  Johns  Hopkins  possesses,  and  in  which  all  possible  pre- 
cautions are  taken  to  prevent  the  infection  spreading  from  patient  to  patient, 
1.8  per  cent,  of  all  the  cases  have  been  of  hospital  origin,  the  advisability  of 
isolation  of  typhoid  fever  patients  is  certainly  worth  considering.  On  the 
other  hand,  in  the  general  hospital,  with  students  in  the  wards,  the  cases  are 
more  thoroughly  studied,  and  in  the  graver  complications,  as  perforation,  it  is 
of  the  greatest  advantage  to  have  the  early  co-operation  of  the  house  surgeon. 

When  the  disease  is  prevalent  the  drinking-water  and  the  milk  should 
be  boiled.  Travellers  should  drink  mineral  water  rather  than  ordinary  water 
or  milk.     Care  should  be  taken  to  thoroughly  cook  oysters  which  have  been 


38  SPECIFIC  INFECTIOUS  DISEASES 

fattened  or  freshened  in  streams  contaminated  with  sewage.  While  in  camps 
it  is  easy  to  boil  and  filter  the  water,  with  troops  on  the  march  it  is  a  very 
different  matter.  Various  chemical  methods  have  been  recommended  of  which 
chlorination  has  proved  the  most  satisfactory. 

During  an  epidemic  the  early  recognition  of  all  cases  followed  by  isolation 
and  thorough  disinfection  is  most  important.  Preventive  inoculation  should 
be  given  as  generally  as  possible.  Every  effort  should  be  made  to  find  the 
source  of  infection  with  a  thorough  search  for  carriers,  especially  in  local 
outbreaks.  In  the  search  for  carriers  the  agglutination  test  is  not  sufficient 
and  cultural  studies  of  the  contents  of  the  duodenum,  of  the  faeces  and  urine 
should  be  made. 

Protective  Inoculation. — Introduced  by  Wright  this  has  proved  of 
inestimable  value  in  reducing  the  occurrence  of  typhoid  fever.  The  experi- 
ence of  the  European  War  gives  ample  proof  of  this.  The  material 
used  is  a  bouillon  or  agar  culture  of  bacilli  heated  to  a  temperature  of  53° 
to  55°  C.  in  order  to  kill  them.  Lysol  or  tricresol  may  be  added.  Three 
inoculations  are  given  at  intervals  of  ten  days.  The  use  of  a  sensitized  vaccine 
has  some  advantages. 

A  triple  vaccine  against  typhoid  and  paratyphoid  A  and  B  should  be 
used.  Untoward  results  are  rare.  Of  31,000  inoculated  at  the  Valcartier 
camp,  Quebec,  only  one  had  a  local  abscess  and  there  were  no  serious  sequels. 
The  inoculation  fever  begins  in  from  four  to  six  hours  and  may  reach  101° 
or  even  103°  to  104°.  Headache,  chilliness,  pains  in  the  back  and  limbs, 
and  vomiting  may  occur.  In  many  there  is  only  a  transient  indisposition. 
More  severe  symptoms  may  occur,  such  as  arthritis,  fugitive  erythema,  diar- 
rhoea, abdominal  pains,  septicasmia,  with  pneumonia,  pleurisy  and  pericarditis. 
In  a  few  cases  a  fever  resembling  typhoid  has  followed.  No  case  of  a  fatality 
due  directly  to  the  inoculation  was  found.  A  light  diet,  avoidance  of  stimulants 
and  rest  lessen  the  possibility  of  serious  sequels.  The  evidence  so  far  points 
to  a  persistence  of  the  protective  effect  for  at  least  two  years  after  inoculation. 
The  typ.hoidin  skin  reaction  is  a  guide  to  the  duration  of  immunity.  If  in- 
fection results  after  proper  inoculation  it  is  probably  due  to  a  very  large  dose 
of  typhoid  bacilli. 

Treatment. — (a)  General  Management.^ — The  profession  was  long  in 
learning  that  typhoid  fever  is  not  a  disease  to  be  treated  mainly  with  drugs. 
Careful  nursing,  a  proper  diet,  and  hydrotherapy  are  the  essentials  in  a 
majority  of  cases.  The  patient  should  be  in  a  well- ventilated  room  (or  in 
summer  out  of  doors  during  the  day),  strictly  confined  to  bed  from  the  outset, 
and  there  remain  until  convalescence  is  well  established.  The  bed  should  be 
single,  not  too  high,  and  the  mattress  should  not  be  too  hard.  The  woven 
wire  bed,  with  soft  hair  mattress,  upon  which  are  two  folds  of  blanket,  com- 
bines the  two  great  qualities  of  a  sick-bed,  smoothness  and  elasticity.  A 
rubber  cloth-  should  be  placed  under  the  sheet.  An  intelligent  nurse  should 
be  in  charge.  When  this  is  impossible,  the  physician  should  write  out  specific 
instructions  regarding  diet  and  treatment  of  the  discharges  and  bed-linen. 

(&)  Diet. — More  liberality  is  now  generally  practised,  as  was  advised 
years  ago  by  Austin  Flint  and  strongly  supported  by  Shattuck,  Kinnicutt  and 
ethers.  The  patient  should  be  nourished  as  well  as  possible  and  food  given 
with  a  value  of  3,500  to  3,000  calories  and  containing  about  70  grams  of 


TYPHOID  FEVER  39 

protein  if  conditions  permit.  The  bulk  of  the  food  should  be  liquid  and  milk 
or  its  modifications  form  the  largest  part.  Milk  in  any  form,  cream,  ice 
cream,  cocoa,  tea  or  coffee  with  cream,  strained  soups,  eggs,  either  the  white 
or  the  whole  egg,  raw  or  soft  boiled,  gruels  and  jellies  may  be  given.  The 
milk  may  be  boiled  or  diluted,  or  some  modification  given — peptonised  milk, 
fermented  milk,  malted  milk,  buttermilk  or  whey.  Soft  food  is  often  permis- 
sible, such  as  milk  toast,  custard,  junket,  crackers  and  milk,  bread  and  butter, 
and  mashed  potatoes.  It  is  important  to  give  carbohydrate  freely  to  spare 
the  body  proteins,  and  this  is  aided  by  the  addition  of  milk  sugar  to  the  diet ; 
it  can  be  given  with  each  feeding  of  milk.  Cane  sugar  can  also  be  given  freely. 
The  food  should  be  chosen  for  each  patient  and  a  routine  diet  not  allowed. 
In  case  of  digestive  disturbance — undigested  food  in  the  stools,  diarrhoea, 
meteorism — the  diet  should  be  made  very  simple,  buttermilk,  whey,  peptonised 
milk  or  albumin  water  usually  being  suitable.  The  beef  extracts,  meat  juices, 
and  artificially  prepared  foods  are  unnecessary,  and  sometimes  harmful. 
Water  should  be  given  freely  at  fixed  intervals.  A  good  plan  is  to  have  a 
jug  of  water  beside  the  patient  and  tubing  with  a  glass  mouthpiece,  so  that 
he  can  drink  as  much  as  he  wishes.  It  is  desirable  to  have  the  patient  take 
at  least  four  litres  of  water  daily  and  larger  amounts  are  an  advantage.  This 
causes  polyuria,  and  is  a  sort  of  internal  hydrotherapy  by  which  the  toxins 
are  washed  out.  Barley  water,  lemonade,  soda  water,  or  iced-tea  may  be  used. 
It  is  doubtful  if  alcohol  is  of  any  value  except  when  the  addition  of  small 
amounts  enables  the  patient  to  take  nourishment  more  freely. 

Special  care  must  be  given  to  the  mouth,  which  should  be  cleaned  after 
each  feeding.  A  mouth  wash  should  be  used  freely  (such  as  phenol  3  i,  4 
c.  c,  glycerine  §  i,  30  c.  c,  and  boric  acid,  saturated  solution,  to  5  ^,  300-c,  c). 

(c)  Hydrotherapy. — The  use  of  water,  inside  and  outside,  was  no  new 
treatment  in  fevers  at  the  end  of  the  eighteenth  century,  when  James  Currie 
(a  friend  of  Burns  and  the  editor  of  his  poems)  wrote  his  Medical  Reports 
on  the  Effects  of  Water,  Cold  and  Warm,  as  a  Remedy  in  Fevers  and  other 
Diseases,  In  the  United  States  it  was  used  with  great  effect  and  recommended 
strongly  by  Nathan  Smith,  of  Yale,  Since  1861  the  value  of  bathing  in  fevers 
has  been  specially  emphasized  by  the  late  Dr,  Brand,  of  Stettin. 

Hydrotherapy  may  be  carried  out  in  several  ways,  of  which,  the  most 
satisfactory  are  sponging,  the  wet  pack,  the  ice  rub,  and  the  full  bath. 

(1)  Cold  Sponging. — The  water  may  be  tepid  or  cold,  according  to  the 
height  of  the  fever.  A  thorough  sponge-bath  should  take  from  fifteen  to 
twenty  minutes.  The  cold  sponging  and  the  ice-rub  are  not  quite  as  for- 
midable as  the  full  bath,  for  which,  when  there  is  an  insuperable  objection  in 
private  practice,  they  are  excellent  alternatives.  But  frequently  it  is  difficult 
to  get  the  friends  to  appreciate  the  advantages  of  the  sponging.  When  such 
is  the  case,  and  in  children  and  delicate  persons,  it  can  be  made  a  little  less 
formidable  by  sponging  limb  by  limb  and  then  the  back  and  abdomen. 

(2)  The  cold  pack  is  not  so  generally  useful  in  typhoid  fever,  but  in  cases 
with  very  pronounced  nervous  symptoms,  if  the  tub  is  not  available,  the 
patient  may  be  wrapped  in  a  sheet  wrung  out  of  water  at  00°  or  65°,  and 
then  cold  water  sprinkled  over  him  with  an  ordinary  watering-pot. 

(3)  The  Bath. — The  tub  should  be  long  enough  so  that  the  patient  can 
be  completely  covered  except  his  head.    Our  rule  has  been  to  give  a  bath  every 


40  SPECIFIC  INFECTIOUS  DISEASES 

third  hour  when  the  temperature  was  above  102.5°.  The  patient  remains  in 
the  tub  for  tifteen  or  twenty  minutes^  is  taken  out,  wrapped  in  a  dry  sheet, 
and  covered  with  a  blanket.  While  in  the  tub  the  limbs  and  trunk  are  rubbed 
thoroughly,  either  with  the  hand  or  with  a  suitable  rubber.  It  is  well  to  give 
the  first  one  or  two  baths  at  a  temperature  of  80°  to  85°.  There  is  no  routine 
temperature  and  that  between  70°  and  85°  which  suits  best  is  chosen.  It  is 
important  to  see  that  the  canvas  supports  are  properly  arranged,  and  that  the 
rubber  pillow  is  comfortable  for  the  patient's  head.  The  amount  of  complaint 
made  by  the  patient  is  largely  dependent  upon  the  skill  and  care  with  which 
the  baths  are  given.  The  blueness  and  shivering,  which  may  follow  the  bath, 
are  not  serious  features.  The  rectal  temperature  is  taken  immediately  after 
the  bath,  and  again  three-quarters  of  an  hour  later.  Contra-indications  are 
peritonitis,  hsemorrhage,  phlebitis,  abdominal  pain,  and  great  prostration. 

The  good  effects  of  the  baths  are:  (i)  The  influence  on  the  nervous  sys- 
tem; delirium  lessens,  tremor  diminishes  and  toxic  features  are  less  marked, 
(ii)  Increased  excretion  of  toxins  by  the  kidney,  (iii)  The  tonic  effect  on 
the  circulation;  the  heart  rate  falls,  the  jDulse  becomes  smaller  and  harder, 
and  the  blood  pressure  rises.  Vaso-motor  paresis  is  lessened,  (iv)  With 
hydrotherapy  the  initial  bronchitis  is  benefited,  and  there  is  less  chance  of 
passive  congestion  of  the  bases  of  the  lungs,  (v)  The ' liability  to  bed-sores 
is  diminished  and  the  frequent  cleansing  of  the  skin  is  beneficial.  The 
addition  of  half  a  pound  of  alum  to  the  water  is  an  advantage.  Should  boils 
occur,  one  bath-tub  should  be  used  for  that  patient  alone,  (vi)  Reduction 
of  the  temperature  may  occur  but  is  not  an  important  effect,  (vii)  The  mor- 
tality is  reduced.  In  general  hospitals  from  six  to  eight  patients  in  every 
hundred  are  saved  by  this  plan  of  treatment.  At  the  Brisbane  Hospital, 
where  F.-E.  Hare  used  it  so  thoroughly,  the  mortality  was  reduced  from  14.8 
to  7.5  per  cent.  There  is  a  remarkable  uniformity  in  the  death-rate  of  institu- 
tions using  the  method — usually  from  6  to  8  per  cent. 

(d)  Medicinal  Tre^atment. — There  is  no  specific  drug  treatment,  but 
it  is  usually  advisable  to  give  hexamine  after  the  second  week,  twenty  to  thirty 
grains  (1.3  to  2  gm.)  daily.  In  private  practice  it  may  be  safer,  for  the  young 
practitioner  especially,  to  order  an  acid  or  a  mild  fever  mixture.  The  ques- 
tion of  medicinal  antipyretics  is  important :  they  are  used  far  too  often  and 
too  rashly  in  typhoid  fever.  An  occasional  dose  may  do  no  harm  but  the  daily 
use  of  these  drugs  is  most  injurious.  Quinine  in  moderate  doses  is  sometimes 
given  but  its  value  is  doubtful.  In  the  various  antiseptic  drugs  which  have 
been  advised  we  have  no  faith.  Most  of  them  do  no  harm,  except  that  in 
private  practice  their  use  has  too  often  diverted  the  practitioner  from  more 
rational  and  safer  courses. 

(e)  Vaccine  and  Serum  Ther.a.py. — Treatment  by  vaccines  during  the 
height  of  the  disease  is  still  in  an  experimental  stage.  Various  forms  of  vac- 
cines are  used  and  given  subcutaneously  or  intravenously.  Doses  varying  from 
50  to  500  million  bacilli  are  given,  usually  three  or  four  days  apart.  A  mod- 
erate reaction  should  be  produced.  As  patients  react  very  differently,  the 
smaller  doses  are  safer  at  first,  especially  if  given  iutravenously.  Gay  reports 
good  results  from  the  intravenous  injection  of  sensitized .  vaccine  sediment. 
His  initial  dose  is  1/50  mg.,  corresponding  to  150  million  bacteria.  In  long- 
continued  attacks  when  progress  is  slow,  for  complications  due  to  the  presence 


TYPHOID  FEVER  41 

of  typhoid  bacilli  in  organs  or  tissues,  and  for  carriers,  vaccine  therapy  is 
helpful.     No  serum  of  proved  value  has  been  obtained. 

(/)  Treatment  of  Special  Symptoms. — For  severe  toxcemia  water  should 
be  given  freely  by  mouth  if  possible,  otherwise  by  the  bowel  or  subcutaneously. 
Hydrotherapy  should  be  used  actively,  best  by  tub  baths.  For  headache  and 
delirium  an  ice-bag  or  cold  compresses  should  be  kept  to  the  head.  If  the 
patient  is  delirious  and  restless  a  dose  of  morphia  hypodermically  is  the 
best  treatment.  Lumbar  puncture  is  also  useful,  the  fluid  being  allowed  to 
run  as  long  as  it  flows  under  pressure.  Every  delirious  patient  should  be  con- 
stantly watched.  It  is  important  to  secure  sleep  for  these  patients,  for  which 
morphia  is  most  reliable.  Hydrotherapy,  internal  and  external,  is  our  great- 
est aid  in  the  treatment  of  the  nervous  conditions.  The  abdominal  pain  and 
tympanites  are  best  treated  with  fomentations  or  turpentine  stupes.  The  lat- 
ter, if  well  applied,  give  great  relief.  Sir  William  Jenner  used  to  lay  great 
stress  on  the  advantages  of  a  well-applied  turpentine  stupe.  He  directed  it 
to  be  applied  as  follows :  A  flannel  roller  was  placed  beneath  the  patient,  and 
then  a  double  layer  of  thin  flannel,  wrung  out  of  very  hot  water,  with  a  dram 
of  turpentine  mixed  with  the  water,  was  applied  to  the  abdomen  and  covered 
with  the  ends  of  the  roller.  When  the  stomach  is  greatly  distended  the  pas- 
sage of  a  stomach  tube  gives  relief.  When  the  gas  is  in  the  large  bowel,  a 
rectal  tube  may  be  passed  or  a  turpentine  enema  given.  For  tympanites, 
with  a  dry  tongue,  turpentine  may  be  given,  nx  xv  ( 1  c.  c. )  every  three  hours. 
If  whey  and  albumen-water  are  substituted  for  milk,  the  distention  lessens, 
Pituitary  extract  or  eserine  V50  gr.  (0.0013  gm.)  hypodermically,  may  be 
tried.     Opium  should  not  be  given. 

For  the  diarrhoea,  if  severe — that  is,  if  there  are  more  than  three  or  four 
stools  daily — a  starch  and  opium  enema  may  be  given;  or,  by  the  mouth,  a 
combination  of  bismuth,  in  large  doses,  with  Dover's  powder;  or  the  acid 
diarrhoea  mixture,  acetate  of  lead  (gr,.  ii,  0.13  gm.),  dilute  acetic  acid  (TTt  xv, 
1  c.  c),  and  acetate  of  morphia  (gr.  ^/g,  0.01  gm.).  Repeated  saline  irrigations 
are  sometimes  helpful.  The  amount  of  food  should  be  reduced,  and  whey  and 
albumen-water  in  small  amounts  substituted  for  the  milk.  An  ice-bag  or  cold 
compresses  relieve  the  soreness  which  sometimes  accompanies  diarrhoea. 

Constipation  is  present  in  many  cases  and  it  is  well  to  give  an  ordinary 
enema  every  second  day.  The  addition  of  turpentine  (§  ss,  15  c.  c.)  is  advisa- 
ble if  there  is  meteorism. 

Hcemorrhage. — As  absolute  rest  is  essential,  the  greatest  care  should  be 
taken  in  the  use  of  the  bed-pan.  It  is  perhaps  better  to  allow  the  patient  to 
pass  the  m.otions  into  a  large  pad.  Ice  may  be  given  and  a  light  ice-bag 
placed  on  the  abdomen.  The  amount  of  food  should  be  restricted  for  eight 
or  ten  hours.-  If  there  is  a  tendency  to  collapse,  stimulants  should  be  given, 
and,  if  necessary,  hypodermic  injections  of  camphor  (gr.  iii,  0.2  gm.  in 
oil).  Injection  of  salt  solution  beneath  the  skin  or  into  a  vein  may  revive  a 
failing  heart,  but  should  only  be  done  in  case  of  emergency.  Turpentine 
is  warmly  recommended  by  certain  authors.  Should  opium  be  given?  One- 
fifth  of  the  cases  of  perforation  occur  with  hii?morrhagc,  and  the  opium  may 
obscure  the  features  upon  which  alone  the  diagnosis  of  perforation  may  bo 
made.     Opium  increases  any  tendency  to  tympanites.     We  have  abandoned 


42  SPECIFIC  INFECTIOUS  DISEASES 

the  use  of  opium.  The  injection  of  human  or  horse  serum  (10  to  20  e.  c.) 
is  sometimes  of  value.     Transfusion  should  be  done  in  serious  cases. 

Perforation  and  Peritonitis. — Early  diagnosis  and  early  operation  mean 
the  saving  of  one-third  of  the  cases  of  this  otherwise  fatal  complication.  The 
aim  should  be  to  operate  for  the  perforation,  and  not  to  wait  until  a  general 
peritonitis  diminishes  the  chances  of  recovery.  An  incessant,  intelligent 
watchfulness  on  the  part  of  the  medical  attendant  and  the  early  co-operation 
of  the  surgeon  are  essentials.  Every  case  of  more  than  ordinary  severity  should 
be  watched  with  special  reference  to  this  complication.  Thorough  prepara- 
tion by  early  observation,  careful  notes,  and  knowledge  of  the  conditions  will 
help  to  prevent  needless  exploration.  Xo  case  is  too  desperate;  we  had  a 
recovery  after  three  operations.  Twenty  cases  of  perforation  in  our  series  were 
operated  upon  with  seven  recoveries;  in  an  eighth  case  the  patient  died  of 
toxaemia  on  the  eighth  day  after  the  laparotomy.  In  doubtful  cases  it  is  best 
to  operate,  as  experience  shows  that  patients  stand  an  exploration  very  well. 

Cholecystitis. — A  majority  of  the  cases  recover,  but  if  the  symptoms  are 
very  severe  and  progressive,  operation  should  be  advised.  For  chronic  chole- 
cystitis hexamine  should  be  given  in  large  doses  and  the  vaccine  treatment 
employed. 

With  signs  of  failure  of  the  circulation,  hydrotherapy  should  be  carried 
on  actively  and  strychnine  given  hypodermically  (gr,  Vso  to  V20,  0.001  to 
0.003  gm.)  every  three  hours.  Saline  infusions  (500  c.  c.)  are  useful  espe- 
cially if  the  patient  is  not  taking  much  water  by  mouth.  Digitalis  may  be 
given  as  the  tincture  (n\  xv,  1  c.  c.)  but  if  collapse  or  severe  symptoms  occur, 
strophanthin  gr.  Vioo  (0.00065  gm.)  intramuscularly  or  intravenously  is  bet- 
ter. For  collapse,  camphor  (gr.  ii,  0.13  gm.)  or  epinephrine  (nx  xv,  1  c.  c.) 
should.be  given  intramuscularly.  The  bath  treatment  is  the  best  preventive 
of  circulatory  failure.  For  phlebitis  the  limb  should  be  kept  absolutely  at  rest 
and  wrapped  in  raw  cotton.  The  application  of  a  sedative  lotion  may  relieve 
pain. 

Bacilluria. — When  bacilli  are  present,  hexamine  may  be  given  in  ten-grain 
(0.65  gm.)  doses  and  kept  up,  if  necessary,  for  several  weeks.  If  the  urine 
is  alkaline  sodium  benzoate  gr.  x  (0.6  gm.)  should  be  added.  A  patient  should 
not  be  discharged  with  bacilli  in  his  urine.  Pyelitis  should  be  treated  in 
the  same  way,  large  amounts  of  water  being  given.  For  cystitis,  irrigations 
of  bichloride  of  mercury  (1/100,000  solution  and  gradually  increased  in 
strength)  may  be  given. 

For  orchitis,  mastitis,  parotitis,  etc.,  an  ice-bag  should  be  applied.  In- 
cision and  drainage  are  advisable  on  the  first  signs  of  suppuration.  Vaccine 
treatment  may  be  helpful. 

In  protracted  cases  special  care  should  be  taken  to  guard  against  bed-sores. 
Absolute  cleanliness  and  careful  drying  of  the  parts  after  an  evacuation  should 
be  enjoined.  Pressure  should  be  avoided  by  the  use  of  rubber  rings.  The 
patient  should  be  turned  from  side  to  side  and  propped  with  pillows,  and  the 
back  sponged  with  alcohol. 

Bone  Lesio7is.—The  use  of  a  typhoid  vaccine  is  well  worthy  of  trial.  Ty- 
phoid periostitis  does  not  always  go  on  to  suppuration,  though,  as  a  rule,  it 
requires  o|)eration.     This  should  be  done  very  thoroughly  and  the  diseased 


PAKATYPHOID  FEVEE  43 

parts  completely  removed,  as  otherwise  recurrence  is  inevitable.  Eor  typhoid 
spine  fixation  by  a  plaster  jacket  or  some  form  of  apparatus  is  advisable. 
Trauma  should  be  guarded  against.  In  the  milder  cases  active  counter-irri- 
tation is  useful.     If  pain  is  severe,  large  doses  of  sedatives  are  necessary. 

(g)  Convalescence. — The  diet  can  be  gradually  increased,  but  it  is  usu- 
ally best  to  wait  at  least  a  week  after  the  temperature  is  normal  before  giving 
ordinary  meats  or  coarse  vegetables.  Solid  food  sometimes  disagrees  if  it  is 
given  too  early.  Whether  an  error  in  diet  may  cause  relapse  is  doubtful. 
The  patient  may  be  allowed  to  sit  up  for  a  short  time  about  the  end  of  the 
first  week  of  convalescence,  and  the  period  may  be  prolonged  with  a  gradual 
return  of  strength.  He  should  move  about  slowly,  and  when  the  weather  is 
favorable  should  be  in  th  open  air  as  much  as  possible.  He  should  be  guarded 
at  this  period  against  all  unnecessary  excitement.  Emotional  disturbance 
not  infrequently  is  the  cause  of  recrudescence  of  the  fever.  Constipation  is 
not  uncommon  in  convalescence  and  is  best  treated  by  enemata.  A  pro- 
tracted diarrhoea,  which  is  usually  due  to  ulceration  in  the  colon,  may  retard 
recovery.  In  such  cases  the  diet  should  be  restricted  to  milk  and  the  patient 
confined  to  bed;  large  doses  of  bismuth  and  astringent  injections  will  prove 
useful.  The  recrudescence  of  the  fever  does  not  require  special  measures. 
The  treatment  of  the  relapse  is  essentially  that  of  the  original  attack. 

Post-typhoid  insanity  requires  the  judicious  care  of  an  expert.  The  cases 
usually  recover.  The  swollen  leg  after  phlebitis  is  a  source  of  great  worry. 
A  bandage  or  a  well-fitting  elastic  stocking  should  be  worn  during  the  day. 
The  outlook  depends  on  the  completeness  with  which  the  collateral  circulation 
is  established.     In  a  good  many  cases  there  is  permanent  disability. 

The  post-typhoid  neuritis,  a  cause  of  much  alarm  and  distress,  usually 
gets  well,  though  it  may  take  months,  or  even  a  couple  of  years,  before  the 
paralysis  disappears.  After  the  subsidence  of  the  acute  symptoms  systematic 
massage  of  the  paralyzed  and  atrophic  muscles  is  the  best  treatment. 

Typhoid  Carriers. — Treatment  of  these  is  difficult.  Hexamine  should  be 
given  persistently  and  in  large  doses.  Drainage  or  removal  of  the  gall  bladder 
and  X-ray  exposures  over  it  have  been  successful  in  some  cases.  The  employ- 
ment of  an  autogenous  vaccine  offers  the  best  chance  of  success.  Doses  increas- 
ing from  25  to  1,000  or  1,500  million  bacilli  are  given  at  intervals  of  10  days. 
Carriers  should  not  be  allowed  to  handle  or  prepare  food. 

Lastly,  no  patient  should  be  discharged  from  observation  until  we  are  cer- 
tain that  he  can  not  infect  others. 


II.     PARATYPHOID  FEVER 

Definition. — An  acute  infection  caused  by  the  Bacillus  paratyphosus  A 
and  B,  which  are  closely  related  to  the  typhoid  bacillus  and  cause  a  clinical 
picture  much  like  typhoid  fever. 

Historical. — In  1896  Achard  and  Bensaude  reported  a  case  of  "typhoid 
fever"  in  which  they  found  an  organism  which  was  not  B.  typhosus  and  to 
which  they  gave  the  name  of  paratyphoid.  In  1898  Gwyn  isolated  an  organism 
to  which  he  gave  the  name  of  paracolon  bacillus.  In  1902  Buxton  described  the 
two  varieties  A  and  B.     Since  then  many  reports  on  this  disease  have  been 


M  SPECIFIC  INFECTIOUS  DISEASES 

made  and  the  experience  of  the  great  war  added  much  to  our  knowledge  of 
these  infections. 

Occurrence. — Before  the  recent  war  paratyphoid  A  was  more  common  in 
the  United  States  and  paratyphoid  B  in  Europe.  During  tlie  recent  war 
the  relative  proportions  have  varied  in  different  places^  hut  as  a  rule  the  B 
form  has  been  the  more  common.  As  regards  the  relative  incidence  of  typhoid 
and  paratyphoid  fever  in  soldiers,  one  army  series  of  4,218  cases  showed  1,684 
of  typhoid  and  2,534  of  paratyphoid  fever,  and  in  another  series  of  5,700 
cases,  93  per  cent,  were  paratyphoid.  The  inoculation  in  the  majority  had 
been  against  typhoid  fever  only. 

Etiology. — The  paratyphoid  organisms  difEer  from  B.  typhosus  in  cultural 
and  agglutination  properties.  The  A  form  is  nearer  to  the  typhoid  bacillus 
and  the  B  form  closer  to  B.  suipestifer  and  enteritidis.  The  general  problems 
of  infection  are  the  same  as  those  of  typhoid  fever  with  particular  importance 
on  the  part  played  by  carriers,  especially  in  paratyphoid  B.  The  B  form  at 
times  occurs  with  .outbreaks  of  meat  poisoning. 

Pathology. — The  toxins  of  the  paratyphoid  organisms  do  not  show  the 
same  tendency  to  attack  lymphoid  tissues  as  the  toxin  of  the  typhoid  bacillus 
and  appear  to  cause  a  greater  variety  of  lesions  elsewhere.  As  there  is  a  bac- 
tersemia  there  is  a  possibility  of  any  part  of  the  body  being  attacked.  In  gen- 
eral the  intestinal  lesions  are  much  like  those  of  typhoid  fever  but  show  a 
tendency  to  superficial  necrosis  rather  than  to  deep  ulceration.  In  some  cases 
the  intestines  are  acutely  inflamed  without  involvement  of  the  lymphoid  tis- 
sue. Some  statistics  suggest  that  the  colon  frequently  shows  ulceration. 
Haemorrhage  and  perforation  are  not  so  common  as  in  typhoid  fever.  There 
are  several  forms :  ( 1 )  A  septicaemia  with  little  or  no  change  in  the  bowels ; 
(2)  cases  not  distinguishable  from  ordinary  typhoid;  (3)  a  dysenteric  form, 
in  which  the  lesions  are  chiefly  in  the  large  bowel,  and  (4)  cases  in  which 
the  lesions  are  particularly  in  one  part  of  the  body.  In  Dawson  and  Whit- 
tingdon's  study  of  17  fatal  cases,  in  10  the  large  bowel  was  involved. 

Symptoms.— TYiQ  average  incubation  period  is  about  ten  days  and  an  acute 
onset  is  common.  Headache  and  abdominal  pain  may  occur  at  the  onset, 
to  be  followed  by  the  usual  signs  of  an  infection,  malaise,  chilly  sensations, 
and  general  pains.  Bronchitis  is  common  early  in  the  attack.  The  clinical 
features  are  variable,  as  in  typhoid  fever,  and  various  forms  have  been  de- 
scribed depending  on  the  predominant  symptoms,  such  as  typhoid,  septicgemic, 
dysenteric,  biliary,  urinary,  respiratory,  arthritic,  etc.  Apathy  is  often 
marked,  especially  early,  and  severe  headache  is  common.  The  striking  point 
about  the  fever  curve  is  the  irregularity.  It  may  be  of  the  classical  typhoid 
type  with  remissions  beginning  about  the  end  of  the  second  week,  the  duration 
of  fever  may  be  short,  there  may  be  constant  remissions  or  the  fever  may  be 
irregular  throughout.  The  pulse  rate  is  usually  slow  and  with  a  rising  tem- 
perature may  be  a  suggestive  point.  The  blood  pressure  is  usually  low.  The 
rash  is  generally  like  the  roseola  of  typhoid  fever,  but  sometimes  consists  of 
large  irregular  spots,  raised  and  not  fading  completely  on  pressure,  leaving 
areas  of  pigmentation.  It  is  sometimes  general.  Sweating  is  common  espe- 
cially in  patients  with  a  remittent  type  of  fever.  The  spleen  is  usually  en- 
larged. Intestinal  disturbance  may  be  marked,  more  particularly  at  the  onset, 
especially  in  the  B  form.     Haemorrhage  is  rarely  profuse  and  perforation  is 


COLON  BACILLUS  INFECTIONS  45 

rare.  Relapse  rarely  occurs.  The  course  as  a  rule  is  shorter  than  in  typhoid 
fever.  Some  writers  comment  on  the  slow  improvement  after  the  acute  fea- 
tures are  over  and  emphasize  mental  depression  in  convalescence. 

Complications. — These  are  much  like  those  of  typhoid  fever  with  more 
tendency  to  involvement  of  the  respiratory  tract,  jaundice  with  infection  of 
the  bile  passages,  nephritis,  abscess  formation  and  arthritis.  The  sequelae  are 
the  same  as  typhoid  fever,  even  to  the  bone  lesions. 

Diagnosis. — For  practical  purposes  typhoid  and  paratyphoid  fever  may  be 
considered  as  one  disease ;  clinically  the  diagnosis  is  based  on  the  same  findings 
and  only  a  bacteriological  diagnosis  can  be  regarded  as  absolutely  beyond 
doubt.    The  agglutination  tests  are  fairly  reliable  if  markedly  positive. 

Prognosis. — In  civil  life  the  death  rate  is  very  low,  about  one  per  cent.,  but 
in  the  armies  it  has  been  higher. 

Prophylaxis. — This  is  the  same  as  for  typhoid  fever  and  the  use  of  preven- 
tive inoculation  has  had  the  same  success.  The  triple  vaccine  (typhoid  and 
both  paratyphoids)  should  be  used.  The  importance  of  carriers  should  be 
kept  in  mind. 

Treatment. — This  is  the  same  as  in  typhoid  fever. 


III.     COLON  BACILLUS  INFECTIONS 

The  colon  bacillus,  or  more  properly  speaking  the  group  of  colon  bacilli, 
in  their  biological  and  pathological  peculiarities  are  closely  related  to  the 
organisms  of  the  typhoid  group.  Normal  inhabitants  of  the  intestines,  where 
in  all  probability  they  serve  a  useful  function,  the  Bacillus  coli  communis 
may  be  taken  as  the  typical  member  of  the  group.  There  are  great  difficulties 
in  determining  the  extent  of  the  lesions  caused  by  this  organism,  which  varies 
extraordinarily  in  virulence.  To  it  has  been  attributed  a  host  of  maladies  from 
appendicitis  to  old  age,  but  more  conservative  pathologists  limit  very  much  its 
pathogenic  scope.  It  is  not  easy  to  separate  the  effects  of  the  B.  coli  from 
those  of  other  organisms  with  which  it  is  so  often  associated.  The  needful 
bacteriological  distinction  must  be  considered  in  connection  with  agglutina- 
tion tests. 

Eecognized  infections  may  be  classed  as  follows: 

A.  General  Haemic  Infections. — There  are  several  groups  of  cases: 

(a)  Terminal  Infections. — After  death  the  colon  bacillus  swarms  in  the 
body,  invading  the  blood  and  contaminating  all  parts.  In  protracted  illnesses, 
in  acute  intestinal  and  peritoneal  affections  it  may  be  present  in  the  blood 
some  time  before  death  and  may  be  responsible  for  the  terminal  fever. 

(6)   Cases  running  a  course  resembling  typhoid  fever. 

(c)   Cases  of  general  infection  with  secondary  abscesses. 

{d)   Secondary  infection  in  other  diseases,  as  for  example  typhoid  fever. 

B.  Sub-infections. — x\dami  suggested  that  a  number  of  chronic  diseases 
have  their  origin  in  a  mild,  continuous  infection  with  7:>.  coll  and  he  brought 
forward  evidence  to  show  that  such  affections  as  ansmia  and  cirrhosis  of  the 
liver  may  be  due  to  it.  Metchnikoff  induced  the  lesions  of  early  cirrhosis 
and  of  arterio-sclerosis  by  administering  the  products  of  the  growth  of  the 
B.  coli.     The  question  is  far  from  settled. 


46  SPECIFIC  INFECTIOUS  DISEASES 

C.  Local  Infections. — Here  we  are  on  safer  ground  and  have  definite 
lesions  produced  by  the  organism. 

(a)  Peritonitis. — In  perforation  of  the  bowel,  in  strangulated  hernia,  in 
obstruction,  in  various  types  of  ulcer,  the  associated  peritonitis  may  be  due 
to  B.  coli. 

(h)  Cholecystitis  and  cholangitis,  either  of  the  simple  catarrhal  type  or 
suppurative,  may  be  caused  by  it. 

(c)  Infection  of  the  Urinary  Tract. — The  bladder  and  the  pelvis  of  the 
kidneys  are  chiefly  affected.  There  are  three  possible  channels  of  infection — 
by  the  ureter,  the  blood  stream,  and  the  lymphatics.  Hsematogenous  infection 
is  the  most  common  but  lymphatic  infection  from  the  bowel  plays  an  im- 
portant role  in  many  cases.  Bowel  troubles  have  been  present,  constipation 
or  diarrhoea,  and  with  very  slight  abrasion  of  the  mucosa  of  the  colon  the 
bacilli  may  enter  the  lymphatics.  An  interesting  point  is  the  relative  fre- 
quency of  involvement  of  the  right  kidney;  Franke  states  that  the  csecum 
and  ascending  colon  are  connected  by  a  train  of  lymphatics  with  the  right 
kidney,  an  anatomical  communication  not  present  with  the  left.  There  are 
several  groups  of  cases.  (1)  In  children,  in  whom  it  seems  by  no  means 
uncommon.  In  Jeffrey's  study  of  60  cases  at  the  Hospital  for  Sick  Children 
a  large  proportion  occurred  in  females  (53).  Death  followed  in  9  cases.  (2) 
In  connection  with  pregnancy.  The  cases  are  common  and  important  and 
may  occur  at  any  time  during  pregnancy  or  follow  delivery.  The  pelvis  of 
the  right  kidney  is  most  often  attacked.  (3)  As  a  secondary  infection  in 
other  diseases,  especially  typhoid  fever.  (4)  The  group  of  cases  in  adults, 
men  and  women^  in  whom,  without  any  obvious  cause,  and  in  the  majority 
of  cases  without  any  previous  intestinal  trouble,  acute  pyelitis  or  pyelocystitis 
comes  on.  The  infection  is  obstinate  and  very  difficult  to  treat.  A  distressing 
sequel  is  a  chronic  arthritis.  In  one  instance  the  condition  was  very  similar 
to  that  of  a  gonorrhoeal  synovitis  and  peri-arthritis.  The  clinical  picture 
presents  nothing  peculiar.  (5)  Cystitis  and  urethritis  in  newly  married 
women  are  sometimes  due  to  colon  infection.  Care  should  be  taken  not  to 
regard  them  as  gonorrhoeal. 

(d)  Intestines. — To  the  hacillus  coli  almost  all  the  diseases  of  the  bowels 
from  ulcers  of  the  duodenum  to  appendicitis  have  been  attributed.  Ulcers 
of  the  stomach  and  of  the  duodenum  have  been  produced  by  feeding  cultures 
of  B.  coli  to  dogs,  and  from  the  peptic  ulcers  of  very  young  infants  Helmholz 
isolated  the  organism  in  pure  culture.  There  is  great  difficulty  in  determining 
the  precise  etiological  relationship  of  B.  coli  to  the  various  lesions  of  the 
gastro-intestinal  tract. 

(e)  Other  local  infections  with  which  the  colon  hacillus  has  been  associ- 
ated are  acute  meningitis,  abscess  of  the  brain,  endocarditis,  and  suppuration 
in  various  parts.  Only  in  a  small  proportion  of  these  cases  has  the  associa- 
tion been  demonstrated  by  cultural  and  biological  tests. 

Treatment. — In  the  cases  of  general  infection,  rest,  careful  diet,  and  large 
amounts  of  water  are  indicated.  In  the  local  infections  the  treatment  is  that 
of  the  condition  present,  as  peritonitis  and  cholecystitis.  For  infection  of 
the  urinary  tract  the  diet  should  be  simple  and  large  amounts  of  water  should 
be  given  with  urinary  antiseptics,  especially  hexamine  (gr.  xl  to  Ix  a  day,  3,0 


TYPHUS  FEVER  47 

to  4  gm.).  Local  treatment  by  irrigations  is  helpful  in  cystitis  and  in  some 
cases  of  pyelitis.  The  use  of  an  autogenous  vaccine  is  an  aid  in  some  cases 
but  is  often  disappointing. 


IV.     TYPHUS  FEVER 

Definition. — An  acute  infectious  disease  characterized  by  sudden  onset, 
maculated  and  hgemorrhagic  rash,  marked  nervous  symptoms,  and  a  cyclical 
course  terminating  by  crisis,  usually  about  the  end  of  the  second  week. 

The  disease  is  known  by  the  names  of  hospital  fever,  spotted  fever,  jail 
fever,  camp  fever,  and  ship  fever,  and  in  Germany  is  called  exaiithemaiic 
typhus,  in  contradistinction  to  abdominal  typhus.  The  word  signifies  "smoke" 
or  "mist"  in  Greek  and  was  used  by  Hippocrates  to  describe  any  condition 
with  a  tendency  to  stupor.  In  the  eighteenth  century  the  name  was  given  by 
de  Sauvages  to  the  common  putrid  or  pestilential  fever,  and  the  general  use 
came  in  through  its  adoption  by  Cullen. 

Etiology. — Typhus  has  been  one  of  the  great  epidemics  of  the  world, 
whose  history,  as  Hirsch  remarks,  is  written  in  those  dark  pages  which  tell 
of  the  grievous  visitations  of  mankind  by  war,  famine,  and  misery.  It  now 
exists  in  a  few  endemic  areas,  where  from  time  to  time  sporadic  cases  occur. 
Ireland  was  terribly  scourged  by  the  disease  between  the  years  1817  and  1819, 
and  again  in  1846.  It  prevailed  extensively  in  all  the  large  cities  of  Great 
Britain  and  the  Continent.  In  1875  in  England  and  Wales  there  were  1,499 
deaths  from  the  disease.  Of  late  years  the  name  typhus  has  rarely  appeared 
in  the  Eegistrar-General's  report.  In  the  United  States  and  Canada  it  pre- 
vailed extensively  in  the  early  years  of  the  nineteenth  century,  and  there 
were  severe  epidemics  in  the  wake  of  the  Irish  immigrations  in  '46  and  '47. 
It  is  endemic  in  parts  of  Eussia  and  in  the  Slav  countries,  and  there  have  been 
extensive  epidemics  in  the  recent  war. 

Sporadic  typhus  fever  offers  peculiarities  which  are  apt  to  make  its  recog- 
nition difficult.  There  may  be  outbreaks  of  a  few  cases,  the  origin  of  which 
may  be  very  difficult  to  trace.  Two  such  limited  outbreaks  came  under 
observation,  one  at  the  House  of  Refuge,  Montreal,  in  1877,  in  which  eleven 
persons  were  afiiected,  and  the  second  in  1901  at  the  Johns  Hopkins  Hos- 
pital, where  three  cases  occurred. 

A  question  of  interest  has  arisen  as  to  the  relation  of  typhus  fever  to  the 
cases  of  fever  studied  by  Brill  in  New  York.  This  is  a  sporadic  type  of  typhus, 
confirmed  by  the  studies  of  Anderson  and  Goldberger.  Beginning  with  the 
usual  prodromes,  the  fever  increases  rapidly  and  reaches  a  maximum  about 
the  third  or  fourth  day,  where  it  remains  fairly  constant  between  103°  and 
104°.  On  the  5th  or  6th  day  an  eruption  appears,  maculo-papular  in  type, 
dull  red  in  color,  rarely  ha^morrhagic,  not  appearing  in  crops,  not  disappear- 
ing on  pressure,  and  neither  profuse  as  in  measles  nor  diffuse  as  in  typical 
typhus ;  there  may  be  only  a  few  hundred  spots.  The  rash  persists  until  the 
crisis  and  then  fades  rapidly.  The  patients  are  much  prostrated,  with  severe 
headache,  but  no  abdominal  symptoms.  Constipation  is  usually  a  marked 
feature.  After  persisting  for  13  to  15  days,  the  fever  declines  rapidly,  usually 
with  a  critical  fall,  and  there  is  a  speedy  convalescence.     It  is  rarely  fatal. 


48  SPECIFIC  INFECTIOUS  DISEASES 

The  typhus  fever  prevailing  in  Mexico  City,  where  it  is  known  as  Tabardillo, 
is  more  severe,  and  in  its  study  Eicketts  of  Chicago  fell  a  victim.  Xeither  the 
Eocky  Mountain  spotted  fever,  nor  the  Flood  or  Eiver  fever  of  Japan  is  identi- 
cal with  typhus. 

The  disease  is  transmitted  by  the  body  louse  and  possibly  by  the  head 
louse  and  so  is  associated  with  filth  and  overcrowding.  In  epidemics  it  is 
one  of  the  most  dangerous  of  all  diseases,  and  those  in  attendance  upon  pa- 
tients are  almost  invariably  attacked  unless  special  precautions  are  taken 
to  guard  against  lice.  In  a  period  of  twenty-five  years  in  Ireland,  among 
1,230  physicians  attached  to  institutions,  550  died  of  this  disease.  The  dis- 
ease has  been  transmitted  to  animals. 

Plotz  and  his  co-workers  have  isolated  a  small  slender  bacillus.  Bacillus 
typhi-exantliematici.  It  was  found  in  the  blood  throughout  the  course  of 
the  disease  and  the  percentage  of  successful  cultures  was  highest  in  the  severe 
forms.  The  organism  has  been  isolated  from  monkeys  and  guinea-pigs  to 
which  the  disease  had  been  conveyed.  The  same  organism  has  been  found  in 
infected  lice.  Specific  antibodies  are  formed  and  the  agglutination  and  com- 
plement fixation  tests  are  important  aids  in  diagnosis. 

Morbid  Anatomy. — The  anatomical  changes  are  those  which  result  from 
intense  fever.  The  blood  is  dark  and  fluid;  the  muscles  are  of  a  deep  red 
color,  and  often  show  a  granular  degeneration,  particularly  in  the  heart;  the 
liver  is  enlarged  and  soft  and  may  have  a  dull  clay-like  lustre;  the  kidneys 
are  swollen ;  there  is  moderate  enlargement  of  the  spleen,  and  a  general  hyper- 
plasia of  the  lymph-follicles.  Peyer's  glands  are  not  ulcerated.  Bronchial 
catarrh  is  usually,  and  hypostatic  congestion  of  the  lungs  often,  present.  The 
skin  shows  the  petechial  rash. 

Symptoms. — Ixcubation. — This  is  placed  at  about  twelve  days,  but  it  may 
be  less'.  There  may  be  ill-defined  feelings  of  discomfort.  As  a  rule,  however, 
the  invasion  is  abrupt  and  marked  by  chills  or  a  single  rigor,  followed  by 
fever.  The  chills  may  recur  during  the  first  few  days,  and  there  is  headache 
with  pains  in  the  back  and  legs.  There  is  early  prostration,  and  the  patient 
is  glad  to  take  to  his  bed  at  once.  The  temperature  is  high  at  first,  and  may 
attain  its  maximum  on  the  second  or  third  day.  The  pulse  is  full,  rapid,  and 
not  so  frequently  dicrotic  as  in  typhoid.  The  tongue  is  furred  and  white, 
and  there  is  an  early  tendency  to  dryness.  The  face  is  fiushed,  the  eyes  con- 
gested, and  the  expression  dull  and  stupid.  Vomiting  may  be  a  distressing 
symptom.  In  severe  cases  mental  symptoms  are  present  from  the  outset, 
either  a  mild  febrile  delirium  or  an  excited,  active,  almost  maniacal  condition. 
Bronchial  catarrh  is  common. 

Stage  or  Eruption. — From  the  third  to  the  fifth  day  the  eruption  ap- 
pears— first  upon  the  abdomen  and  upper  part  of  the  chest,  and  then  upon  the 
extremities  and  face;  occurring  so  rapidly  that  in  two  or  three  days  it  is  all 
out.  There  are  two  elements  in  the  eruption:  a  subcuticular  mottling,  "a 
fine,  irregular,  dusky  red  mottling,  as  if  below  the  surface  of  the  skin  some 
little  distance,  and  seen  through  a  semi-opaque  medium"  (Buchanan)  ;  and 
distinct  papular  rose-spots  which  change  to  petechige.  In  some  instances  the 
petechial  rash  comes  out  with  the  rose-spots.  Collie  describes  the  rash  as  con- 
sisting of  three  parts :  rose-colored  spots  which  disappear  on  pressure,  dark- 
red  spots  which  are  modified  by  pressure,  and  petechias  upon  which  pressure 


TYPHUS  FEVER 


49 


produces  uo  effect.  In  children  the  rash  at  first  may  present  a  striking  resem- 
blance to  that  of  measles  and  give  as  a  whole  a  curiously  mottled  appearance 
to  the  skin.  The  term  mulberry  rash  is  sometimes  applied  to  it.  In  mild 
cases  the  eruption  is  slight,  but  even  then  is  largely  petechial  in  character. 
As  the  rash  is  hsemorrhagic,  it  does  not  disappear  after  death.  Usually  the 
skin  is  dry,  so  that  sudaminal  vesicles  are  not  common.  It  is  stated  by  some 
authors  that  a  distinctive  odor  is  present.  During  the  second  week  the  gen- 
eral symptoms  are  much  aggravated.  The  prostration  becomes  more  marked, 
the  delirium  more  intense,  and  the  fever  rises.     The  patient  lies  on  his  back 


DAY  OF 

DISEASE 

1 

2 

3 

4 

5         e 

3           7 

8 

9 

10 

11 

12 

F 

105 

* 

104 

A 

A 

\ 

h 

I 

\ 

n        I\ 

/ 

V 

l/ 

/ 

l^^ 

^ 

/ 

* 

\  1 

A 

1 

\  i 

I  5Z 

I 

/ 

w 

/ 

103 

h 

/ 

\  ' 

\  f> 

\ 

y 

\  1  \, 

^ 

1 

\  / 

\    , 

T 

\ 

V 

1 

1 

w 

\l 

1/ 

\ 

/ 

A 

1 

V 

^ 

)1 

w 

V  /  1 

1 

102 

1 

1 

j 

j\ 

1 

'  \ 

I 

101 

\ 

Ij 

• 

100 

1 

99 

1 

1 

1 

1 

Chart  III. — Typhus  Fever  (Murchison). 


with  a  dull,  expressionless  face,  flushed  cheeks,  injected  conjunctivae,  and 
contracted  pupils.  The  pulse  increases  in  frequency  and  is  feebler;  the  face 
is  dusky,  and  the  condition  becomes  more  serious.  Eetention  of  urine  is  com- 
mon. Coma-vigil  is  frequent,  a  condition  in  which  the  patient  lies  with  open 
eyes,  but  quite  unconscious;  with  it  there  may  be  subsultus  tendinum  and 
picking  at  the  bedclothes.  The  tongue  is  dry,  brown,  and  cracked,  and  there 
are  sordes  on  the  teeth.  Respiration  is  accelerated,  the  heart's  action>  becomes 
more  and  more  enfeebled,  and  death  takes  place  from  exhaustion.  In  favora- 
ble cases  about  the  end  of  the  second  week  occurs  the  crisis,  in  Avhich,  often 
after  a  deep  sleep,  the  patient  awakes  feeling  much  better  and  with  a  clear 
mind.  The  temperature  falls,  and  although  the  prostration  may  be  extreme 
convalescence  is  rapid  and  relapse  very  rare.  This  abrupt  termination  by 
crisis  is  in  striking  contrast  to  the  mode  of  termination  in  typhoid  fever. 


50  SPECIFIC  INFECTIOUS  DISEASES 

Fever. — The  temperature  rises  steadily  during  the  first  four  or  five  days, 
and  the  morning  remissions  are  not  marked.  The  maximum  is  usually  at- 
tained by  the  fifth  day,  when  the  temperature  may  be  105°,  106°,  or  107°  F. 
In  mild  cases  it  seldom  rises  above  103°  F.  After  reaching  its  maximum  the 
fever  generally  continues  with  slight  morning  remissions  until  the  twelfth  or 
fourteenth  da3^  when  the  crisis  occurs,  during  which  the  temperature  may 
fall  below  normal  within  twelve  or  twenty-four  hours.  Preceding  a  fatal 
termination,  there  is  usually  a  rapid  rise  in  the  fever  to  108°  or  even  109°  F. 

The  heart  may  early  show  signs  of  weakness.  The  first  sound  becomes 
feeble  and  almost  inaudible,  and  a  systolic  murmur  at  the  apex  is  not  infre- 
quent. Il3'postatic  congestion  of  the  lungs  occurs  in  all  severe  cases.  The 
brain  symptoms  are  usually  more  pronounced  than  in  typhoid,  and  the  de- 
lirium is  more  constant.     A  slight  leucocytosis  is  common. 

The  urine  shows  the  usual  febrile  characteristics.  The  chlorides  dimin- 
ish or  disappear.  Albumin  is  present  in  a  large  proportion  of  the  cases,  but 
nej)hritis  seldom  occurs. 

Variations  in  the  course  of  the  disease  are  naturally  common.  There  are 
malignant  cases  which  rapidly  prove  fatal  within  two  or  three  days;  the 
so-called  typhus  siderans.  On  the  other  hand,  during  epidemics  there  are 
extremely  mild  cases  in  which  the  fever  is  slight,  the  delirium  absent,  and 
convalescence  is  established  by  the  tenth  day. 

Complications  and  Sequelae. — Broncho-pneumonia  is  perhaps  the  most 
common  complication.  It  may  pass  on  to  gangrene.  In  certain  epidemics 
gangrene  of  the  toes,  the  hands,  or  the  nose,  and  in  children  noma  or  cancrum 
oris,  have  occurred.  Meningitis  is  rare.  Paralyses,  which  are  probably  due 
to  a  post-febrile  neuritis,  are  not  very  uncommon.  Septic  processes,  such  as 
parotitis  and  abscesses  in  the  subcutaneous  tissues  and  in  the  joints,  are  occa- 
sionally met  with.     Xephritis  is  rare.     Hsmatemesis  may  occur. 

Prognosis. — The  mortality  ranges  in  different  epidemics  from  12  to  20 
per  cent.  It  is  very  slight  in  the  young.  Children,  who  are  quite  as  fre- 
quently attacked  as  adults,  rarely  die.  After  middle  age  the  mortality  is 
high,  in  some  epidemics  50  per  cent.  Death  usually  occurs  toward  the  close 
of  the  second  week  and  is  due  to  the  toxaemia.  In  the  third  week  it  more  com- 
monly results  from  pneumonia. 

Diagnosis. — During  an  epidemic  there  is  rarely  any  doubt,  for  the  disease 
presents  distinctive  general  characters.  Isolated  cases  and  the  form  de- 
scribed by  Brill  may  be  very  difficult  to  distinguish  from  typhoid  fever. 
While  in  typical  instances  the  eruption  in  the  two  affections  is  very  dif- 
ferent, yet  taken  alone  it  may  be  deceptive,  since  in  typhoid  fever  a  roseo- 
lous  rash  may  be  abundant  and  there  may  be  occasionally  a  subcuticular 
mottling  and  even  petechia.  The  diff'erence  in  the  onset,  particularly  in 
the  temperature,  is  marked;  but  cases  in  which  it  is  important  to  make  an 
accurate  diagnosis  are  not  usually  seen  until  the  fourth  or  fifth  day.  The 
suddenness  of  the  onset,  the  greater  frequency  of  the  chill,  and  the  early 
prostration  are  the  distinctive  features  in  typhus.  The  brain  symptoms, 
too,  are  earlier.  It  is  easy  to  put  down  on  paper  elaborate  differential  distinc- 
tions, which  are  practically  useless  at  the  bedside.  The  Widal  reaction  and 
blood  cultures  are  important  aids,  but  in  sporadic  cases  the  diagnosis  is  some- 
times extremely  difficult.     Severe  cerebro-spinal  fever  may  closely  simulate 


THE  PYOGEXIG  IXFECTIOXS  51 

typhus  at  the  outset,  but  the  diagnosis  is  usually  clear  -within  a  few  days. 
Malignant  variola  also  has  certain  features  in  common  with  severe  typhus, 
but  the  greater  extent  of  the  haemorrhages  and  the  bleeding  from  the  mucous 
membranes  make  the  diagnosis  clear  within  a  short  time.  The  rash  at  first 
resembles  that  of  measles,  but  in  the  latter  the  eruption  is  brighter  red  in 
color,  often  crescentic  or  irregular  in  arrangement,  and  appears  first  on  the 
face. 

The  agglutination  test  with  the  organism  is  positive.  What  is  termed 
the  "Weil-Felix  reaction  is  positive  in  many  cases.  This  consists  in  the  agglu- 
tination of  a  proteus-like  organism  obtained  from  the  urine  of  patients  with 
the  disease.     It  is  not  given  till  the  sixth  or  seventh  day. 

Prophylaxis. — This  involves  measures  against  lice.  The  patient's  cloth- 
ing should  be  sterilized  by  heat.  Eemoval  of  the  patient  to  an  isolation  hos- 
pital is  important.  During  epidemics  when  this  can  not  be  done,  those  at- 
tending the  patients  should  take  special  precautions  to  prevent  infection  by 
lice  and  wear  louse-proof  clothing. 

Treatment. — The  general  management  is  like  that  of  typhoid  fever. 
Hydrotherapy  should  be  thoroughly  and  systematically  employed;  water 
should  be  given  freely.  Judging  from  the  good  results  which  we  have  ob- 
tained by  this  method  in  typhoid  cases  with  nervous  symptoms,  much  may  be 
expected  from  it.  Medicinal  antipyretics  are  even  less  suitable  than  in 
typhoid,  as  the  tendency  to  heart-weakness  is  often  more  pronounced.  As  a 
rule,  the  patients  require  from  the  outset  a  supporting  treatment. 

The  bowels  may  be  kept  open  by  mild  aperients.  The  so-called  specific 
medication,  by  sulphocarbolates,  the  sulphides,  carbolic  acid,  etc.,  is  not  com- 
mended by  those  who  have  had  the  largest  experience.  The  special  nervous 
symptoms  and  the  pulmonary  symptoms  should  be  dealt  with  as  in  typhoid 
fever.  In  epidemics,  when  the  conditions  of  the  climate  are  suitable,  the 
patients  are  best  treated  in  tents  in  the  open  air. 


V.     THE  PYOGENIC  INFECTIONS 

{Saprcemia,  Septiaemia,  Pycemia,  Focal  Infection,  Terminal  Infections) 

Definition. — A  group  of  non-specific  diseases,  induced  by  a  number  of 
micro-organisms,  of  which  the  pyogenic  cocci  are  the  most  important,  charac- 
terized by  fever,  chills,  leucocytosis,  often  a  profound  intoxication  and  some- 
times by  foci  of  suppuration.  A  hard-and-fast  line  can  not  be  drawn  between 
an  infection  and  an  intoxication,  but  agents  of  infection  alone  are  capable 
of  reproduction,  whereas  those  of  intoxication  are  chemical  poisons,  some  of 
which  are  produced  by  the  agency  of  bacteria,  or  by  vegetable  and  animal 
cells.     There  are  five  chief  clinical  types  of  pyogenic  infection : 

1.  LOCAL  INFECTIONS  WITH  THE  DEVELOPMENT  OF  TOXINS 

This  is  the  common  mode  of  invasion  of  many  of  tiie  infectious  diseases. 
Tetanus,  diphtheria  and  erysipelas  are  diseases  which  have  sites  of  local 
infection  in  which  the  pathogenic  organisms  develop;  but  the  constitutional 


53  SPECIFIC  INFECTIOUS  DISEASES 

effects  are  caused  by  the  absorption  of  the  poisonous  products.  The  diph- 
theria toxin  produces  all  the  general  symptoms^  the  tetanus  toxin  every  feature 
of  the  disease  without  the  presence  of  their  respective  bacilli.  Certain  of 
the  symptoms  following  the  absorption  of  the  toxins  are  general  to  all ;  others 
are  special  and  peculiar,  according  to  the  organism  which  produces  them. 
A  chill,  fever,  general  malaise,  prostration,  rapid  pulse,  restlessness,  and 
headache  are  the  most  frequent.  With  but  few  exceptions  the  febrile  disturb- 
ance is  the  most  common  feature.  The  most  serious  effects  are  upon  the  ner- 
vous system  and  the  circulation,  and  the  gravity  of  the  symptoms  on  the  part 
of  these  organs  is  to  some  extent  a  measure  of  the  intensity  of  the  intoxica- 
tion. The  organisms  of  certain  local  infections  produce  poisons  which  have 
special  actions;  thus,  the  diphtheria  toxin  is  especially  prone  to  attack  the 
nervous  system  and  to  cause  peripheral  neuritis.  The  tetanus  toxin  has  a 
specific  action  on  the  motor  neurones. 

2.     SEPTICEMIA 

Formerly,  and  in  a  surgical  sense,  the  term  "septicsemia'^  was  used  to 
designate  the  invasion  of  the  blood  and  tissues  of  the  body  by  the  organisms 
of  suppuration,  but  in  the  medical  sense  the  term  may  be  applied  to  any  con- 
dition in  which,  with  or  without  a  local  site  of  infection,  there  is  microbic 
invasion  of  the  blood  and  tissues,  but  without  metastatic  foci  of  suppuration. 
Owing  to  the  development  of  bacteria  in  the  blood,  and  to  separate  it  sharply 
from  local  infectious  processes  with  toxic  invasion  of  the  body,  this  condition 
is  termed  bactergemia ;  toxsemia  denotes  the  latter  state. 

(a)  Progressive  Septicaemia  from  Local  Infection. -^The  common  strepto- 
coccus and  staphylococcus  infection  is,  as  a  rule,  first  local,  and  the  toxins 
alone  pass  into  the  blood.  In  other  instances  the  cocci  appear  in  the  blood 
and  throughout  the  tissues,  causing  a  septicaemia  which  intensifies  greatly  the 
severity  of  the  case.  The  clinical  features  of  this  form  are  well  seen  in  the 
cases  of  puerperal  septicsemia  or  in  dissection  wounds,  in  which  the  course 
of  the  infection  may  be  traced  along  the  lymphatics.  The  symptoms  usually 
set  in  within  twenty-four  hours,  and  rarely  later  than  the  third  or  fourth  day. 
There  is  a  chill  or  chilliness,  with  moderate  fever  at  first,  which  gradually 
rises  and  is  marked  by  daily  remissions  and  even  intermissions.  The  pulse 
is  small  and  compressible,  and  may  reach  120  or  higher.  Gastro-intestinal 
disturbances  are  common,  the  tongue  is  red  at  the  margin,  and  the  dorsum  is 
dry  and  dark.  There  may  be  early  delirium  or  marked  mental  prostration 
and  apathy.  As  the  disease  progresses  there  may  be  pallor  of  the  face  or  a 
yellowish  tint.     Capillary  haemorrhages  are  not  uncommon. 

In  streptococcus  cases  we  now  recognize  that  these  infections  are  not 
always  so  serious  as  we  thought.  Death  may  occur  within  twenty-four  hours 
or  be  delayed  for  several  days,  even  for  weeks,  and  recovery  may  occur.  One 
patient  showed  streptococci  in  the  blood  for  six  weeks,  but  recovered  (Cole). 
On  post-mortem  examination  there  may,  be  no  gross  focal  lesions  in  the  viscera, 
and  the  seat  of  infection  may  present  only  slight  changes.  The  spleen  is  en- 
larged and  soft,  the  blood  may  be  extremely  dark  in  color,  and  haemorrhages 
are  common,  particularly  on  the  serous  surfaces.  Neither  thrombi  nor  em- 
boli are  found.     Certain  clinical  features  separate  the  streptococcus  from  the 


THE  PYOGENIC  INFECTIONS  53 

staphylococcus  infection,  chiefly  the  absence  of  delirium,  a  rather  abnormal 
mental  acuteness,  and  the  presence  of  a  greater  degree  of  anaemia. 

Many  instances  of  septicaemia  are  combined  infections;  thus  in  diphtheria 
streptococcus  septicsemia  is  a  common,  and  the  most  serious,  event.  The  local 
disease  and  the  symptoms  produced  by  absorption  of  the  toxins  dominate  the 
clinical  picture ;  but  the  features  are  usually  much  aggravated  by  the  systemic 
invasion.  A  similar  infection  may  occur  in  typhoid  fever  and  tuberculosis, 
and  obscure  the  typical  picture.  These  secondary  septicsemias  are  caused 
most  frequently  by  the  streptococcus,  but  may  be  due  to  other  bacteria. 

(b)  General  Septicaemia  without  Reco^izable  Local  Infection. — Crypto- 
genetic  Septiccemias. — This  is  a  group  of  very  great  interest  to  the  physician, 
the  full  importance  of  which  we  have  only  recently  recognized. 

The  subjects  when  attacked  may  be  in  perfect  health;  more  commonly 
they  are  already  weakened  by  acute  or  chronic  illness.  The  jjathogenic  organ- 
isms are  varied.  Streptococcus  pyogenes  is  the  most  common;  the  forms  of 
staphylococcus  more  rare.  Other  occasional  causal  agents  are  the  pneu- 
mococcus.  Bacillus  proteus.  Bacillus  pyocyaneus  and  Bacillus  influenzce.  Be- 
tween May  1,  1892,  and  June  1,  1895,  from  the  medical  wards  of  the  Hopkins 
Hospital,  21  cases  of  general  infection  came  to  autopsy,  of  which  13  were  due 
to  Streptococcus  pyogenes,  2  to  Staphylococcus  pyogenes,  and  6  to  the  pneu- 
mococcus.  In  19  of  these  cases  the  patients  were  already  the  subjects  of  some 
other  malady,  which  was  aggravated,  or  in  most  instances  terminated,  by  the 
septicEemia.  The  symptoms  vary  somewhat  with  the  character  of  the  micro- 
organisms. In  the  streptococcus  cases  there  may  be  chills  with  high,  irregu- 
lar fever,  and  a  more  characteristic  septic  state  than  in  the  pneumococcus  in- 
fection. 

These  cases  come  correctlv  under  the  term  ''cryptogenetic  septicgemia"  as 
employed  by  Leube,  inasmuch  as  the  local  focus  of  infection  is  not  evident 
during  life  and  may  not  be  found  after  death.  Although  most  of  these  cases 
are  terminal  infections,  yet  there  are  instances  of  this  type  of  affection  coming 
on  in  apparently  healthy  persons.  The  fever  may  be  extremely  irregular,  char- 
acteristically septic,  and  persist  for  many  weeks.  Foci  of  suppuration  may 
not  develop,  and  may  not  be  found  even  at  autopsy.  There  are  cases  of  an 
intermittent  pyrexia  persisting  for  weeks,  in  which  it  is  impossible  to  give 
any  explanation  of  the  phenomena,  which  ultimately  recover,  and  in  which 
tuberculosis  and  malaria  can  be  excluded.  These  cases  require  to  be  carefully 
studied  bacteriologically.  Local  symptoms  may  be  absent,  thoi;gh  there  may 
be  enlargement  of  the  liver,  in  some  due  to  a  diffuse  suppurative  hepatitis. 
The  pyocyanic  disease,  or  cyano-pyaimia,  is  an  extremely  interesting  form  of 
infection  with  Bacillus  pyocyaneus,  of  which  a  number  of  cases  have  been  re- 
ported. 

3.     SEPTICO-PY-EMIA 

The  pathogenic  micro-organisms  which  invade  the  blood  and  tissues  may 
settle  in  certain  foci  and  there  cause  suppuration.  When  multiple  abscesses 
are  thus  produced  in  connection  witli  a  general  infection,  the  condition  is 
known  as  pyaemia  or,  perhaps  better,  septico-pya?mia.  There  are  no  specific 
organisms  of  suppuration,  and  the  condition  of  i)yaunia  may  be  produced  l)y 
organisms  other  than  the  streptococci  and  staphylococci,  thougli  those  are  the 


54  SPECIFIC  INFECTIOUS  DISEASES 

most  common.  Other  forms  vhich  may  invade  the  system  and  cause  foci  of 
suppuration  are  the  pneumococcus^  the  gonococcus.  Bacillus  coli.  Bacillus  ty- 
■pliosus.  Bacillus  proteus.  Bacillus  pyocyaneus.  Bacillus  influenzcB.  In  a  large 
joroportion  of  all  cases  of  pyaemia  there  is  a  focus  of  infection,  either  a  sup- 
purating external  "wound,  an  osteomyelitis,  a  gonorrhoea,  an  otitis  media,  an 
empyema,  or  an  area  of  suppuration  in  a  lymph-gland  or  about  the  appendix. 
In  a  large  majority  of  all  these  cases  the  common  pus  cocci  are  present. 

In  a  suppurating  wound,  for  example,  the  pus  organisms  induce  hyaline' 
necrosis  in  the  smaller  vessels  with  the  production  of  thrombi  and  purulent 
phlebitis.  The  entrance  of  pus  organisms  in  small  numbers  into  the  blood 
does  not  necessarily  produce  pygemia.  Commonly  the  transmission  to  various 
parts  from  the  local  focus  takes  place  by  the  fragments  of  thrombi  which  pass 
as  emboli  to  different  parts,  where,  if  the  conditions  are  favorable,  the  pus 
organisms  excite  suppuration.  A  thrombus  which  is  not  septic  or  contami- 
nated, when  dislodged  and  impacted  in  a  distant  vessel,  produces  at  most  only 
a  simple  infarction;  but,  coming  from  an  infected  source  and  containing  pus 
microbes,  an  independent  centre  of  infection  is  established  wherever  the  em- 
bolus may  lodge.  These  independent  suppurative  centres  in  pyaemia,  known 
as  ernbolic  or  metastatic  abscesses,  have  the  following  distribution : 

(«)  In  external  wounds,  in  osteomyelitis,  and  in  acute  phlegmon  of  the 
skin,  the  embolic  particles  very  frequently  excite  suppuration  in  the  lungs, 
producing  wedge-shaped  pygemic  infarcts ;  from  these,  or  rarely  by  paradoxical 
embolism,  or  direct  passage  of  bacteria  or  minute  emboli  through  the  pul- 
monary capillaries,  metastatic  foci  of  inflammation  may  occur  in  other  parts. 

(h)  Suppurative  foci  in  the  territory  of  the  portal  system,  particularly  in 
the  intestines,  produce  metastatic  abscesses  in  the  liver  with  or  without  sup- 
purative pylephlebitis. 

Endocarditis  is  an  event  which  is  very  liable  to  occur  in  all  forms  of  sep- 
ticaemia, and  modifies  materially  the  character  of  the  clinical  features.  Strep- 
tococci and  staphylococci  are  the  most  common  organisms  in  the  vegetations, 
but  pneumococci,  gonococci,  tubercle  bacilli,  typhoid  bacilli,  and  other  forms 
have  been  isolated.  The  vegetations  -udiich  grow  at  the  site  of  the  valve  lesion 
become  covered  with  thrombi,  particles  of  which  may  be  dislodged  and  carried 
as  emboli  to  different  parts  of  the  body,  causing  multiple  abscesses  or  infarcts. 

Symptoms  of  Septico-pyaemia. — In  a  case  of  wound  infection,  prior  to  the 
onset  of  the  characteristic  symptoms,  there  may  be  signs  of  local  trouble,  and 
in  the  case  of  a  discharging  wound  the  pus  may  change  in  character.  The 
onset  of  the  disease  is  marked  by  a  severe  rigor,  during  which  the  temperature 
rises  to  103°  or  104°  and  is  followed  by  a  profuse  sweat.  These  chills  are 
repeated  at  intervals,  either  daily  or  every  other  day.  In  the  intervals  there 
may  be  slight  pyrexia.  The  constitutional  disturbance  is  marked  and  there 
are  loss  of  appetite,  nausea,  and  vomiting,  and,  as  the  disease  progresses,  rapid 
emaciation.  Local  symptoms  usually  occur.  If  the  lungs  become  involved 
there  are  dyspnoea  and  cough.  The  physical  signs  may  be  slight.  Involve- 
ment of  the  jDleura  and  j)ericardiuni  is  common.  The  anaemia,  often  pro- 
found, causes  great  pallor  of  the  skin,  Avhich  later  may  be  bile-tinged.  The 
spleen  is  enlarged,  and  there  may  be  intense  pain  in  the  side,  pointing  to 
perisplenitis  from  embolism.  Usually  in  the  rapid  cases  a  typhoid  state  super- 
venes, and  the  patient  dies  comatose. 


THE  PYOGENIC  INFECTIONS  65 

Skin  Lesions, —  These  are  very  numerous.  Erythema,  the  so-called  "sur- 
gical scarlet  fever/'  may  extend  from  the  infected  wound  or  appear  on  the 
face  or  chest  and  spread  widely.  Purpura,  occurs  as  a  widespread  lesion  in  all 
hyper-intense  types  of  septicaijmia  and  is  met  with  in  the  later  stages  as  a 
remarkable  discrete  rash  in  various  parts  of  the  body.  In  the  acute  purpura 
of  septicsemia  the  skin  may  be  completely  covered  within  36  hours,  usually 
preceded  by  a  dusky  erythema.  Pustules,  vesicles,  ecthyma,  urticaria  and 
papular  rashes  are  occasional  complications.     Ordinary  herpes  is  rare. 

In  the  chronic  cases  the  disease  may  be  prolonged  for  months;  the  chills 
recur  at  long  intervals,  the  temperature  is  irregular,  and  the  condition  of  the 
patient  varies  from  month  to  month.  The  course  is  usually  slow  and  pro- 
gressively downward. 

Diagnosis. — Septicaemia  and  pysemia  are  frequently  overlooked  and  often 
mistaken  for  other  affections.  Cases  following  a  wound,  an  operation,  or  par- 
turition are  readily  recognized.  On  the  other  hand,  the  following  conditions 
may  be  overlooked: 

Osteo-myelitis. — Here  the  lesion  may  be  limited,"  the  constitutional  symp- 
toms severe,  and  the  course  of  the  disease  very  rapid.  The  cause  of  the  trouble 
may  be  discovered  only  post  mortem 

So,  too,  acute  septico-pytemia  may  follow  gonorrhoea  or  a  prostatic  abscess. 

Cases  are  sometimes  confounded  with  typhoid  fever,  paticularly  the  more 
chronic  instances,  in  which  there  are  diarrhoea,  great  prostration,  delirium, 
and  irregular  fever.  The  spleen,  too,  is  often  enlarged.  The  marked  leuco- 
cytosis  is  an  important  differential  point. 

In  some  of  the  instances  of  ulcerative  endocarditis  the  diagnosis  is  very 
difficult,  particularly  in  what  is  known  as  the  typhoid,  in  contradistinction 
to  the  septic,  type.  In  acute  miliary  tuberculosis  the  symptoms  may  resemble 
those  of  septicgemia,  more  commonly  those  of  typhoid  fever. 

The  post-febrile  arthritides,  such  as  occur  after  scarlet  fever  and  gonor- 
rhoea, are  really  instances  of  mild  septic  infection.  The  joints  may  some- 
times suppurate  and  pyaemia  develop.  So,  also,  in  tuberculosis  of  the  kidneys 
and  calculous  pyelitis  recurring  rigors  and  sweats  due  to  septic  infection  are 
common.  In  some  latitudes  septic  and  pyemic  processes  are  too  often  con- 
founded with  malaria.  In  early  tuberculosis,  or  even  when  signs  of  excava- 
tion are  present  in  the  lungs,  and  in  cases  of  suppuration  in  various  parts, 
particularly  empyema  and  abscess  of  the  liver,  the  diagnosis  of  malaria  is 
made.  The  practitioner  may  take  it  as  a  safe  rule,  to  which  he  will  find  very 
few  exceptions,  that  an  intermittent  fever  which  resists  quinine  is  not  malaria. 

Other  conditions  associated  with  chills  which  may  be  mistaken  for  pyaemia 
are  profound  anemia,  infective  sinus  thrombosis,  certain  cases  of  Hodgkin's 
disease,  cholecystitis,  the  hepatic  intermittent  fever  associated  with  the  lodg- 
ment of  gall-stones  at  the  orifice  of  the  common  duct,  rare  cases  of  essential 
fever  in  nervous  women,  and  the  intermittent  fever  sometimes  seen  in  rapidly 
growing  cancer. 

Treatment. —  {a)  General. — Nourishment  should  be  given  liberally  in 
the  form  of  liquids  and  soft  foods  up  to  3,000  calories  with  SO  grams  of  protein 
a  day.  Water  should  be  forced  and  it  is  well  to  give  it  by  the  drop  method 
into  the  bowel  and  by  infusion  if  there  is  any  difficulty  in  taking  it  by  mouth. 


56  SPECIFIC  IXFECTIOUS  DISEASES 

Free  purgation  is  advisable  especially  by  calomel  and  salines.     Hydrotherapy 
by  tub  baths  is  useful.     Sedatives  should  be  given  for  sleep. 

(&)  Surgical.- — In  pysemia,  when  the  pus  is  accessible,  free  evacuation 
and  drainage  is  often  the  only  treatment  required.  In  a  case  of  empyema 
with  weeks  of  high  and  irregular  fever  the  day  after  operation  the  temperature 
may  be  normal,  and  remain  so.  Unfortunately,  in  only  too  many  cases  the 
focus  of  infection  is  not  accessible;  it  then  is  a  septicaemia,  and  for  such 
cases  we  have  the  treatment  with  serums  and  vaccines. 

(c)  Vacciis^e  and  Serum  Treatment. — By  blood  cultures  or  by  cultures 
from  the  focus  of  infection  the  organism  is  isolated,  and  an  autogenous  vac- 
cine prepared.  "Stock"  vaccines  may  be  used,  but  are  not  as  useful  as  an 
autogenous  vaccine.  In  many  cases  in  which  the  germ  cannot  be  isolated 
and  the  condition  is  one  of  septic  fever  the  ordinary  antistreptococcus  serum 
or  one  of  the  polyvalent  serums  is  used.  Good  results  are  not  infrequently 
obtained. 

(d)  Drugs. — There  are  none  which  control  septic  fever.  The  coal-tar 
products  are  of  doubtfiil  "service.  Quinine  may  be  used.  The  intravenous 
injection  of  antiseptic  drugs  has  not  been  proved  to  be  of  value. 

4.     FOCAL  INFECTION 

A  local  focus  of  infection  may  be  the  source  of  acute  septicaemia,  but  in 
addition  a  variety  of  chronic  infections  may  arise  with  distant  and  important 
manifestations.  The  resulting  infection  may  be  either  local  or  general. 
The  importance  and  frequency  of  focal  sepsis  have  been  emphasized  in  recent 
years  and  it  gives  the  clue  to  the  etiology  of  many  obscure  conditions.  Foci 
of  infection  may  be  primary  and  secondary.  The  latter  are  usually  the  result 
of  infection  through  the  blood  or  lymph. 

Etiology. — The  organism  most  often  concerned  is  some  variety  of  strepto- 
coccus, such  as  8.  licemolyticus,  nnucosus,  viridans.  These  organisms  vary  in 
virulence  and  especially  in  their  hsemolytic  properties.  The  colon  bacillus  is 
sometimes  responsible.  The  foci  may  be  situated  in  many  parts  of  the  body 
and  may  be  open  to  the  surface  or  closed.  An  example  of  the  former  is  seen 
in  pyorrhoea  alveolaris  and  of  the  latter  in  the  closed  abscess  at  the  root  of  a 
tooth.  The  local  infection  may  be  situated  in  many  parts  of  the  body  but 
in  a  majority  the  situation  is  in  the  mouth  or  tonsib.  Investigation  has  shown 
the  frequency  of  deep  tonsillar  infection,  which  may  show  no  indication  on 
the  surface,  and  of  suppuration  about  the  roots  of  teeth.  Infection  of  the 
nose,  or  sinuses,  bronchi,  gall-bladder,  appendix,  intestine,  pelvic  organs  in 
the  male  and  female  and  the  urinary  tract  may  be  the  source. 

Pathology. — The  lesions  may  be  varied  and  situated  in  almost  any  part  of 
the  body.  Perhaps  the  most  frequent  sites  are  in  the  joints  and  fibrous  tis- 
sues. Arthritis  is  common  and  many  of  the  obscure  pains,  termed  myalgia, 
neuritis,  "chronic  and  muscular  rheumatism,"  are  really  due  to  fibrositis  sec- 
ondary to  a  focal  infection.  Among  other  resulting  lesions  are  endocarditis, 
myocarditis,  gastric  ulcer,  cholecystitis,  appendicitis  and  nephritis.  The  re- 
sulting disturbance  is  due  to  absorbed  toxins  or  to  bacteria  which  reach  the 
blood  stream  or  lymph  and  are  carried  to  other  parts.  Systemic  intoxication 
from  absorption  is  not  rare.     In  some  cases  the  individual  becomes  sensitized 


THE  PYOGENIC  INFECTIONS  57 

to  the  protein  of  the  organism  concerned.  The  lesions  produced  do  not  show 
any  particular  characteristic.  In  general  they  are  those  of  a  chronic  inflam- 
matory process  with  occasional  acute  exacerbations,  but  on  the  whole  tending 
to  chronicity.  The  organisms  are  usually  of  low  virulence.  The  disparity 
between  the  frequency  of  foci  of  infection  and  resulting  disease  is  apparently 
largely  due  to  natural  resistance  and  immunity. 

Symptoms. — These  cannot  be  stated  in  detail  as  so  many  different  struc- 
tures may  be  involved.  In  general,  however,  there  are  some  statements  that 
can  be  made.  (1)  The  condition  is  usually  chronic  and  may  vary  much  from 
time  to  time.  Thus  secondary  arthritis  is  generally  sub-acute  or  chronic, 
although  there  are  occasional  cases  with  an  acute  course  and  more  with  acute 
exacerbations.  (2)  The  onset  of  symptoms  may  be  determined  by  some  inter- 
current disease  or  debilitating  condition.  (3)  The  general  health  is  apt  to 
be  affected.  (4)  Active  reaction  as  shown  by  marked  fever  is  unusual,  as  the 
process  is  too  chronic.  (5)  There  is  a  tendency  to  anaemia  and  disturbance 
of  nutrition. 

Diagnosis. — This  cannot  be  stated  in  any  exact  terms.  The  first  essential 
is  the  recognition  of  the  important  part  that  focal  infection  plays.  Chronic 
arthritis  and  fibrositis  are  not  primary  maladies ;  they  are  secondary  to  infec- 
tion somewhere.  We  know  that  if  a  patient  has  gonorrhoea!  arthritis  there  is 
a  primary  local  process.  The  primary  focus  has  often  to  be  searched  for; 
it  may  give  no  symptoms.  This  may  involve  the  examination  of  many  organs. 
If  there  is  no  localizing  indication,  the  teeth  and  tonsils  may  be  examined 
first.  The  nose  and  sinuses,  bronchi,  gall  bladder,  etc.,  have  all  to  be  con- 
sidered. Duodenal  cultures  are  important  in  the  recognition  of  biliary  tract 
infection.  Nor  is  it  safe  to  conclude  that  a  focus  when  found  is  the  responsi- 
ble one.     There  may  be  multiple  foci. 

Prognosis. — Many  factors  enter  into  this,  especially  the  resistance  of  the 
individual  and  the  virulence  of  the  organism.  The  degree  of  anatomical 
change  must  be  considered,  thus  if  extensive  joint  changes  have  occurred  the 
removal  of  a  focus  of  infection  cannot  alter  these  although  it  may  prevent 
further  damage.  Naturally  the  earlier  proper  treatment  is  instituted  the  bet- 
ter the  outlook. 

Treatment. —  (1)  Eemoval  of  the  cause,  the  focus  of  infection.  This  de- 
mands proper  diagnosis  and  should  not  be  done  until  this  is  as  definite  as  pos- 
sible. A  man  with  mouth  infection  may  have  the  real  focus  in  his  prostate. 
Caution  should  he  exercised  in  the  treatment  of  foci  if  the  general  symptoms 
are  acute.  (2)  Vaccine  therapy.  In  some  cases  this  is  of  value  and,  if 
possible,  an  autogenous  vaccine  should  be  used.  (3)  Injection  of  non-specific 
protein,  for  example  fifty  millions  of  killed  typhoid  bacilli  intravenously.  This 
has  proved  useful,  particularly  in  cases  of  chronic  arthritis,  but  is  to  be  em- 
ployed with  caution.  (4)  Helping  the  patient's  powers  of  resistance  by 
attention  to  the  general  health.  Fresh  air  and  sunlight,  sufficient  food,  and 
proper  treatment  for  ansemia,  are  indicated. 

5.     TERMINAL  INFECTIONS 

There  is  truth  in  the  paradoxical  statement  that  persons  rarely  die  of  the 
disease  with  which  they  suffer.     Secondary  terminal  infections  carry  off  many 


58  SPECIFIC  INFECTIOUS  DISEASES 

incurable  eases.  Flexner  analyzed  255  cases  of  chronic  renal  and  cardiac 
disease  in  which  complete  bacteriological  examinations  were  made  at  autopsy. 
Excluding  tuberculous  infection,  313  gave  positive  and  42  negative  results. 
The  infections  may  be  local  or  general.  The  former  are  extremely  common, 
and  are  found  in  a  large  proportion  of  all  cases  of  nephritis,  arterio-sclerosis, 
heart  disease,  cirrhosis  of  the  liver,  and  other  chronic  disorders.  Affections 
of  the  serous  membranes  (acute  pleurisy,  pericarditis,  or  peritonitis),  menin- 
gitis, and  endocarditis  are  the  most  frequent  lesions.  It  is  perhaps  safe  to 
say  that  the  majority  of  cases  of  advanced  arterio-sclerosis  and  of  nephritis 
succumb  to  these  intercurrent  infections.  The  infective  agents  are  very  varied. 
The  streptococcus  is  the  most  common,  but  the  pneumococcus,  staphylococcus 
and  gonococcus,  and  the  proteus,  pyocyaneus,  and  gas  bacillus  are  also  found. 
It  is  surprising  in  how  many  instances  of  arterio-sclerosis,  of  chronic  heart 
disease,  of  nephritis,  and  particularly  of  cirrhosis  of  the  liver  in  Flexner's 
series  the  fatal  event  was  determined  by  an  acute  tuberculosis  of  the  perito- 
neum or  pleura. 

The  general  terminal  infections  are  somewhat  less  common.  Of  85  cases 
of  chronic  renal  disease  in  which  Flexner  found  micro-organisms  at  autopsy, 
38  exhibited  general  infections;  of  48  cases  of  chronic  cardiac  disease,  in  14 
the  distribution  of  bacteria  was  general.  The  blood-serum  of  persons  suffering 
from  advanced  chronic  disease  was  found  by  him  to  be  less  destructive  to  the 
staphylococcus  aureus  than  normal  human  serum.  Other  diseases  in  which 
general  terminal  infection  may  occur  are  Hodgkin's  disease,  leuksemia,  and 
chronic  tuberculosis.  And,  lastly,  probably  of  the  same  nature  is  the  terminal 
entero-colitis  so  frequently  met  with  in  chronic  disorders. 


VI.     EEYSIPELAS 

Definition. — A  special  pyogenic  infection  caused  by  the  Streptococcus  ery- 
sipelatis,  characterized  by  inflammation  of  the  skin  with  fever  and  toxaemia. 

Etiology. — Erysipelas  is  a  widespread  affection,  endemic  in  most  com- 
munities, and  at  certain  seasons  epidemic.  We  are  as  yet  ignorant  of  the  at- 
mospheric or  telluric  influences  which  favor  the  diffusion  of  the  poison. 

It  is  particularly  prevalent  in  the  spring  of  the  year.  Of  2,012  cases  col- 
lected by  Anders,  1,214  occurred  during  the  first  five  months  of  the  year.  April 
had  the  largest  number  of  cases.  The  affection  prevails  extensively  in  old, 
ill-ventilated  hospitals  and  institutions  in  which  the  sanitary  conditions  are 
defective.  With  improved  sanitation  the  number  of  cases  has  materially  di- 
minished. It  has  been  observed,  however,  to  break  out  in  new  institutions 
under  the  most  favorable  hygienic  circumstances.  Erysipelas  is  both  infectious 
and  inoculable;  but,  except  under  special  conditions,  the  poison  is  not  very 
virulent  and  does  not  seem  to  act  at  any  great  distance.  .  It  can  be  conveyed 
by  a  third  person.  The  virus  attaches  itself  to  the  furniture,  bedding,  and 
walls  of  rooms  in  which  patients  have  been  confined. 

The  disposition  to  the  disease  is  widespread,  but  the  susceptibility  is 
specially  marked  in  the  case  of  individuals  with  wounds  or  abrasions  of  any 
sort.  Eecently  delivered  women  and  persons  who  have  been  the  subjects  of 
surgical  operations  are  particularly  prone  to  it.     A  wound,  however,  is  not 


EEYSIPELAS  59 

necessary,  and  in  the  so-called  idiopathic  form,  although  it  may  be  difficult  to 
say  that  there  was  not  a  slight  abrasion  about  the  nose  or  lips,  in  very  many 
cases  there  certainly  is  no  observable  external  lesion.  In  some  cases  the  infec- 
tion apparently  spreads  through  the  tissues  from  the  nasal  cavity  to  the  skin. 

Chronic  alcoholism,  debility,  and  nephritis  are  predisposing  agents.  Cer- 
tain persons  show  a  special  susceptibility  to  erysipelas,  and  it  may  recur  in 
them  repeatedly.    There  are  instances,  too,  of  a  family  predisposition. 

The  specific  agent  of  the  disease  is  a  streptococcus  growing  in  long  chains, 
which  is  included  under  the  group  name  Streptococcus  pyogenes,  with  which 
Streptococcus  erysipelatis  appears  to  be  identical.  The  fever  and  constitu- 
tional symptoms  are  due  in  great  part  to  the  toxins ;  the  more  serious  visceral 
complications  are  the  result  of  secondary  metastatic  infection. 

Morbid  Anatomy. — Erysipelas  is  a  simple  inflammation.  In  its  uncom- 
plicated forms  there  is  seen,  .post  mortem,  little  else  than  inflammatory 
oedema.  Investigations  have  shown  that  the  cocci  are  found  chiefly  in  the 
lymph-spaces  and  most  abundantly  in  the  zone  of  spreading  inflammation. 
In  the  uninvolved  tissue  beyond  the  inflamed  margin  they  are  to  be  found  in 
the  lymph-vessels,  and  it  is  here,  according  to  Metschnikoff  and  others,  that 
an  active  warfare  goes  on  between  the  leucocytes  and  the  cocci  (phagocytosis). 
In  more  extensive  and  virulent  forms  there  is  usually  suppuration. 

Infarcts  occur  in  the  lungs,  spleen,  and  kidneys,  and  there  may  be  the  gen- 
eral evidences  of  pygemic  infection.  Some  of  the  worst  cases  of  malignant 
endocarditis  are  secondary  to  erysipelas;  thus,  of  23  cases,  3  occurred  in  con- 
nection with  this  disease.  Septic  pericarditis  and  pleuritis  also  occur.  The 
disease  may  in  rare  cases  extend  to  and  involve  the  meninges.  Pneumonia 
is  not  a  very  common  complication.  Acute  nephritis  is  also  met  with;  it  is 
often  ingrafted  upon  an  old  chronic  trouble. 

Symptoms. — The  following  description  applies  specially  to  erysipelas  of  the 
face  and  headj  the  form  of  the  disease  which  is  most  common. 

The  incubation  is  variable,  probably  from  three  to  seven  days. 

The  stage  of  invasion  is  often  marked  by  a  rigor,  and  followed  by  a  rapid 
rise  in  the  temperature  and  other  characteristics  of  an  acute  fever.  When 
there  is  a  local  abrasion,  the  spot  is  slightly  reddened;  but  if  the  disease  is 
idiopathic,  there  is  seen  within  a  few  hours  slight  redness  over  the  bridge  of 
the  nose  and  on  the  cheeks.  The  swelling  and  tension  of  the  skin  increase 
and  within  twenty-four  hours  the  external  symptoms  are  well  marked.  The 
skin  is  smooth,  tense,  and  oedematous.  It  looks  red,  feels  hot,  and  the  super- 
ficial layers  of  the  epidermis  may  be  lifted  as  small  blebs.  The  patient  com- 
plains of  an  unpleasant  feeling  of  tension  in  the  skin;  the  swelling  rapidly 
increases;  and  during  the  second  day  the  eyes  are  usually  closed.  The  first- 
affected  parts  gradually  become  pale  and  less  swollen  as  the  disease  extends  at 
the  periphery.  When  it  reaches  the  forehead  it  progresss  as  an  advancing 
ridge  perfectly  well  defined  and  raised;  and  often,  on  palpation,  hardened  ex- 
tensions can  be  felt  beneath  the  skin  which  is  not  yet  reddened.  Even  in  a 
case  of  moderate  severity,  the  face  is  enormously  swollen,  the  eyes  are  closed, 
the  lips  greatly  rpdematous,  the  ears  thickened,  the  scalp  is  swollen,  and  the 
patient's  features  are  quite  unrecognizable.  The  formation  of  blebs  is  com- 
mon on  the  eyelids,  ears,  and  forehead.  The  cervical  lymph-glands  are  swol- 
len, but  are  usually  masked  in  the  oedema  of  the  neck.    The  temperature  keeps 


60  SPECIFIC  INFECTIOUS  DISEASES 

high  without  marked  remissions  for  four  or  five  days  and  then  defervescence 
takes  place  by  crisis.  Leucocytosis  is  present.  The  general  condition  of  the 
patient  varies  much  with  his  previous  state  of  health.  In  old  and  debilitated 
persons,  jDarticularly  in  those  addicted  to  alcohol,  the  constitutional  depres- 
sion from  the  outset  may  be  very  great.  Delirium  is  present,  the  tongue 
becomes  dry,  the  pulse  feeble,  and  there  is  marked  tendency  to  death  from 
toxaemia.  In  the  majority  of  cases,  however,  even  with  extensive  lesions,  the 
constitutional  disturbance,  considering  the  height  of  the  fever,  is  slight.  The 
mucous  membrane  of  the  mouth  and  throat  may  be  swollen  and  reddened. 
The  process  may  extend  to  the  larynx,  but  the  severe  oedema  of  this  part 
occasionally  met  with  is  commonly  due  to  the  extension  of  the  inflammation 
from  without  inward. 

There  are  cases  in  which  the  inflammation  extends  from  the  face  to  the 
neck,  and  over  the  chest,  and  may  gradually  migrate  or  wander  over  the 
greater  part  of  the  body  {E.  migrans). 

The  close  relation  between  the  erysipelas  coccus  and  the  pus  organisms 
is  shown  by  the  frequency  Math  which  suppuration  occurs  in  facial  erysipelas. 
Small  cutaneous  abscesses  are  common  about  the  cheeks  and  forehead  and 
neck,  and  beneath  the  scalp  large  collections  of  pus  may  accumulate.  Sup- 
puration seems  to  occur  more  frequently  in  some  epidemics  than  in  others, 
and  at  the  Philadelphia  Hospital  during  one  year  nearly  all  the  cases  in  the 
erysipelas  wards  presented  local  abscesses. 

Complications. — Meningitis  is  rare.  The  cases  in  which  death  occurs 
with  marked  brain  symptoms  do  not  usually  show,  post  mortem,  meningeal 
affection.  Pneumonia  is  an  occasional  complication.  Ulcerative  endocarditis 
and  septiccemia  are  more  common.  Albuminuria  is  almost  constant,  particu- 
larly in  persons  over  fifty.  True  nephritis  is  occasionally  seen.  Da  Costa 
called  attention  to  curious  irregular  returns  of  the  fever  which  occur  during 
convalescence  without  any  aggravation  of  the  local  condition. 

Diagnosis. — This  rarely  presents  any  difficulty.  The  mode  of  onset,  the 
rapid  rise  in  fever,  and  the  characters  of  the  local  disease  are  distinctive. 

Prognosis. — Healthy  adults  rarely  die.  The  general  mortality  in  hospitals 
is  about  7  per  cent.;  in  private  practice  about  4  per  cent.  (Anders.)  In  the 
new-born,  when  the  disease  attacks  the  navel,  it  is  almost  always  fatal.  In 
drunkards  and  in  the  aged  erysipelas  is  a  serious  affection,  and  death  may 
result  either  from  the  intensity  of  the  fever  or,  more  commonly,  from  toxae- 
mia. The  wandering  or  ambulatory  erysipelas,  which  has  a  more  protracted 
course,  may  cause  death  from  exhaustion. 

Treatment. — Isolation  should  be  strictly  carried  out,  particularly  in  hos- 
pitals. A  practitioner  in  attendance  upon  a  case  of  erysipelas  should  hot 
attend  cases  of  confinement. 

The  disease  is  self -limited  and  a  large  majority  of  the  cases  get  well  with- 
out any  internal  medication.  The  diet  should  be  nutritious  and  light.  Large 
amounts  of  water  should  be  given.  For  the  restlessness,  delirium,  and  in- 
somnia, chloral  or  the  bromides  may  be  given ;  or,  if  thes«  fail,  opium.  When 
the  fever  is  high  the  patient  may  be  bathed  or  sponged,  or,  in  private  practice, 
if  there  is  an  objection  to  this,  antipyrin  or  antifebrin  may  be  given.  Of 
internal  remedies  believed  to  influence  the  disease,  the  tincture  of  the  per- 
ehloride  of  iron  has  been  highly  recommended  but  it  is  doubtful  if  any  medi- 


BIPHTHEEIA  61 

cine,  given  internally,  has  a  definite  control  over  the  course  of  the  disease. 

Antistreptococcic  serum  may  be  tried  or,  better  still,  an  autogenous  vac- 
cine, with  the  use  of  which  good  results  have  been  obtained. 

Of  local  treatment,  the  injection  of  antiseptic  solutions  at  the  margin  of 
the  spreading  areas  has  been  much  practised.  Two-per-cent.  solutions  of 
phenol,  corrosive  sublimate  (1  to  4,000),  and  the  biniodide  of  mercury  have 
been  much  used.  The  injection  should  be  made  not  into  but  just  a  little  be- 
yond the  border  of  the  inflamed  patch. 

Of  local  applications,  ichthyol  (as  a  salve,  1  to  4  of  lanolin),  bichloride 
of  mercury  solution  (1  to  5,000),  salicylic  acid  (1  to  500),  phenol  in  oil 
(5  per  cent.),  a  saturated  solution  of  magnesium  sulphate,  powdered  stearate 
of  zinc,  collodion,  or  ichthyol  in  collodion  (1  to  4),  may  be  used.  Painting 
the  skin  ahead  of  the  advancing  area  with  tincture  of  iodine  is  sometimes  ef- 
fectual. Perhaps  as  good  an  application  as  any  is  cold  water,  which  was 
highly  recommended  by  Hippocrates.  If  the  disease  involves  the  eyelids  boric 
acid  compresses  should  be  applied  and  one  or  two  drops  of  argyrol  solution 
(10  per  cent.)   instilled  several  times  a  day. 


VII.     DIPHTHERIA 

Definition. — A  specific  infectious  disease,' characterized  by  a  local  fibrinous 
exudate,  usually  upon  the  mucous  membrane  of  the  throat,  and  by  constitu- 
tional symptoms  due  to  toxins  produced  at  the  site  of  the  lesion.  The  pres- 
ence of  the  Klebs-LoefQer  bacillus  is  the  etiological  criterion  by  which  true 
diphtheria  is  distinguished  from  other  forms  of  membranous  inflammation. 

Cases  of  angina,  diagnosed  as  diphtheria,  may  be  due  to  other  organisms 
and  to  these  the  term  diphtheroid  is  applied.  Though  usually  milder,  severe 
constitutional  "disturbance,  and  even  paralysis,  may  follow  these  forms. 

History. — Known  in  the  East  for  centuries,  and  referred  to  in  the  Baby- 
lonian Talmud,  it  is  not  until  the  first  century  a.  d.  that  an  accurate  clinical 
account  ai)pears  in  the  writings  of  Aretseus.  The  i)aralysis  of  the  palate  was 
recognized  by  yEtius  (sixth  century  A.  d.).  Throat  pestilences  are  mentioned 
in  the  Middle  Ages.  Severe  epidemics  occurred  in  Europe  in  the  sixteenth 
and  seventeenth  centuries,  particularly  in  Spain.  In  England  in  the  latter 
part  of  the  eighteenth  century  it  was  described  by  Fothergill  and  Huxham, 
and  in  America  by  Bard.  Washington  died  of  the  disease.  Ballonius  recog- 
nized the  affection  of  the  larynx  and  trachea  in  1762,  Home  in  Scotland 
described  it  as  croup.  The  modern  description  dates  from  Bretonneau,  of 
Tours  (1826),  who  gave  to  it  the  name  diphflierite.  Throughout  the  nine- 
teenth century  it  prevailed  extensively  in  all  known  countries,  and  it  is  at 
present  everywhere  epidemic.  After  innumerable  attempts,  in  which  Klebs 
took  a  leading  part,  the  organism  was  isolated  by  Loeffler.  The  toxin  was 
determined  by  the  work  of  Eoux,  Yersin,  and  others,  and  finally  the  antitoxin 
Avas  discovered  by  Behring. 

Etiology. — Everywhere  endemic  in  large  centres  of  population,  the  disease 
becomes  at  times  epidemic.  It  is  more  prevalent  on  the  continent  of  Europe 
than  in  Great  Britain,  and  Ireland  has  less  than  other  countries.  In  England 
and  Wales  in  1916,  5,358  persons  died  of  the  disease.    In  the  registration  area 


62  SPECIFIC  INFECTIOUS  DISEASES 

ill  the  United  States  the  death  rate  per  100,000  has  fallen  from  43  in  1900 
to  16.5  in  1917.  In  the  tropics  it  is  not  a  very  serious  disease.  Pandemics 
occur  cyclically,  at  irregular  intervals,  under  conditions  as  yet  imperfectly 
known.  Dry  seasons  seem  to  favor  the  disease,  which  shows  an  autumnal 
prevalence. 

Modes  of  Infection. — The  disease  is  highly  infectious.  The  bacilli  may 
be  transmitted  (a)  from  one  person  to  another;  few  diseases  have  proved  more 
fatal  to  physicians  and  nurses.  (&)  Infected  articles  may  convey  the  bacilli, 
which  may  remain  alive  for  many  months;  scores  of  well-attested  instances 
have  been  recorded  of  this  mode  of  transmission,  (c)  Persons  suifering  from 
atypical  forms  of  diphtheria  may  convey  the  disease;  nasal  catarrh,  mem- 
branous rhinitis,  mild  tonsillitis,  otorrhoea  may  be  caused  by  the  diphtheria 
bacilli,  and  from  each  of  these  sources  cases  have  been  traced,  (d)  From 
the  throats  of  healthy  contacts — diphtheria  carriers,  persons  who  present  no 
signs  of  the  disease — the  bacilli  have  been  obtained  by  culture,  (e)  Even 
healthy  children  without  any  naso-pharyngeal  catarrh,  who  have  not  been  in 
contact  with  the  disease,  may  harbor  the  bacilli.  In  1,000  children  from  the 
Xew  York  tenements  Shelley  found  18  with  virulent  and  38  with  non-viru- 
lent bacilli,  and  the  percentage  has  been  sometimes  much  higher.  Long  after 
recovery  virulent  bacilli  have  been  isolated  from  the  throat.  It  is  important 
to  bear  in  mind  under  d  and  e  that  it  is  only  persons  who  harbor  the  virulent 
forms  who  are  capable  of  transmitting  the  disease.  In  schools  the  interchange 
of  articles,  such  as  sweets,  pencils,  etc.,  and  the  habit  which  children  have  of 
putting  everything  into  their  mouths  afford  endless  opportunities  for  the 
transmission  of  the  disease.  As  Wesbrook  remarked,  diphtheria  is  trans- 
mitted usually  by  almost  direct  exchange  of  the  flora  of  the  nose  and  mouth. 
(/)  Numerous  epidemics  have  been  traced  to  milk,  since  Power  in  1878  de- 
termined this  method  of  spread.  Virulent  bacilli  have  been  found  in  milk, 
and  Dean  and  Todd  and  Ashby  found  virulent  organisms  in  the  acquired 
lesions  on  the  teats  of  cows,  (g)  A  few  instances  of  accidental  infection  from 
cultures  and  through  animals  are  on  record. 

Predisposing  Causes. — Ag&  is  the  most  important.  Sucklings  are  not 
often  attacked,  but  Jacobi  saw  three  cases  in  the  new-born.  Early  in  the 
second  year  the  disposition  increases  rapidly,  and  continues  at  its  height  until 
the  fifth  year.  At  Baginsky's  clinic,  Berlin,  among  2,711  cases,  1,235  oc- 
curred from  the  second  to  the  fifth  years  inclusive.  In  New  York  between 
1891-1900  among  the  deaths  80.8  per  cent,  occurred  under  five,  17  per  cent, 
between  five  and  ten — figures  which  show  the  extraordinary  preponderance  of 
the  disease  among  children.  Girls  are  attacked  in  slightly  larger  numbers 
than  boys.  November,  December,  and  January  are  the  months  of  greatest 
prevalence  in  the  United  States;  in  London  October  and  November.  Soil 
and  altitude  have  little  or  no  influence;  nor  does  race  play  an  important  role. 

Individual  susceptibility  is  a  very  special  factor;  not  only  do  many  of 
those  exposed  escape,  but  even  those,  too,  in  whose  throats  virulent  bacilli 
lodge  and  grow.  Probably  about  70  per  cent,  of  all  persons  have  antitoxin  in 
the  blood  and  so  are  protected.  The  Schick  reaction  (intradermic  injection 
of  diphtheria  toxin)  is  of  great  value  in  determining  the  presence  of  im- 
munity, A  negative  reaction  indicates  the  presence  of  antitoxin  as  when  it 
is  not  present  the  toxin  causes  a  reaction  on  the  skin. 


DIPHTHERIA  63 

The  Klebs-Loeffler  Bacillus  occurs  in  a  large  number  of  all  suspected 
cases.  It  is  found  chiefly  in  the  false  membrane,  and  does  not  extend  into 
the  subjacent  mucosa.  The  organisms  are  localized,  and  only  a  few  penetrate 
into  the  interior.  Post  mortem  the  bacilli  may  be  found  in  the  blood  and 
in  the  internal  organs.  Occasionally  they  are  found  in  the  blood  during  life. 
It  may  be  the  predominating  or  sole  organism  in  the  broncho-pneumonia  so 
common  in  the  disease.  Outside  the  throat,  the  Klebs-Loefller  bacillus  has 
been  found  in  diphtheritic  conjunctivitis,  in  otitis  media,  sometimes  in  wound 
diphtheria,  upon  the  genitals,  in  fibrinous  rhinitis,  and  in  ulcerative 
endocarditis. 

Morphological  Characters. — The  bacillus  is  non-motile,  varies  from  3  to  6 
fi  in  length  and  from  0.3  to  0.8  //,  in  thickness.  In  appearance  it  is  multi- 
form, varying  from  short,  rather  sharply  pointed  rods  to  irregular  bizarre 
forms,  with  one  or  both  ends  swollen,  and  staining  more  or  less  unevenly  and 
intensely.  Wesbrook  recognized  three  main  types — granular,  barred,  and 
solid  staining.  Branching  forms  are  occasionally  met  with.  The  bacillus 
stains  in  sections  or  on  the  cover-glass  by  the  Gram  method. 

The  bacillus  is  very  resistant,  and  cultures  have  been  made  from  a  bit  of 
membrane  preserved  for  five  months  in  a  dry  cloth.  Incorporated  with  dust 
and  kept  moist,  the  bacilli  were  still  cultivable  at  the  end  of  eight  weeks; 
kept  in  a  dried  state  they  no  longer  grew  at  the  end  of  this  period  (Eitter). 

The  Klebs-Loefller  bacillus  has  very  varying  grades  of  virulence  down  even 
to  complete  absence  of  pathogenic  effects.  The  name  pseudo-bacillus  of  diph- 
theria should  not  be  given  to  this  avirulent  organism. 

The  Presence  of  the  Klehs-Loeffler  Bacillus  in  Non-memhranous  Angina 
and  in  Healthy  Throats. — The  bacillus  has  been  isolated  from  cases  which 
show  nothing  more  than  a  simple  catarrhal  angina,  of  a  mild  type  without  any 
membrane,  with  diffuse  redness,  and  perhaps  huskiness  and  signs  of  catarrhal 
laryngitis.  In  other  cases  the  anatomical  picture  may  be  that  of  a  lacunar 
tonsillitis.  The  organisms  may  be  met  with  in  perfectly  healthy  throats 
(diphtheria  carriers),  particularly  in  persons  in  the  same  house,  or  the  ward 
attendants  and  nurses  in  fever  hospitals.  Following  an  attack  of  diphtheria 
the  bacilli  may  persist  in  the  throat  or  nose  after  all  the  membrane  has  disap- 
peared for  weeks  or  months — even  15  months.  In  explanation  of  this  per- 
sistence Councilman  has  called  attention  to  the  frequency  with  which  the 
antrum  is  affected. 

Toxins  of  the  Klehs-Loeffler  Bacillus. — Eoux  and  Yersin  showed  that  a 
fatal  result  following  the  inoculation  with  the  bacillus  was  not  caused  by  any 
extension  of  the  micro-organisms  within  the  body ;  and  they  were  enabled  in 
bouillon  cultures  to  separate  the  poison  from  the  bacilli.  The  toxin  so  sep- 
arated killed  with  very  much  the  same  effects  as  those  caused  by  the  inocula- 
tion of  the  bacilli;  the  pseudo-membrane,  however,  is  not  formed. 

Susceptible  animals  may  be  rendered  immune  from  diphtheritic  infection 
by  injecting  weakened  cultures  of  the  bacillus  or,  what  is  better,  suitable  doses 
of  the  diphtheria  toxin.  The  result  is  a  febrile  reaction  which  soon  passes 
away  and  leaves  the  animal  less  susceptil)le  to  the  poison  or  the  living  bacilli. 
By  repeating  and  gradually  increasing  the  quantity  of  poison  injected  a  high 
degree  of  immunity  can  be  produced  in  large  animals. 

The  Bacteria  Associated  with  the  Diphtheria  Bacillus. — The  most  com- 


64  SPECIFIC  INFECTIOUS  DISEASES 

mon  is  the  streptococcus  pyogenes.  Others,  in  addition  to  the  organisms  con- 
stantly found  in  the  mouth,  are  the  pneumococcus,  the  bacillus  coli,  and  the 
staphylococcus  aureus  and  albus.  Of  these,  probably  the  streptococcus  pyo- 
genes is  the  most  important,  as  cases  of  general  infection  with  this  organism 
have  been  found  in  diphtheria.  The  suppuration  in  the  lymph-glands  and 
the  broncho-pneumonia  are  usually  caused  by  this  organism. 

Pseudo-Diphtheria  Bacillus. — The  Klebs-LoefEler  bacillus  varies  very  much 
in  its  virulence,  and  may  exist  in  a  form  entirely  devoid  of  pathogenic  prop- 
erties. This  organism  should  not,  however,  be  designated  pseudo-diphtheria 
bacillus.  The  name  should  be  confined  to  bacilli,  which,  though  resembling 
the  diphtheria  bacillus  morphologically  and  in  their  cultural  reactions,  do 
not  produce  diphtheria  toxin.  They  may  be  found  both  in  healthy  and  dis- 
eased throats.  Another  bacillus,  showing  certain  cultural  differences  from  the 
pseudo-diphtheria  bacillus,  has  been  repeatedly  found  in  the  conjunctival  sac 
in  health  and  disease  {B.  xerosis) .  Hoffmanns  Bacillus,  which  is  also  spoken 
of  as  pseudo-diphtheria  bacillus,  is  a  common  organism  in  the  throats  of 
healthy  persons  and  is  found  also  in  cases  of  diphtheria;  but  how  far  it  is 
responsible  for  pathological  conditions  is  not  settled.  Vincent's  Bacillus  is  a 
fusiform  organism  associated  with  a  diphtheroid  angina  (Vincent's  angina), 
which  occurs  in  two  forms :  a  membranous  and  an  ulcerative  and  destructive. 
The  fusiform  bacilli  have  been  found  in  healthy  throats  and  also  in  associa- 
tion with  true  diphtheria. 

Diphtheroid  Inflammations. — Under  the  term  diphtheroid  may  be  grouped 
those  membranous  inflammations  which  are  not  associated  with  the  Klebs- 
Loeffler  bacillus.  It  is  perhaps  c.  more  suitable  designation  than  pseudo-diph- 
theria or  secondary  diphtheria.  Streptococci  and  pneumococci  are  the 
organisms  most  often  found.  The  name  "diphtheritis"  is  best  used  in  an 
anatomical  sense  to  designate  an  inflammation  of  a  mucous  membrane  or 
integumentary  surface  characterized  by  necrosis  and  a  fibrinous  exudate, 
whereas  the  term  "diphtheria'^  should  be  limited  to  the  disease  caused  by  the 
Klebs-Loeffier  bacillus.  The  proportion  of  cases  of  diphtheroid  inflamma- 
tion varies  greatly  in  the  difilerent  statistics.  Of  the  observations  made  by 
Park  and  Beebe  (5,611)  in  New  York,  40  per  cent,  were  diphtheroid.  Figures 
from  other  sources  do  not  show  so  high  a  percentage. 

Conditions  under  Which  the  Diphtheeoid  Affection  Occurs. — Of 
450  cases  (Park  and  Beebe),  300  occurred  in  the  autumn  months  and  150  in 
the  spring;  198  occurred  in  children  from  the  first  to  the  seventh  year.  In  a 
large  proportion  of  all  the  cases  the  disease  develops  in  children,  and  can  be 
differentiated  from  diphtheria  proper  only  by  the  bacteriological  examination. 
It  may  be  simply  an  acute  catarrhal  angina  with  lacunar  tonsillitis.  Some 
of  the^cases  are  due  to  Hoffmann's  bacillus,  a  few  to  Vincent's  fusiform  bacil- 
lus. The  diphtheroid  inflammations  are  particularly  prone  to  develop  in  con- 
nection with  the  acute  fevers. 

(a)  Scarlet  Fever. — In  a  large  proportion  of  the  cases  of  angina  in  scar- 
let fever  the  Ivlebs-Loeffler  bacillus  is'  not  present.  Streptococci  are  usually 
found,  but  the  angina  is  not  always  due  to  the  streptococcus.  Where  diph- 
theria, is  prevalent  and  opportunities  are  favorable  for  exposure,  a  large  pro- 
portion of  the  cases  of  membranous  throats  in  scarlet  fever  may  be  genuine 
diphtheria. 


•    DIPHTHERIA  65 

(b)  MeaMes. — Membranous  angina  is  much  less  common  in  this  disease. 
It  occurred  in  6  of  the  450  diphtheroid  cases  in  New  York.  Of  4  cases  with 
severe  membranous  angina  at  the  Boston  City  Hospital,  only  1  presented  the 
Klebs-Loeffler  bacillus. 

(c)  Whooping-cough  may  be  complicated  with  membranous  angina. 
Escherich  records  -4  cases,  the  Klebs-Loeffler  bacillus  being  found  in  all. 

(d)  Typhoid  Fever. — ^Membranous  inflammations  in  this  disease  are  not 
very  infrequent;  they  may  occur  in  the  throat,  the  pelvis  of  the  kidney,  the 
bladder,  or  the  intestines.  The  complication  may  be  caused  by  the  Klebs-Loef- 
fler bacillus,  but  it  is  frequently  a  streptococcus  infection.  Ernst  Wagner  has 
remarked  upon  the  greater  frequency  of  these  membranous  inflammations  in 
typhoid  fever  when  diphtheria  is  prevailing. 

Clinical  Features  of  the  Diphtheroid  Affection. — The  cases,  as  a  rule,  are 
milder,  and  the  mortality  is  low,  only  2.5  per  cent,  in  the  450  cases  of  Park 
and  Beebe.  The  diphtheroid  inflammations  complicating  the  specific  fevers 
are  often  very  fatal,  and  a  general  streptococcus  infection  is  not  infrequent. 
As  in  the  Klebs-Loeffler  angina,  there  may  be  only  a  simple  catarrhal  process. 
In  other  instances  the  tonsils  are  covered  with  a  creamy,  pultaceous  exudate, 
without  any  actual  membrane.  An  important  group  may  begin  as  a  simple 
lacunar  tonsillitis,  while  in  others  the  entire  fauces  and  tonsils  are  covered 
by  a  continuous  membrane,  and  there  is  a  foul  sloughing  angina  with  intense 
constitutional  disturbance. 

Are  the  diphtheroid  cases  contagious?  General  clinical  experience  war- 
rants the  statement  that  the  membranous  angina  associated  with  the  fevers 
is  rarely  communicated  to  other  patients.  The  health  department  of  New 
York  does  not  keep  the  diphtheroid  cases  under  supervision.  Their  investiga- 
tion of  the  450  diphtheroid  cases  seems  to  justify  this  conclusion.  Park  and 
Beebe  say  that  "it  did  not  seem  that  the  secondary  cases  were  any  less  liable 
to  occur  when  the  primary  case  was  isolated  than  when  it  was  not." 

Sequelce  of  the  Diphtheroid  Angina. — The  usual  mildness  of  the  disease 
is  in  part,  no  doubt,  due  to  the  less  frequent  systemic  invasion.  Some  of  the 
worst  forms  of  general  streptococcus  infection  are,  however,  seen  in  this  dis- 
ease. There  are  no  peculiarities,  local  or  general,  which  are  distinctive;  and 
even  the  most  extensive  paralysis  may  follow  an  angina  caused  by  it. 

Morbid  Anatomy. — Distribution  op  Membeane. — A  definite  membrane 
was  found  in  127  of  the  220  fatal  Boston  cases,  distributed  as  follows:  tonsils, 
65  cases;  epiglottis,  60;  larynx,  75;  trachea,  66;  pharynx,  51;  mucous  mem- 
brane of  nares,  43 ;  bronchi,  42 ;  soft  palate,  including  uvula,  13 ;  oesophagus, 
12 ;  tongue,  9 ;  stomach,  5 ;  duodenum,  1 ;  vagina,  2 ;  vulva,  1 ;  skin  of  ear,  1 ; 
conjunctiva,  1.  An  interesting  point  in  the  Boston  investigation  was  the  great 
frequency  with  which  the  accessory  sinuses  of  the  nose  were  found  to  be  in- 
fected. In  the  fatal  cases,  the  exudation  is  very  extensive,  involving  the  uvula, 
the  soft  palate^  the  posterior  nares,  and  the  lateral  and  posterior  walls  of  the 
pharynx.  These  parts  are  covered  with  a  dense  pseudo-membrane,  in  places 
firmly  adherent,  in  others  beginning  to  separate.  In  extreme  cases  the  necrosis 
is  advanced  and  there  is  a  gt^ngrenous  condition  of  the  parts.  The  membrane 
is  of  a  dirty  greenish  or  gray  color,  and  the  tonsils  and  palate  may  be  in  a 
state  of  necrotic  sloughing.  The  erosion  may  be  deep  enough  in  the  tonsils 
to  open  the  carotid  artery,  or  a  false  aneurism  may  be  produced  in  the  deep 


66  SPECIFIC  INFECTIOUS  DISEASES 

tissues  of  the  neck.  The  nose  may  be  completely  blocked  by  the  membrane, 
which  may  extend  into  the  conjunctivae  and  through  the  Eustachian  tubes 
into  the  middle  ear.  In  laryngeal  diphtheria  the  exudate  in  the  pharynx  may 
be  extensive.  In  many  cases  it  is  slight  upon  the  tonsils  and  fauces  and 
abundant  upon  the  epiglottis  and  the  larynx,  which  may  be  completely  oc- 
cluded by  false  membrane.  In  severe  cases  the  exudate  extends  into  the 
trachea  and  to  the  bronchi  of  the  third  or  fourth  dimension. 

In  all  these  situations  the  membrane  varies  very  much  in  consistence,  de- 
pending greatly  upon  the  stage  at  which  death  has  taken  place.  If  death 
has  occurred  early,  it  is  firm  and  closely  adherent;  if  late,  it  is  soft,  shreddy, 
and  readily  detached.  When  firmly  adherent  it  is  torn  off  with  difficulty  and 
le^Tves  an  abraded  mucosa.  In  the  most  extreme  cases,  in  which  there  is  ex- 
tensive necrosis,  the  parts  look  gangrenous.  In  fatal  cases  the  lymphatic 
glands  of  the  neck  are  enlarged,  and  there  is  a  general  infiltration  of  the 
tissues  with  serum ;  the  salivary  glands,  too,  may  be  swollen.  In  rare  instances 
the  membrane  extends  to  the  gullet  and  stomach. 

On  inspection  of  the  larynx  of  a  child  dead  of  laryngeal  diphtheria  the 
rima  is  seen  filled  with  mucus  or  with  a  shreddy  material  which,  when  washed 
off,  leaves  the  mucosa  covered  by  a  thin  grayish-yellow  membrane,  which  may 
be  uniform  or  in  patches.  It  covers  the  ary-epiglottic  folds  and  the  true  cords, 
and  may  be  continued  into  the  ventricles  or  even  into  the  trachea.  Above, 
it  may  involve  the  epiglottis.  It  varies  much  in  consistency.  In  some  fatal 
cases  the  exudation  is  not  actually  membranous,  but  rather  friable  and  granu- 
lar. The  exudation  may  extend  down  the  trachea  and  into  the  bronchi,  and 
may  pass  beyond  the  epiglottis  to  the  fauces.  Usually  it  is  readily  stripped 
off  from  the  mucous  membrane  of  the  larynx  and  leaves  the  swollen  and  in- 
jected mucosa  exposed.  The  fibrinous  material  involves  chiefly  the  epithelial 
lining  and  does  not  greatly  infiltrate  the  subjacent  tissues. 

We  owe  largely  to  Wagner,  Weigert,  and  more  particularly  to  Oertel,  our 
knowledge  of  the  histological  changes.  The  beginning  of  the  lesion  is  due 
to  the  toxic  action  of  the  bacilli  growing  in  the  throat.  The  primary  lesion 
is  a  necrosis  and  degeneration  of  the  epithelial  tissues.  The  organisms  grow, 
not  in  the  living,  but  in  the  necrotic  tissues.  The  first  step  is  necrosis  of  the 
epithelium,  often  preceded  by  active  proliferation  of  the  nuclei  of  the  cells, 
which  become  changed  into  refractive  hyaline  masses.  From  the  structures 
below  an  inflammatory  exudate  rich  in  fibrin  factors  is  poured  out,  and  fibrin 
is  formed  when  this  comes  in  contact  with  the  necrotic  epithelium. 

The  following  are  the  important  changes  in  the  other  organs : 

Heart. — Fatty  degeneration  is  found  in  a  majority  of  the  cases.  It  may 
precede  the  more  advanced  degeneration,  in  which  the  sarcous  elements  be- 
come swollen  and  converted  into  hyaline  masses.  There  is  a  primary,  acute, 
interstitial  myositis,  and  also  a  form  secondary  to  degeneration  of  the  heart 
muscle,  to  which  some  of  the  cases  of  fibrous  myocarditis  may  be  due.  Peri- 
carditis and  endocarditis  are  rare;  endocarditis  was  present  in  7  of  220  cases 
at  the  Boston  City  Hospital.  The  diphtheria  bacilli  have  been  found  in  the 
vegetations. 

The  PULMONARY  COMPLICATIONS  are  the  most  important,  and  death  is  due 
to  them  as  often  as  to  the  throat  lesion.  Broncho-pneumonia,  or,  as  Council- 
man terms  it,  acinous  pneumonia,  is  the  most  common,  and  was  present  in  131 


DIPHTHEEIA  67 

of  the  220  Boston  cases.  Acute  lobar  pneiimonia  is  rare.  The  pneumococcus 
is  the  principal  agent  in  producing  the  lung  infection.  The  streptococci  and 
the  diphtheria  bacilli  are  frequently  met  with. 

Kidneys. — The  lesions,  which  are  due  to  the  action  of  the  toxins,  not  to 
the  presence  of  bacteria,  vary  from  simple  degeneration  to  an  intense  nephritis. 
There  is  no  specific  type  of  lesion.  Interstitial  and  glomerular  nephritis  are 
most  common  in  the  older  subjects.  Degenerative  changes  are  present  in  a 
large  proportion  of  all  the  fatal  cases.  The  liver  and  spleen  show  the  de- 
generative lesions  of  acute  infections. 

General  infection  is  common,  and  is  about  equal  with  the  streptococcus  and 
the  diphtheria  bacillus.  It  occurs  generally  in  the  grave  septic  cases,  in 
which  type  of  cases. the  former  organism  is  more  frequently  met  with. 

Symptoms. — The  period  of  incubation  is  "from  two  to  seven  days,  oftenest 
two."  The  initial  symptoms  are  those  of  an  ordinary  febrile  attack — slight 
chilliness,  fever,  and  aching  pains  in  the  back  and  limbs.  In  mild  cases 
these  symptoms  are  trifling,  and  the  child  may  not  feel  ill  enough  to  go  to 
bed.  Usually  the  temperature  rises  within  the  first  twenty-four  hours  to 
102.5°  or  103°  F. ;  in  severe  cases  to  104°  F,  In  young  children  there  may  be 
convulsions  at  the  outset. 

Pharyngeal  Diphtberia. — In  a  typical  case  there  is  at  first  redness  of 
the  fauces,  and  the  child  complains  of  slight  difficulty  in  swallowing.  The 
membrane  first  appears  upon  the  tonsils,  and  it  may  be  a  little  difficult  to 
distinguish  a  patchy  diphtheritic  pellicle  from  the  exudate  of  the  tonsillar 
crypts.  The  pharyngeal  mucous  membrane  is  reddened,  and  the  tonsils  them- 
selves are  swollen.  By  the  third  day  the  membrane  has  covered  the  tonsils,  the 
pillars  of  the  fauces,  and  perhaps,  the  uvula,  which  is  thickened  and  oedematous, 
and  may  fill  completely  the  space  between  the  swollen  tonsils.  The  membrane 
may  extend  to  the  posterior  wall  of  the  pharynx.  At  first  grayish-white  in 
color,  it  changes  to  a  dirty  gray,  often  to  a  yellow-white.  It  is  firmly 
adherent,  and  when  removed  leaves  a  bleeding,  slightly  eroded  surface,  which 
is  soon  covered  by  fresh  exudate.  The  glands  in  the  neck  are  swollen,  and 
may  be  tender.  The  general  condition  of  a  patient  in  a  case  of  moderate 
severity  is  usually  good;  the  temperature  not  very  high,  in  the  absence  of 
complications  ranging  from  102°  to  103°  F.  The  pulse  range  is  from  100 
to  120.  The  local  condition  of  the  throat  is  not  of  great  severity,  and  the 
constitutional  depression  is  slight.  The  symptoms  gradually  abate,  the  swell- 
ing of  the  neck  diminishes,  the  membranes  separate,  and  from  the  seventh  to 
the  tenth  day  the  throat  becomes  clear  and  convalescence  sets  in. 

Clinically  atypical  forms  are  common,  and  we  follow  Koplik's  division: 

(a)  There  may  be  no  local  manifestation  of  membrane,  but  a  simple 
catarrhal  angina  associated  sometimes  with  a  croupy  cough.  The  detection 
in  these  cases  of  the  Klebs-Loeffler  bacillus  can  alone  determine  the  diagnosis. 
Such  cases  are  of  great  moment,  inasmuch  as  they  may  communicate  the 
severer  disease  to  other  children. 

(&)  There  are  cases  in  which  the  tonsils  are  covered  by  a  pultaceous  exu- 
date, not  a  consistent  membrane. 

(c)  Cases  presenting  a  punctate  form  of  membrane,  isolated,  and  usually 
on  the  surface  of  the  tonsils. 


68  SPECIFIC  INFECTIOUS  DISEASES 

(d)  Cases  which  begin  and  often  run  their  entire  course  with  the  local 
picture  of  a  typical  lacunar  amygdalitis.  They  may  be  mild^  and  the  local 
exudate  may  not  extend,  but  in  other  cases  there  is  rapid  development  of 
membrane,  and  extension  of  the  disease  to  the  pharynx  and  the  nose,  with 
severe  septic  and  constitutional  symptoms. 

(e)  Under  the  term  "latent  diphtheria"  Heubner  has  described  cases, 
usually  secondary,  occurring  chiefly  in  hospital  practice,  in  young  persons  the 
subject  of  wasting  affections,  such  as  rickets  and  tuberculosis.  There  are 
fever,  naso-pharyngeal  catarrh,  and  gastro-intestinal  disturbances.  Diphtheria 
may  not  be  suspected  until  severe  laryngeal  complications  develop,  or  the 
condition  may  not  be  determined  until  autopsy. 

Systemic  Infection. — The  constitutional  disturbance  in  mild  diphtheria 
is  very  slight.  There  are  instances,  too,  of  extensive  local  disease  without 
grave  systemic  symptoms.  As  a  rule,  the  general  features  bear  a  definite 
relation  to  the  severity  of  the  local  disease.  There  are  rare  instances  in 
which  from  the  outset  the  constitutional  prostration  is  extreme,  the  pulse 
frequent  and  small,  the  fever  high,  and  the  nervous  phenomena  are  pro- 
nounced; the  patient  may  sink  in  two  or  three  days  overwhelmed  by  the 
intensity  of  the  toxaemia.  There  are  cases  of  this  sort  in  which  the  exudate 
in  the  throat  may  be  slight,  but  usually  the  nasal  symptoms  are  pronounced. 
The  temperature  may  be  very  slightly  raised  or  even  subnormal.  More  com- 
monly the  severe  systemic  symptoms  appear  at  a  later  date  when  ,the 
pharyngeal  lesion  is  at  its  height.  They  are  constantly  present  in  extensive 
disease,  and  when  there  is  a  sloughing,  fetid  condition.  The  lymphatic  glands 
become  greatly  enlarged;  the  pallor  is  extreme;  the  face  has  an  ashen-gray 
hue;  the  pulse  is  rapid  and  feeble,  and  the  temperature  sinks  below  normal. 
In  the. most  aggravated  forms  there  are  gangrenous  processes  in  the  throat, 
and  in  rare  instances,  extensive  sloughing  of  the  tissues  of  the  neck. 

Escherich  accounts  for  the  discrepancy  sometimes  observed  between  the 
severity  of  the  constitutional  disturbance  and  the  intensity  of  the  local 
process,  by  assuming  varying  degrees  of  susceptibility  to  the  diphtheria  bacillus 
on  the  one  hand,  and  to  its  toxin  on  the  other  hand.  With  high  local 
susceptibility  to  the  action  of  the  bacillus,  with  little  general  susceptibility 
to  the  toxin,  there  is  extensive  local  exudate  with  mild  constitutional  symp- 
toms, or  vice  versa,  severe  systematic  disturbance  with  limited  local  inflam- 
mation. 

A  leucocytosis  is  present  in  diphtheria.  Morse  does  not  think  it  of  any 
prognostic  value,  since  it  is  present  and  may  be  pronounced  in  mild  cases. 

Nasal  Diphtheria. — In  cases  of  pharyngeal  diphtheria  the  Klebs-Loef- 
fler  bacillus  is  found  on  the  mucous  membrane  of  the  nose  and  in  the  secre- 
tions, even  when  no  membrane  is  present,  but  it  may  apparently  produce  two 
affections  similar  enough  locally  but  widely  differing  in  their  general  features. 

In  viemhranous  or  fibrinous  rhinitis,  a  very  remarkable  affection  seen 
usually  in  children,  the  nares  are  occupied  by  thick  membranes,  but  there  is  an 
entire  absence  of  any  constitutional  disturbance.  Eavenel  collected  77  cases, 
in  41  of  which  a  bacteriological  examination  was  made,  in  33  the  Klebs- 
Loeffler  bacillus  being  present.  All  the  cases  ran  a  benign  course,  and  in  all 
but  a  few  the  membrane  was  limited  to  the  nose,  and  the  constitutional 
symptoms  were  either  absent  or  very  slight.    Eemarkable  and  puzzling  features 


DIPHTHERIA  69 

are  that  the  disease  runs  a  benign  course,  and  that  infection  of  other  chiklren 
in  the  family  is  extremely  rare. 

On  the  other  hand,  nasal  diphtheria  is  apt  to  present  a  most  malignant 
type  of  the  disease.  The  infection  may  be  primary  in  the  nose,  and  in  one 
case  there  was  otitis  media,  and  the  Klebs-Loeffler  bacillus  was  separated 
from  the  discharge  before  the  condition  of  nasal  diphtheria  was  suspected. 
While  some  cases  are  of  mild  character,  others  are  very  malignant,  and  the 
constitutional  symptoms  most  profound.  The  glandular  inflammation  is 
usually  very  intense,  owing,  as  Jacobi  points  out,  to  the  great  richness  of 
the  nasal  mucosa  in  lymphatics.  From  the  nose  the  inflammation  may  extend 
through  the  tear-ducts  to  the  conjunctivae  and  into  the  antra. 

Laeyngeal  Diphtheria  {Membranous  Croup). — With  a  very  large  pro- 
portion of  all  the  cases  of  membranous  laryngitis  the  Klebs-Loeffler  bacillus  is 
associated;  in  a  smaller  number  other  organisms,  particularly  the  strep- 
tococcus, are  found.  Of  286  cases  in  which  the  disease  was  confined  to  the 
larynx  or  bronchi,  in  229  the  Klebs-Loeffler  bacilli  were  found.  In  57  they 
were  not  present,  but  17  of  these  cultures  were  unsatisfactory  (Park  and 
Beebe).  The  streptococcus  cases  are  more  likely  to  be  secondary  to  other 
acute  diseases. 

Symptoms. — Xaturally,  the  clinical  symptoms  are  almost  identical  in  the 
non-specific  and  specific  forms  of  membranous  laryngitis. 

The  afl'ection  begins  like  an  acute  laryngitis  with  slight  hoarseness  and 
'rough  cough,  to  which  the  term  croupy  has  been  applied.  After  these 
symptoms  have  lasted  for  a  day  or  two  with  varying  intensity,  the  child  sud- 
denly becomes  worse,  usually  at  night,  and  there  are  signs  of  impeded 
respiration.  At  first  the  difficulty  in  breathing  is  paroxysmal,  due  probably 
to  more  or  less  spasm  of  the  muscles  of  the  glottis.  Soon  the  dyspnoea  becomes 
continuous,  inspiration  and  expiration  become  difficult,  particularly  the  latter, 
and  with  the  inspiratory  movement  the  epigastrium  and  lower  intercostal 
spaces  are  retracted.  The  voice  is  husky  and  may  be  reduced  to  a  whisper. 
The  color  gradually  changes  and  the  imperfect  aeration  of  the  blood  is 
shown  in  the  lividity  of  the  lips  and  finger-tips.  Restlessness  comes  on  and 
the  child  tosses  from  side  to  side,  vainly  trying  to  get  breath.  Occasionally,, 
in  a  severer  paroxysm,  portions  of  membrane  are  coughed  out.  The  fever  in 
membranous  larjaigitis  is  rarely  very  high  and  the  condition  of  the  child  is 
usually  good  at  the  time  of  the  onset.  The  pulse  is  always  increased  in 
frequency  and  is  small  if  cyanosis  be  present.  In  favorable  cases  the 
dyspnoea  is  not  very  urgent,  the  color  of  the  face  remains  good,  and  after 
one  or  two  paroxysms  the  child  goes  to  sleep  and  wakes  in  the  morning, 
perhaps  without  fever  and  feeling  comfortable.  The  attack  may  recur  the 
following  night  with  greater  severity.  In  unfavorable  cases  the  dyspnoea 
becomes  more  and  more  urgent,  the  cyanosis  deepens,  the  child,  after  a  period 
of  intense  restlessness,  sinks  into  a  semi-comatose  state,  and  death  finally 
occurs  from  poisoning  of  the  nerve  centres.  In  other  cases  the  onset  is 
less  sudden  and  is  preceded  by  a  longer  period  of  indisposition.  As  a  rule, 
there  are  pharyngeal  symptoms.  The  constitutional  disturbance  may  be 
more  severe,  the  fever  higher,  and  there  may  be  swelling  of  the  glands  of 
the  neck.  Inspection  of  the  fauces  may  show  the  presence  of  false  mem- 
branes on  the  pillars  or  on  the  tonsils.     Bacteriological  examination  can  alone 


70  SPECIFIC  INFECTIOUS  DISEASES 

determine  whether  these  are  due  to  the  Klebs-Loeffler  bacillus  or  to  the 
streptococcus.  Fagge  held  that  non-contagious  membranous  croup  may  spread 
upward  from  the  larynx  just  as  diphtheritic  inflammation  is  in  the  habit  of 
spreading  downward  from  the  fauces.  Ware,  of  Boston, .  whose  essay  on 
croup  is  one  of  the  most  solid  contributions  to  the  subject,  reported  the 
presence  of  exudate  in  the  fauces  in  74  out  of  75  cases  of  croup.  These 
observations  were  made  prior  to  1840,  during  periods  in  which  diphtheria 
was  not  epidemic  to  any  extent  in  Boston.  In  protracted  cases  pulmonary 
symptoms  may  occur,  which  are  sometimes  due  to  the  difficulty  in  expelling 
the  muco-pus  from  the  tubes;  in  others,  the  false  membrane  extends  into 
the  trachea  and  even  into  the  bronchial  tubes.  During  the  paroxysm  the 
vesicular  murmur  is  scarcely  audible,  but  the  laryngeal  stridor  may  be  loudly 
communicated  along  the  bronchial  tubes. 

Diphtheria  of  Other  Parts. — Primary  diphtheria  occurs  occasionally 
in  the  conjunctiva.  It  follows  in  some  instances  the  affection  of  the  nasal 
mucous  membrane.  Some  of  the  cases  are  severe  and  serious,  but  it  has  been 
shown  that  the  diphtheria  bacilli  may  be  present  in  a  conjunctivitis  catarrhal 
in  character,  or  associated  with  only  slight  croupous  deposits. 

Diphtheria  of  the  external  auditory  meatus  is  seen  when  a  diphtheritic 
otitis  media  has  extended  through  the  tympanic  membrane. 

Diphtheria  of  the  skin  is  most  frequently  seen  in  the  severer  forms  of 
pharyngeal  diphtheria,  in  which  the  membrane  extends  to  the  mouth  and  lips, 
and  invades  the  adjacent  portions  of  the  skin  of  the  face.  The  skin  about 
the  anus  and  genitals  may  also  be  attacked.  Pseudo-membranous  inflamma- 
tion is  not  uncommon  on  ulcerated  surfaces  and  wounds.  In  very  many  of 
these  cases  it  is  a  streptococcus  infection,  but  in  a  majority,  perhaps,  in 
which  the  patient  is  suffering  with  diphtheria,  the  Klebs-Loeflfler  bacillus  will 
be  found  in  the  fibrinous  exudate.  As  proposed  by  Welch,  the  term  "wound 
diphtheria"  should  be  limited  to  infection  of  a  wound  by  the  Klebs-Loeffler 
bacillus.  Paralysis  may  follow  wound  diphtheria.  Pseudo-membranous  in- 
flammations of  wounds  are  caused  more  frequently  by  other  micro-organisms, 
particularly  the  streptococcus  pyogenes,  than  by  the  Klebs-Loeffler  bacillus. 
The  fibrinous  membrane  so  common  in  the  neighborhood  of  the  tracheotomy 
wound  in  diphtheria  is  rarely  associated  with  the  Klebs-Loeffler  bacillus. 
Diphtheria  of  the  genitals  is  occasionally  seen. 

Complications  and  Sequelae. — Of  local  complications,  hsemorrhage  from 
the  nose  or  throat  may  occur  in  the  severe  ulcerative  cases.  Skin  rashes  are 
not  infrequent,  particularly  the  diffuse  erythema.  Occasionally  there  is  urti- 
caria and  in  the  severe  cases  purpura.  Fatal  cases  almost  invariably  show 
capillary  bronchitis  with  broncho-pneumonia  and  large  patches  of  collapse,  or 
the  septic  particles  may  reach  the  bronchi  and  excite  gangrenous  processes 
which  may  lead  to  severe  and  fatal  hsemorrhage.  Jaundice,  usually  a  feature 
of  the  toxsemia,  is  rarely  of  serious  import.    Local  gangrene  may  occur. 

Albuminuria,  present  in  all  severe  cases,  is  alarming  only  when  the  albumin 
is  in  considerable  quantity  and  associated  with  epithelial  or  blood  casts. 
'Nephritis  may  appear  quite  early,  setting  in  occasionally  with  complete 
suppression  of  urine.  In  comparison  with  scarlet  fever  the  renal  changes  lead 
less  frequently  to  general  dropsy.  In  rare  instances  there  may  be  coma,  and 
even  convulsions,  without  albumin  in  the  urine,  and  without  dropsy. 


DIPHTHERIA  71 

Of  the  sequels,  paralysis  is  by  far  the  most  important.  It  can  he  experi- 
mentally produced  in  animals  by  the  inoculation  of  the  toxins.  The  process 
is  a  toxic  neuritis,  due  to  the  absorption  of  the  toxin  which  probably  travels 
in  the  perineural  channels  of  the  cranial  nerves  to  the  centres  in  the  medulla. 
The  generalized  neuritis,  usually  a  later  manifestation,  appears  to  be  part 
of  a  systemic  toxsemia  through  the  blood  stream.  The  proportion  of  the  cases 
in  which  it  occurs  ranges  from  10  to  15  and  even  to  20  per  cent.  It  usually 
comes  on  in  the  second  or  third  week  of  convalescence.  It  may  follow  very 
mild  cases;  indeed,  the  local  lesion  may  be  so  trifling  that  the  onset  of  the 
paralysis  alone  calls  attention  to  the  true  nature  of  the  trouble.  It  is  pro- 
portionately less  frequent  in  children  than  in  adults.  J.  D.  Rolleston's  study 
of  the  subject  indicates  that  the  early  use  of  antitoxin  diminishes  the  liability 
to  paralysis.  In  494  cases  collected  by  Woodhead,  the  palate  was  involved 
in  155,  the  ocular  muscles  in  197,  in  10  other  muscles.  Ninety-one  of  the 
patients  died. 

Of  the  local  paralyses  the  most  common  is  that  which  affects  the  palate. 
This  gives  a  nasal  character  to  the  voice,  and,  owing  to  a  return  of  liquids 
through  the  nose,  causes  a  diificulty  in  swallowing.  The  palate  is  seen  to  be 
relaxed  and  motionless,  and  the  sensation  in  it  is  also  much  impaired.  The 
affection  may  extend  to  the  constrictors  of  the  pharynx,  and  deglutition 
become  embarrassed.  Within  two  or  three  weeks  or  even  a  shorter  time 
the  paralysis  disappears.  In  many  cases  the  affection  of  the  palate  is  only 
part  of  a  general  neuritis.  Of  other  local  forms  perhaps  the  most  common 
are  paralyses  of  the  eye-muscles,  intrinsic  and  extrinsic.  There  may  be 
strabismus,  ptosis,  and  loss  of  power  of  accommodation.  Facial  paralysis  is 
rare.  The  neuritis  may  be  confined  to  the  nerves  of  one  limb,  though  more 
commonly  the  legs  or  the  arms  are  affected  together.  Very  often  with  the 
palatal  paralysis  is  associated  a  weakness  of  the  legs  without  definite  palsy  but 
Avith  loss  of  the  knee-jerk. 

The  multiple  form  of  diphtheritic  neuritis  may  begin  with  the  palatal 
affection,  or  with  loss  of  power  of  accommodation  and  loss  of  the  tendon 
reflexes.  This  last  is  an  important  sign,  which  may  occur  early,  but  is  not 
necessarily  followed  by  other  symptoms  of  neuritis.  There  is  paraplegia, 
which  may  be  complete  or  involve  only  the  extensors  of  the  feet.  The  paralysis 
may  extend  and  involve  the  arms  and  face  and  render  the  patient  entirely 
helpless.  The  muscles  of  respiration  may  be  spared.  Sensory  is  less  common 
than  motor  disturbance. 

Heart. — Irregularity  is  common  and  was  present  in  60  per  cent,  of  the 
Boston  cases  of  White  and  Smith.  A  murmur  at  the  apex  or  base  of  the 
heart  is  present  in  94  per  cent,  of  all  cases.  This  means,  of  course,  that  a 
majority  of  young  children  with  fever  have  a  heart  murmur.  Only  a  few 
cases  of  diphtheria  have  serious  heart  symptoms,  36  out  of  the  946  cases 
specially  studied.  Rapid  action  of  the  heart  with  gallop  rhythm  and  epigastric 
pain  and  tenderness  are  serious  symptoms.  The  cases  in  which  the  pulse 
drops  from  110  to  40  or  30  are  usually  very  serious.  Some  are  due  to 
heart  block.  The  heart  symptoms  are  more  common  in  the  second  or  third 
week  of  the  disease,  and  fatal  dilatation  may  conic  on  as  late  ns  the  sixth 
or  seventh  week.  It  seems  probable  that  the  heart  weakness  is  due  to  degenera- 
tion of  the  muscle.     Possibly  in  some  of  the  cases  there  is  degeneration  of  the 


72  SPECIFIC  INFECTIOUS  DISEASES 

vagus,  a  view  which  is  supported  by  the  frequency  of  paralysis  of  the  palate 
with  vomiting  and  epigastric  pain  and  tenderness.  Experimental  evidence  is 
against  the  vasomotor  centre  being  impaired. 

Diagnosis. — The  presence  of  the  Klebs-Loeffler  bacillus  is  regarded  by 
bacteriologists  as  the  sole  criterion  of  true  diphtheria,  and  as  this  organism 
may  be  associated  with  all  grades  of  throat  affections,  from  a  simple  catarrh 
to  a  sloughing,  gangrenous  process,  it  is  evident  that  in  many  instances 
there  will  be  a  striking  discrepancy  between  the  clinical  and  the  bacteriological 
diagnosis. 

The  bacteriological  diagnosis  is  simple.  The  plan  adopted  by  the  New 
York  Health  Department  is  a  model  which  may  be  followed  with  advantage 
in  other  cities.  Outfits  for  making  cultures,  consisting  of  a  box  containing  a 
tube  of  blood-serum  and  a  sterilized  swab  in  a  test-tube,  are  distributed  at 
convenient  points.  The  directions  are  as  follows:  "The  patient  should  be 
placed  in  a  good  light,  and,  if  a  child,  properly  held.  In  cases  where  it  is 
possible  to  get  a  good  view  of  the  throat,  depress  the  tongue  and  rub  the 
cotton  swab  gently  but  freely  against  any  visible  exudate.  In  other  cases, 
including  those  in  which  the  exudate  is  confined  to  the  larynx,  avoiding  the 
tongue,  pass  the  swab  far  back  and  rub  it  freely  against  the  mucous  mem- 
brane of  the  pharynx  and  tonsils.  Without  laying  the  swab  down,  withdraw 
the  cotton  plug  from  the  culture-tube,  insert  the  swab,  and  rub  that  portion 
of  it  which  has  touched  the  exudate  gently  but  thoroughly  all  over  the  surface 
of  the  blood-serum.  Do  not  push  the  swab  into  the  blood-serum,  nor  break 
the  surface  in  any  way.  Then  replace  the  swab  in  its  own  tube,  plug  both 
tubes,  put  them  in  the  box,  and  return  the  culture  outfit  at  once  to  the 
station  from  which  it  was  obtained."  The  culture-tubes  which  have  been 
inoculated  are  kept  in  an  incubator  at  37°  C.  for  twelve  hours  and  are  then 
ready  for  examination.  Some  prefer  a  method  by  which  the  material  from 
the  throat  collected  on  a  sterile  swab,  or  on  small  pieces  of  sterilized  sponge, 
is  sent  to  the  laboratory. 

An  immediate  diagnosis  may  be  possible  by  making  a  smear  preparation 
of  the  exudate.  The  Klebs-Loeffler  bacilli  may  be  present  in  sufficient  numbers, 
and  may  be  quite,  characteristic.  In  this  connection  may  be  given  the  follow- 
ing statement  by  Park,  who  has  had  an  exceptional  experience :  "The  examina- 
tion by  a  competent  bacteriologist  of  the  bacterial  growth  in  a  blood-serum 
tube  which  has  been  properly  inoculated  and  kept  for  fourteen  hours  at  the 
body  temperature  can  be  thoroughly  relied  upon  in  cases  ^\here  there  is 
visible  membrane  in  the  throat,  if  the  culture  is  made  during  the  period  in 
which  the  membrane  is  forming,  and  no  antiseptic,  especially  no  mercurial 
solution,  has  lately  been  applied.  In  cases  in  which  the  disease  is  confined 
to  the  larynx  or  bronchi,  surprisingly  accurate  results  can  be  obtained  from 
cultures,  but  in  a  certain  proportion  of  cases  no  diphtheria  bacilli  will  be 
found  in  the  first  culture,  and  yet  will  be  abundantly  present  in  later  cul- 
tures. We  believe,  therefore,  that  absolute  reliance  for  a  diagnosis  can  not  be 
placed  upon  a  single  culture  from  the  pharynx  in  purely  laryngeal  eases.'^ 

Where  a  bacteriological  examination  can  not  he  made,  the  'practitioner 
must  regard  as  suspicious  all  forms  of  throat  affections  in  children,  and 
carry  out  measures  of  isolation  and  disinfection.  In  this  way  alone  can 
serious   errors  be  avoided.     It  is  not,  of   course,  in  the   severer  forms   of 


DIPHTHERIA  73 

membranous  angina  that  mistake  is  likely  to  occur,  but  in  the  various  lighter 
forms,  many  of  which  are  in  reality  due  to  the  Klebs-Loeffler  bacillus. 

A  large  proportion  of  the  cases  of  diphtheroid  inflammation  of  the  throat 
are  due  to  the  streptococcus  pyogenes.  They  are  usually  milder,  and  the 
liability  to  general  infection  is  less  intense;  still,  in  scarlet  fever  and  other 
specific  fevers  some  of  the  most  virulent  cases  of  throat  disease  which  we  see, 
with  intense  systemic  infection,  are  caused  by  this  micro-organism.  These 
streptococcus  cases  are  probably  much  less  numerous  than  the  figures  given 
would  indicate.  The  more  careful  examinations  in  the  diphtheria  pavilions 
of  hospitals,  particularly  in  Europe,  have  shown  that  in  the  large  majority 
of  cases  admitted  the  Klebs-Loeffler  bacillus  is  present.  The  question  of  the 
diagnosis  between  scarlet  fever  with  severe  angina  and  diphtheria  is  discussed 
in  the  section  on  scarlet  fever. 

Prognosis. — The  outlook  in  any  case  depends  on  the  promptness  and  thor- 
oughness with  which  antitoxin  treatment  is  carried  out.  In  hospital  practice 
the  mortality  was  formerly  from  30  to  50  per  cent.  In  the  Boston  City  Hos- 
pital the  death-rate  between  1888  and  1894  was  only  once  below  40  per  cent., 
and  in  1893  and  1893  rose  to  nearly  50  per  cent.  Following  the  introduction 
of  antitoxin  from  1895  to  1913  the  death-rate  has  not  once  been  above  15  per 
cent.,  and  in  6,080  recent  cases  has  been  7.8  per  cent.  (McCollom).  In  coun- 
try places  the  disease  may  display  an  appalling  virulence.  In  cases  of  ordinary 
severity  the  outlook  is  usually  good.  Death  results  from  involvement  of 
the  larynx,  septic  infection,  sudden  heart-failure,  diphtheritic  paralysis,  occa- 
sionally from  uraemia,  and  sometimes  from  broncho-pneumonia  occurring  dur- 
ing convalescence.    Of  late  years  the  mortality  has  been  steadily  falling. 

Prophylaxis. — Isolation  of  the  sick,  disinfection  of  the  clothing  and  of 
everything  that  has  come  in  contact  with  the  patient,  careful  scrutiny  of  the 
milder  cases  of  throat  disorder,  and  more  stringent  surveillance  in  the  period 
of  convalescence  are  the  essential  measures  to  prevent  the  spread  of  the 
disease.  Suspected  cases  in  families  or  schools  should  be  at  once  isolated 
or  removed  to  a  hospital  for  infectious  disorders.  When  a  death  has  occurred 
from  diphtheria,  the  body  should  be  wrapped  in  a  sheet  which  has  1jeen 
soaked  in  a  corrosive-sublimate  solution  (1  to  3,000),  and  placed  in  a 
closely  sealed  coffin.    The  funeral  should  always  be  private. 

In  cases  of  well-marked  diphtheria  these  precautions  are  usually  carried 
out,  but  the  chief  danger  is  from  the  milder  cases,  particularly  the  ambulatory 
form,  in  which  the  disease  has  perhaps  not  been  suspected.  But  from  such 
patients  mingling  with  susceptible  children  the  disease  is  often  conveyed. 
The  healthy  children  in  a  family  in  which  diphtheria  exists  may  carry  the 
disease.  The  question  of  the  influence  of  isolation  hospitals  on  the  spread 
of  the  disease  has  been  solved  in  Boston,  a  city  which  has  sufl:ered  terribly 
from  diphtheria.  The  ratio  of  mortality  per  10,000  living  in  1893  was 
11-|-,  and  in  1894  it  was  18-j-.  In  1895  the  infectious  pavilion  was  opened. 
Prior  to  that  year  only  about  10  per  cent,  of  the  reported  cases  wore  treated 
in  hospital;  in  succeeding  years  50  per  cent,  were  treated  in  hospital.  In 
1898  the  mortality  per  10,000  had  fallen  to  3,  and  in  1913  it  was  1.5. 

A  very  important  matter  relates  to  the  period  of  convalescence  as  after 
all  the  membrane  has  cleared  away,  virulent  bacilli  may  persist  in  the 
throat  from  periods  ranging  from  six  weeks  to  six  months,  or  even  longer.    The 


74  SPECIFIC  INFECTIOUS  DISEASES 

disease  may  be  communicated  by  these  carriers  and  they  should  be  isolated  and 
the  throat  carefully  treated,  but  there  are  cases  very  resistant  to  all  forms  of 
throat  antiseptics.  Antitoxin  may  be  applied  locally  to  the  throat  and  spray- 
ing the  throat  and  nose  with  a  culture  of  lactic  acid  bacilli  is  sometimes 
efficient.  Among  other  measures  is  the  use  of  kaolin,  which  is  blown  over 
the  nasal  surfaces  every  two  hours.  The  application  of  iodized  phenol 
(phenol  60,  iodine  crystals  20,  glycerine  20)  every  second  day  is  sometimes 
effectual.  In  some  patients  the  organisms  are  deep  in  the  tonsils  and  their 
removal  may  be  advisable. 

It  cannot  be  too  strongly  emphasized  that  the  important  elements  in  the 
prophylaxis  of  diphtheria  are  the  rigid  scrutiny  of  the  milder  types  of 
throat  affection,  and  the  thorough  isolation  and  disinfection  of  the  individual 
patients.  During  an  epidemic  there  should  be  repeated  examinations  made 
of  all  those  exposed  to  infection  to  detect  carriers. 

Careful  attention  should  be  given  to  the  throats  and  mouths  of  children, 
particularly  to  the  teeth  and  tonsils.  Swollen  and  enlarged  tonsils  should 
be  removed.  Cats  and  dogs  may  carry  infection  and  should  be  excluded 
from  contact  with  patients.  In  persons  exposed,  the  antiseptic  mouth  washes, 
such  as  corrosive  sublimate  (1  to  10,000),  hydrogen  peroxide,  or  swabbing 
the  throat  with  a  diluted  Loeffier's  solution,  should  be  employed.  Physicians 
and,  nurses  should  wear  gowns  and  caps,  and  cover  the  nose  and  mouth  with 
gauze. 

Immunization. — The  giving  of  antitoxin  as  a  preventive  measure  has  an 
important  place.  Its  value  is  well  shown  in  the  children's  hospitals  in 
which  it  is  given  as  a  routine  prophylactic  measure.  The  usual  dose  for 
adults  is  1,000  units,  for  older  children  750  units,  and  for  children  under 
two  years  of  age  500  units.  The  immunity  lasts  about  three  weeks.  The 
same  precautions  should  be  taken  as  in  giving  antitoxin  to  those  with  the 
disease. 

Toxin-antitoxin  inoculations  have  been  used  in  those  found  susceptible 
by  the  Schick  test.  Three  injections  are  given  at  weekly  intervals.  Park 
and  Zingher  suggest  that  it  would  be  well  to  immunize  susceptible  children 
at  the  beginning  of  the  second  year  of  age  to  protect  them  during  the  years 
of  greatest  prevalence.     The  immunity  may  last  for  two  years. 

Treatment. — The  important  points  are  hygienic  measures  to  prevent  the 
spread  of  the  malady,  local  treatment  of  the  throat  to  destroy  the  bacilli, 
medication,  general  or  specific,  to  counteract  the  effects  of  the  toxins,  and, 
lastly,  to  meet  the  complications  and  sequelae. 

(a)  Hygienic  Measures. — The  patient  should  be  in  a  room  from  which 
the  carpets,  curtains,  and  superfluous  furniture  have  been  removed.  The 
temperature  should  be  about  68°,  and  thorough  ventilation  should  be  secured. 
The  air  may  be  kept  moist  by  a  kettle  or  a  steam-atomizer.  If  possible,  only 
the  nurse,  the  child's  mother,  and  the  doctor  should  come  in  contact  with  the 
patient.  During  the  visit  the  physician  should  wear  a  gown  and  cap,  and 
on  leaving  the  room  he  should  thoroughly  wash  his  hands  and  face  in  corrosive 
sublimate  solution.  The  strictest  quarantine  should  be  employed  against  other 
members  in  the  house. 

(&)  Local  Treatment. — In  mild  cases  the  throat  symptoms  are  alone 
prominent.     Local  treatment  should  be  carried  out,  taking  especial  care  to 


DIPHTHERIA  75 

avoid  mechanical  injury  to  the  tissues.  Since  the  introduction  of  antitoxin, 
this  is  much  less  important  than  formerly  and  many  patients  do  perfectly 
well  with  little  or  no  local  treatment.  There  are  a  large  number  of  solutions 
recommended  which  may  be  employed  locally  by  a  swab,  by  spraying,  or  by 
irrigation.  In  the  use  of  the  last,  the  temperature  of  the  solution  should 
be  as  hot  as  is  comfortable.  In  all  cases  the  frequency  of  local  treatment 
should  be  determined  by  the  local  lesion.  Of  the  solutions  to  be  applied  by 
swabbing,  the  following  are  examples :  Loeflfler's  solution :  Menthol,  10  grams 
dissolved  in  toluol  to  36  c.  c. ;  Liq.  ferri  sesquichlorati,  4  c.  c. ;  alcohol  absol., 
60  c,  c.  Another  solution  is :  The  tincture  of  the  perchloride  of  iron,  5  iss 
(6  c.  c),  glycerine,  §i  (30  c.  c),  water,  §i  (30  c.  c.)  with  nx  xv  (1  c.  c.)  of 
phenol.    Boric  acid  and  peroxide  of  hydrogen  may  be  used. 

Boracic  acid  solutions,  peroxide  of  hydrogen,  Dobell's  solution,  and  bichlor- 
ide of  mercury  (1-2000)  may  be  employed  in  the  form  of  sprays,  but  in  many 
cases  the  use  of  irrigations  is  the  most  satisfactory.  This  should  always  be 
done  very  gently  with  the  patient  lying  on  the  side.  Either  a  saline 
solution  or  a  3  per  cent,  boric  acid  solution  is  satisfactory. 

Nasal  diphtheria  requires  prompt  and  thorough  disinfection  of  the  pas- 
sages. Jacobi  recommends  chloride  of  sodium,  saturated  boric  acid,  or  1 
part  of  bichloride  of  mercury,  35  of  chloride  of  sodium,  and  1,000  of  water, 
or  the  1-per-cent.  solution  of  phenol.  Loeffler's  solution  may  •  be  diluted 
and  applied  with  a  syringe  or  spray.  To  be  effectual  the  injection  must  be 
properly  given.  The  nozzle  of  the  syringe  should  be  passed  horizontally,  not 
vertically ;  otherwise  the  fluid  will  return  through  the  same  nostril. 

When  the  larynx  becomes  involved,  a  steam  tent  may  be  arranged,  so 
that  the  child  may  breathe  an  atmosphere  saturated  with  moisture.  When 
the  signs  of  obstruction  are  marked  there  should  be  no  delay  in  the  per- 
formance of  intubation  or  tracheotomy.  The  choice  between  these  must 
depend  on  the  circumstances  in  each  case.  Intubation  may  be  regarded  as 
the  operation  of  choice  in  the  majority  of  cases.  Tracheotomy  is  preferable 
in  adults  "and  may  be  the  operation  of  necessity.  The  patient  requires  more 
skilful  care  after  intubation  than  after  tracheotomy. 

Hot  applications  to  the  neck  are  usually  very  grateful,  particularly  to 
young  children,  though  in  the  case  of  older  children  and  adults  the  ice 
poultices  are  to  be  preferred. 

(c)  General  Measures. — Every  effort  should  be  made  to  nourish  the 
patient.  The  food  should  be  liquid — ^milk,  beef  juices,  barley  water,  ice 
cream,  albumen  water,  and  soups.  If  there  is  difficulty  in  swallowing,  these 
should  be  given  by  a  tube.  The  patient  should  be  encouraged  to  drink 
water  freely.  If  there  is  difficulty  in  taking  it  by  mouth,  it  should  be  given 
by  the  bowel  or  subcutaueously.  The  bowels  should  be  freely  opened,  for 
which  a  calomel  and  saline  purge  is  usually  best.  When  the  pharyngeal  in- 
volvement is  very  great  and  swallowing  painful,  a  5  per  cent,  glucose  solution 
can  be  given  by  the  bowel. 

Medicines  given  internally  are  of  little  avail,  but  there  is  a  widespread 
belief  that  forms  of  mercury  are  beneficial.  The  tincture  of  the  perchloride 
of  iron  is  also  warmly  recommended.  We  must  rely  on  general  measures  of 
feeding  and  stimulation  to  support  the  strength.  For  the  circulation  the  early 
giving  of  antitoxin  is  the  best  preventive  of  trouble.     When  symptoms  aris3, 


're  SPECIFIC  INFECTIOUS  DISEASES 

circulatory  stimulants,  such  as  digitalis,  camiDlior,  and  epinephrine  are  indi- 
cated.    Saline  solution  by  rectum  or  subcutaneously  is  useful. 

(d)  Antitoxin  Treatment. — As  the  years  go  on  experience  has  shown 
that,  thoroughly  carried  out,  this  method  of  treatment  is  both  safe  and 
efficacious.  There  are  no  reasonable  grounds  for  skepticism  on  the  part  of 
intelligent  practitioners,  and  still  less  on  the  part  of  those  in  charge  of  the 
hospitals  for  infectious  diseases. 

The  principle  of  action  depends  on  the  circumstance  that  the  blood-serum 
of  an  animal  rendered  immune,  when  introduced  into  another  animal,  pro- 
tects it  from  infection  with  the  diphtheria  bacilli,  and  has  also  an  impor- 
tant curative  influence  upon  diphtheria,  whether  artificially  given  to  animals, 
or  spontanecusly  acquired  by  man.  In  the  preparation  of  the  serum  a  uniform 
standard  strength  is  procured.  The  antitoxin  unit  is  the  amount  of  anti- 
toxin which,  injected  into  a  guinea-pig  of  250  grams  in  weight,  neutralizes 
100  times  the  minimum  fatal  dose  of  toxin  of  standard  strength. 

Dosage. — This  is  one  of  the  most  important  questions  relating  to  the 
use  of  the  antitoxin.  J.  H.  McCollom,  of  the  Boston  City  Hospital,  who 
probably  had  a  richer  experience  with  the  disease  than  any  man  in  the 
United  States,  insisted  that  the  guiding  practice  in  the  use  of  the  antitoxin 
is  to  give  it  until  the  characteristic  effects  are  produced,  whether  4,000  or 
70,000  units  be  required  foj  this  result.  He  very  rightly  said  that  in  the 
case  of  a  patient  ill  with  diphtheria  there  is  no  way  of  estimating  the  quantity 
of  toxin  generated  by  the  membrane,  and  therefore  one  must  administer 
the  agent  until  the  characteristic  effect  is  produced — viz.,  the  shriveling  of 
the  membrane,  the  diminution  of  the  nasal  discharge,  the  correction  of  the 
fetid  odor,  and  a  general  inqDrovement  in  the  condition  of  the  patient.  No 
case,  he  says,  in  the  acute  stage  should  be  considered  hopeless.  "When  one 
sees  a  patient  in  whom  the  intubation  tube  has  been  repeatedly  clogged,  when 
the  hopeless  condition  of  the  patient  changes  for  the  better  after  the  adminis- 
tration of  50,000  units,  one  can  not  help  but  be  convinced  of  the  impor- 
tance of  giving  large  doses  of  antitoxin  in  the  very  severe  and  apparently 
hopeless  cases.  In  the  majority  of  instances  these  large  doses  are  not  re- 
quired, particularly  if  the  patients  are  seen  early  in  the  attack,  4,000 
to  6,000  units  being  enough  to  produce  the  characteristic  effect  on  the  mem- 
brane." The  initial  dose  in  ordinary  cases  should  be  from  3,000  to  10,000 
units  and  the  result  must  determine  the  frequency  of  repetition.  In  severe 
cases  and  in  laryngeal  diphtheria  the  first  dose  should  be  from  10,000  to 
15,000  units,  repeated  in  six  hours.  The  danger  is  in  giving  too  small  and  not 
too  large  a  dose. 

Administration. — Antitoxin  may  be  injected  subcutaneously,  intramuscu- 
larly or  intravenously.  The  last  is  advisable  in  severe  cases.  Intramuscular 
is  better  than  subcutaneous  injection.  The  skin  and  needle  should  be  thor- 
oiighly  clean. 

Favorable  effects  are  seen  in  the  improvement  in  both  the  local  and 
general  condition.  The  swelling  of  the  fauces  subsides,  the  membrane  begins 
to  disappear,  the  temperature  falls,  and  the  pulse  becomes  slower. 

Untoivard  Effects. — "Serum  Disease." — This  may  appear  in  any  normal 
individual  and  is  due  to  the  serum  and  not  to  the  antitoxin.  Following  the 
injection  after  a  varying  interval,  which  varies  from  one  to  eighteen  days, 


DIPHTHERIA  77 

but  is  usually  between  seven  and  ten  days,  a  local  reaction  appears  which 
may  be  accompanied  by  general  symptoms.  The  site  of  injection  shows 
oedema,  urticaria  or  erythema,  which  may  become  more  or  less  general. 
Malaise,  vomiting,  fever,  adenitis,  albuminuria,  and  arthralgia  may  accom- 
pany this.  The  symptoms  are  usually  not  severe  and  disappear  in  three  or 
four  days.  Calcium  lactate  (gr.  xv,  1  gm.  three  times  a  day)  may  be  given 
as  a  prophylactic  or  when  the  symptoms  have  appeared.  There  is  another 
reaction  which  is  much  more  serious.  In  individuals  who  have  been  given 
antitoxin  previously,  even  at  a  long  interval — who  have  been  sensitized — in 
some  who  have  had  asthma  and  in  some  of  those  who  are  affected  by  the 
smell  or  proximity  of  horses,  an  acute  dangerous  condition  may  be  caused 
by  the  injection  of  serum — anaphylaxis.  This  comes  on  very  suddenly  and 
with  acute  symptoms,  among  which  are  extreme  distress,  dyspnoea,  cyanosis, 
oedema,  collapse,  respiratory  failure  iand  convulsions;  death  may  follow 
rapidly.  Fortunately  this  occurs  rarely,  but  its  possibility  should  be  kept 
in  mind,  and  before  giving  antitoxin  the  patient  should  be  asked  as  to  a 
history  of  asthma,  an  idiosyncrasy  to  horses  and  previous  administration  of 
antitoxin.  This  must  be  kept  in  mind  in  the  case  of  patients  who  have  a 
relapse,  as  if  seven  days  have  elapsed  since  the  first  dose  the  patient  may  be 
sensitized.  If  there  is  any  reason  to  suspect  the  possibility  of  a  reaction, 
the  patient  should  be  tested  by  the  administration  of  two  or  three  drops  of 
antitoxin,  which  will  not  give  a  dangerous  reaction.  If  he  is  susceptible  a 
reaction  usually  occurs  in  an  hour,  but  it  is  safer  to  wait  three  hours.  The 
skin  reaction  may  also  be  tried  (Moss),  but  this  demands  twenty-four  hours, 
too  long  to  wait  if  the  diphtheria  is  severe.  If  the  patients  are  sensitive 
and  the  need  of  antitoxin  is  great,  small  doses  (2  to  4  c.  c.)  should  be  given 
at  hourly  intervals.  In  the  absence  of  reaction  it  is  safe  to  give  the  usual 
dose,  for  a  sensitized  individual,  after  receiving  a  small  dose,  is  refractory 
to  larger  doses  some  hours  later.  Children  seem  to  be  much  less  liable  to 
sensitization  than  adults.  If  anaphylaxis  should  occur,  morphia  (gr.  1/4, 
0.016  gm.)  and  atropine  (gr.  1-100,  0.0006  gm.)  hypodermically  should  be 
given  at  once.  Artificial  respiration  should  be  done  if  there  is  respiratory 
failure. 

Results. — Of  183,256  cases  treated  in  150  cities  previous  to  the  serum 
period,  the  mortality  was  38.-1  per  cent.  Since  the  introduction  of  serum 
among  132,548  cases,  there  was  a  mortality  of  14.6  per  cent.  Leaving  out 
those  not  treated  with  the  serum,  the  mortality  was  9.8  per  cent.  (Edwin 
Rosenthal). 

Convalescejice. — This  demands  special  care,  particularly  if  there  are  signs 
of  cardiac  disturbance.  In  this  event  the  patient  should  be  kept  absolutely  at 
rest  and  this  may  be  necessary  for  a  long  period.  ISTourishment  should  be 
given  freely,  strychnine  administered  in  full  doses,  and  iron  with  arsenic 
if  there  is  angemia.  If  swallowing  becomes  difficult  it  is  wise  to  use  the 
stomach  tube  for  feeding.  With  the  post-diphtheritic  paralysis  the  patients 
should  be  kept  in  bed,  fed  liberally  and  given  strychnine  hypodermically. 
Antitoxin  is  valuable  in  doses  of  1,000  to  3,000  units  daily.  In  the  chronic 
forms  with  muscular  wasting,  electricity  and  massage  should  be  used.  The 
patient  should  not  be  discharged  from  quarantine  until  two  successive  cultures 
from  the  throat  and  nose,  two  days  apart,  have  been  negative. 


78  SPECIFIC  INFECTIOUS  DISEASES 


VIII.    THE  PNEUMONIAS  AND  PNEUMOCOCCIO  INFECTIONS 

A  variety  of  diseases  are  caused  by  the  pneumococcus,  among  which  lobar 
and  lobular  pneumonia  are  the  most  important.  Various  inflammatory  affec- 
tions of  the  lungs  may  be  caused  by  other  organisms^  but  the  pneumococcus 
plays  the  important  role  in  the  common  lobar  pneumonia  and  in  the  ordinary 
broncho-pneumonia.  It  may  set  up  also  many  local  affections  and  is  the  cause 
of  many  terminal  infections  in  chronic  diseases. 

A.      LOBAE   PNEUMONIA 
(Croupous  or  Fibrinous  Pneumonia,  Lung  Fever) 

Definition. — An  infection  caused  by  the  pneumococcus,  characterized  by 
inflammation  of  the  lungs,  a  toxaemia  of  varying  intensity  and  a  fever  which 
usually  terminates  by  crisis.     Secondary  infective  processes  are  common. 

History. — The  disease  was  known  to  Hippocrates  and  the  old  Greek 
physicians,  by  whom  it  was  confounded  with  pleurisy.  Among  the  ancients, 
Aretajus  gave  a  remarkable  description.  "Euddy  in  countenance,  but  especially 
the  cheeks;  the  white  of  the  eyes  very  bright  and  fatty;  the  point  of  the 
nose  flat;  the  veins  in  the  temples  and  neck  distended;  loss  of  appetite; 
pulse,  at  first,  large,  empty,  very  frequent,  as  if  forcibly  accelerated;  heat 
indeed,  externally,  feeble,  and  more  humid  than  natural,  but,  internally, 
dry  and  very  hot,  by  means  of  which  the  breath  is  hot;  there  is  thirst, 
dryness  of  the  tongue,  desire  of  cold  air,  aberration  of  mind;  cough  mostly 
dry,  but  if  anything  be  brought  up  it  is  a  frothy  phlegm,  or  slightly  tinged 
with  bile,  or  with  a  very  florid  tinge  of  blood.  The  blood-stained  is  of  all 
others  the  worst."  At  the  end  of  the  seventeenth  and  the  beginning  of  the 
eighteenth  century  Morgagni  and  Valsalva  made  many  accurate  clinical  and 
anatomical  observations  on  the  disease.  Our  modern  knowledge  dates  from 
Laennec  (1819),  whose  masterly  description  of  the  physical  signs  and 
morbid  anatomy  left  very  little  for  subsequent  observers  to  add  or  modify. 

Incidence. — One  of  the  most  widespread  and  fatal  of  all  acute  diseases, 
pneumonia  has  become  the  "Captain  of  the  Men  of  Death,'''  to  use  the  phrase 
applied  by  John  Bunyan  to  consumption.  In  England  and  Wales  in  1916 
there  were  37,916  deaths  from  this  cause.  In  the  United  States  in  the  regis- 
tration area  in  1917  there  were  112,821  deaths,  a  rate  of  149.8  per  100,000; 
of  these  65,438  were  due  to  lobar  pneumonia,  37,947  to  broncho-pneumonia, 
and  9,436  were  unclassified.  It  is  a  disease  of  cities,  in  the  overcrowded 
districts  of  which  there  has  been  an  increase  of  late,  particularly  in  America. 

Careful  studies  of  tropical  pneumonia  have  been  made  at  Panama.  At  the 
Ancon  Hospital  among  574  cases  the  mortality  was  37  per  cent.;  among  the 
mixed  races,  natives  of  the  Isthmus,  from  50  to  60  per  cent.  The  same  high 
death  rate  prevails  at  the  Colon  Hospital..  Among  the  natives  employed  in  the 
Transvaal  mines  the  disease  was  very  fatal,  killing  a  larger  number  than  any 
other  disease,  tuberculosis  coming  second.  It  is  more  particularly  among  the 
natives  during  the  first  month  of  work  in  the  mines,  443  per  thousand 
of  all  deaths  during  this  period.     There  is  a  marked  decline  in  succeeding 


PNEUMONIAS  AND  PNEUMOCOCCIC  INFECTIONS  79 

periods  of  six  months — from  16  per  thousand  in  the  first  six  months  to  9.24 
per  thousand  in  the  second  six  months,  and  5.5  per  thousand  in  the  third 
six  months.  Of  a  total  of  6,333  deaths  in  1909-1910  in  the  labor  area,  2,264, 
more  than  one-third,  were  due  to  pneumonia  (G.  D.  Maynard).  The  case 
mortality  is  not  extraordinarily  high.  In  Johannesburg  the  deaths  among 
the  colored  people  fell  from  1,196  in  1912-13  (a  rate  of  10.79  per  1,000 
population)  to  325  in  1913-14  (a  rate  of  3.09  per  1,000)  coincident  with  im- 
provement in  the  sanitary  condition  of  the  dwellings. 

Etiology. — Age. — To  the  sixth  year  the  predisposition  to  pneumonia  is 
marked;  it  diminishes  to  the  fifteenth  year,  but  then  for  each  subsequent 
decade  it  increases.  For  children  Holt's  statistics  of  500  cases  give:  First 
year,  15  per  cent.;  from  the  second  to  the  sixth  year,  62  per  cent.;  from 
the  seventh  to  the  eleventh  year,  21  per  cent.;  from  the  twelfth  to  the 
fourteenth  year,  2  per  cent.  Lobar  pneumonia  has  been  met  with  in  the  new- 
born. The  relation  to  age  is  well  shown  in  the  U.  S.  Census  Eeport  for 
1900.  The  death-rate  in  persons  from  fifteen  to  forty-five  years  was  100.05 
per  100,000  of  population ;  from  forty-five  to  sixty-five  years  it  was  263.12 ; 
and  in  persons  sixty-five  years  of  age  and  over  it  was  733.77.  Pneumonia 
may  well  be  called  the  friend  of  the  aged.  Taken  off  by  it  in  an  acute,  short, 
not  often  painful  illness,  the  old  escape  those  "cold  gradations  of  decay" 
that  make  the  last  stage  of  all  so  distressing. 

Sex. — Males  are  more  frequently  affected  than  females — 533  to  125  in  the 
Johns  Hopkins  Hospital  series. 

Race. — In  the  United  States  pneumonia  is  more  fatal  in  negroes  than 
among  the  whites.  This  was  not  so  marked  in  our  figures  at  the  Johns  Hop- 
kins Hospital,  but  at  the  Charite  Hospital,  New  Orleans,  and  at  the  Ancon 
and  Colon  hospitals  of  the  Canal  Zone  the  death  rate  among  the  negroes  is 
much  higher.     It  is  rare  among  the  Chinese. 

Social  Condition. — The  disease  is  more  common  in  the  cities.  Over- 
crowding probably  is  a  factor.  Individuals  who  are  much  exposed  to  hardship 
and  cold  are  particularly  liable  to  the  disease.  Newcomers  and  immigrants 
are  stated  to  be  less  susceptible  than  native  inhabitants. 

Personal  Condition. — Debilitating  causes  of  all  sorts  render  individuals 
more  susceptible.  Alcoholism  is  perhaps  the  most  potent  predisposing  fac- 
tor.   Eobust,  healthy  men  are,  however,  often  attacked. 

Previous  Attack. — No  other  acute  disease  recurs  in  the  same  individual 
with  such  frequency.  Instances  are  oh  record  of  individuals  who  have  had 
ten  or  more  attacks.  The  percentage  of  recurrences  has  been  placed  as  high 
as  50.  Netter  gives  it  as  31,  and  he  has  collected  the  statistics  of  eleven 
observers  who  place  the  percentage  at  26.8.  Among  the  highest  figures  for 
recurrences  are  those  of  Benjamin  Push,  28,  and  Andral,  16. 

Trauma — Contusion-pneumonia. — Pneumonia  may  follow  directly  upon 
injury,  particularly  of  the  chest,  without  necessarily  any  lesion  of  the  lung. 
Litten  gives  4.4  per  cent..  Stern  2.8  per  cent.  Stern  describes  three  clinical 
varieties:  first,  the  ordinary  lobar  pneumonia  following  a  contusion  of  the 
chest  wall;  secondly,  atypical  cases,  with  slight  fever  and  not  very  characteristic 
physical  signs;  thirdly,  cases  with  the  physical  signs  and  features  of  broncho- 
pneumonia.   The  last  two  varieties  have  a  favorable  prognosis.     According  to 


80  SPECIFIC  IXFECTIOUS  DISEASES 

Ballard,  workers  in  certain  phosphate  factories,  where  they  breathe  a  very 
dusty  atmosjDhere,  are  particularly  prone  to  pneumonia. 

Cold  has  been  for  years  regarded  as  an  important  etiological  factor.  The 
frequent  occurrence  of  an  initial  chill  has  been  one  reason  for  this  wide- 
spread belief.  As  to  the  close  association  of  pneumonia  with  exposure  there 
can  be  no  question.  We  see  the  disease  occur  promptly  after  a  wetting  or  a 
chilling  due  to  some  imusual  exposure,  or  come  on  after  an  ordinary  catarrh 
of  one  or  two  days'  duration.  Cold  is  now  regarded  simply  as  a  factor  in 
lowering  the  resistance  of  the  bronchial  and  pulmonary  tissues. 

Climate  and  Seasox. — Climate  does  not  appear  to  have  very  much  in- 
fluence, as  pneumonia  prevails  equally  in  hot  and  cold  countries.  It  is  stated 
to  be  more  prevalent  in  the  Southern  than  in  the  Xorthern  States,  but 
the  Census  Eeports  show  that  there  is  little  difference  in  the  various  State 
groups.  The  disease  is  less  prevalent  in  England  than  in  the  United 
States,  where  the  dry,  overheated  air  of  the  houses  favors  catarrhal  processes 
in  the  air  passages. 

Much  more  important  is  the  influence  of  season.  Statistics  are  almost 
unanimous  in  placing  the  highest  incidence  of  the  disease  in  the  winter 
and  spring  months.  In  Montreal,  January,  the  coldest  month  of  the  year, 
but  with  steady  temperature,  has  usually  a  comparatively  low  death-rate  from 
pneumonia.  The  large  statistics  of  Seitz  from  Munich  and  of  Seibert  of  New 
York  give  the  highest  percentage  in  February  and  March. 

Bacteriology. —  (a)  Micrococcus  laxceolatus,  Pneumococcus  or  Dip-- 
Lococcus  PNEUMONIAE  OF  Fraenkel  AND  Weichselbaum. — In  September, 
1880,  Sternberg  inoculated  rabbits  with  his  own  saliva  and  isolated  a  micrococ- 
cus. The  publication  was  not  made  until  April,  1881.  Pasteur  discovered  the 
same  organism  in  the  saliva  of  a  child  dead  of  hydrophobia  in  December,  1880, 
and  the  priority  of  the  discovery  belongs  to  him,  as  his  publication  is  dated 
January,  1881.  There  was,  however,  no  suspicion  that  this  organism  was 
concerned  in  the  etiology  of  lobar  pneumonia,  and  it  was  not  really  until 
April,  1881,  that  Fraenkel  determined  that  the  organism  found  by  Sternberg 
and  Pasteur  in  the  saliva,  and  known  as  the  coccus  of  sputum  septicaemia, 
was  the  most  frequent  germ  in  pneumonia. 

The  organism  is  a  somewhat  elliptical,  lance-shaped  coccus,  usually  occur- 
ring in  pairs ;  hence  the  term  diplococcus.  About  the  organism  in  the  sputum 
a  capsule  can  always  be  demonstrated.  Its  kinship  to  Streptococcus  pyogenes 
is  regarded  by  many  as  very  close.  E.  Cole  and  his  co-workers  recognize 
four  groups  based  upon  well  defined  immunological  differences.  Types  I  and 
II  each  comprise  about  one  third  of  the  cases  Avith  a  mortality  of  25-30  per 
cent.  Type  III  comprises  10-15  per  cent,  with  a  mortality  about  50  per 
cent,  and  Type  IV,  the  remainder  with  a  mortality  about  12  per  cent.  Organ- 
isms of  Type  IV  are  the  commonest  forms  in  the  mouths  of  healthy  indi- 
viduals. A  fifth  well-marked  strain  has  been  determined  in  South  Africa  by 
Lister. 

Distribution  in  the  Body. — In  the  bronchial  secretions  and  in  the  affected 
lung  the  pneimiococcus  is  readily  demonstrated  in  smears,  and  in  the  latter 
in  sections.  It  is  possible  to  isolate  the  pneumococcus  from  the  blood  in  a 
large  proportion  of  all  cases. 

Pneumococcus    Under   Normal    Conditions. —  (1)    In   the   Mouth. — 


PNEUMONIAS  AND  PNEUMOCOCCIC  INFECTIONS  81 

The  pneumococcus  is  present  in  the  mouths  of  a  large  proportion  of  healthy 
individuals,  various  observers  giving  80  to  90  per  cent,  of  positive  results. 
The  virulence  is  not  always  uniform,  and  Longcope  and  Fox  showed  that  the 
saliva  of  the  same  individual  increased  in  virulence  during  the  winter  months. 
Some  persons  always  harbor  a  virulent  variety.  Buerger  studied  the  com- 
municability  of  the  organism  from  one  person  to  another  and  it  was  found 
repeatedly  that  normal  individuals — i.  e.,  persons  in  whose  mouths  the 
pneumococcus  was  proved  by  repeated  examinations  to  be  absent — acquired  the 
organisms  by  association  with  cases  of  pneumonia,  or  with  healthy  persons 
in  whose  saliva  pneumococci  were  present. 

(2)  Outside  the  Body. — The  viability  of  the  pneumococcus  is  not  great. 
It  has  been  found  occasionally  in  the  dust  and  sweepings  of  rooms,  but  Wood 
has  shown  (New  York  Commission  Eeport)  that  the  germs  exposed  to  sun- 
light die  in  a  very  short  time — an  hour  and  a  half  being  the  limit.  In  moist 
sputum  kept  in  a  dark  room  the  germs  lived  ten  days,  and  in  a  badly  venti- 
lated room  in  which  a  person  with  pneumonia  coughed,  the  germs  suspended 
in  the  air  retained  their  vitality  for  several  hours. 

(&)  Bacillus  pxeumoxi^  of  Fkiedlaxder. — This  is  a  larger  organism 
than  the  pneumococcus,  and  appears  in  the  form  of  plump,  short  rods.  It  also 
shows  a  capsule,  but  presents  marked  differences  from  Fraenkel's  pneumococ- 
cus. It  may  cause  broncho-pneumonia-  and  other  affections,  and  is  not  a  cause 
of  genuine  lobar  pneumonia.  The  exudate  caused  by  this  bacillus  is  usually 
more  viscid  and  poorer  in  fibrin  than  that  in  diplococcus  pneumonia. 

(c)  Other  Organisms. — Various  bacteria  may  be  associated  with  the 
pneumococcus  in  lobar  pneumonia,  the  most  common  of  these  being  Strep- 
tococcus -pyogenes,  the  pyogenic  staphylococci,  and  Friedlander's  pneumo- 
bacillus;  but  while  these  latter  may  cause  broncho-pneumonia,  they  have  not 
been  satisfactorily  demonstrated  to  be  other  than  secondary  invaders  in  lobar 
pneumonia.  Likewise  the  pneumonias  caused  by  Bacillus  typhosus,  Bacillus 
diphtherice,  and  the  influenza  bacillus  are  not  to  be  identified  with  true  lobar 
pneumonia. 

Clinically,  the  infectious  nature  of  pneumonia  was  recognized  long  before 
we  knew  anything  of  the  pneumococcus.  It  may  occur  in  endemic  form,  local- 
ized in  certain  houses,  in  barracks,  jails,  and  schools.  As  many  as  ten  occu- 
pants of  one  house  have  been  attacked.  We  have  seen  several  members  of  a 
family  consecutively  attacked  with  a  most  malignant  type  of  pneumonia. 
Among  the  more  remarkable  endemic  outbreaks  is  that  reported  by  W.  B, 
Piodman,  of  Frankfort,  Ivy.  In  a  prison  with  a  population  of  735  there 
occurred  in  one  year  118  cases  of  pneumonia  with  25  deaths.  The  disease 
may  assume  epidemic  proportions.  In  the  Middlesborough  epidemic,  studied 
by  Ballard,  682  persons  were  attacked,  with  a  mortality  of  21  per  cent. 
During  some  years  pneumonia  is  so  prevalent  that  it  is  practically  pandemic. 
Direct  contagion  is  suggested  by  the  fact  that  a  patient  in  the  next  bed  to  a 
pneumonia  case  may  take  the  disease,  or  2  or  3  cases  may  follow  in  rapid 
succession  in  a  ward.  It  is  very  exceptional,  however,  for  nurses  or  doctors  to 
be  attacked. 

Infection,  the  Symptoms  and  Immunity. — A  majority  of  persons  harbor 
the  germ  in  mouth,  nose,  or  throat,  but  the  virulence  of  the  ordinary  mouth 
form  is  low  and  varies  with  the  season.     A  virulent  germ  may  be  constant 


82  .   SPECIFIC  INFECTIOUS  DISEASES 

and  such  persons  are  true  carriers  and  play  an  important  role  in  the  spread 
of  the  disease.  Some  individuals  are  less  resistant,  and  in  no  other  acute 
disease  may  so  many  successive  attacks  occur  in  the  same  person.  The 
negro  race  in  the  United  States,  in  the  Canal  Zone,  and  in  South  Africa 
shows  an  extreme  susceptibility;  on  the  other  hand  the  Chinese  workmen, 
when  in  South  Africa,  showed  an  extraordinary  resistance  to  the  disease. 

There  are  three  phases  in  the  infection — a  period  of  incubation  and  onset, 
the  clinical  manifestations,  and  the  immunization  characterized  by  the  crisis. 
The  attack  is  usually  attributed  to  lowered  general  resistance,  but  experimen- 
tally there  is  basis  for  the  view  that  local  conditions  in  the  lung,  such  as  the 
catarrhal  processes,  favor  the  development  of  pneumococci.  Changes  leading 
to  lobar  consolidation  may  be  regarded  as  local  defensive  reactions.  The 
explosive  onset  bears  a  certain  resemblance  to  the  anaphylactic  reaction. 

The  clinical  features  are  a  toxaemia,  plus  disturbances  of  respiratory  and 
circulatory  functions.  The  intoxication  bears  no  proportion  to  the  local 
lesion.  There  are  profound  general  infections  with  little  or  no  pulmonary 
involvement.  Some  of  the  most  toxic  cases,  particularly  in  the  aged,  have 
very  slight  lesions,  while  a  lung  may  be  solid  and  the  patient  show  no  signs 
of  poisoning.  The  nature  of  the  toxaemia  is  unknown,  nor  whether  due  to 
absorption  of  the  products  of  digestion  of  the  local  exudate,  which  does  not 
seem  likely,  as  the  symptoms  abate  after  crisis  when  this  absorption  is  most 
active.  To  regard  the  symptoms  as  due  to  absorption  of  a  toxin  is  natural  but 
no  special  substance  has  been  discovered  in  the  culture  fluids  of  pneumococci ; 
the  problem  is  under  discussion.  Studies  on  the  oxygen  and  carbon  dioxide 
contents  of  the  blood  by  Peabody  show  no  change  in  the  reaction  of  the 
body  tissues  beyond  the  mild  grade  of  acidosis  present  in  all  fevers.  Prob- 
ably, as  Pfeifer  suggests,  it  is  an'  endotoxin  produced  from  the  bodies  of  the 
pneumococci. 

The  explanation  of  the  crisis  is  obscure.  Immune  bodies  are  not  con- 
stantly increased  after  it,  or  they  may  not  appear  for  several  days.  Upon 
what  the  neutralization  of  the  toxins  depends  is  doubtful. 

The  serum  of  a  horse  actively  immunized  will  protect  a  mouse  against 
a  million  lethal  doses  when  injected  together;  but  if  injected  only  a  few 
hours  after  the  lethal  dose  it  is  not  possible  to  save  the  animal  (Cole). 
Insufficient  dosage  may  account  for  the  common  failure  and  in  each  case 
the  special  strain  must  be  determined.  A  univalent  serum  was  efficient  to 
protect  animals  against  about  40  per  cent,  of  cultures  obtained  from  the 
blood  of  patients.  Up  to  the  present  the  serum  has  been  found  useful  in 
the  treatment  of  infections  with  Type  I.  No  effective  serum  has  been  obtained 
for  Type  III  (Pneumococcus  Mucosus). 

Morbid  Anatomy. — Since  the  time  of  Laennec,  pathologists  have  recog- 
nized three  stages  in  the  inflamed  lung:  engorgement,  red  hepatization,  and 
gray  hepatization. 

In  the  stage  of  engorgement  the  lung  tissue  is  deep  red  in  color,  firmer 
to  the  touch,  and  more  solid,  and  on  section  the  surface  is  bathed  Avith  blood 
and  serum.  It  still  crepitates,  though  not  so  distinctly  as  healthy  lung,  and 
excised  portions  float.  The  air-cells  can  be  dilated  by  insufflation  from  the 
bronchus.  The  capillary  vessels  are  greatly  distended,  the  alveolar  epithelium 
swollen,  and  the  air-cells  occupied  by  a  variable  number  of  blood  corpuscles  and 


PNEUMONIAS  AND  PNEUMOCOCCIC  INFECTIONS  83 

detached  alveolar  cells.  In  the  stage  of  red  hepatization  the  lung  tissue 
is  solid,  firm,  and  airless.  If  the  entire  lobe  is  involved  it  looks  voluminous, 
and  shows  indentations  of  the  ribs.  On  section,  the  surface  is  dry,  reddish- 
brown  in  color,  and  has  lost  the  deeply  congested  appearance  of  the  first 
stage.  One  of  the  most  remarkable  features  is  the  friability;  in  striking 
contrast  to  the  healthy  lung,  which  is  torn  with  difficulty.  The  surface  has  a 
granular  appearance  due  to  the  fibrinous  plugs  filling  the  air-cells.  The 
distinctness  of  this  appearance  varies  greatly  with  the  size  of  the  alveoli, 
which  are  about  0.10  mm.  in  diameter  in  the  infant,  0.15  or  0.16  in  the 
adult,  and  from  0.20  to  0.25  in  old  age.  On  scraping  the  surface  with  a 
knife  a  reddish  viscid  serum  is  removed,  containing  small  granular  masses. 
The  smaller  bronchi  often  contain  fibrinous  plugs.  If  the  lung  has  been 
removed  before  the  heart,  it  is  not  uncommon  to  find  solid  moulds  of  clot 
filling  the  blood-vessels.  Microscopically,  the  air-cells  are  seen  to  be  occupied 
by  coagulated  fibrin  in  the  meshes  of  which  are  red  blood-corpuscles,  leucocytes, 
and  alveolar  epithelium.  The  alveolar  walls  are  infiltrated  and  leucocytes  are 
seen  in  the  interlobular  tissues.  Cover-glass  preparations  from  the  exudate, 
and  thin  sections  show,  as  a  rule,  the  diplococci,  many  of  which  are  contained 
within  cells.  Staphylococci  and  streptococci  may  also  be  seen  in  some 
cases.  In  the  stage  of  gray  hepatization  the  tissue  has  changed  from  a  red- 
dish-brown to  a  grayish-white  color.  The  surface  is  moister,  the  exudate  ob- 
tained on  scraping  is  more  turbid,  the  granules  in  the  acini  are  less  distinct, 
and  the  lung  tissue  is  still  more  friable.  The  air-cells  are  densely  filled  with 
leucocytes,  the  fibrin  network  and  the  red  blood-corpuscles  have  largely  dis- 
appeared. A  more  advanced  condition  of  gray  hepatization  is  that  known 
as  purulent  infiltration,  in  which  the  lung  tissue  is  softer  and  bathed  with  a 
purulent  fluid.  Small  abscess  cavities  may  form,  and  by  their  fusion  larger 
ones,  though  this  is  a  rare  event  in  ordinary  pneumonia. 

Eesolution. — The  changes  in  the  exudate  which  lead  to  its  resolution  are 
due  to  an  autolytic  digestion  by  proteolytic  enzymes  which  are  present  much 
more  abundantly  in  gray  hepatization  than  in  the  preceding  stage.  The 
dissolved  exudate  is  for  the  most  part  excreted  by  the  kidneys.  By  following 
the  nitrogen  excess  in  the  urine  the  progress  of  resolution  may  be  followed 
and  even  an  estimate  formed  of  the  amount  of  the  exudate  thus  eliminated. 
H.  W.  Cook  found  in  cases  of  delayed  resolution  that  the  nitrogen  excess 
in  the  urine  (which  persisted  until  the  lung  was  clear)  was  very  large, 
and  he  suggests  that  delayed  resolution  may  really  be  a  matter  of  continued 
exudation. 

General  Details  of  the  Morbid  Anatomy. — ^In  100  autopsies  at  the 
General  Hospital,  Montreal,  in  51  cases  the  right  lung  was  aft'ected,  at  32 
the  left,  in  17  both  organs.  In  27  cases  the  entire  lung,  with  the  exception, 
perhaps,  of  a  narrow  margin  at  the  apex  and  anterior  border,  was  consoli- 
dated. In  34  cases,  the  lower  lobe  alone  was  involved;  in  13  cases,  the  upper 
lobe  alone.  When  double,  the  lower  lobes  were  usually  affected  together,  but 
in  three  instances  the  lower  lobe  of  one  and  the  upper  lobe  of  the  other  were 
attacked.  In  3  cases,  also,  both  upper  lobes  were  affected.  Occasionally  the 
disease  involves  the  greater  part  of  both  lungs.  In  a  third  of  the  cases,  red 
and  gray  hepatization  existed  together.  In  22  instances  there  was  gray 
hepatization.     As   a  rule  the   unaffected   portion   of  the   lung  is   congested 


84  SPECIFIC  INFECTIOUS  DISEASES 

or  cedematous.  When  the  greater  portion  of  a  lobe  is  attacked,  the  uninvolved 
part  may  be  in  a  state  of  ahnost  gelatinous  oedema.  The  unaffected  lung  is 
usually  congested,  particularly  at  the  posterior  part.  This  may  be  largely 
due  to  post  mortem  subsidence.  The  uninilamed  portions  are  not  always 
congested  and  oedematous.  The  upper  lobe  may  be  dry  and  bloodless  when 
the  lower  lobe  is  uniformly  consolidated.  The  average  weight  of  a  normal 
lung  is  about  600  grams,  while  that  of  an  inflamed  organ  may  be  1,500,  2,000, 
or  even  2,500  grams. 

The  bronchi  contain,  as  a  rule,  at  the  time  of  death  a  frothy  serous  fluid, 
rarely  the  tenacious  mucus  so  characteristic  of  pneumonic  sputum.  The 
mucous  membrane  is  usually  reddened,  rarely  swollen.  In  the  affected  areas 
the  smaller  bronchi  often  contain  fibrinous  plugs,  which  may  extend  into  the 
larger  tubes,  forming  perfect  casts.  The  bronchial  glands  are  swollen  and 
may  even  be  soft  and  pulpy.  The  pleural  surface  of  the  inflamed  lung  is 
invariably  involved  when  the  process  becomes  superficial.  Commonly,  there 
is  only  a  thin  sheeting  of  exudate,  producing  slight  turbidity  of  the  mem- 
brane. The  pleura  was  not  involved  in  only  two  of  the  hundred  instances. 
In  some  cases  the  fibrinous  exudate  may  form  a  creamy  layer  an  inch  in 
thickness.    A  serous  exudation  of  variable  amount  is  not  uncommon. 

Lesioxs  in  Other  Organs. — The  heart,  particularly  its  right  chamber, 
is  distended  with  firm,  tenacious  coagula,  which  can  be  withdrawn  from  the 
vessels  as  dendritic  moulds.  In  no  other  acute  disease  do  we  meet  with 
coagula  of  such  solidity.  The  spleen  is  often  enlarged,  though  in  only  35 
of  the  100  cases  was  the  weight  above  200  grams.  The  kidneys  show  parenchy- 
matous swelling,  turbidity  of  the  cortex,  and,  in  a  very  considerable  proportion 
of  the  cases — 25  per  cent. — chronic  interstitial  changes. 

Pericarditis  was  present  in  35  of  658  cases  in  our  series  (Chatard). 
Endocarditis  occurred  in  16  of  the  100  post  mortems.  In  5  of  these  the 
endocarditis  was  of  the  simple  character;  in  11  the  lesions  were  ulcerative. 
Of  209  cases  of  malignant  endocarditis  collected  from  the  literature,  51: 
occurred  in  pneumonia.  Kanthack  found  an  antecedent  pneumonia  in  14.2 
per  cent,  of  cases  of  infective  endocarditis.  In  the  figures  collected  by  E.  F. 
Wells,  of  517  fatal  cases  of  acute  endocarditis,  22.3  per  cent,  were  in  pneu- 
monia. It  is  more  common  on  the  left  than  on  the  right  side  of  the  heart. 
Among  658  cases  of  pneumonia  in  the  Johns  Hopkins  Hospital  endocarditis 
occurred  in  15  (Marshall).  Myocarditis  and  fatty  degeneration  of  the  heart 
may  be  present  in  protracted  cases. 

Meningitis,  which  is  not  infrequent,  may  be  associated  with  malignant 
endocarditis.  It  was  present  in  8  of  the  100  autopsies.  Of  20  cases  of  menin- 
gitis in  ulcerative  endocarditis  15  occurred  in  pneumonia. 

Croupous  or  diphtheritic  inflammation  may  occur  in  other  parts.  A 
croupous  colitis,  as  pointed  out  by  Bristowe,  is  not  very  uncommon.  It 
occurred  in  5  of  the  100  post  mortems.  It  is  usually  a  thin,  flaky  exudation, 
most  marked  on  the  tops  of  the  folds  of  the  mucous  membrane.  In  one  case 
there  was  a  patch  of  croupous  gastritis,  covering  an  area  2  by  8  cm.,  situated 
to  the  left  of  the  cardiac  orifice.  The  liver  shows  parenchymatous  changes^ 
and  often  extreme  engorgement  of  the  hepatic  veins. 

Symptoms. — Course  of  the  Disease  in  Typical  Cases. — We  know  but 
little  of  the  incubation  period,  but  it  is  probably  very  short.    There  are  some- 


PNEUMONIAS  AXD  PNEUMOCOCCIC  INFECTIONS  85 

times  slight  catarrhal  symptoms  for  a  day  or  two.  As  a  rule,  the  disease  sets 
in  abruptly  with  a  severe  chill,  which  lasts  from  fifteen  to  thirty  minutes  or 
longer.  In  no  acute  disease  is  an  initial  chill  so  constant  or  so  severe. 
The  patient  may  be  taken  abruptly  in  the  midst  of  his  work,  or  may  aM-aken 
out  of  a  sound  sleep  in  a  rigor.  The  temperature  taken  during  the  chill 
shows  that  the  fever  has  already  begun.  If  seen  shortly  after  the  onset,  the 
patient  usually  has  features  of  an  acute  fever,  and  complains  of  headache 
and  general  pains.  Within  a  few  hours  there  is  pain  in  the  side,  often  of  an 
agonizing  character;  a  short,  dry,  painful  cough  begins,  and  the  respirations 
are  increased  in  frequency.  When  seen  on  the  second  or  third  day,  the  picture 
in  typical  pneumonia  is  more  distinctive  than  that  presented  by  any  other 
acute  disease.  The  patient  lies  often  on  the  affected  side;  the  face  is 
flushed,  particularly  one  or  both  cheeks;  the  breathing  is  hurried,  accom- 
panied often  with  a  short  expiratory  grunt;  the  ala?  nasi  dilate  with  each 
inspiration;  herpes  is  usually  present  on  the  lips  or  nose;  the  eyes  are  bright, 
the  pupils  are  often  unequal,  the  expression  is  anxious,  and  there  is  a  fre- 
quent short  cough  which  makes  the  patient  wince  and  hold  his  side.  The 
expectoration  is  blood-tinged  and  extremely  tenacious.  The  temperature  may 
be  104°  or  105°.  The  pulse  is  full  and  bounding  and  the  pulse-respiration 
ratio  much  disturbed.  Examination  of  the  lungs  shows  the  physical  signs 
of  consolidation  with  blowing  breathing  and  fine  rales.  After  persisting  for 
from  seven  to  ten  days  the  crisis  occurs,  and  with  a  fall  in  the  temperature 
the  patient  passes  from  the  condition  of  extreme  distress  and  anxiety  to  one 
of  comparative  comfort. 

Special  Features. — The  fever  rises  rapidly,  and  the  height  may  be  104° 
F.  or  105°  F.  within  twelve  hours.  Having  reached  the  fastigium,  it  is 
remarkably  constant.  Often  the  two-hour  temperature  chart  will  not  show 
more  than  a  degree  of  variation  for  several  days.  In  children  and  in  cases 
without  chilL  the  rise  is  more  gradual.  In  old  persons  and  in  drunkards  the 
temperature  range  is  lower  than  in  children  and  in  healthy  individuals ;  one 
occasionally  meets  with  an  afebrile  pneumonia. 

The  Crisis. — ^After  the  fever  has  persisted  for  from  five  to  nine  or  ten 
days  there  is  an  abrupt  drop,  known  as  the  crisis,  which  is  one  of  the  most 
characteristic  features  of  the  disease.  The  day  of  the  crisis  is  variable.  It 
is  very  uncommon  b'efore  the  third  day,  and  rare  after  the  twelfth.  We  have 
seen  it  as  early  as  the  third  day.  From  the  time  of  Hippocrates  it  has  been 
thought  to  be  more  frequent  on  the  uneven  days,  particularly  the  fifth  and 
seventh;  the  latter  has  the  largest  number  of  cases  (Musser  and  Norris).  A 
precritical  rise  of  a  degree  or  two  may  occur.  In  one  case  the  temperature 
rose  from  105°  to  nearly  107°,  and  then  in  a  few  hours  fell  to  normal. 
Not  even  after  the  chill  in  malarial  fever  do  we  see  such  a  prompt  and  rapid 
drop  in  the  temperature.  The  usual  time  is  from  five  to  twelve  hours,  but 
often  in  an  hour  there  may  occur  a  fall  of  six  or  eight  degrees  (S.  West). 
The  temperature  may  be  subnormal  after  the  crisis,  as  low  as  96°  or  97°. 
Usually  there  is  an  abundant  sweat,  and  the  patient  sinks  into  a  comfort- 
able sleep.  The  day  after  the  crisis  there  may  be  a  slight  post-critical 
rise.  A  pseud o-n'ins  is  not  very  uncommon,  in  which  on  the  fifth  or  sixth 
day  the  temperature  drops  from  104°  or  105°  to  102°,  and  then  rises  again. 
\A'hen  the  fall  takes  place  gradually  within   twenty-four  hours  it  is  called 


86  SPECIFIC  INFECTIOUS  DISEASES 

a  protracted  crisis.  If  the  fever  persists  beyond  the  twelfth  day,  the  fall 
is  likely  to  be  by  lysis.  In  children  this  mode  of  termination  is  common, 
and  occurred  in  one-third  of  a  series  of  183  cases  reported  by  Morrill.  Occa- 
sionally in  debilitated  individuals  the  temperature  drops  rapidly  just  before 
death;  more  frequently  there  is  an  ante-mortem  elevation.  In  delayed  resolu- 
tion the  fever  may  persist  for  six  or  eight  weeks.  The  crisis,  the  most 
remarkable  phenomenon  of  pneumonia,  appears  to  represent  the  stage  of  active 
immunity  to  the  toxin  of  the  pneumococcus.  The  fever,  dyspnoea  and  general 
symptoms  disappear  when  the  immunity  reaches  a  certain  stage.  With  the 
fall  in  the  fever  the  respirations  become  reduced  almost  to  normal,  the  pulse 
slows,  and  the  patient  passes  from  perhaps  a  state  of  extreme  hazard  and 
distress  to  one  of  safety  and  comfort,  and  yet,  so  far  as  the  physical  examina- 
tion indicates,  there  is  with  the  crisis  no  special  change  in  the  condition  in 
the  lung.  For  a  study  of  the  problem  see  Emerson,  Johns  Hopkins  Hos- 
pital Eeports,  Vol.  XV. 

Pavn. — There  is  early  a  sharp,  agonizing  pain,  generally  referred  to  the 
region  of  the  nipple  or  lower  axilla  of  the  affected  side,  and  much  aggravated 
on  deep  inspiration  and  on  coughing.  It  is  associated,  as  Aretseus  remarks, 
with  involvement  of  the  pleura.  It  is  absent  in  central  pneumonia,  and 
much  less  frequent  in  apex  pneumonia.  The  pain  may  be  severe  enough  to 
require  a  hypodermic  injection  of  morphia.  As  has  been  recognized  for  many 
years,  the  pain  may  be  altogether  abdominal,  either  central  or  in  the  right 
iliac  fossa,  suggesting  appendicitis.  The  operation  for  appendicitis  has  been 
performed. 

Dyspnoea  is  almost  constant  and  even  early  in  the  disease  the  respira- 
tions may  be  30  in  the  minute,  and  on  the  second  or  third  day  between  40 
and  50.  The  movements  are  shallow,  evidently  restrained,  and  if  the  patient 
is  asked  to  draw  a  deep  breath  he  cries  out  with  the  pain.  Expiration  is 
frequently  interrupted  by  an  audible  grunt.  At  first  with  the  increased 
respiration  there  may  be  no  sensation  of  distress.  Later  this  may  be  present 
in  a  marked  degree.  In  children  the  respirations  may  be  80  or  even  100. 
Many  factors  combine  to  produce  the  shortness  of  breath — the  pain  in  the 
side,  the  toxaemia,  the  fever,  acidosis  possibly,  and  the  loss  of  function  in  a 
considerable  area  of  the  lung  tissue.  Sometimes  there  appear  to  be  nervous 
factors  at  work.  That  it  does  not  depend  upon  the  consolidation  is  shown 
by  the  fact  that  after  the  crisis,  without  any  change  in  the  condition  of  the 
lung,  the  number  of  respirations  may  drop  to  normal.  The  ratio  between 
•the  respirations  and  the  pulse  may  be  1  to  2  or  even  1  to  1.5,  a  disturbance 
rarely  so  marked  in  any  other  disease. 

Cough. — This  usually  comes  on  with  the  pain  in  the  side,  and  at  first  is 
dry,  hard,  and  without  any  expectoration.  Later  it  becomes  very  charac- 
teristic— frequent,  short,  restrained,  and  associated  with  great  pain  in  the 
side.  In  old  persons,  in  drunkards,  in  the  terminal  pneumonias,  and  some- 
times in  young  children,  there  may  be  no  cough.  After  the  crisis  the  cough 
usually  becomes  much  easier  and  the  ■  expectoration  more  easily  expelled. 
The  cough  is  sometimes  persistent,  continuous,  and  by  far  the  most  aggra- 
vated and  distressing  symptom  of  the  disease.  Paroxysms  of  coughing  of 
great  intensity  after  the  crises  suggest  a  pleural  exudate. 

Sputum. — A  brisk  haemoptysis  may  be  the  initial  symptom.     At  first  the 


PNEUMONIAS  AND  PNEUMOCOCCIC  INFECTIONS  87 

sputum  may  be  mucoid,  but  usually  after  twenty-four  hours  it  becomes 
blood- tinged,  viscid,  and  very  tenacious.  At  first  quite  red  from  the  un- 
changed blood,  it  gradually  becomes  rusty  or  of  an  orange  yellow.  The 
tenacious  viscidity  of  the  sputum  is  remarkable;  it  often  has  to  be  wiped 
from  the  lips  of  the  patient.  When  jaundice  is  present  it  may  be  green  or 
yellow.  In  low  types  of  the  disease  the  sputum  may  be  fluid  and  of  a  dark 
brown  color,  resembling  prune  juice.  The  amount  is  very  variable,  ranging 
from  100  to  300  c.  c.  in  the  twenty-four  hours.  In  100  cases  studied  by 
Emerson,  in  16  there  was  little  or  no  sputum;  in  32  it  was  typically  rusty; 
in  33  blood-streaked;  in  3  cases  the  sputum  was  very  bloody.  In  children 
and  very  old  people  there  may  be  no  sputum  whatever.  After  the  crisis 
the  quantity  is  variable,  abundant  in  some  cases,  absent  in  others. 

Microscopically,  the  sputum  consists  of  leucocytes,  mucus  corpuscles,  red 
blood-corpuscles  in  all  stages  of  degeneration,  and  bronchial  and  alveolar 
epithelium.  Hsematoidin  crystals  are  occasionally  met  with.  Of  micro- 
organisms the  pneumococcus  is  usually  present,  and  sometimes  Friedlander's 
bacillus,  the  influenza  bacillus,  streptococci  and  the  colon  bacillus.  Very  inter- 
esting constituents  are  small  cell  moulds  of  the  alveoli  and  the  fibrinous  casts 
of  the  bronchioles;  the  latter  may  be  plainly  visible  to  the  naked  eye;  and 
sometimes  may  form  good-sized  dendritic  casts.  Chemically,  the  expectoration 
is  particularly  rich  in  calcium  chloride. 

Physical  Signs. — Inspection. — The  position  of  the  patient  is  not  con- 
stant. He  usually  rests  more  comfortably  on  the  affected  side,  or  he  is 
propped  up  with  the  spine  curved  toward  it.     Orthopnoea  is  rare. 

In  a  small  lesion  no  differences  may  be  noted  between  the  sides;  as  a 
rule,  movement  is  much  less  on  the  affected  side,  which  may  look  larger. 
With  involvement  of  a  lower  lobe,  the  apex  on  the  same  side  may  show  greater 
movement.  The  compensatory  increased  movement  on  the  sound  side  is 
sometimes  very  noticeable  even  before  the  patient's  chest  is  bared.  The  inter- 
costal spaces  are  not  usually  obliterated.  When  the  cardiac  lappet  of  the  left 
upper  lobe  is  involved  there  may  be  a  marked  increase  in  the  area  of  visible 
cardiac  pulsation.  Pulsation  of  the  affected  lung  may  cause  a  marked  move- 
ment of  the  chest  wall  (Graves).  Other  points  to  be  noticed  in  the  inspection 
are  the  frequency  of  the  respiration,  the  action  of  the  accessory  muscles,  such 
as  the  sterno-cleido-mastoids  and  scaleni,  and  the  dilatation  of  the  nostrils  with 
each  inspiration.  Asynchronous  contractions  of  the  respiratory  muscles  occur 
in  many  cases.  When  fully  developed  the  diaphragm  and  thoracic  respiratory 
muscles  contract  alternately  (Coleman).    It  is  of  grave  significance. 

Mensuration  may  show  a  definite  increase  in  the  volume  of  the  side 
affected,  rarely  more,  however,  than  1  or  II/2  cm. 

Palpation. — The  lack  of  expansion  on  the  affected  side  is  sometimes  more 
readily  perceived  by  touch  than  by  sight.  The  pleural  friction  may  be  felt. 
The  voice  fremitus  is  greatly  increased  in  comparison  with  the  corresponding 
point  on  the  healthy  side.  It  is  to  be  noted  that  if  the  bronchi  are  filled 
with  thick  secretion,  or  if,  in  what  is  known  as  massive  pneumonia,  they  are 
filled  with  fibrinous  exudate,  the  tactile  fremitus  may  be  diminished.  It  is 
always  well  to  ask  the  patient  to  cough  before  testing  the  fremitus. 

Percussion. — In  the  stage  of  engorgement  the  note  is  higher  pitched  and 
may  have  a  somewhat  tympanitic  quality.    This  can  often  be  obtained  over  the 


88  SPECIFIC  I\TFECTIOIJS  DISEASES 

lung  tissue  just  above  a  consolidated  area.  L.  A.  Conner  calls  attention  to  a 
point  which  all  observers  must  have  noticed,  that,  when  the  patient  is  lying 
on  his  side,  the  percussion  at  the  dependent  base  is  "deeper  and  more 
resonant  than  that  of  the  upper  side,''  which  by  contrast  may  seem  abnormal, 
and  there  may  even  be  a  faint  tubular  element  added  to  the  vesicular  breath- 
ing on  the  compressed  side.  When  the  lung  is  hepatized,  the  percussion 
note  is  dull,  the  quality  varying  a  good  deal  from  a  note  which  has  in  it 
a  certain  tympanitic  quality  to  one  of  absolute  flatness.  There  is  not  the 
wooden  flatness  of  efi'usion  and  the  sense  of  resistance  is  not  so  great.  During 
resolution  the  tympanitic  quality  of  the  percussion  note  usually  returns.  For 
weeks  or  months  after  convalescence  there  may  be  a  higher-pitched  note  on 
the  afi'ected  side.  Wintrich's  change  in  the  percussion  note  when  the  mouth 
is  open  may  be  very  well  marked  in  pneumonia  of  the  upper  lobe.  Occasionally 
there  is  an  almost  metallic  quality  over  the  consolidated  area,  and  when  this 
exists  with  a  very  pronounced  amphoric  quality  in  the  breathing  the  presence 
of  a  cavity  may  be  suggested.  In  deep-seated  pneumonias  there  may  be  no 
change  in  the  percussion  note  for  several  days. 

Auscultation. — Quiet,  suppressed  breathing  in  the  affected  part  is  often 
a  marked  feature  in  the  early  stage,  and  is  always  suggestive.  Only  in  a  few 
cases  is  the  breathing  harsh  or  puerile.  Very  early  there  is  heard  at  the 
end  of  inspiration  the  fine  crepitant  rale,  a  series  of  minute  cracklings  heard 
close  to  the  ear,  and  perhaps  not  audible  until  a  full  breath  is  drawn.  This 
is  possibly  a  fine  pleural  crepitus,  as  J.  B.  Leaming  maintained;  it  is  usually 
believed  to  be  produced  in  the  air-cells  and  finer  bronchi  by  the  separation 
of  the  sticky  exudate.  In  the  stage  of  red  hepatization  and  when  dulness 
is  well  defined,  the  respiration  is  tubular.  It  is  heard  first  with  expiration 
(a  point  noted  by  James  Jackson,  Jr.),  and  is  soft  and  of  low  pitch.  Gradually 
it  becomes  more  intense,  and  finally  presents  an  intensity  unknown  in  any 
other  pulmonary  affection — of  high  pitch,  perfectly  dry,  and  of  equal  length 
with  inspiration  and  expiration.  It  is  simply  the  propagation  of  the  laryngeal 
and  tracheal  sounds  through  the  bronchi  and  the  consolidated  lung  tissue. 
The  permeability  of  the  bronchi  is  essential  to  its  production.  Tubular 
breathing  is  absent  in  the  excessively  rare  cases  of  massive  pneumonia  in 
which  the  larger  bronchi  are  completely  filled  Avith  exudation.  When  resolu- 
tion begins  mucous  rales  of  all  sizes  can  be  heard.  At  first  they  are  small 
and  have  been  called  the  redux-crepitus.  The  voice-sounds  and  the  expiratory 
grunt  are  transmitted  through  the  consolidated  lung  with  great  intensity. 
This  bronchophony  may  have  a  curious  nasal  quality,  to  which  the  term 
segophony  has  been  given.  There  are  cases  in  which  the  consolidation  is 
deeply  seated — so-called  central  pneumonia,  in  which  the  physical  signs  are 
slight  or  even  absent,  yet  the  cough,  the  rusty  expectoration,  and  general 
features  make  the  diagnosis  certain. 

Circulatory  Symptoms. — ^During  the  chill  the  pulse  is  small,  but  in  the 
succeeding  fever  it  becomes  full  and  bounding.  In  cases  of  moderate  severity 
it  ranges  from  100  to  120.  It  is  not  often  dicrotic.  In  strong,  healthy 
individuals  and  in  children  there  may  be  no  sign  of  failing  pulse  throughout 
the  attack.  With  extensive  consolidation  the  left  ventricle  may  receive  a 
very  much  diminished  amount  of  blood  and  the  pulse  in  consequence  may  be 
small.     In  the  old  and  feeble  it  may  be  small  and  rapid  from  the  outset. 


PNEUMOXIAS  AND  PXErMOCOCCiC  IX'FECTIOXS  89 

The  pulse  may  be  full,  soft,  very  deceptive,  and  of  no  value  whatever  in 
prognosis. 

Blood  Pressure. — During  the  first  few  days  there  is  no  change.  The 
extent  of  involvement  seems  to  have  no  effect  upon  the  peripheral  blood  pres- 
sure. In  the  toxic  cases  the  pressure  may  begin  to  fall  early;  a  drop  of 
15-20  mm.  Hg  is  perfectly  safe,  but  a  progressive  fall  indicates  the  need  of 
stimulation.  A  sudden  drop  is  rarely  seen  except  just  before  death.  A  slow, 
gradual  fall  of  more  than  20  mm.  Hg  means  cardio-vascular  asthenia,  and 
calls  for  an  increase  in  the  stimulation.  The  crisis  has  no  effect  on  the  blood 
pressure.  The  opinion  commonly  held,  that  when  the  blood  pressure  as 
expressed  in  millimeters  of  Hg  does  not  fall  below  the  pulse  rate  expressed 
in  beats  per  minute,  the  outlook  is  good,  and  vice  versa,  is  by  no  means 
always  correct.  The  heart  sounds  are  usually  loud  and  clear.  During  the 
intensity  of  the  fever,  particularly  in  children,  murmurs  are  not  uncommon 
both  in  the  mitral  and  in  the  pulmonic  areas.  The  second  sound  over  the 
pulmonary  artery  is  accentuated.  Attention  to  this  sign  gives  a  valuable 
indication  as  to  the  condition  of  the  lesser  circulation.  With  distention  of  the 
right  chambers  and  failure  of  the  right  ventricle  to  empty  itself  completely, 
the  pulmonary  second  sound  becomes  much  less  distinct.  When  the  right 
heart  is  engorged  there  may  be  an  increase  in  the  diilness  to  the  right  of  the 
sternum.  With  gradual  heart  weakness  and  signs  of  dilatation  the  long  pause 
is  greatly  shortened,  the  sounds  approach  each  other  in  tone  and  have  a 
fetal  character  (embr3'ocardia). 

There  may  be  a  sudden  early  collapse  of  the  heart  with  very  feeble,  rapid 
pulse  and  increasing  cyanosis.  This  may  happen  on  the  third  day.  Even  when 
these  symptoms  are  very  serious  recovery  may  take  place.  In  other  instances 
without  any  special  warning  death  may  occur  even  in  robust,  previously  healthy 
men.  The  heart  weakness  may  be  due  to  paralysis  of  the  vaso-motor  centre 
and  consequent,  lowering  of  the  general  arterial  pressure.  The  soft,  easily  com- 
pressed pulse,  with  the  gray,  ashy  f-acies,  cold  hands  and  feet,  the  clammy 
perspiration,  and  the  progressive  prostration  tell  of  a  toxic  action  on  the  cir- 
culation. Endocarditis  and  pericarditis  will  be  considered  under  complica- 
tions. 

Blood. — Pneumococci  are  present  in  the  Ijlood  in  a  large  proportion  of  all 
cases.  Angemia  is  rare.  A  decrease  in  the  red  cells  may  occur  at  the  time 
of  the  crisis.  There  is  in  most  cases  a  leucocytosis,  which  appears  early, 
persists,  and  disappears  with  the  crisis.  The  leucocytes  may  number  from 
12,000  to  40,000  or  even  100,000  per  culjic  millimetre.  The  fall  in  the 
leucocytes  is  often  slower  than  the  drop  in  the  fever,  particularly  when 
resolution  is  delayed  or  complications  are  present.  The  annexed  chart  gives  a 
study  by  Chatard  of  the  leucocytes  in  582  cases  at  the  Johns  Hopkins  Hos- 
pital. More  than  half  of  the  patients,  about  350,  had '  a  leucocytosis  of 
between  15,000  and  35,000,  and  nearly  one-third  (198)  ■  between  20,000 
and  30,000.  The  broken  line  represents  the  mortality  which  is  high  when 
the  leucocytes  are  below  10,000,  but  steadily  decreases  and  is  lowest  when 
they  are  between  20,000  and  30,000.  With  the  leucocytes  between  30,000 
and  60,000  the  mortality  is  again  higher.  The  two  patients  with  the  highest 
leucocytosis  of  the  series,  95,000  and  105,000  respectively,  recovered.  A  strik- 
ing feature  in  the  blood-slide  is  the  richness  and  density  of  the  fibrin  net- 


90 


SPECIFIC  INFECTIOUS  DISEASES 


work.  This  corresponds  to  the  great  increase  in  the  fibrin  elements,  the 
proportion  rising  from  4  to  10  parts  per  thousand.  The  blood-plates  are 
greatly  increased. 

Digestive  Oegans. — The  tongue  is  white  and  furred,  and  in  severe  toxic 
cases  rapidly  becomes  dry.  Vomiting  is  not  uncommon  at  the  onset  in 
children.     The  appetite  is  lost.     Constipation  is  more  common  than  diarrhoea. 


3 

Number  -' 
of  Cases 

o 
o 

o 

in 

1 
o 

o 
o 
o 
o" 

rH 
IT) 

o 
o 

o 

in 

o 

o 
o 

o 
o" 

CN 

in 

8 

o 
in 

1 
o 

CM 

o 
o 

q 
o" 

CO 

in 

o 

o 
q 

1 

o 
m 

o 
o 

o 
o* 

in 

o 

o 

q 

<* 
o 

o 
o 

q 
o" 

in 

8 

q 

o 

in 

o 
o 
o 
o" 
in 
1 

in 

o 
o 
o 

in 

ID 

1 
o 

o 
o 
o 
o 

in 

lO 

o     o 

o     o 

o     q 
in      o" 

r^      CO 

o      in 

o 
o 
o 

in 

CO 

1 
o 

CO 

o 
o 
o 
o" 

Ol 
CO 

o 
o 
o_ 

en 

o 

01 

o 
o 
q 
o" 
o 

in 

CJl 

o 

o 
q 

o 

o 
o 

Mortality  % 

100-105 

100-105 

95  -100 

r 

I 

95-100 

90-  95 

/ 

/ 

tv 

90-  95 

85  -  90 

/ 

85  -  90 

80-  85 

/ 

80  -  85 

75-  80 

, 

'l 

75  -  80 

70  -  75 

1 

1 

70-75 

65  -  70 

\ 

1 

\ 

65-  70 

60  -  65 

I 

,' 

60  -  65 

55  -  60 

^ 

\ 

■' 

55  -  60 

50-55 

\ 

1 

X 

50-  55 

45  -  50 

\ 

1 

45-  50 

40  -  45 

I 

\ 

^ 

1 

40-  45 

35  -  40 

1 

\ 

\ 

\ 

; 

'    \ 

. 

35  -  40 

30  -  35 

J 

1 

»\ 

,* 

/ 

30-  35 

25  -  30 

' 

^ 

/ 

\ 

fc- 

.-o 

25  -  30 

20-  25 

1 

\ 

V 

A 

20  -  25 

15-  20 

\ 

/ 

\ 

15  -  20 

10  -  15 

1 

*" 

"-0 

\ 

\ 

10-  15 

5-10 

1 

\, 

5-10 

0-5 

0-5 

V!. 
UJ 

o 

s 

CO 

in 
in 

00 

o 
in 

o 
en 

CO 

ro 

CO 

m 

o 
o 

00 

o 

CO 

CO 

CO 
CM 

00 

eg 

o 

o 
in 

o     o 

8    S 

-o 

> 
o 

> 
o 

en 

Exact 

Num- 
ber 

in 

CO 
CO 

00 

o 
o 

lO 

01 
CO 

o 

CM 

CO 
CM 

to 

r^ 

px 

CM 

C\i        CVJ 

- 

- 

Chart  IV. — Blcod  Count  in  Pneumonia  and  Comparative  Mortality.  Continuous 
Line  Eepresents  Number  of  Cases  of  Pneumonia.  Broken  Line  Eepresents 
Mortality  Percentage  of  Same. 


A  distressing  and  sometimes  dangerous  symptom  is  meteorism.  Fibrinous, 
pneumococcic  exudates  may  occur  in  the  conjunctivse,  nose,  mouth,  prepuce, 
and  anus  (Cary).  The  liver  may  be  depressed  by  the  large  right  lung,  or 
enlarged  from  the  engorged  right  heart  or  as  a  result  of  the  infection.  The 
spleen  is  usually  enlarged,  and  the  edge  can  be  felt  during  a  deep  inspira- 
tion. 

Skin. — Among  cutaneous  symptoms  one   of  the  most  interesting  is  the 
association  of  herpes  with  pneumonia.     Not  excepting  malaria,  we  see  labial 


PNEUMONIAS  AND  PNEUMOCOCCIC  INFECTIONS  91 

herpes  more  frequently  in  this  than  in  any  other  disease,  occurring,  as  it 
does,  in  from  12  to  40  per  cent,  of  the  cases.  It  is  supposed  to  be  of  favor- 
able prognosis,  and  figures  have  been  quoted  in  proof  of  this  assertion. 
It  may  also  occur  on  the  nose,  genitals,  and  anus.  Its  significance  and  rela- 
tion to  the  disease  are  unknown.  At  the  height  of  the  disease  sweats  are  not 
common,  but  at  the  crisis  they  may  be  profuse.  Eedness  of  one  cheek  is  a 
phenomenon  long  recognized  in  pneumonia,  and  is  usually  on  the  same  side  as 
the  disease.  A  difl:use  erythema  is  occasionally  seen,  and  in  rare  cases  pur- 
pura.    Jaundice  is  referred  to  among  the  complications. 

Ueixe.— Early  in  the  disease  it  presents  the  usual  febrile  characters  of 
high  color,  high  specific  gravity,  and  increased  acidity.  A  trace  of  albumin 
is  very  common.  There  may  be  tube-casts,  and  in  a  few  instances  the  existence 
of  albumin,  tube-casts,  and  blood  indicates  the  presence  of  an  acute  nephritis. 
The  urea  and  uric  acid  are  usually  increased  at  first,  but  may  be  much 
diminished  before  the  crisis,  to  increase  greatly  with  its  onset.  Eobert 
Hutchison's  researches  show  that  a  true  retention  of  chlorides  within  the 
body  takes  place,  the  average  amount  being  about  2  grams  daily.  It  is  a  more 
constant  feature  of  pneumonia  than  of  any  other  febrile  disease,  and  this  being 
the  case,  a  diminution  of  the  chlorides  in  the  urine  may  be  of  value  in 
the  diagnosis  from  pleurisy  wath  effusion  or  empyema.  It  is  to  be  remem- 
bered that  in  dilatation  of  the  stomach  chlorides  may  be  absent.  Haimaturia 
is  a  rare  complication. 

Cerebral  Symptoms. — Headache  is  common.  In  children  vomiting  or 
convulsions  may  occur  at  the  outset.  Apart  from  meningitis,  considered  sep- 
arately, one  may  group  the  cases  with  marked  cerebral  features  into : 

First,  the  so-called  cerebral  pneumonias  of  children,  in  which  the  disease 
sets  in  with  a  convulsion,  and  there  are  high  fever,  headache,  delirium,  great 
irritability,  muscular  tremor,  and  perhaps  retraction  of  the  head  and  neck 
with  Kernig's  sign  and  an  extensor  plantar  reflex.  The  diagnosis  of  meningitis 
is  usually  made,  and  the  local  affection  may  be  overlooked. 

Secondly,  the  cases  with  maniacal  symptoms.  These  may  occur  at  the 
very  outset,  and  there  may  be  no  suspicion  whatever  that  the  disease  is  other 
than  acute  mania. 

Thirdly,  alcoholic  cases  with  the  features  of  delirium  tremens.  It  should 
be  an  invariable  rule,  even  if  fever  be  not  present,  to  examine  the  lungs  in  a 
case  of  mania  a  potu. 

Fourthly,  cases  with  toxic  features,  rather  reseml)ling  those  of  ura?mia. 
Without  a  chill  and  without  cough  or  pain  in  the  side,  a  patient  may  have 
fever,  a  little  shortness  of  breath,  and  then  gradually  grow  dull  mentally,  and 
within  three  days  be  in  profound  toxEemia  with  low,  muttering  delirium. 

It  is  stated  that  apex  pneumonia  is  more  often  accompanied  with  severe 
delirium.  Occasionally  the  cerebral  symptoms  occur  immediately  after  the 
crisis.  Mental  disturbance  may  persist  during  and  after  convalescence,  and 
in  a  few  instances  delusional  insanity  follows,  the  outlook  in  which  is  favor- 
able. 

Hemiplegia  may  be  due  to  thrombosis,  embolism,  ab.scess  or  oodcma.  With- 
ington  called  attention  to  a  form  associated  with  encephalitis.  It  may  be 
transient  and  recovery  complete.  Transient  aphasia,  with  or  without  hemi- 
plegia, may  occur  and  there  are  cases  in  which  no  gross  lesions  have  been 


92  SPECIFIC  INFECTIOUS  DISEASES 

found,  so  that  it  has  been  suggested  that  it  is  due  to  oedema  or  to  a  relative 
ischsemia.  Inequality  of  the  pupils  is  not  uncommon  but  has  no  special  sig- 
nificance. 

Complications. — Compared  "with  typhoid,  fever,  j)iieumonia  has  but  few 
complications  and  still  fewer  sequelae.     The  most  important  are  the  following: 

Pleurisy  is  an  inevitable  event  when  the  inflammation  reaches  the  surface 
of  the  lung,  and  thus  can  scarcely  be  termed  a  complication.  But  there  are 
cases  in  which  the  pleuritic  features  take  the  first  place.  The  exudation  may 
be  sero-fibrinous  with  copious  effusion,  differing  from  that  of  an  ordinary 
acute  pleurisy  in  the  greater  richness  of  the  fibrin,  which  may  form  thick, 
tenacious,  curdy  layers.  Pneumonia  on  one  side  with  extensive  pleurisy  on 
the  other  is  sometimes  a  puzzling  complication  to  diagnose,  and  an  aspirating 
needle  may  be  required  to  settle  the  question.  Empyema  is  a  most  common 
complication  occurring  in  2.2  per  cent,  of  clinical  cases  collected  by  Musser 
and  Xorris  and  in  3.6  per  cent,  of  the  Johns  Hopkins  Hospital  series.  During 
the  eight  years,  1883-'90,  there  were  at  Guy's  Hospital  7  cases  of  empyema 
among  445  cases  of  pneumonia,  while  in  the  eight  years,  1891-'98,  there  were 
38  cases  among  896  cases  of  pneumonia  (Hale  White).  Influenza  may  be 
responsible  for  the  increase.  The  pneumococcus  is  usually  present;  in  a  few 
the  streptococcus,  in  which  case  the  prognosis  is  not  so  good.  Some  cases  may 
be  due  to  extension  from  or  rupture  of  a  small  lung  abscess.  Eecurrence  of 
the  fever  after  the  crisis  or  persistence  of  it  after  the  tenth  day,  with  sweats, 
leucocytosis,  and  an  aggravation  of  the  cough,  are  suspicious  symptoms.  The 
dulness  persists  at  the  base,  or  may  extend.  The  breathing  is  feeble  and  there 
are  no  rales.  Such  a  condition  may  be  closely  simulated,  of  course,  by  a  thick- 
ened pleura.  Exploratory  aspiration  may  settle  the  question  at  once.  There 
are  obscure  cases  in  which  the  pus  has  been  found  only  after  operation,  as  the 
collection  may  be  very  small.     The  X-rays  often  give  aid. 

Pericarditis,  one  of  the  most  serious  of  complications,  was  present  in  35  of 
658  patients  in  the  Johns  Hopkins  Hospital  (Chatard).  It  is  often  a  terminal 
affair  and  overlooked.  The  mortality  is  very  high;  31  of  the  35  patients  died. 
It  was  most  frequently  associated  with  pneumonia  of  the  right  lung.  In  only 
three  instances  was  the  amount  of  fluid  above  500  c.  c.  Pleurisy  is  an  almost 
constant  accompaniment,  being  present  in  28  of  the  29  autopsies  in  my  series. 

Endocarditis. — The  valves  on  the  left  side  are  more  commonly  attacked, 
and  particularly  if  the  seat  of  arterio-sclerosis.  It  is  especially  liable  to  attack 
persons  with  old  valvular  disease.  There  may  be  no  symptoms  indicative  of 
this  complication  even. in  very  severe  cases.  It  may,  however,  be  suspected  in 
cases  (1)  in  which  the  fever  is  protracted  and  irregular;  (2)  when  signs  of 
septic  mischief  arise,  such  as  chills  and  sweats;  (3)  when  embolic  phenomena 
appear.  The  frequent  complication  of  meningitis  with  the  endocarditis  of 
pneumonia  gives  prominence  to  the  cerebral  symptoms  in  these  cases.  The 
physical  signs  may  be  deceptive.  There  are  instances,  in  which  no  cardiac 
murmurs  have  been  heard.  In  others  the  occurrence  under  observation  of  a 
loud,  rough  murmur,  particularly  if  diastolic,  is  extremely  suggestive. 

Ante-mortem  clotting  in  the  heart,  upon  which  the  old  writers  laid  great 
stress,  is  very  rare.  Thromhods  in  the  peripheral  veins  is  also  uncommon. 
Three  cases  occurred  in  the  Hopkins,  clinic,  which  liave  been  reported  by 
Steiner,  who  was  able  to  collect  only  54  cases  from  the  literature.    In  35  out 


PNEUMOmAS  AND  PNEUMOCOCGIC  IXFECTIOXS  93 

of  44  cases  which  were  fully  reported,  the  thrombosis  occurred  during  conva- 
lescence. It  is  almost  always  in  the  femoral  veins.  A  rare  complication  is 
embolism  of  one  of  the  larger  arteries.  The  senior  author  saw  an  instance  of 
embolism  of  the  femoral  artery  at  the  height  of  pneumonia,  which  necessi- 
tated amputation  at  the  thigh.     The  patient  recovered. 

Meningitis  is  perhaps  the  most  serious  complication  and  varies  very  much 
at  different  times  and  in  different  regions.  The  Montreal  series  is  rather 
exceptional,  as  8  per  cent,  of  the  fatal  cases  had  this  complication.  In  twenty 
years  at  the  Johns  Hopkins  Hospital  there  were  25  cases  of  pneumococcus 
meningitis,  in  18  of  which  pneumonia  was  present.  In  IC  of  the  cases  the 
organism  was  demonstrated  in  the  cerebro-spiiial  fluid.  Endocarditis  was 
present  in  7  of  the  18  cases.  The  percentage  of  meningitis  in  the  pneumonia 
cases  was  3.4,  which  is  lower  than  the  figures  of  Musser  and  ISTorris  of  3.5 
per  cent,  in  4,883  autopsies.  It  usually  comes  on  at  the  height  of  the  fever, 
and  in  the  majority  of  the  cases  is  not  recognized  unless  the  base  is  involved, 
which  is  not  common.  Occurring  later  in  the  disease,  it  is  more  easily  diag- 
nosed. The  prognosis  is  bad ;  all  of  our  patients  died.  A  few  instances  of 
recovery  are  on  record. 

Feripheral  neuHtis  is  a  rare  complication,  of  which  several  cases  have 
been  described. 

Gastric  complications  are  rare.  Fussell  has  drawn  attention  to  the  occur- 
rence of  acute  dilatatio)i  of  the  stomach.  Persistent  vomiting,  sudden  ab- 
dominal distention  and  collapse  are  the  most  common  features.  A  croupous 
gastritis  has  been  mentioned.  The  croupous  colitis  may  induce  severe  diar- 
rhoea. It  is  by  no  means  uncommon  to  have  early  pain,  either  in  the  region 
of  the  umbilicus  or  in  the  right  iliac  fossa,  and  a  suspicion  of  appendicitis  is 
aroused;  indeed,  a  catarrhal  form  of  this  disease  may  occur  coincidently  with 
the  pneumonia.  In  other  instances  so  localized  may  the  pain  be  in  the  region 
of  the  pancreas,  associated  with  mete,orism  and  high  fever,  that  the  diagnosis 
of  acute  haemorrhagic  pancreatitis  is  made.  Such  a  case  occurred  in  the  wards 
of  our  colleague  Dr.  Halsted.  The  patient  was  admitted  in  a  desperate  con- 
dition, all  the  symptoms  were  abdominal,  and  the  apex  pneumonia  was  not 
discovered.  Peritonitis  is  a  rare  complication,  of  which  we  have  had  only 
two  or  three  instances.  It  is  sometimes  in  the  upper  peritoneum,  and  a  direct 
extension  through  the  diaphragm.  It  is  usually  in  the  severer  cases  and  not 
easy  to  recognize.  In  one  case,  indeed,  in  which  there  was  a  friction  along 
the  costal  border,  which  we  thought  indicated  a  peritonitis,  it  was  communi- 
cated from  the  diaphragmatic  pleura.  Meteorisw  is  not  infrequent,  and  is 
sometimes  serious.  In  some  cases  it  may  be  due  to  a  defect  in  the  mechanical 
action  of  the  diaphragm,  in  others  to  an  acute  septic  catarrh  of  the  bowels, 
or  to  a  toxic  paresis  of  the  walls,  occasionally  to  peritonitis.  Jaundice  occurs 
with  curious  irregularity  in  different  outbreaks  of  the  disease.  In  Baltimore 
it  was  more  common  among  the  negro  patients.  It  sets  in  early,  is  rarely 
very  intense,  and  has  not  the  characters  of  obstructive  jaundice.  There  are 
cases  in  which  it  assumes  a  very  serious  form,  'ilie  mode  of  production  is  not 
well  ascertained.  It  does  not  appear  to  bear  any  definite  relation  to  the 
degree  of  hepatic  engorgement,  and  it  is  not  always  due  to  catarrh  of  the 
ducts.     Possibly  it  may  be,  in  great   pai't,  ba'niatogcnous. 


94  SPECIFIC  II^FECTIOUS  DISEASES 

Parotitis  occasionally  occurs,  commonly  in  association  with  endocarditis. 
In  children,  middle-ear  disease  is  not  an  infrequent  complication. 

Nepltritis  does  not  often  follow  pneumonia. 

A7thritis  occurred  in  5  of  658  cases  at  the  Johns  Hopkins  Hospital  (How- 
ard). It  may  precede  the  onset,  and  the  pneumonia,  possibly  with  endocarditis 
and  pleurisy,  may  occur  as  a  complication.  In  other  instances  at  the  height 
of  the  pneumonia  one  or  two  joints  may  become  red  and  sore  or  after  the 
crisis  has  occurred  pain  and  swelling  may  come  on  in  the  joints.  It  is  a  serious 
complication  as  recovery  is  often  slow  and  a  stiff  joint  may  follow. 

Eelapse. — There  are  cases  in  which  from  the  ninth  to  the  eleventh  day  the 
fever  subsides,  and  after  the  temperature  has  been  normal  for  a  day  or  two  a 
rise  occurs  and  fever  may  persist  for  another  ten  days  or  even  two  weeks. 
Though  this  might  be  termed  a  relapse,  it  is  more  correct  to  regard  it  as  an 
instance  of  an  anomalous  course  or  delayed  resolution.  Wagner,  who  has 
studied  the  subject  carefully,  says  that  in  his  experience  of  1,100  cases  he 
met  with  only  3  doubtful  cases.  When  it  does  occur,  the  attack  is  usually 
abortive  and  mild.  In  one  case,  with  pneumonia  of  the  right  lower  lobe, 
crisis  occurred  on  the  seventh  day,  and  after  a  normal  temperature  for  thir- 
teen days  he  was  discharged.  That  night  he  had  a  shaking  chill,  followed  by 
fever,  and  he  had  recurring  chills  with  reappearance  of  the  pneumonia.  In  a 
second  case  the  crisis  occurred  on  the  third  day,  and  there  was  recurrence  of 
pneumonia  on  the  thirteenth  day. 

Recurrence  is  more  common  in  pneumonia  than  in  any  other  acute  disease. 
Eush  gives  an  instance  in  which  there  were  28  attacks.  Other  authorities  nar- 
rate cases  of  8,  10,  and  even  more  attacks. 

Convalescence  in  pneumonia  is  usually  rapid,  and  sequela?  are  rare.  After 
the  crisis,  sudden  death  has  occurred  when  the  patient  has  got  up  too  soon. 
With  the  onset  of  fever  and  persistence  of  the  leucocytosis  the  affected  side 
should  be  very  carefully  examined  for  pleurisy.  With  a  persistence  of  the 
dulness  the  physical  signs  may  be  obscure,  but  the  use  of  a  small  exploratory 
needle  or  the  X-rays  will  help  to  clear  the  diagnosis. 

Clinical  Varieties. — Local  variations  are  responsible  for  some  of  the  most 
marked  deviations  from  the  usual  type.  Apex  pneumonia  is  said  to  be  more 
often  associated  with  adynamic  features  and  with  marked  cerebral  symptoms. 
The  expectoration  and  cough  may  be  slight.  Migratory  or  creeping  pneuinonia 
is  a  form  which  successively  involves  one  lobe  after  the  other.  DouMe  pneu- 
monia has  no  peculiarities  other  than  the  greater  danger  connected  with  it. 
Massive  pneumonia  is  a  rare  form,  in  which  not  alone  the  air-cells  but  the 
bronchi  of  an  entire  lobe  or  even  of  a  lung  are  filled  with  the  fibrinous  exu- 
date. The  auscultatory  signs  are  absent;  there  is  neither  fremitus  nor  tubu- 
lar breathing,  and  on  percussion  the  lung  is  absolutely  flat.  It  closely  resem- 
bles pleurisy  with  effusion.  The  moulds  of  the  bronchi  may  be  expectorated 
in  violent  fits  of  coughing. 

Central  Pneumonia. — ^The  inflammation  may  be  deep-seated  at  the  root 
of  the  lung  or  centrally  placed  in  a  lobe,  and  for  several  days  the  diagnosis 
may  be  in  doubt.  It  may  not  be  until  the  third  or  fourth  day  that  a  pleural 
friction  is  detected,  or  that  dulness  or  blowing  breathing  and  rales  are  recog- 
nized. The  senior  author  saw  with  Drs.  H.  Adler  and  Chew  a  young,  thin- 
chested  girl  in  whom  at  the  end  of  the  fourth  day  all  the  usual  symptoms  of 


PNEUMONIAS  AND  PNEUMOCOCCIC  INFECTIONS  95 

pneumonia  were  present  without  any  physical  signs  other  than  a  few  clicking 
rales  at  the  left  apex  behind.  The  thinness  of  the  patient  greatly  facilitated  the 
examination.  The  general  features  of  pneumonia  continued,  and  the  crisis 
occurred  on  the  seventh  day. 

Pneumonia  in  Infants. — It  is  sometimes  seen  in  the  new-born.  In  in- 
fants it  very  often  sets  in  with  a  convulsion.  The  apex  of  the  lung  seems 
more  frequently  involved  than  in  adults,  and  the  cerebral  symptoms  are  more 
marked.  Ihe  torpor  and  coma,  particularly  if  they  follow  convulsions,  and 
the  preliminary  stage  of  excitement,  may  lead  to  the  diagnosis  of  meningitis. 
Pneumonic  sputum  is  rarely  seen  in  children. 

Pneumonia  in  the  Aged. — The  disease  may  be  latent  and  set  in  with- 
out a  chill;  the  cough  and  expectoration  are  slight,  the  physical  signs  ill- 
defmed  and  changeable,  and  the  constitutional  symptoms  out  of  all  proportion 
to  the  extent  of  the  local  lesion. 

Pneumonia  in  Alcopiolic  Subjects. — The  onset  is  insidious,  the  symp- 
toms masked,  the  fever  slight,  and  the  clinical  picture  usually  that  of  delirium 
tremens.  The  thermometer  alone  may  indicate  the  presence  of  an  acute  dis- 
ease. Often  the  local  condition  is  overlooked,  as  the  patient  makes  no  com- 
plaint, and  there  may  be  very  little  dyspnoea,  no  cough,  and  no  sputum. 

Terminal  Pneumonia. — The  wards  and  the  post  mortem  room  show  a 
very  striking  contrast  in  their  pneumonia  statistics,  owing  to  the  occurrence 
of  what  may  be  called  terminal  pneumonia.  During  the  winter  months  pa- 
tients with  chronic  pulmonary  tuberculosis,  arterio-sclerosis,  heart  disease, 
nephritis,  and  diabetes  are  not  infrequently  carried  off  by  a  pneumonia  which 
may  give  few  or  no  signs.  In  the  Johns  Hopkins  Hospital  series  of  658  cases, 
there  were  35  cases  of  this  variety,  20  of  which  were  associated  with  cardio- 
vascular and  14  with  renal  disease.  It  is  nearly  always  of  the  lobar  form. 
There  may  be  slight  fever,  with  increase  in  the  respirations,  but  the  patient 
is  near  the  end  and  perhaps  not  in  a  condition  in  which  a  thorough  physical 
examination  can  be  made.  In  our  -series  the  right  lung  was  involved  in  19 
cases  and  9  had  a  low  leucocyte  count.  In  diabetic  patients  the  disease  often 
runs  a  rapid  and  severe  course,  and  may  end  in  abscess  or  gangrene. 

Secondary  Pneumonia. — This  is  met  with  chiefly  in  the  specific  fevers, 
particularly  diphtheria,  typhoid  fever,  typhus,  influenza,  and  the  plague.  Ana- 
tomically, it  rarely  presents  the  typical  form  of  red  or  gray  hepatization.  The 
surface  is  smoother,  not  so  dry,  and  it  is  often  a  pseudo-lobar  condition,  a  con- 
solidation caused  by  closely  set  areas  of  lobular  involvement.  Histologically, 
it  is  characterized  in  many  instances  by  a  more  cellular,  less  fibrinous  exudate, 
which  may  also  infiltrate  the  alveolar  walls.  Bacteriologically,  the  pneu- 
mococcus  may  be  the  dominant  organism;  but  Friedlander's  bacillus,  strepto- 
cocci, staphylococci,  the  influenza  and  colon  bacillus  have  been  found. 

The  symptoms  of  the  secondary  pneumonias  often  lack  the  striking  defi- 
niteness  of  the  primary  lobar  pneumonia.  The  pulmonary  features  may  be 
latent  or  masked  altogether.  There  may  be  no  cough  and  only  a.  slight  in- 
crease in  the  number  of  respirations.  The  lower  lobe  of  one  lung  is  most  com- 
monly involved,  and  the  physical  signs  are  obscure  and  rarely  amount  to  more 
than  impaired  resonance,  feeble  breathing,  and  a  few  crackling  rales. 

Epidemic  Pneumonia  is,  as  a  rule,  more  fatal,  and  often  displays  minor 
complications  which  vary  in  different  outbreaks.     In  some  the  cerebral  mani- 


96  SPECIFIC  INFECTIOUS  DISEASES 

festations  are  marked;  in  others,  the  cardiac;  in  others  again,  the  gastro-in- 
testinal. 

Laeval  Pneumonia. — Mild,  abortive  types  are  seen,  particularly  in  insti- 
tutions when  pneumonia  is  prevailing  extensively.  A  patient  may  have  the 
initial  symptoms  of  the  disease,  a  slight  chill,  moderate  fever,  a  few  indefi- 
nite local  signs,  and  herpes.  The  Avhole  process  may  only  last  for  two  or  three 
days;  some  authors  recognize  even  a  one-day  pneumonia. 

Asthenic,  Toxic,  or  Typhoid  Pneumonia. — The  toxsemic  features  domi- 
nate the  scene  throughout.  The  local  lesions  may  be  slight  in  extent  and  the 
subjective  phenomena  of  the  disease  absent.  The  nervous  symptoms  usually 
predominate.  There  are  delirium,  prostration,  and  early  weakness.  Very  fre- 
quently there  is  jaundice.  Gastro-intestinal  symptoms  may  be  present,  par- 
ticularly diarrhoea  and  meteorism.  In  such  a  case,  seen  about  the  end  of  th6 
first  week,  it  may  be  difficult  to  say  whether  the  condition  is  one  of  asthenic 
pneumonia  or  one  of  typhoid  fever  which  has  set  in  with  early  localization  in 
the  lung.  Here  the  Widal  reaction  and  blood  cultures  are  important  aids. 
Possibly,  too,  there  is  a  mixed  infection,  and  the  streptococcus  pyogenes  may 
be  in  large  part  responsible  for  the  toxic  features. 

Association  of  Pneumonia  witi-i  Other  Diseases. —  (a)  With  Malaria. 
— A  malarial  pneumonia  is  described  and  thought  to  be  particularly  prevalent 
in  some  parts  of  the  United  States.  One  hears  of  it,  indeed,  even  where  true 
malaria  is  rarely  seen.  Pneumonia  is  a  common  disease  in  the  tropics  and  often 
attacks  the  subjects  of  malaria.  The  prognosis  is  bad  in  the  sestiA'o-autumnal 
infections.  A  special  form  of  pneumonia  due  to  the  malarial  parasite  is  un- 
known. Yet  there  are  cases  reported  by  Craig  and  others  in  which  in  an  acute 
malarial  infection  the  features  suggest  pneumonia  at  the  onset,  but  the  para- 
sites a-re  found  in  the  blood,  and  under  the  use  of  quinine  the  fever  drops 
rapidly  and  the  pneumonia  symptoms  clear  up.  In  some  instances  we  have 
foimd  a  chill  in  the  course  of  an  ordinary  pneumonia  to  be  associated  with  a 
malarial  infection. 

(&)  Pneumonia  and  Acute  Arthritis. — We  have  already  spoken  under 
complications  of  this  association,  which  is  more  frequently  seen  in  children. 

(c)  Pneumonia  and  Tuberculosis. — Subjects  of  chronic  pulmonary  tuber- 
culosis may  die  of  an  acute  lobar  pneumonia.  A  point  to  be  specially  borne 
in  mind  is  the  fact  that  acute  tuberculous  pneumonia  may  set  in  with  all  the 
features  and  physical  signs  of  lobar  pneumonia. 

For  the  consideration  of  the  association  of  pneumonia  with  typhoid  fever 
and  influenza,  the  reader  is  referred  to  the  sections  on  those  diseases. 

Post-operation  Pneumonia. — Before  the  days  of  auEesthesia,  lobar  pneu- 
monia was  a  well-recognized  cause  of  death  after  surgical  injuries  and  opera- 
tions. Norman  Cheevers,  in  an  early  number  of  the  Guy's  Hospital  Eeports, 
called  attention  to  it  as  one  of  the  most  frequent  causes  of  death  after  surgical 
procedures,  and  Erichsen  states  that  of  41  deaths  after  surgical  injuries  23 
cases  showed  signs  of  pneumonia.  In  the  statistics  collected  by  Homans  the 
mortality  due  to  lung  complications  after  laparotomies  ranged  from  0.56  to 
18.5.  Operations  on  the  stomach  seem  to  be  peculiarly  liable  to  be  followed 
by  pneumonia.  The  low  figure,  0.5G,  in  Kronlein's  clinic  may  be  attributed 
to  the  use  of  ether  by  the  open  method,  to  the  absence  of  all  preparation  on 
the  table  and  to  shortening  as  much  as  possible  the  period  of  anaesthesia.     The 


PNEUMONIAS  AND  PNEUMOCOCCIC  INFECTIONS  97 

cases  may  be  divided  into  three  groups:  (1)  Inhalation  or  anesthesia  pneu- 
monia which  may  be  lobar  or  broncho-pneumonia.  (2)  Hypostatic  pneumonia 
due  to  enfeebled  circulation.  (3)  Embolic  cases  with  sudden  onset.  The 
route  may  be  lymphatic  or  by  the  veins. 

Anesthesia  Pneumonia. — The  cases  appear  to  be  quite  as  frequent  after 
chloroform  as  after  ether.  The  vapor  of  the  anaesthetic  may  itself  have  a 
damaging  influence  on  the  bronchial  and  alveolar  epithelium,  but  a  more  im- 
portant influence  is  the  aspiration  of  mucus  and  saliva  into  the  air  passages 
during  the  ansesthesia.  Thorough  disinfection  of  the  mouth  and  throat  before 
operation  is  a  useful  preventive  measure.  W.  Pasteur  called  attention  to  a 
condition  of  massive  collapse  of  the  lungs  due  to  deflation  of  the  lower  lobes, 
owing  to  imperfect  action  or  paralysis  of  the  diaphragm.  He  published  the 
statistics  of  lung  complications  at  the  Middlesex  Hospital;  following  3,559 
abdominal  operations  there  were  201  pulmonary  complications,  with  45  deaths. 
Among  these  pneumonia  heads  the  list  with  88  cases  and  31  deaths.  The  com- 
plications are  much  more  numerous  in  operations  above  the  umbilicus.  The 
pneumonia  is  usually  patchy,  involving  both  lungs ;  sometimes  it  is  lobar, 
and  as  a  rule  the  signs  are  well  marked  within  the  first  two  days  after  opera- 
tion. The  collapse,  to  which  Pasteur  calls  attention,  may  involve  both  lower 
lobes  or  only  one  lung,  and  it  may  simulate  pneumonia  very  closely,  or  may 
initiate  it.  When  unilateral,  the  mediastinum  and  heart  are  drawn  towards 
the  affected  side.  It  may  come  on  with  great  suddenness,  and  when  widespread 
it  may  prove  fatal. 

Delayed  Eesolution. — The  lung  is  restored  to  its  normal  state  by  the 
liquefaction  and  absorption  of  the  exudate.  There  are  cases  in  which  resolu- 
tion takes  place  rapidly  without  any  increase  in  (or,  indeed,  without  any)  ex- 
pectoration; on  the  other  hand,  during  resolution  it  is  not  uncommon  to  find 
in  the  sputum  the  little  plugs  of  fibrin  and  leucocytes  which  have  been  loos- 
ened from  the  air-cells  and  expelled  by  coughing.  A  variable  time  is  taken 
in  the  restoration  of  the  lung. .  Sometimes  within  a  week  or  ten  days  the  dul- 
ness  is  greatly  diminished,  the  breath-sounds  become  clear,  and,  so  far  as 
physical  signs  are  any  guide,  the  lung  seems  perfectly  restored.  Delayed  reso- 
lution occurs  in  from  3  to  4  per  cent,  of  cases.  Of  40  cases  at  the  Johns  Hop- 
kins Hospital,  33  were  males  and  7  females;  23  of  the  patients  were  negroes,  a 
very  high  incidence.  The  lower  lobe  is  most  frequently  involved,  37  cases  in 
this  series,  usually  the  right  one  and  as  a  rule  only  one  lobe.  The  duration 
was  to  the  fourth  week  5  cases,  fifth  week  10  cases,  sixth  week  4  cases,  ninth 
week  3  cases,  tenth,  eleventh  and  twelfth  weeks  each  one  case.  In  one  patient 
the  left  lung,  except  a  small  portion  of  tlie  upper  lobe,  remained  solid  for 
eleven  weeks  and  then  cleared  perfectly. 

Clinically,  there  are  several  groups  of  cases :  First,  those  in  which  the 
crisis  occurs  naturally,  the  temperature  falls  and  remains  normal;  but  the 
local  features  persist — well-marked  flatness  with  tubular  breathing  and  rales. 
Resolution  may  occur  very  slowly  and  gradually,  taking  from  two  to  three 
weeks.  In  a  second  group  of  cases  the  temperature  falls  by  lysis,  and  with  the 
persistence  of  the  local  signs  there  is  slight  fever,  sometimes  sweats  and  rapid 
pulse.  The  condition  may  persist  for  three  or  four  weeks  and  during  all  this 
time  there  may  be  little  or  no  sputum.  The  practitioner  is  naturally  much 
exercised,  and  he  dreads  lest  tuberculosis  should  supervene.     In  a  third  group 


98  SPECIFIC  IXFECTIOUS  DISEASES 

the  crisis  occurs  or  the  fever  falls  by  lysis ;  but  the  consolidation  persists,  and 
there  may  be  intense  bronchial  breathing,  with  few  or  no  rales,  or  the'  fever 
may  recur  and  the  patient  may  die  exhausted. 

Termination  in  Chronic  Pneumonia. — The  exudate  may  organize  and 
the  alveolar  walls  thicken  with  the  gradual  production  of  a  chronic  inter- 
stitial or  fibroid  pneumonia.  In  one  pneumonia  autopsy  on  a  patient  aged 
58,  dead  on  the  thirty-second  day  from  the  initial  chill,  the  right  lung  was 
solid  and  the  cut  surface  grayish  in  color  with  a  smooth,  translucent  appear- 
ance. This  is  most  frequently  seen  as  a  sequence  of  delayed  resolution  in 
debilitated  subjects.  Milne  found  10  instances  of  organization  of  the  exudate 
among  150  fatal  cases.  The  shortest  duration  in  the  series  was  twenty-three 
days. 

Ordinary  lobar  pneumonia  never  terminates  in  tuberculosis.  The  instances 
of  caseous  pneumonia  and  softening  which  have  followed  an  acute  pneumonic 
process  have  been  tuberculous  from  the  outset. 

Termination  in  Abscess. — This  occurred  in  4  of  the  100  autopsies. 
Usually  the  lung  breaks  down  in  limited  areas  and  the  abscesses  are  not  large, 
but  they  may  fuse  and  involve  a  considerable  proportion  of  a  lobe.  The  con- 
dition is  recognized  by  the  sputum,  which  is  usually  abundant  and  contains 
pus  and  elastic  tissue,  sometimes  cholesterin  crystals  and  h^ematoidin  crystals. 
The  cough  is  often  paroxysmal  and  of  great  severity;  usually  the  fever  is  re- 
mittent, or  in  protracted  cases  intermittent  in  character,  and  there  may  be 
pronounced  hectic  symptoms.  When  a  case  is  seen  for  the  first  time  it  may 
be  difficult  to  determine  whether  it  is  one  of  abscess  of  the  lung  or  a  local 
empyema  which  has  perforated  the  lung. 

Gangrene. — This  is  most  commonly  seen  in  old  debilitated  persons.  It 
was  present  in  3  of  the  100  autopsies.  It  very  often  occurs  with  abscess.  The 
gangrene  is  associated  with  the  growth  of  the  saprophytic  bacteria  on  a  soil 
made  favorable  by  the  presence  of  the  pneumococcus  or  the  streptococcus. 
Clinically,  the  gangrene  is  rendered  very  evident  by  the  horribly  fetid  odor 
of  the  expectoration  and  its  characteristic  features.  In  some  instances  the  gan- 
grene may  be  found  post  mortem  when  clinically  there  has  not  been  any  evi- 
dence of  its  existence. 

Prognosis. — Pneumonia  is  one  of  the  most  fatal  of  all  acute  diseases, 
outranking  even  tuberculosis  as  a  cause  of  death  in  some  years.  In  America 
the  mortality  appears  to  be  increasing. 

The  statistics  of  the  clinic  at  the  Johns  Hopkins  Hospital  from  1889  to 
1905  have  been  analyzed  by  Chatard.  There  were  658  cases  v/ith  200  deaths, 
a  mortality  of  30.4  per  cent.  Excluding  35  cases  of  terminal  pneumonia,  the 
percentage  is  26.4.  The  death  rate  among  245  negroes  was  very  little  above 
that  of  the  whites.  Greenwood  and  Candy  in  a  study  of  the  pneumonia  sta- 
tistics at  the  London  Hospital  from  1854-1903,  a  total  of  5,097  cases,  conclude 
that  the  fatality  of  the  disease  has  not  appreciably  changed  in  this  period.  In 
comparing  the  collected  figures  of  these  authors  with  those  from  otlier  in- 
stitutions, there  is  an  extraordinary  uniformity  in  the  mortality  rate.  Be- 
tween the  ages  of  21-30  the  mortality  is  everywhere  about  20  per  cent.;  be- 
tween the  ages  of  31-40,  30  per  cent.;  and  then  after  each  decade  it  rises,  until 
above  the  age  of  60  more  than  one-half  of  the  persons  attacked  die. 

The  mortality  in  private  practice  varies  greatly.     R.  P.  Howard  treated 


PKEUMOXIAS  AND  PXEUMOCOCCIC  IXFECTIOXS  99 

170  cases  with  only  G  per  cent,  of  deaths.  Fussell  reported  134  cases  with  a 
mortality  of  17.9  per  cent.  The  mortality  in  children  is  sometimes  very  low. 
^lorrill  reported  6  deaths  in  123  cases  of  frank  pneumonia.  On  the  other 
hand,  Goodhart  had  25  deaths  in  120  cases. 

The  following-  are  among  the  factors  which  influence  prognosis : 

Age. — As  Sturges  remarks,  the  old  are  likely  to  die,  the  young  to  recover. 
Under  one  year  it  is  more  fatal  than  between  two  and  five.  Of  50  cases  under 
10  years  of  age,  4  died;  of  119  cases  under  20,  16  died  (Chatard).  Above 
sixty  the  death  rate  is  very  high,  amounting  to  60  or  80  per  cent.;  33  of  44 
cases  in  our  series.  From  the  reports  of  its  fatality  in  some  places,  one  may 
say  that  to  die  of  pneumonia  is  almost  the  natural  end  of  old  people. 

Previous  habits  of  life  and  the  condition  of  bodily  health  at  the  time  of 
the  attack  are  most  important  factors.  In  analyzing  a  series  of  fatal  cases 
one  is  very  much  impressed  with  the  number  of  cases  in  which  the  organ's 
show  signs  of  degeneration.  In  25  of  the  100  autopsies  at  the  Montreal  Gen- 
eral Hospital  the  kidneys  showed  extensive  interstitial  changes.  Individuals 
debilitated  from  sickness  or  poor  food,  hard  drinkers,  and  that  large  class  of 
hospital  patients,  composed  of  robust-looking  laborers  between  the  ages  of 
fort3'-five  and  sixty,  whose  organs  show  signs  of  wear  and  tear,  and  who  have 
by  excesses  in  alcohol  weakened  the  reserve  power,  fall  an  easy  prey  to  the 
disease.  Very  few  fatal  cases  occur  in  robust,  healthy  adults.  Some  of  the 
statistics  given  by  army  surgeons  show  the  low  mortality  from  pneumonia  in 
healthy  picked  men.  The  death  rate  in  the  German  army  in  over  40,000  cases 
was  only  3.6  per  cent. 

Certain  complications  and  terminations  are  particularly  serious.  The 
meningitis  of  pneumonia  is  almost  always  fatal.  Endocarditis  is  extremely 
grave,  more  so  than  pericarditis.  Much  stress  has  been  laid  upon  the  factor 
of  leucocytosis  as  an  element  in  the  prognosis.  A  very  slight  or  complete  ab- 
sence of  a  leucocytosis  is  rightly  regarded  as  very  unfavorable. 

Toxcemia  is  the  important  progiiostic  feature,  to  which  in  a  majority  of 
the  cases  the  degree  of  pyrexia  and  the  extent  of  consolidation  are  entirely 
subsidiary.  It  is  not  at  all  proportionate  to  the  degree  of  lung  involved.  A 
severe  and  fatal  toxEemia  may  occur  with  the  consolidation  of  only  a  small 
part  of  one  lobe.  On  the  other  hand,  a  patient  with  complete  solidification 
of  one  lung  may  have  no  signs  of  a  general  infection.  The  question  of  in- 
dividual resistance  seems  to  be  the  most  important  one,  and  one  sees  robust- 
looking  individuals  fatally  stricken  within  a  few  days. 

The  determination  of  the  type  of  organism  is  of  assistance.  The  death 
rate  in  Types  I  and  II  is  from  25  to  30  per  cent;  in  Type  III  about  50  per 
cent.,  and  in  Type  IV  12  per  cent.  A  high  degree  of  blood  infection  as  shown 
by  cultures  is  a  bad  omen. 

Death  is  rarely  due  to  direct  interference  with  the  function  of  respira- 
tion, even  in  double  pneumonia.  Sometimes  it  seems  to  be  caused  by  the  ex- 
tensive involvement  with  oedema  of  the  other  parts  of  the  lungs,  an  engorge- 
ment with  progressive  weakness  of  the  right  heart.  But  death  is  most  fre- 
cpicntlv  due  to  the  action  of  the  toxin  on  the  circulation,  with  progressive 
lowering  of  the  blood  pressure. 

Diagnosis. — No  disease  is  more  readily  recognized  in  a  large  majority 
of  the  cases-     The  external  characters,  the  sputum,  and  the  physical  signs 


100  SPECIFIC  INFECTIOUS  DISEASES 

combine  to  make  one  of  the  clearest  of  clinical  pictures.  The  ordinary  lobar 
pneumonia  of  adults  is  rarely  overlooked.  Errors  are  particularly  liable  to 
occur  in  the  intercurrent  pneumonias,  in  those  complicating  chronic  affections, 
and  in  the  disease  as  met  with  in  children,  the  aged,  and  drunkards.  Acute 
pneumonic  tuberculosis  is  frequently  confounded  with  pneumonia.  Pleurisy 
with  effusion  is  not  often  mistaken  except  in  children.  The  diagnostic  points 
will  be  referred  to  under  pleurisy. 

In  diabetes,  nephritis,  chronic  heart-disease,  pulmonary  tuberculosis,  and 
cancer,  an  acute  pneumonia  often  ends  the  scene,  and  is  frequently  over- 
looked. In  these  cases  the  temperature  is  perhaps  the  best  index,  and  should, 
more  particularly  if  cough  occurs,  lead  to  a  careful  examination  of  the  lungs. 
The  absence  of  expectoration  and  of  pulmonary  symptoms  may  make  the  diag- 
nosis very  difficult. 

In  children  there  are  two  special  sources  of  error :  the  disease  may  be 
entirely  masked  by  the  cerebral  symptoms  and  the  case  mistaken  for  one  of 
meningitis.  It  is  remarkable  in  these  cases  how  few  indications  there  are  of 
pulmonary  trouble.  Lumbar  puncture  is  of  great  aid  in  these  cases.  The 
other  condition  is  pleurisy  with  effusion,  which  in  children  often  has  deceptive 
physical  signs.  The  breathing  may  be  intensely  tubular  and  tactile  fremitus 
may  be  present.  The  exploratory  needle  is  sometimes  required  to  decide  the 
question.  In  the  old  and  debilitated  a  knowledge  that  the  onset  of  pneumonia 
is  insidious,  and  that  the  symptoms  are  ill-defined  and  latent,  should  put  the 
practitioner  on  his  guard  and  make  him  very  careful  in  the  examination  of 
the  lungs  in  doubtful  cases.  In  chronic  alcoholism  the  cerebral  symptoms  may 
completely  mask  the  local  process.  As  mentioned,  the  disease  may  assume  the 
form  of  violent  mania,  but  more  commonly  the  symptoms  are  those  of  de- 
lirium tremens.  In  any  case,  rapid  pulse,  rapid  respiration,  and  fever  are 
symptoms  which  should  invariably  excite  suspicion  of  pneulmonia.  The 
acute  signs  due  to  a  foreign  body  in  a  bronchus  are  often  mistaken  for  those 
of  pneumonia. 

Pneumonia  is  rarely  confounded  with  pulmonary  tuberculosis,  but  to  dif- 
ferentiate acute  pneumonic  tuberculosis  is  often  difficult.  The  attack  may 
set  in  with  a  chill.  It  may  be  impossible  to  determine  which  condition  is 
present  until  softening  occurs  and  elastic  tissue  and  tubercle  bacilli  appear  in 
the  sputum.  A  similar  mistake  is  sometimes  made  in  children.  With  typhoid 
fever,  pneumonia  is  not  infrequently  confounded.  There  are  instances  of 
pneumonia  with  the  local  signs  well  marked  in  which  the  patient  rapidly 
sinks  into  what  is  known  as  the  typhoid  state,  with  dry  tongue,  rapid  pulse, 
and  diarrhoea.  Unless  the  case  is  seen  from  the  outset  it  may  be  very  difficult 
to  determine  the  true  nature  of  the  malady.  On  the  other  hand,  there  are 
cases  of  typhoid  fever  which  set  in  with  symptoms  of  lobar  pneumonia — the 
so-called  pneumo-typhus.  It  may  be  impossible  to  make  a  differential  diag- 
nosis in  such  a  case  unless  the  characteristic  eruption  occurs,  a  blood  culture 
is  positive,  or  the  Widal  reaction  is  given. 

Prophylaxis. — We  do  not  know  the  percentage  of  individuals  who  harbor 
the  pneumococcus  normally  in  the  secretions  of  the  mouth  and  throat.  In  a 
great  majority  of  cases  it  is  an  auto-infection,  and  the  lowered  resistance  due 
to  exposure  or  to  alcohol,  or  a  trauma  or  anesthetization,  simply  furnishes  coi> 
ditions  which  favor  the  spread  and  growth  of  an  organism  already  present. 


PNEUMONIAS  AND  PNEUMOCOCCIC  INFECTIONS         101 

Individuals  who  have  already  had  pneumonia  should  be  careful  to  keep  the 
teeth  in  good  condition,  and  the  mouth  and  throat  in  as  healthy  a  state  as 
possible.    Antiseptic  mouth  washes  may  be  used. 

The  experimental  evidence  suggests  that  there  may  be  value  in  vaccines  as 
a  preventive.  When  done  it  should  be  regarded  as  an  experiment  and  careful 
records  kept.     The  question  requires  much  further  study. 

We  know  practically  nothing  of  the  conditions  under  which  the  pneumo- 
coccus  lives  outside  the  body,  or  how  it  gains  entrance  in  healthy  individuals. 
The  sputum  of  each  case  should  be  very  carefully  disinfected.  In  institutions 
the  patients  should  be  isolated. 

Treatment. — Pneumonia  is  a  self-limited  disease  and  even  under  the  most 
unfavorable  circumstances  it  may  terminate  abruptly  and  naturally.  So  also, 
under  the  favoring  circumstances  of  good  nursing  and  careful  diet,  the  ex- 
perience of  many  physicians  in  different  lands  has  shown  that  pneumonia  runs 
its  course  in  a  definite  time,  terminating  sometimes  spontaneously  on  the  third 
or  the  fifth  day,  or  continuing  until  the  tenth  or  twelfth. 

Morgenroth  and  Levy  claim  for  optochin,  a  quinine  derivative,  a  specific 
action  on  the  pneumococcus.  It  has  a  well-marked  protective  action  against 
experimental  infection  in  mice;  encouraging,  but  scarcely  good  enough  re- 
sults to  use  the  term  specific  have  been  reported  clinically.  It  is  given  in 
amounts  of  1.5  gm.  per  day  in  doses  of  0.2  to  0.25  gm.  Over-dosage  is  usually 
manifested  by  disturbances  of  vision. 

(a)  General  Management  of  a  Case. — The  same  careful  hygiene  of  the 
bed  and  of  the  sick-room  should  be  carried  out  as  in  typhoid  fever.  Every- 
thing should  be  done  to  make  the  patient  comfortable  and  to  save  him  exer- 
tion. Whenever  possible  the  patient  should  be  in  the  open  air.  In  cold 
weather  he  should  have  sufficient  covering  to  keep  him  warm,  but  should  not 
be  overburdened  by  a  heavy  weight  of  clothes.  A  blanket  and  rubber  sheet, 
under  the  mattress,  which  can  be  folded  up  over  the  bed  prevent  chilling  from 
below.  A  hot- water  bag  should  be  kept  at  the  feet.  The  patient  is  brought 
indoors  when  necessary  for  hydrotherapy.  For  the  heavy  undershirts  should 
be  substituted  a  thin,  light  flannel  jacket,  open  in  front,  which  enables  the 
physician  to  make  his  examinations  without  unnecessarily  disturbing  the  pa- 
tient. If  the  patient  is  indoors  the  room  should  be  bright  and  light,  letting 
in  the  sunshine  if  possible,  and  thoroughly  well  ventilated.  Only  one  or  two 
persons  should  be  allowed  in  the  room  at  a  time.  Even  when  not  called  for 
on  account  of  the  high  fever,  the  patient  should  be  carefully  sponged  each  day 
with  tepid  water.  This  should  be  done  with  as  little  disturbance  as  possible. 
Special  care  should  be  taken  to  keep  the  mouth  and  nose  clean.  The  giving 
of  an  alkali,  such  as  potassium  citrate  (gr.  xv,  1  gm.  four  times  a  day)  is 
advisable. 

(6)  Diet. — Plain  water,  a  pleasant  table  water,  or  lemonade  should  be 
given  freely.  When  the  patient  is  delirious  the  water  should  be  given  at  fixed 
intervals  and  by  the  bowel  or  subcutaneously  if  it  is  not  taken  by  mouth.  The 
food  should  be  liquid,  consisting  chiefly  of  milk,  either  alone  or,  better,  mixed 
with  food  prepared  from  some  one  of  the  cereals,  and  eggs,  either  soft  boiled 
or  raw.  Carbohydrate,  as  milk  sugar,  can  be  added  to  each  feeding  of  milk, 
and  as  cane  sugar  to  lemonade. 

(c)   Bowels. — At  the  onset  it  is  well  to  give  a  calomel. and  saline  purge. 


102  SPECIFIC  INFECTIOUS  DISEASES 

The  bowels  can  be  kept  open  by  salines  or  enemata.  Drastic  purgation  is  not 
advisable.  It  is  important  to  prevent  meteorism,  if  possible,  by  care  in  the 
diet,  giving  water  freely  and  preventing  constipation.  If  present,  measures 
for  relief  should  be  begun  at  once.  Turpentine  stupes,  turpentine  (§  ss,  15 
c.  c.)  added  to  an  enema,  and  the  use  of  the  rectal  tube,  are  helpful.  Strych- 
nine and  pituitary  extract  hypodermically  are  also  useful.  If  the  stomach  is 
distended  a  stomach  tube  should  be  passed. 

{d)  Bleeding. — The  reproach  of  Van  Helmont,  that  "a  bloody  Moloch 
presides  in  the  chairs  of  medicine,^'  can  not  be  brought  against  this  genera- 
tion of  phj'sicians.  Before  Louis'  iconoclastic  paper  on  bleeding  in  pneumonia 
it  would  have  been  regarded  as  almost  criminal  to  treat  a  case  without  vene- 
section. We  employ  it  much  more  than  we  did  a  few  years  ago,  but  more 
often  late  in  the  disease  than  early.  To  bleed  at  the  very  onset  in  robust, 
healthy  individuals  in  whom  the  disease  sets  in  with  great  intensity  and  high 
fever  is  good  practice.  Late  in  the  course  marked  dilatation  of  the  right 
heart  is  the  common  indication.  The  quantity  of  blood  removed  must  be  de- 
cided by  the  effect;  small  amounts  are  often  sufficient. 

(e)  Antipneumococcic  Serum. — The  value  of  this  method  of  treatment 
is  established  for  Type  I.  The  type  of  infection  must  be  determined.  In 
Type  I,  the  serum  should  be  given  as  soon  as  possible  in  doses  of  50-100  c.  c 
diluted  one  half  with  freshly  prepared  salt  solution.  This  is  repeated  twice 
daily,  four  or  five  doses  usually  being  necessary,  A  rise  in  temperature  indi- 
cates further  dosage.  Immune  bodies  are  found  in  the  blood  after  the  first 
injection  and  remain  if  the  treatment  is  continued.  There  is  no  proof  that 
the  use  of  vaccines  is  of  value  in  treatment. 

(/)  Hydrotheeapy.: — This — internal  and  external — is  our  principal 
means  of  combating  toxfemia  and  circulatory  failure.  Cold  sponging  is 
usually  'the  best  measure,  done  every  three  hours  and  with  the  least  possible 
disturbance  of  the  patient.  With  marked  toxemia  or  hyperpyrexia  a  bath  at 
80°  with  constant  friction  may  be  given  for  five  minutes  if  it  does  not  increase 
distress  or  dyspnoea.  The  application  of  linen  compresses  covered  by  flannel 
is  an  excellent  measure.  They  should  be  cut  to  the  size  of  the  body,  in  the 
shape  of  a  jacket,  with  the  opening  at  one  side  instead  of  in  the  front,  which 
can  be  applied  from  the  side  of  the  body  with  the  patient  turned,  and  fastened 
over  the  other  shoulder  and  in  the  axilla.  They  should  be  wrung  out  of  water 
at  50°  to  60°  and  be  changed  every  hour.  The  compress  should  cover  the 
thorax  and  upper  abdomen.  A  large  flat  ice  bag  may  be  kept  to  the  side  or 
back  constantly,  unless  it  causes  distress.  Probably  the  best  effect  of  hydro- 
therapy is  on  the  vaso-motor  system. 

{g)  Symptomatic  Treatment. —  (1)  To  Believe  the  Pain. — The  stitch  in 
the  side  at  onset,  which  is  sometimes  so  agonizing,  is  best  relieved  by  a  hypo- 
dermic injection  of  morphia  (gr.  I/4,  0.016  gm.).  When  the  pain  is  less  in- 
tense and  diffuse  over  one  side,  the  Paquelin  cautery  applied  lightly  is  very 
helpful,  but  the  ice  bag  is  usually  efficacious.  When  the  disease  is  fairly  es- 
tablished the  pain  is  not,  as  a  rule,  distressing,  except  when  the  patient  coughs, 
and  for  this  codein  (gr.  i/o,  0.03  gm.)  may  be  used,  heroin  (gr.  1/12,  0.005 
gm.),  or  morphia  given  hypodermically  (gr.  1/6,  0.01  gm.),  according  to 
the  patient's  needs.  Hot  poultices  relieve  the  pain,  though  not  more  than  the 
cold  applications.     For  children  they  are  often  preferable. 


PXEUMOXIAS  AXD  PXEUMOCOCCIC  INFECTIONS  103 

(2)  To  Combat  the  Toxcemia. — Abundance  of  water  should  be  given  to 
promote  the  flow  of  urine,  and  saline  subcutaneously  seems  to  act  helpfully  in 
this  way,  but  care  must  be  taken  not  to  give  too  large  an  amount  if  the  circu- 
lation is  failing;  500  c.  c.  is  usually  sufficient.  External  hydrotherapy  should 
be  kept  up  actively.  The  bowels  should  be  kept  freely  open  by  saline  laxa- 
tives. 

(3)  An  all-important  indication  is  to  support  the  circulation.  Hydro- 
therapy and  keeping  the  patient  out  of  doors  are  of  great  value  for  this. 
Mechanical  disturbance,  as  from  meteorism,  should  be  prevented  if  possible. 
Drugs  should  not  be  given  in  any  routine  way  and  not  until  they  are  re- 
quired. Strychnine  is  useful  (also  for  its  effects  on  the  respiratory  centre). 
It  should  be  given  hypodermically  and  in  full  doses  (gr.  1/20,  0.003  gm.,  and 
even  gr.  1/10,  0.006  gm.,  for  short  periods)  every  two  or  three  hours.  x\tropine 
is  useful,  especially  when  there  is  stasis,  and  should  be  given  in  full  doses 
hypodermically.  In  severe  cases  it  is  well  to  begin  the  use  of  digitalis  early 
in  the  form  of  the  tincture  (nx  xv,  1  c.  c.)  three  or  four  times  a  day.  With 
signs  of  weakness  of  the  circulation,  intramuscular  injections  of  one  of  the 
digitalis  preparations  are  advisable.  In  severe  conditions  the  use  of  strophan- 
thus  is  often  more  efficient,  given  as  the  tincture  (nx  xv,  1  c.  c.)  or  strophan- 
thin  (gr.  1/100,  0.0006  gm.)  intramuscularly  or  intravenously.  This  may  be 
repeated  once  in  twelve  or  twenty-four  hours.  For  severe  circulatory  failure, 
camphor  gr.  iii,  0.2  gm.  in  olive  oil,  caffeine  (sodiobenzoate)  gr.  v.  (0.3  gm.), 
or  epinephrine  (nx  xv,  1  c.  c.)  may  be  given  hypodermically.  Pituitary  ex- 
tract (posterior  lobe)  has  been  warmly  recommended.  An  injection  of  hot 
saline  solution  given  high  in  the  bowel  or  a  saline  infusion  is  helpful. 

(4)  Besp)iratory  Tract. — The  most  comfortable  position,  avoidance  of  ex- 
ertion, and  abundance  of  fresh  air  are  important  aids  in  preventing  dyspnoea. 
Pain  should  be  relieved  as  much  as  possible.  The  value  of  the  administration 
of  oxygen  is  doubtful.  If  used,  it  should  be  given  slowly  and  through  a  funnel 
held  over  the  mouth  and  nose.  The  effect  is  the  best  guide  as  to  its  con- 
tinuance. Expectorant  drugs  are  not  indicated  and  often  upset  the  stomach. 
^Yhen  the  cough  is  severe  it  is  well  to  give  sedatives,  of  which  codein  or 
heroin  are  the  best.  Morphia  in  small  doses  may  be  required,  but  these  drugs 
should  be  given  only  when  necessary.  For  oedema  of  the  lungs  digitalis  or 
strophanthup  should  be  given  intramuscularly  and  atropine  (gr.  1/100,  0.0006 
gm.)  and  caffeine  hypodermically.  Venesection  is  advisable  if  the  right 
heart  be  dilated. 

(5)  Nervous  System. — The  patient  with  delirium  should  be  constantly 
watched.  An  ice  bag  to  the  head  and  frequent  ice  packs  or  cold  sponges  are 
useful.  Sleep  is  important  for  every  patient  and  the  need  for  this  is  often 
forgotten.  While  such  drugs  as  the  bromides  and  chloral  hydrate  may  be 
effectual,  it  is  wiser,  as  a  rule,  to  give  morphia  hypodermically  in  a  sufficient 
dose  (gr.  14,  0.016  gm.)  to  secure  rest  and  sleep. 

(6)  Crisis. — As  this  approaches  constant  watch  should  be  kept  for  signs 
of  collapse.  If  sweating  is  profuse  and  the  patient  feeble,  atropine  (gr. 
1/100,  0.0006  gm.)  should  be  given  hypodermically  as  often  as  necessary, 
with  camphor  and  epinephrine. 

(h)  Treatment  of  Complications. — If  the  fever  persists  it  is  im])ort- 
ant  to  look  out  for  pleurisy,  particularly  for  the  empyema.     The  exploratory 


104  SPECIFIC  INFECTIOUS  DISEASES 

needle  should  be  used  if  necessary.  A  sero-fibrinous  effusion  should  be  as- 
pirated, a  purulent  opened  and  drained.  In  a  complicating  pericarditis  with 
a  large  effusion  aspiration  may  be  necessary.  Delayed  resolution  is  a  difficult 
condition  to  treat.  The  use  of  the  X-rays  is  perhaps  the  most  effective  treat- 
ment, but  tuberculosis  should  be  excluded. 

(i)  Convalescence. — The  diet  should  be  increased  as  rapidly  as  possible, 
the  patient  kept  out  of  doors  and  after  an  ordinary  attack  allowed  up  in 
about  a  week.    If  the  heart  has  suffered  rest  should  be  more  prolonged, 

B.     BRONCHO-PNEUMONIA 

(Lohular  Pneumonia,  Capillary  Bronchitis) 

Definition. — A  bacterial  infection  of  the  finer  bronchi  and  their  related 
lobules.  The  process  begins  with  inflammation  of  the  bronchioles  and  smaller 
bronchi,  a  capillary  bronchitis,  which  extends  to  the  alveoli  and  the  whole 
lobule  or  a  group  of  lobules  becomes  filled  with  exudate,  cellular  and  hsenior- 
rhagic  but  distinctly  less  fibrinous  than  in  lobar  pneumonia.     ■ 

Etiology. — Broncho-pneumonia  occurs  either  as  a  primary  or  as  a  sec- 
ondary affection.  The  relative  frequency  in  443  cases  is  thus  given  by  Holt: 
Primary,  without  previous  bronchitis,  154;  secondary  to  bronchitis  of  the 
larger  tubes,  41 ;  to  measles,  89 ;  to  whooping-cough,  66 ;  to  diphtheria,  47 ; 
to  scarlet  fever,  7 ;  to  influenza,  6 ;  to  varicella,  2 ;  to  erysipelas,  2 ;  and  to 
acute  ileo-colitis,  19.  The  proportion  of  primary  to  secondary  forms  as  shown 
in  this  list  is  probably  too  low. 

Primary  acute  broncho-pneumonia,  like  the  lobar  form,  attacks  those 
of  any  age.  The  etiological  factors  are  very  much  those  of  lobar  pneumonia, 
and  probably  the  pneumococcus  is  often  associated  with  it. 

Secondary  broncho-pneumonia  occurs  in  two  great  groups:  (a)  As  a 
sequence  of  the  infectious .  fevers — measles,  diphtheria,  influenza,  whooping- 
cough,  scarlet  fever,  and,  less  frequently  smallpox,  erysipelas,  and  typhoid 
fever.  In  children  it  forms  the  most  serious  complication  of  these  diseases, 
and  in  reality  causes  more  deaths  than  are  due  directly  to  the  fevers.  In  large 
cities  it  ranks  next  in  fatality  to  infantile  diarrhoea.  Following,  as  it  does, 
the  contagious  diseases  which  principally  affect  children,  we  find  that  a  large 
majority  of  cases  occur  during  early  life.  According  to  Morrill's  Boston  sta- 
tistics, it  is  most  fatal  during  the  first  two  years  of  life.  The  number  of  cases 
increases  or  decreases  with  the  prevalence  of  measles,  scarlet  fever,  and  diph- 
theria. It  is  most  prevalent  in  the  winter  and  spring  months.  In  the  febrile 
affections  of  adults  broncho-pneumonia  is  not  very  common.  Thus  in  typhoid 
fever  it  is  not  so  frequent  as  lobar  pneumonia,  though  isolated  areas  of  con- 
solidation at  the  bases  are  by  no  means  rare  in  protracted  cases  of  this  disease. 
In  old  people^it  may  follow  debilitating  causes  of  any  sort,  and  is  met  with 
in  chronic  nephritis  and  various  acute  and  chronic  maladies. 

(h)  In  the  second  division  of  this  affection  are  embraced  the  cases  of 
so-called  aspiration  or  deglutition  pneumonia.  Whenever  the  sensitiveness 
of  the  larynx  is  benumbed,  as  in  the  coma  of  apoplexy  or  uraemia,  minute  par- 
ticles of  food  or  drink  are  allowed  to  pass  the  rima,  and,  reaching  finally  the 
smaller  tubes,  excite  an  intense  inflammation  similar  to  the  vagus  pneumonia 


PNEUMONIAS  AND  PNEUMOCOCCIC  INFECTIONS  105 

which  follows  the  section  of  the  pneumogastrics  in  the  dog.  Cases  are  com- 
mon after  operations  about  the  mouth  and  nose,  after  tracheotomy,  and  in 
cancer  of  the  larynx  and  oesophagus.  The  aspirated  particles  in  some  in- 
stances induce  such  an  intense  broncho-pneumonia  that  suppuration  or  gan- 
grene supervenes.     The  ether  pneumonia  may  be  lobular  in  type. 

An  aspiration  broncho-pneumonia  may  follow  hfemoptysis,  the  aspiration 
of  material  from  a  bronchiectatic  cavity,  and  occasionally  the  material  from 
an  empyema  which  has  ruptured  into  the  lung.  A  common  and  fatal  form  of 
broncho-pneumonia  is  that  excited  by  the  tubercle  bacillus. 

Among  general  predisposing  causes  may  be  mentioned  age.  It  is  prone  to 
attack  infants,  and  a  majority  of  cases  of  pneumonia  in  children  under  five 
years  of  age  are  of  this  form.  Of  370  cases  in  children  under  five  years  of 
age,  75  per  cent,  were  broncho-pneumonia  (Holt).  At  the  opposite  extreme 
of  life  it  is  also  common,  in  association  with  influenza  and  with  various  de- 
bilitating circumstances  and  chronic  diseases.  In  children,  rickets  and  diar- 
rhoea are  marked  predisposing  causes,  and  broncho-pneumonia  is  one  of  the 
most  frequent  post  mortem  lesions  in  infants'  homes  and  foundling  asylums. 
The  disease  prevails  most  extensively  among  the  poorer  classes. 

Morbid  Anatomy. — On  the  pleural  surfaces,  particularly  toward  the  base, 
are  seen  depressed  bluish  or  blue-brown  areas  of  collapse,  between  which  the 
lung  tissue  is  of  a  lighter  color.  Here  and  there  are  projecting  portions  over 
which  the  pleura  may  be  slightly  turbid  or  granular.  The  lung  is  fuller  and 
firmer  than  normal,  and,  though  in  great  part  crepitant,  solid,  nodular  bodies 
can  be  felt  in  places  throughout  the  substance.  The  dark  depressed  areas 
may  be  isolated  or  a  large  section  of  one  lobe  may  be  in  the  condition  of 
collapse.  Gradual  inflation  by  a  blow-pipe  inserted  in  the  bronchus  will  dis- 
tend a  great  majority  of  these  collapsed  areas.  On  section,  the  general  sur- 
face has  a  dark  reddish  color  and  usually  drips  blood.  Projecting  above  the 
level  of  the  section  are  lighter  red  or  reddish-gray  areas  representing  the 
patches  of  broncho-pneumonia.  These  may  be  isolated  and  separated  from 
each  other  by  tracts  of  uninflamed  tissue  or  they  may  be  in  groups;  or  the 
greater  part  of  a  lobe  may  be  involved.  Study  of  a  favorable  section  of  an 
isolated  patch  shows:  {a)  A  dilated  central  bronchiole  full  of  tenacious 
purulent  mucus.  A  fortunate  section  parallel  to  the  long  axis  may  show  a 
racemose  arrangement — the  alveolar  passages  full  of  muco-pus.  {h)  Sur- 
■  rounding  the  bronchus  for  from  3  to  5  mm.  or  even  more,  an  area  of  grayish- 
red  consolidation,  usually  elevated  above  the. surface  and  firm  to  the  touch. 
It  may  present  a  perfectly  smooth  surface,  though  in  some  instances  it  is 
distinctly  granular.  In  a  late  stage  small  grayish-white  poiiits  may  be  seen, 
which  on  pressure  may  be  scjueczed  out  as  purulent  droplets.  A  section  in 
the  axis  of  the  lobule  may  present  a  somewhat  grape-like  arrangement,  the 
stalks  and  stems  representing  the  bronchioles  and  alveolar  passages  filled  with 
a  yellowish  or  grayish-white  pus,  while  surrounding  them  is  a  reddish-brown 
hepatized  tissue,  (c)  In  the  immediate  neighborhood  of  this  peribronchial 
inflammation  the  tissue  is  dark  in  color,  smooth,  airless,  at  a  somewhat  lower 
level  than  the  hepatized  portion,  and  ditt'ers  distinctly  in  color  and  appearance 
from  the  other  portions  of  the  lung.  This  is  the  condition  to  which  the  term 
splenization  has  been  given.    It  really  represents  a  tissue  in  the  early  stage  of 


106  SPECIFIC  INFECTIOUS  DISEASES 

inflammation,  and  it  would  be  well  to  give  up  the  use  of  this  term  and  also 
that  of  carnifi cation,  which  is  only  a  more  advanced  stage. 

There  are  three  groups  of  cases:  (1)  Those  in  which  the  bronchitis  and 
bronchiolitis  are  most  marked,  and  in  which  there  may  be  no  definite  consoli- 
dation, and  yet  on  microscopic  examination  many  of  the  alveolar  passages  and 
adjacent  air-cells  appear  filled  with  inflammatory  products.  (2)  The  dissemi- 
nated broncho-pneumonia,  in  which  there  are  scattered  areas  of  peribronchial 
hepatization  with  patches  of  collapse,  while  a  considerable  proportion  of  the 
lobe  is  still  crepitant.  This  is  by  far  the  most  common  condition.  (3)  The 
pseudo-lobar  form,  in  which  the  greater  portion  of  the  lobe  is  consolidated, 
but  not  uniformly,  for  intervening  strands  of  dark  congested  lung  tissue  sep- 
arate the  groups  of  hepatized  lobules. 

Microscopically,  the  centre  of  the  bronchus  is  seen  filled  with  a  plug  of 
exudation,  consisting  of  leucocytes  and  swollen  epithelium.  Section  in  the 
long  axis  may  show  irregular  dilatations  of  the  tube.  The  bronchial  wall  is 
swollen  and  infiltrated  with  cells.  The  air-cells  next  the  bronchus  are  mostly 
densely -filled,  while  toward  the  periphery  the  alveolar  exudation  becomes  less. 
The  contents  of  the  air-cells  are  made  up  of  leucocytes  and  swollen  epithelial 
cells  in  varying  proportions.  Eed  corpuscles  are  not  often  present  and  a  fibrin 
network  is  rarely  seen,  though  it  may  be  present  in  some  alveoli.  In  the 
swollen  walls  are  seen  distended  capillaries  and  numerous  leucocytes.  As 
Delafield  pointed  out,  the  interstitial  inflammation  of  the  bronchi  and  alveolar 
walls  is  the  special  feature  of  broncho-pneumonia. 

The  histological  changes  in  the  aspiration  or  deglutition  broncho-pneu- 
monia difl^er  from  the  ordinary  post-febrile  form  in  a  more  intense  infiltra- 
tion of  the  air-cells  Avith  leucocytes,  producing  suppuration  and  foci  of  soften- 
ing; even  gangrene  may  be  present. 

Bacteriology. — The  organisms  most  commonly  found  in  broncho-pneumo- 
nia are  the  pneumococcus.  Streptococcus  pyogenes  (either  alone  or  with  the 
pneumococcus),  Staphylococcus  aureus  et  albus,  Friedlander's  Bacillus  pneu- 
monice,  and  the  influenza  bacillus.  The  Klebs-Loeftler  bacillus  is  not  infre- 
quently found  in  the  secondary  lesions  of  diphtheria.  Except  the  pneu- 
mococcus these  microbes  are  rarely  found  in  pure  cultures.  In  the  lobular 
type  the  streptococcus  is  the  most  constant  organism,  in  the  pseudo-lobar  the 
pneumococcus.     Mixed  infections  are  almost  the  rule  in  broncho-pneumonia. 

Terminations  of  Broncho-pneumonia.— (a)  In  resolution,  which  when  it 
once  begins  goes  on  more  rapidly  than  in  fibrinous  pneumonia.  Broncho- 
pneumonia of  the  apices,  in  a  child,  persisting  for  three  or  more  weeks,  par- 
ticularly if  it  follow  measles  or  diphtheria,  is  often  tuberculous.  In  these  in- 
stances, when  resolution  is  supposed  to  be  delayed,  caseation  has  in  reality 
taken  place.  (5)  In  suppuration,  which  is  rarely  seen  apart  from  the  aspira- 
tion and  deglutition  forms,  in  which  it  is  extremely  common,  (c)  In  gan- 
grene, which  occurs  under  the  same  conditions,  {d)  In  fibroid  changes — 
chronic  hronclio-pneumonia — a  rare  termination  in  the  simple,  a  common 
sequence  of  the  tuberculous,  disease.  '  Formerly  it  was  thought  that  one  of 
the  most  common  changes  in  broncho-pneumonia,  particularly  in  children,  was 
caseation,  but  this  is  really  a  tuberculous  process,  the  natural  termination  of 
an  originally  specific  broncho-pneumonia. 

Symptoms. — The  primary  form  sets  in  abruptly  with  a  chill  or  a  con- 


PNEUMONIAS  AND  PNEUMOCOCCIC  INFECTIONS  107 

vulsion.  The  patient  has  not  had  a  previous  ilhiess,  but  there  may  have  been 
slight  exposure.  The  temperature  rises  rapidly  and  is  more  constant;  the 
physical  signs  are  more  local  and  there  is  not  the  widespread  diffuse  catarrh  of 
the  smaller  tubes.  Many  cases  are  mistaken  for  lobar  pneumonia.  In  others 
the  pulmonary  features  are  in  the  background  or  are  overlooked  in  the  in- 
tensity of  the  general  or  cerebral  symptoms.  The  termination  is  often  by 
crisis,  and  the  recovery  is  prompt.  The  mortality  of  this  form  is  slight.  S. 
West  has  called  attention  to  the  importance  of  recognizing  these  primary 
cases  and  to  their  resemblance  in  clinical  features  to  acute  lobar  pneumonia. 
The  secondary  form  begins  usually  as  a  bronchitis  of  the  smaller  tubes.  Much 
confusion  has  arisen  from  the  description  of  capillary  bronchitis  as  a  separate 
aifection,  whereas  it  is  only  a  part,  though  a  primary  and  important  one,  of 
broncho-pneumonia.  At  the  outset  it  may  be  said  that  if  in  convalescence 
from  measles  or  whooping-cough  a  child  has  an  accession  of  fever  with  cough, 
rapid  pulse,  and  rapid  breathing,  and  if,  on  auscultation,  fine  rales  are  heard 
at  the  bases,  or  widely  spread  throughout  the  lungs,  even  though  neither  con- 
solidation nor  blowing  breathing  can  be  detected,  the  diagnosis  of  broncho- 
pneumonia may  safely  be  made.  We  have  never  seen  in  a  fatal  case  after 
diphtheria  or  measles  a  capillary  bronchitis  as  the  sole  lesion.  The  onset  is 
rarely  sudden,  or  with  a  distinct  chill;  but  after  a  day  or  so  of  indisposition 
the  child  becomes  feverish  and  begins  to  cough  and  be  short  of  breath.  The 
fever  is  extremely  variable;  a  range  of  from  102°  to  104°  F.  is  common.  The 
skin  is  very  dry  and  hot.  The  cough  is  hard,  distressing,  and  may  be  painful. 
Dyspnoea  gradually  becomes  a  prominent  feature.  Expiration  may  be  jerky 
and  grunting.  The  respirations  may  rise  as  high  as  60  or  even  80  per  minute. 
Within  the  first  forty-eight  hours  the  percussion  resonance  is  not  impaired; 
the  note,  indeed,  may  be  very  full  at  the  anterior  borders  of  the  lungs.  On 
auscultation,  many  rales  are  heard,  chiefly  the  fine  subcrepitant  variety,  with 
sibilant  rhonchi.  There  may  really  be  no  signs  indicating  that  the  parenchyma 
of  the  lung  is  involved,  and  yet  ev'en  at  this  early  stage,  within  forty-eight 
hours  of  the  onset  of  the  pulmonary  symptoms,  scattered  nodules  of  lobular 
hepatization  may  be  found.  Northrup,  in  a  case  in  which  death  occurred 
within  the  first  twenty-four  hours,  in  addition  to  the  extensive  involvement 
of  the  smaller  bronchi,  found  the  intralobular  tissue  also  involved  in  places. 
The  dyspnoea  is  constant  and  progressive  and  soon  signs  of  deficient  aeration 
of  the  blood  are  noted.  The  face  becomes  a  little  suffused  and  the  finger-tips 
bluish.  The  patient  has  an  anxious  expression  and  gradually  enters  upon 
the  most  distressing  stage  of  asphyxia.  At  first  the  urgency  of  the  symptoms 
is  marked,  but  soon  the  influence  of  the  toxins  is  seen  and  there  are  no  longer 
strenuous  efforts  to  breathe.  The  cough  subsides,  and,  with  a  gradual  increase 
in  lividity  and  a  drowsy  restlessness,  the  right  ventricle  becomes  more  and 
more  distended,  the  bronchial  rales  become  more  liquid  as  the  tubes  fill  with 
mucus,  and  death  follows.  These  are  symptoms  of  a  severe  case  of  broncho- 
pneumonia, or  what  the  older  writers  called  suffocative  caiarrli. 

The  PHYSICAL  SIGNS  may  at  first  be  those  of  capillary  bronchitis,  as  indi- 
cated by  the  absence  of  dulness  and  the  presence  of  fine  subcrepitant  and 
whistling  rales.  In  many  cases  death  takes  place  before  any  definite  pneu- 
monic signs  are  detected.  When  these  exist  they  are  much  more  frequent  at 
the  bases,  where  there  may  be  areas  of  impaired  resonance  or  even  of  positive 


108  SPECIFIC  mFECTIOUS  DISEASES 

(liilness.  When  numerous  foci  involve  the  greater  part  of  a  lobe  the  breath- 
ing may  become  tubular,  but  in  the  scattered  patches  of  ordinary  broncho-pneu- 
monia, following  the  fevers,  the  breathing  is  more  commonly  harsh  than 
blowing.  In  grave  cases  there  is  retraction  of  the  base  of  the  sternum  and 
of  the  lower  costal  cartilages  during  inspiration,  pointing  to  deficient  lung 
expansion.  There  is  a  group  in  which  an  area  of  consolidation  at  the  base 
may  persist  for  some  time,  weeks  or  months. 

Diag^nosis. — With  lobar  pneumonia  it  may  readily  1)e  confounded  if  the 
areas  of  consolidation  are  large  and  merged  together.  It  is  to  be  remembered, 
as  Holt's  figures  well  show,  that  in  children  broncho-pneumonia  occurs  chiefly 
under"  one  year,  whereas  lobar  pneumonia  is  more  common  after  the  third  year. 
Xo  writer  has  so  clearly  brought  out  the  difference  between  pneumonia  at 
these  periods  as  Gerhard,*  of  Philadelphia,  whose  papers  on  this  subject  have 
the  freshness  and  accuracy  which  characterized  all  the  writings  of  that  emi- 
nent physician.  Between  lobar  pneumonia  and  the  secondary  form  of  broncho- 
pneumonia the  diagnosis  is  eas}'.  The  mode  of  onset  is  essentially  different 
in  the  two  infections,  the  one  developing  insidiously  in  the  course  or  at  the 
conclusion  of  another  disease,  the  other  setting  in  abruptly  in  a  person  in 
good  health.  In  lobar  pneumonia  the  disease  is  usually  unilateral,  in  broncho- 
pneumonia bilateral.  The  chief  trouble  arises  in  cases  of  primary  broncho- 
pneumonia, -v^hich  by  aggregation  of  the  foci  involves  the  greater  part  of  one 
lobe.  Here  the  difficulty  is  very  great,  and  the  physical  signs  may  be  prac- 
tically identical,  but  in  broncho-pneumonia  it  is  much  more  likely  that  a  lesion, 
however  slight,  will  be  found  on  the  other  side.  In  children  the  signs  caused 
by  a  foreign  body  in  a  bronchus,  especially  a  peanut,  may  be  mistaken  for 
those  of  broncho-pneumonia. 

A  still  more  difficult  question  to  decide  is  whether  an  existing  broncho- 
pneumonia is  simple  or  tuberculous.  In  many  instances  the  decision  cannot 
be  made,  as  the  circumstances  under  which  the  disease  occurs,  the  mode  of 
onset,  and  the  physical  signs  may  be  identical.  A  case  may  be  sent  down  from 
the  children's  ward  to  the  dead  house  with  the  diagnosis  of  broncho-pneumonia 
in  which  there  was  no  suspicion  of  the  existence  of  tuberculosis;  but  the  sec- 
tion shows  tuberculous  bronchial  glands  and  scattered  areas  of  broncho-pneu- 
monia, some  of  which  are  distinctly  caseous,  while  others  show  signs  of  soft- 
ening. It  is  well  to  emphasize  the  fact  that  there  are  many  cases  of  broncho- 
pneumonia which  time  alone  enables  us  to  distinguish  from  tuberculosis.  The 
existence  of  extensive  disease  at  the  apices  or  central  regions  is  a  suggestive 
indication,  and  signs  of  softening  may  be  detected.  In  the  vomited  matter, 
which  is  brought  up  after  severe  spells  of  coughing,  sputum  may  be  picked 
out  and  elastic  tissue  and  tubercle  bacilli  detected. 

It  must  not  be  forgotten  that,  as  in  lobar  pneumonia,  cerebral  symptoms 
may  mask  the  true  nature  of  the  disease,  and  may  even  lead  to  the  diagiiosis 
of  meningitis.  Without  an  autopsy  it  may  not  be  possible  to  determine 
whether  the  infant  had  tuberculous  meningitis  or  a  cerebral  complication  of 
an  acute  pulmonary  affection. 

Prognosis. — In  the  primary  form  the  outlook  is  good.  In  children  en- 
feebled by  constitutional  disease  and  prolonged  fevers  broncho-pneumonia  is 

*  American   Journal  of  Medical   Sciences,  vols,  xiv    and  xv. 


PNEUMONIAS  AND  PNEUMOCOCCIC  INFECTIONS  109 

terribly  fatal,  bnt  in  cases  coming  on  in  connection  with  whooping-cough  or 
after  measles  recovery  may  take  place  in  the  most  desperate  cases.  It  is  in 
this  disease  that  the  truth  of  the  old  maxim  is  shown — "Never  despair  of  a 
sick  child."  The  death  rate  in  children  under  five  has  been  variously  esti- 
mated at  from  30  to  50  per  cent.  After  di^jhtheria  and  measles  thin,  wiry 
children  seem  to  stand  broncho-pneumonia  much  better  than  fat,  flabby  ones. 
In  adults  the  aspiration  or  deglutition  pneumonia  is  a  very  fatal  disease. 

Prophylaxis. — Much  can  be  done  to  reduce  the  probability  of  attack  after 
febrile  affections.  Thus,  in  the  convalescence  from  measles  and  whooping- 
cough,  it  is  very  important  that  the  child  should  not  be  exposed  to  cold,  par- 
ticularly at  night,  when  the  temperature  of  the  room  naturally  falls.  The 
use  of  light  flannel  "combinations"  obviates  this  nocturnal  chill,  which  is  an 
important  factor  in  the  colds  and  pulmonary  affections  of  young  children. 
The  catarrhal  troubles  of.  the  nose  and  throat  should  be  carefully  attended  to, 
and  during  fevers  the  mouth  should  be  washed  two  or  three  times  a  day 
with  an  antiseptic  solution. 

Treatment. — The  frequency  and  the  seriousness  of  broncho-pneumonia 
render  it  a  disease  which  taxes  to  the  utmost  the  resources  of  the  practitioner. 
There  is  no  acute  pulmonary  affection  over  which  be  at  times  so  greatly 
despairs.  On  the  other  hand,  there  is  not  one  in  which  he  will  be  more 
gratified  in  saving  patients  who  have  seemed  past  ail  succor.  The  general 
measures  are  much  as  in  lobar  pneumonia.  The  patient  should  be  m  the  open 
air  if  a  trial  shows  that  he  is  more  comfortable  than  inside;  if  indoors,  the 
windows  should  be  wide  open  with  the  patient  protected  from  drafts. 

(a)  Diet. — As  much  food  as  possible  should  be  given.  Milk  and  its 
modifications,  ice  cream,  eggs,  broths,  cocoa,  and  gruels  are  suitable.  Water 
should  be  given  freely  by  mouth  and  if  this  is  not  possible  by  the  bowel  or 
subcutaneously.  The  boivels  should  be  opened  by  castor  oil  or  calomel  and 
care  taken  to  secure  a  daily  movement. 

(b)  Hydrothekapy. — This  maybe  given  by  various  methods  to  be  chosen 
for  each  patient,  depending  on  the  condition  and  results.  Sponges  may  be 
given  to  any  patient.  Packs  are  useful,  hot  if  there  is  much  restlessness  or 
cold  if  the  temperature  is  high,  or  baths  may  be  given  to  children  for  short 
periods,  using  water  at  95°  F.  and  gradually  reducing  to  75°  or  80°  F.  Com- 
presses, made  out  of  linen  covered  by  flannel  or  of  flannel  alone,  wrung  out 
of  water  60°  to  70°,  are  often  useful.  They  should  not  be  covered  by  oiled 
silk.  A  mustard  bath  is  of  value  for  children,  especially  early  in  the  attack. 
Hydrotherapy  is  especially  indicated  for  patients  with  high  fever,  deliri\un  or 
stupor,  severe  toxaemia,  or  circulatory  failure. 

(c)  Local  Applications. — Poultices  have  gone  out  of  fashion  but  an- 
sometimes  of  value.  They  should  be  light  and  are  best  kept  in  place  by  being 
slipped  in  pockets  in  a  flannel  jacket  which  is  constantly  worn  so  tlial  Ibc 
poultice  can  be  replaced  without  disturbing  the  patient.  The  use  of  dry 
cups  is  often  advised;  they  should  Ijc  applied  frequently.  The  ice  bag  should 
be  used  if  it  gives  comfort. 

(c?)  Medicinal.— -The  indications  must  be  carefully  studied  and  drugs 
which  may  disturb  the  stomach  given  witb  care.  If  congli  is  distressing  the 
use  of  the  compound  tincture  of  benzoin  in  an  inbalation  sliould  be  tried. 
The  expectorant  drugs  may  aid  and  ot'  tbese  aniniuniuni  chloride  (gr.  ii  to  v, 


110  SPECIFIC  INFECTIOUS  DISEASES 

0.13  to  0.3  gm.)  and  the  wine  of  ipecacuanha  (iTL  x  to  xx,  0.6  to  1.3  c.  c.)  are 
the  most  useful.  To  these  a  sedative,  such  as  paregoric  (5  i,  4  c.  c),  codein 
(gr.  ^,  0,016  gm.)  or  heroin  (gr.  1-20,  0.0032  gm.)  should  be  added  if  the 
cough  is  very  distressing.  Str3-chnine  hypodermically  (gr.  1-40  to  1-20,  0.0016 
to  0.0032  gm.)  is  an  aid  to  the  respiratory  centre  and  to  the  circulation.  For 
circulatory  failure  the  treatment  is  the  same  as  described  under  lobar  pneu- 
monia. AYith  increasing  difficulty  in  getting  up  the  secretions  an  emetic  may 
be  given,  but  only  to  robust  patients.  Ipecacuanha  or  apomorphine  hypoder- 
mically should  be  employed.  Inhalations  of  oxygen  are  advisable  if  they  give 
relief  to  the  dyspnoea  and  lessen  cyanosis. 

In  old  persons  early  stimulation  is  usually  advisable  and  every  effort 
should  be  made  to  persuade  them  to  take  nourishment.  Cold  applications 
must  be  used  "with  caution  and  the  use  of  heat  is  generally  better.  At  all  ages 
frequent  change  in  position  is  advisable  and  in  young  children  this  may  be 
done  by  taking  them  out  of  bed  and  holding  them  in  the  arms. 

C.     OTHER  PXEUMOCOCCIC  INFECTIONS 

The  organism  is  widely  distributed  and  causes  a  number  of  affections 
other  than  pulmonary,  of  which  the  following  are  the  most  important : 

1.  Acute  Septicsemia. — Without  any  recognized  local  lesion  there  may 
be  a  general  infection  with  the  pneumococcus.  In  Townsend's  case,  a  girl, 
aged  six,  had  pain  in  the  abdomen,  vomiting  and  a  temperature  of  104.2°  F. 
without  any  throat  affection.  Death  occurred  in  thirty  hours,  and  a  general 
infection  with  the  organism  was  found  in  the  blood,  spleen,  lungs  and  kidneys. 

2.  Local  Affections. — The  local  affections  caused  by  the  pneumococcus  are 
very  numerous  and  will  be  described  under  their  appropriate  sections.  In  the 
moidli,  erosions,  gingivitis  .and  glossitis;  in  the  pharynx,  inflammation  and 
tonsillitis;  in  the  ear,  acute  and  chronic  suppuration;  in  the  accessory  sinuses, 
of  which  it  is  a  common  habitant,  inflammation  and  suppuration;  in  the 
membrane  of  the  brain  it  is  a  common  cause  of  primary  and  secondary 
meningitis ;  in  the  bronchi  it  has  been  found  associated  with  acute  and  chronic 
bronchitis,  and  bronchiectasis;  in  the  lungs,  in  addition  to  the  two  impor- 
tant diseases  alread}^  considered,  it  may  cause  acute  oedema  and  is  associated 
with  tuberculosis  and  many  chronic  affections.  It  has  been  found  in  acute 
pleurisy  and  it  is  one  of  the  common  causes  of  empyema ;  acute  arthritis, 
primary'  and  secondary  forms ;  acute  peritonitis,  particidarly  in  children ; 
appendicitis;  endocarditis;  pyelitis  and  local  abscesses  in  various  23arts  may 
be  caused  by  it. 

IX.     CEREBRO-SPINAL  FEVER 

Definition. — An  infectious  disease,  occurring  sporadically  and  in  epidem- 
ics, caused  by  the  Meningococcus,  characterized  by  inflammation  of  the 
cerebro-spinal  meninges  and  a  clinical  'course  of  great  irregularity. 

The  affection  is  also  known  by  the  names  of  malignant  purpuric  fever, 
petechial  fever,  spotted  fever  and  epidemic  cerebro-spinal  meningitis. 

History. — Yieusseux  first  described  a  small  outbreak  in  Geneva  in  1805. 
In  1806  L.  Danielson  and  E.  Mann  (Medical  and  Agricultural  Eegister,  Bos- 


CEEEBRO-SPmAL    FEVER  111 

ton)  gave  an  account  of  "a  singular  and  very  mortal  disease  which  lately 
made  its  appearance  in  Medfield,  Mass.'^  The  Massachusetts  Medical  Society, 
in  1809,  appointed  James  Jackson,  Thomas  Welch,  and  J.  C.  AA'arren  to 
investigate  it.  Elisha  Xorth's  little  book  (1811)  gives  a  full  account  of  the 
early  epidemics.  Stille's  monograph  (18G7)  and  the  elaborate  section  in  vol.  i 
of  Joseph  Jones'  works  contain  details  of  the  later  American  outbreaks.  In 
his  Geographical  Pathology,  Hirsch  divides  the  outbreaks  into  four  periods : 
From  1805  to  1830,  in  which  the  disease  was  most  prevalent  throughout 
the  United  States;  a  second  period,  from  1837  to  1850,  when  the  disease 
prevailed  extensively  in  France,  and  there  were  a  few  outbreaks  in  the 
United  States;  a  third  period,  from  1854  to  1874,  when  there  were  out- 
breaks in  Europe  and  several  extensive  epidemics  in  Amerit?a.  During  the 
Civil  War  there  were  comparatively  few  cases.  It  prevailed  extensively 
in  the  Ottawa  A-'alley  early  in  the  seventies.  In  the  fourth  period,  from  1875 
to  the  present  time,  the  disease  has  broken  out  in  a  great  many  regions. 
In  the  United  States,  during  1898-1899,  it  prevailed  in  mild  form  in  27 
states.  Since  1899  there  have  been  extensive  outbreaks  in  the  cities  of  the 
United  States  on  the  Atlantic  coast.  In  New  York  in  1904-5  there  were 
6,755  cases  and  3,455  deaths.  In  Glasgow  in  1907  there  were  nearly  1,000 
cases  with  595  deaths  (Chalmers).  In  Belfast  in  the  eighteen  months 
ending  June,  1908,  there  were  725  cases  with  548  deaths  (Eobb).  There  were 
1,974  deaths  in  England  and  Wales  in  1915,  the  average  for  the  five  years 
before  being  153.  In  the  winter  of  1914-15  the  disease  appeared  among  the 
Canadian  troops  and  was  carried  by  them  to  England.  It  broke  out  in 
many  home  camps  and,  spreading  to  the  civil  population,  for  the  first  time 
in  its  history  the  disease  prevailed  widely  in  England. 

Etiology. — Cerebro-spinal  fever  occurs  in  epidemic  and  in  sporadic  forms. 
The  epidemics  are  localized  and  are  rarety  very  widespread.  Only  in  the 
tropics  have  th-ere  been  extensive  killing  pandemics.  As  a  rule,  country  dis- 
tricts have  been  more  afflicted  than'  cities.  Mining  districts  and  seaports 
have  suffered  most  severely.  The  outbreaks  have  occurred  most  frequently 
in  the  winter  and  spring.  The  concentration  of  individuals,  as  of  troops  in 
barracks,  is  a  special  factor;  recruits  and  young  soldiers  are  specially  liable. 
In  civil  life  children  and  young  adults  are  most  susceptible.  Over-exertion, 
long  marches  in  the  heat,  depressing  mental  and  bodily  surroundings,  and 
the  misery  and  squalor  of  the  large  tenement  houses  in  cities  are  pre- 
disposing causes.  The  disease  is  not  highly  infectious.  It  is  ver}''  rare  to 
have  more  than  one  or  two  cases  in  a  house,  and  in  a  city  epidemic  the  dis- 
tribution of  the  cases  is  very  irregular.  The  organism  enters  and  leaves  the 
body  by  the  naso-pharnygeal  mucous  membrane,  and  hence  infection  may  be 
Ijy  contact  or  by  coughing  and  sneezing.  Meningitis  carriers  play  an  impor- 
tant role  in  transmitting  the  disease.  They  are  found  also  when  the  disease 
is  not  epidemic. 

Sporadic  cerehro-spinal  fever. — The  disease  lingers  indefinitely  after  an 
outbreak,  and  in  all  large  cities  cases  occur.  There  are  two  types,  one  the 
posterior  basic  meningitis  of  Gee  and  Barlow  and  the  other  the  meningococ- 
cus meningitis  of  young  adults  met  with  in  periods  during  which  the  disease 
is  not  specially  prevalent;  two,  tlirce,  and  even  five  cases  may  occur  in  succes- 
sion  in   one   family.      The  meningitis   in   children,  known   as  the  simple   or 


112  SPECIFIC  IXFECTIOUS  DISEASES 

posterior  basic,  is  the  sporadic  form.  Still  determined  the  identity  of  the 
organism  with  tlie  meningococcus,  and  the  view  has  been  confirmed  by  Koplik 
and  many  otliers. 

Bacteriolo^. — In  1877  Weichselbaum  described  the  meningococcus  or 
Diplococcus  intra ceUularis  meningitidis.  In  the  tissues  the  organism  is  al- 
most constantly  within  the  jDolynuclear  leucocytes.  Investigations  have  shown 
that  there  are  two  fixed  types^  and  others  which  are  less  fixed,  distinguishable 
from  one  another  by  immune  reactions.  They  are  comparable  to  the  different 
types  of  pneumococci  causing  pneumonia  (Ellis).  The  type  of  organism  in  the 
cerebro-spinal  fluid  is  the  same  as  in  the  naso-pharynx  and  apparently  if 
one  variet}'  infects  the  mucous  membrane  it  is  not  likely  that  another  will 
be  superimposed  on  it.  The  use  of  agglutination  tests  has  been  of  great 
value  in  identifying  the  organism.  The  occurrence  of  the  organism  in  the 
blood  before  the  signs  of  meningitis  appear  has  been  specially  emphasized 
by  Herrick.  Three  imj)ortant  facts  have  been  brought  out — the  presence  of 
the  germ  in  many  cases  in  the  naso-pharynx,  the  existence  of  it  in  healthy 
contacts,  and  the  preparation  of  a  curative  serum. 

Morbid  Anatomy. — In  malignant  cases  there  may  be  no  characteristic 
fhanges,  the  brain  and  spinal  cord  showing  only  extreme  congestion,  which 
was  the  lesion  described  by  Vieusseux.  In  a  majority  of  the  acutely  fatal 
cases  death  occurs  within  the  first  week.  There  is  intense  injection  of  the 
pia-arachnoid.  The  exudate  is  usually  fibrino-purulent,  most  marked  at 
the  base  of  the  brain,  where  the  meninges  may- be  greatly  thickened  and  plas- 
tered over  with  it.  On  the  cortex  there  niay  be  much  lymph  along  the  larger 
fissures  and  in  the  sulci;  sometimes  the  entire  cortex  is  covered  with  a  thick, 
purulent  exudate.  It  deserves  to  be  recorded  that  Danielson  and  Mann 
made  five  autopsies  and  were  the  first  to  describe  "a  fluid  resembling  pus 
between  the  dura  and  pia  mater."  The  cord  is  always  involved  with  the 
brain^  The  exudate  is  more  abundant  on  the  posterior  surface,  and  involves, 
as  a  rule,  the  dorsal  and  lumbar  regions  more  than  the  cervical  portion. 

In  the  more  chronic  cases  there  is  general  thickening  of  the  meninges 
and  scattered  yellow  patches  mark  where  the  exudate  has  been.  The  ven- 
tricles in  the  acute  cases  are  dilated  and  contain  a  turbid  fluid,  or  in  the 
posterior  cornua  pure  pus.  In  the  chronic  cases  the  dilatation  may  be  very 
great.  The  brain  substance  is  usually  a  little  softer  than  normal  and  has  a 
pinkish  tinge;  foci  of  ha?morrhage  and  of  encephalitis  may  be  found.  The 
cranial  nerves  are  usually  involved,  particularly  the  second,  fifth,  seventh, 
and  eighth.    The  spinal  nerve  roots  are  also  found  imbedded  in  the  exudate. 

Microscopically,  the  exudate  consists  largely  of  polynuclear  leucocytes 
closely  packed  in  a  fibrinous  material.  In  some  instances  there  are  foci  of 
purulent  infiltration  and  hemorrhage.  The  neuroglia  cells  are  swollen, 
with  large,  clear,  and  vesicular  nuclei.  The  ganglion  cells  show  less  marked 
changes.  Diplococci  are  found  in  variable  numbers  in  the  exudate,  being 
more  numerous  in  the  brain  than  in  the  cord. 

The  nasal  secretion  during  life  may  show  diplococci.  The  sphenoidal 
sinuses  may  be  full  of  pus  and  the  surrounding  bone  inflamed.  The  fre- 
quency of  catarrhal  and  other .  changes  in  the  naso-pharynx  and  sinuses  sug- 
gests that  the  infection  reaches  the  meninges  through  this  route. 

Pneumonia  and  pleurisy  have  been  described  in  the  disease.     Councilman 


CEEEBRO-SPINAL    FEVER  113 

reports  that  in  13  cases  there  was  congestion  witli  oedema,  in  7  broncho- 
pneumonia, in  2  characteristic  croupous  pneumonia  with  pneumococci;  in  8 
pneumonia  due  to  tlie  meningococcus  was  present. 

The  spleen  varies  a  good  deal  in  size.  In  only  three  of  the  Boston  fatal 
cases  was  it  much  enlarged.  The  liver  is  rarely  abnormal.  Acute  nephritis 
may  be  present.     The  intestines  sometimes  show  swelling  of  the  follicles. 

Symptoms. — Cases  differ  remarkably  in  their  characters.  Many  different 
forms  have  been  described.  These  are  perhaps  best  grouped  into  three 
classes : 

{a)  Maligxaxt  For:m. — This  fulminant  or  apoplectic  type  is  found  with 
variable  frequency  in  epidemics.  It  may  occur  sporadically.  The'  onset  is 
sudden,  usually  with  violent  chills,  headache,  somnolence,  spasms  in  the  mus- 
cles, great  depression,  moderate  elevation  of  temperature,  and  feeble  pulse, 
which  may  fall  to  fifty  or  sixty  in  the  minute.  Usually  a  purpuric  rash 
develops.  In  a  Philadelphia  case,  in  1888,  a  young  girl,  apparently  quite 
well,  died  within  twenty  hours  of  this  form.  There  are  cases  on  record  in 
Avhich  death  has  occurred  within  a  shorter  time.  Stille  tells  of  a  child 
of  five  years,  in  whom  death  occurred  after  an  illness  of  ten  hours;  and 
refers  to  a  case  reported  by  Gordon,  in  which  the  entire  duration  of  the 
illness  was  only  five  hours.  Two  of  A^ieusseux's  cases  died  within  twenty-four 
hours. 

(5)  Oedinaet  Form. — The  stage  of  incubation  is  not  known.  The  disease 
usvially  sets  in  suddenly.  There  may  be  premonitory  symptoms :  headache, 
pains  in  the  back,  and  loss  of  appetite.  More  commonly,  the  onset  is  M'ith 
headache,  severe  chill,  and  vomiting.  The  temperature  rises  to  101°  or  102°. 
The  pulse  is  full  and  strong.  An  early  and  important  symptom  is  a  painful 
stiffness  of  the  muscles  of  the  neck.  The  headache  increases,  and  there  are 
photophobia  and  great  sensitiveness  to  noises.  Children  become  very  irrit- 
able and  restless.  In  severe  cases  the  contraction  of  the  muscles  of  the  neck 
sets  in  early,  the  head  is  drawn  back,  and  when  the  muscles  of  the  back 
are  also  involved,  there  is  orthotonos,  which  is  more  common  than  opisthotonos. 
The  pains  in  the  back  and  in  the  limbs  may  be  very  severe.  The  motor 
symptoms  are  most  characteristic.  Tremor  of  the  muscles  may  be  present, 
with  tonic  or  clonic  spasms  in  the  arms  or  legs.  Rigidity  of  the  muscles 
of  the  back  or  neck  is  very  common,  and  the  patient  lies  with  the  body  stiff 
and  the  head  drawn  so  far  back  that  the  occiput  may  be  between  the 
shoulder-blades.  Except  in  early  childhood  convulsions  are  not  common. 
Strabismus  is  a  freqiient  and  important  symptom.  Spasm  of  tlic  nnisclcs  oL' 
the  face  may  also  occur.  Cases  have  been  described  in  wbich  the  general 
rigidity  and  stiffness  was  such  that  the  body  could  be  moved  like  a  statue. 
Paralysis  of  the  trunk  muscles  is  rare,  but  paralysis  of  the  muscles  of  the  eye 
and  the  face  is  not  uncommon. 

Of  sensory  symptoms,  headache  is  tlie  most  dominant  and  persists  from 
the  outset.  It  is  chiefly  in  the  back  of  the  head,  and  tlie  pain  extends  into 
the  neck  and  back.  There  may  be  great  sensitiveness  along  tlie  spine,  and 
in  many  cases  there  is  general  hyperaesthesia. 

The  psycMcal  symptoms  are  pronounced.  Delirium  occurs  at  the  onset, 
occasionally  of  a  furious  and  maniacal  kind.    The  patient  may  display  marked 


114  SPECIFIC  IXFECTIOUS  DISEASES 

erotic  symptoms  at  the  onset.  The  delirium  gives  place  in  a  few  days  to 
stupor,  which,  as  the  effusion  increases,  deepens  to  coma. 

The  temperature  is  irregular  and  variable.  Eemissions  occur  frequently, 
and  there  is  no  uniform  or  typical  curve  during  the  disease.  In  some  instances 
there  has  been  little  or  no  fever.  In  others  the  temperature  may  reach  105° 
or  106°  F.,  or,  before  death,  108°  F.  The  pulse  may  be  very  rapid  in 
children ;  in  adults  it  is-  at  first  usually  full  and  strong.  In  some  cases  it  is 
remarkably  slow,  and  may  not  be  more  than  fifty  or  sixty  in  the  minute. 
Sighing  respirations  and  Cheyue-Stokes  breathing  are  met  with  in  some 
instances.  Unless  there  is  pneumonia  the  respirations  are  not  often  increased 
in  frequency. 

The  cutaneous  features  are  important.  Herpes  occurs  with  a  frequency 
almost  equal  to  that  in  pneumonia  or  intermittent  fever.  The  petechial  rash, 
Avhich  has  given  the  name  spotted  fever  to  the  disease,  is  very  variable. 
Stille  states  that  of  98  cases  in  the  Philadelphia  Hospital,  no  eruption  was 
observed  in  37.  In  the  Montreal  cases  petechiag  and  purple  spots  were 
common.  They  appear  to  have  been  more  frequent  in  the  epidemics  in 
America  than  in  Europe.  The  petechi£e  may  be  numerous  and  cover  the 
entire  skin.  An  erythema  or  dusky  mottling  may  be  present.  In  some 
instances  there  have  been  rose-colored  hyperaemic  spots  like  the  typhoid  rash. 
Urticara  or  erythema  nodosum,  ecthyma,  pemphigus,  and  in  rare  instances 
gangrene  of  the  skin  have  been  noted. 

Lcucocytosis  is  an  early  and  constant  feature,  and  ranges  from  25,000 
to  10,000  per  cubic  millimetre.  It  persists  even  in  the  most  protracted 
cases.  The  meningococcus  is  present  in  the  blood  during  life  and  has  been 
demonstrated  in  the  leucocytes. 

Vomiting  may  be  a  special  feature  at  the  onset;  but,  as  a  rule,  it 
gradiialh'  subsides.  In  some  instances,  however,  it  persists  and  becomes  the 
most  serious  and  distressing  of  the  symptoms.  Diarrhoea  is  not  common,  th3 
bowels  being  usually  constipated.  The  abdomen  is  not  tender.  In  the  acuta 
form  the  spleen  is  usuall}'  enlarged.  The  urine  is  sometimes  albuminous 
and  the  quantity  may  be  increased.  Glycosuria  has  been  noted  in  some  in- 
stances, and  hematuria  in  the  malignant  t3'pes. 

The  duration  of  the  disease  is  extremely  variable.  Hirsch  rightlj'  states 
that  it  may  range  between  a  few  hours  and  several  months.  More  than 
half  of  the  deaths  occur  within  the  first  five  days.  In  favorable  cases,  after 
the  symptoms  have  persisted  for  five  or  six  days,  improvement  is  indicated 
by  a  lessening  of  the  spasm,  reduction  of  the  fever,  and  a  return  of  the  intel- 
ligence. A  sudden  fall  in  the  temperature  is  of  bad  omen.  Convalescenca 
is  extremely  tedious,  and  may  be  interrupted  by  complications  and  sequela3. 

(c)  AxoMALOUS  Forms. —  (1)  Ahoriive  Type. — The  attack  sets  in  with 
great  severity,  but  in  a  day  or  two  the  symptoms  subside  and  convalescence  is 
rapid.  Striimpell  would  distinguish  between  this  abortive  variety,  which 
begins  with  such  intensity,  and  the  mild  ambulant  cases  described  by  certain 
writers.  He  reports  a  case  in  which  the  meningeal  symptoms  set  in  with 
the  greatest  intensity  and  persisted  for  four  days,  the  temperature  rising  to 
105. G°  F.  On  the  fifth  day  the  patient  entered  upon  a  rapid  convalescence. 
In  the  mild  cases,  as  distinguished  from  the  abortive,  the  patients  complain 
of  headache,  nausea,  sensations  of   discomfort  in  the  back  and  limbs,   and 


CEEEBEO-SriNAL    FEVER  115 

stiffness  in  the  neck.     There  i.s  little  or  no  fever,  and  only  moderate  vomiting. 
These  cases  could  be  recognized  only  during  the  prevalence  of  an  epidemic. 

(2)  An  intermittent  type  has  been  observed  in  many  epidemics,  and  was 
recognized  by  von  Ziemssen  and  Stille.  It  is  characterized  by  exaeerljations 
of  fever,  which  may  recur  daily  or  every  second  day,  or  follow  a  curve  of  an 
intermittent  or  remittent  character.  The  pyrexia  resembles  that  of  pyaemia 
rather  than  malaria. 

(3)  Chronic  Form. — Heubner  states  that  this  is  a  relatively  frequent 
form,  though  it  does  not  seem  to  be  recognized  by  many  writers  on  the 
subject.  An  attack  may  be  protracted  for  from  two  to  five  or  even  six 
months,  and  may  cause  the  most  intense  marasmus.  It  is  cliaracterized  by 
a  series  of  recurrences  of  the  fever,  and  may  present  the  most  complex 
symptomatology^  It  is  not  improbable  that  in  these  protracted  cases  chronic 
hydrocephalus  or  abscess  of  the  brain  is  present.  This  form  differs  dis- 
tinctly from  the  intermittent  type.  Three  cases  in  our  series  were  of  this 
chronic  form ;  in  one  the  disease  persisted  for  ninety  days. 

Complications. — Pleurisy,  picarditis,  and  parotitis  are  not  uncommon. 

Pneumonia  is  described  as  frequent  in  certain  outbreaks.  Immermann 
found  many  instances  of  the  combination  of  pneumonia  with  meningitis, 
but  it  does  not  seem  possible  to  determine  whether,  in  such  cases,  pneumonia 
is  the  primary  disease  and  the  menii'-.gitis  secondary,  or  vice  versa.  The  fre- 
quency with  which  inflammation  of  the  meninges  of  the  brain  complicates 
pneumonia  is  well  known.  Councilman  suggests  that  the  pneumonia  of  the 
disease  is  not  the  true  lobar  form,  but  due  to  the  meningococcus.  This  was 
found  in  eight  of  the  Boston  cases,  and  in  one  it  was  so  extensive  that  it 
could  have  been  mistaken  for  the  ordinary  lobar  pneumonia.  Cerebro-spinal 
fever  sometimes  prevails  extensively  with  ordinary  pneumonia,  as  in  Xew 
York  in  the  winter  of  1903-'04.  Arthritis  has  been  the  most  frequent  com- 
plication in  certain  epidemics.  Many  joints  are  affected  simultaneously,  and 
there  are  swelling,  pain,  and  exudation,  sometimes  serous,  sometimes  purulent. 
This  was  first  observed  by  James  Jackson,  Sr.,  in  the  epidemic  which  h3 
described.     Enteritis  is  rarer.     Epididymitis  is  common  in  some  epidemics. 

Headache  may  persist  for  months  or  years  after  an  attack.  Chronic 
liydroce[)halus  occurs  in  certain  instances  in  children.  The  symptoms  of  this 
are  '^paroxysms  of  severe  headache,  pains  in  the  neck  and  extremities,  vomiting, 
loss  of  consciousness,  convulsions,  and  involuntary  discharges  of  faeces  and 
urine"  (von  Ziemssen).  On  percussion  of  the  skull  behind  the  junction  of 
the  frontal,  parietal  and  temporal  bones  there  is  a  tympanitic  quality  to 
the  note  (Macewen).  ]\Iental  feeldeness  and  aphasia  have  occasionally  been 
noted.  Paralysis  of  individual  cranial  nerves  or  of  tlie  lower  extremities  may 
persist  for  some  time.  In  some  of  these  cases  there  may  be  peripheral 
neuritis,  as  Mills  suggested. 

Special  Senses. — Eye. — Optic  neuritis  may  follow  involvement  of  the 
nerve  in  the  exudation  at  the  base.  Acute  papillitis  was  found  in  G  out  of  40 
eases  examined  by  Eandolph.  The  inflammation  may  extend  directly  into  the 
eve  along  the  pia-arachnoid  of  the  optic  nerve,  causing  purulent  choroido- 
iritis  or  even  keratitis.  A  neuritis  of  the  fifth  nerve  may  be  followed  by 
keratitis  and  purulent  conjunctivitis. 

]?(jj-_ — Deafness  very  often  follows  inflammation  of  the  labyrinth.     Otitis 


116  SPECIFIC  INFECTIOUS  DISEASES 

media,  with  mastoiditis,  may  occur  from  direct  extension.  In  64  cases '  of 
meningitis  which  recovered,  Moos  found  that  55  per  cent,  were  deaf.  He 
suggests  that  the  abortive  form  of  the  disease  may  be  responsible  for  manv 
cases  of  early  acquired  deafness.  In  children  this  not  infrequently  leads  to 
deaf  mutism.  Von  Ziemssen  states  that  in  the  deaf  and  dumb  institutions  of 
Bamberg  and  Nuremberg,  in  1874,  a  majority  of  the  pupils  had  become  deaf 
from  epidemic  cerebro-spinal  meningitis. 

Nose. — Coryza  is  not  infrequent  early  in  the  disease,  probably  associated 
with  the  presence  of  the  organism  on  the  nasal  mucous  membrane.  In  car- 
riers the  organism  may  persist  for  several  weeks,  in  a  small  number  over  three 
months. 

Diagnosis. —  (a)  General  Features. — The  fever,  headache,  delirium, 
retraction  of  the  neck,  tremor,  and  rigidity  of  the  muscles  are  most  impor- 
tant signs.  In  the  meningitis  of  cerebro-spinal  fever  the  spinal  symptoms  are 
very  much  more  marked  than  in  the  other  forms.  One  has  constantly  to 
bear  in  mind  that  certain  cases  of  typhoid  fever  and  of  pneumonia  closely 
simulate  cerebro-spinal  meningitis. 

(b)   Among  the  special  dlignostic  features  may  be  mentioned: 

Kernig's  Sign. — When  the  thigh  is  flexed  at  right  angles  to  the  abdomen, 
the  leg  can  be  extended  upon  the  thigh  nearly  in  a  straight  line.  If  meningitis 
be  present,  strong  contractures  of  the  flexors  prevent  the  full  extension  of  the 
leg  on  the.  thigh. 

Brudzinskis  Sign. — Flexing  the  head  on  the  chest  causes  flexion  of  tho 
legs  at  the  hip  and  knee  joints,  and  flexing  one  leg  on  the  trunk  produces  the 
same  movement  in  the  other  leg. 

Lumbar  Puncture. — The  procedure  in  a  majority  of  cases  can  be  done 
without  general  ansesthesia.  The  fluid  runs,  as  a  rule,  with  increased  pres- 
sure which  may  reach  250-300  mm.,  the  normal  being  about  120  mm.,  and 
when  meningitis  is  present  it  is  usually  turbid,  sometimes  purulent,  occasion- 
ally bloody.  Meningitis  may  be  present  with  a  clear  fluid.  The  cytology  of  the 
fluid  is  important.  The  polymorphonuclear  leucocytes  are  in  great  excess 
while  in  the  tuberculous  form  the  lymphocytes  are  the  more  abundant.  In 
the  late  stages  and  throughout  the  course  of  the  posterior  basic  form  the 
formula  may  be  reversed.  There  is  rarely  any  difficulty  in  determining  be- 
tween the  pneumococcus  and  the  meningococcus.  If  there  is  any  doubt  as  to 
the  organism  the  agglutination  test  should  be  done  or  the  meningococcus 
searched  for  in  the  naso-pharynx.  For  the  serological  tests  necessary  to 
determine  the  type,  monovalent  serums  are  required,  best  prepared  from 
rabbits.  Careful  search  will  usually  show  tubercle  bacilli  in  cases  of  tuber- 
culous meningitis  or  a  guinea-pig  may  be  inoculated. 

Prognosis. — The  mortality  before  the  use  of  serum  was  about  75  per  cent. 
In  children  the  death  rate  is  higher  than  in  adults.  The  earlier  the  serum 
is  given  the  better  the  outlook. 

Prophylaxis. — The  patient  should  be  isolated,  seen  only  by  the  doctor, 
nurses,  and  one  or  two  special  members  of  the  family.  Cultures  from  the 
naso-pharynx  of  those  in  immediate  contact  should  be  taken  and  earners  should 
be  isolated  until  proved  to  be  free  of  infection.  The  use  of  chloramin  (1  per 
cent.)  and  zinc  sulphate  (1.2  per  cent.)  solution  has  been  helpful  in  some 
cases.     These  may  be  applied  directly  to  the  mucous  membrane  or  the  chloi-a- 


CEREBRO-SPmxVL    FEVER  117 

mill  used  in  an  oil  spray  after  thorough  cleansing  with  saline  solution.  An- 
other method  is  to  use  a  watery  solution  of  chloramin  (2  per  cent.)  and  zinc 
sulphate  (1.2  per  cent.).  A  litre  of  this  solution  is  sprayed  by  steam  into  a 
small  room  and  inhaled.  A  1  per  cent,  solution  of  peroxide  or  a  solution  of 
iodine  and  glycerine  may  be  used  as  a  spray.  Some  carriers  prove  very  re- 
sistant; in  others  the  germs  disappear  after  a  few  days.  Hexamine,  30  to 
50  grains  daily,  may  be  given.  Protective  vaccination  was  tried  extensively 
in  the  last  English  epidemic. 

Treatment. — The  patient  should  be  kept  as  quiet  as  possible,  handled 
gently,  and  all  causes  of  irritation  removed.  Special  attention  should  be  given 
to  the  care  of  the  skin  owing  to  the  danger  of  bedsores.  The  hair  should 
be  clipped  close  and  an  ice-bag  applied  to  the  head.  The  diet  should  be 
liquid,  as  concentrated  as  possible,  and  given  at  short  intervals.  If  swallow- 
ing is  difficult  the  patient  can  be  fed  through  a  tube.  Water  should  be  given 
freely.  The  bowels  are  to  be  opened  by  a  calomel  and  saline  purge,  and 
laxatives  or  enemata  used  later  if  necessary.  For  severe  headache,  general 
pains  or  vomiting,  morphia  hypodermically  is  usually  best.  The  administra- 
tion of  hexamine,  sixty  grains  (4  gm.)  a  day,  is  worthy  of  a  trial. 

Serum  Therapy. — To  Flexner  we  owe  the  specific  serum  which  has 
reversed  the  mortality  and  recovery  rates — one  of  the  most  striking  advances 
in  modern  therapy.  The  serum  should  be  given  as  early  as  possible  and  also 
in  doubtful  cases.  It  should  be  given  intravenously  in  doses  of  100  c.  c. 
every  eight  hours,  first  desensitizing  by  giving  5  c.  c.  subcutaneously.  "When- 
ever the  fluid  obtained  by  lumbar  puncture  is  purulent  the  serum  should  be 
given,  but  repeated  only  if  the  meningococcus  is  found.  Before  giving  the 
serum  as  much  cerebro-spinal  fluid  as  possible  should  be  withdrawn.  If  this 
has  been  large  in  amount  (over  40  c.  c.)  and  in  severe  cases,  45  c.  c.  of  the 
serum  should  be  introduced  through  the  needle.  In  ordinary  cases  30  c.  c. 
of  the  serum  should  be  given.  In  all  cases  with  abnormal  resistance  to  the 
injection  of  serum  after  an  amount  equal  to  the  fluid  removed  has  been 
injected,  it  is  well  to  stop.  If  the  symptoms  are  very  severe  or  increasing, 
the  injection  should  be  repeated  in  twelve  hours.  Otherwise  the  usual  dose 
(30  c.  c.)  should  be  given  daily  for  four  days.  If  diploeocci  are  found  after 
this,  daily  injections  should  be  continued.  Continuance  or  exacerbation  of 
the  symptoms  demands  further  injections.  If  the  condition  remains  stationary 
after  four  days'  interval,  the  four  daily  injections  should  be  given  again  and 
this  repeated  until  the  diploeocci  disappear  and  the  symptoms  abate.  An 
average  dosage  of  serum  is  400-600  c.  c.  intravenously  and  100  e.  c.  intra- 
spinally.  The  failure  of  the  serum  in  many  hands  during  the  recent  epidemic 
may  have  been  due  to  its  preparation  from  different  strains  and  the  need 
of  a  polyvalent  serum  is  evident.  In  the  chronic  forms  the  serum  should  be 
given  if  diploeocci  are  present  and  in  the  posterior  basic  form  in  the  hope 
of  benefit. 

Hydrotherapy. — This  may  give  relief  to  the  symptoms.  Hot  baths  or 
hot  packs  may  be  given  for  fifteen  minutes  every  three  hours. 

Lumbar  Puncture. — Done  for  injection  of  the  scrum  it  is  often  of  value 
in  itself.  Severe  headache  and  marked  cerebral  features  are  indications.  As 
much  fluid  as  possible  should  be  removed  and  if  it  escapes  under  high  pres- 


118  SPECIFIC  INFECTIOUS  DISEASES 

sure  early  rej^etition  is  advisable.    It  should  be  done  early  and  frequently  with 
signs  of  accumulation  of  fluid  in  the  ventricles. 

Complications. — Conditions  due  to  extension  to  the  cranial  nerves  are 
not  influenced  by  treatment.  Otitis  requires  early  incision  and  arthritis  rest, 
local  applications  and  incision  if  suppuration  occurs.  With  signs  of  dilatation 
of  the  ventricles,  drainage  with  injection  of  serum  may  be  tried,  or  the  serum 
may  be  introduced  by  ventricular  puncture.  This  is  readily  done  if  the 
fontanelle  is  still  open,  the  ventricle  being  reached  at  a  depth  of  about  3  cm. 
In  the  chronic  cases  every  effort  should  be  made  to  nourish  the  patient  well 
and  especial  precautions  taken  against  bed-sores.  For  the  pain  and  stiff- 
ness sometimes  occurring  in  convalescence,  hot  baths  and  massage  are  use- 
ful. 

X.      INFLUENZA 

{La  Grippe) 

Definition. — A  pandemic  disease,  appearing  at  irregular  intervals,  charac- 
terized by  extraordinary  rapidity  of  extension  and  the  large  number  of  people 
attacked.  Following  the  pandemic  there  are,  as  a  rule,  for  several  years 
endemic,  epidemic,  or  sporadic  outbreaks  in  different  regions.  Clinically,  the 
disease  has  protean  aspects,  but  a  special  tendency  to  attack  the  respiratory 
mucous  membranes.    A  special  organism,  Bacillus  injiuenzcs,  is  found. 

History. — Great  pandemics  have  been  recognized  since  the  sixteenth  cen- 
tury. There  were  four  with  their  succeeding  epidemics  during  the  last 
century— 1830-'33,  1836-'37,  1847-'48,  and  1889--'90.  The  last  seems  to  have 
begun^  as  many  others  had  before^  in  the  far  East.  The  pandemic  of  1918 
far  exceeded  any  of  its  predecessors  in  its  intensity.  It  is  unusual  to  have 
the  culmination  in  the  summer  months  as  was  the  case  in  some  countries. 
A  special  feature  was  the  high  mortality  in  young  adults,  the  very  young 
and  the  old  being  comparatively  immune.  The  accompanying  pneumonia  was 
very  virulent.  Pregnant  women  seemed  particularly  susceptible.  The  epi- 
demic was  severe  in  the  American  camps  and  on  the  transports.  The  Olympic 
arrived  in  port  with  5,951  troops.  On  the  day  of  arrival  571  cases  of  acute 
respiratory  disease  developed  and  within  three  weeks  there  were  1,668  case^. 
Of  these,  534  (32  per  cent.)  had  pneumonia,  of  whom  317  died,  59  per 
cent. 

The  duration  of  an  epidemic  in  any  one  locality  is  from  six  to  eight 
weeks.  AYith  the  exceptions,  perhaps,  of  dengue,  there  is  no  disease  which 
attacks  indiscriminately  so  large  a  portion  of  the  inhabitants,  about  40  per 
cent.,  as  a  rule.  Fortunately,  as  in  dengue,  the  rat€  of  mortality  is  low  if 
all  cases  are  included.  Leichtenstern's  article  in  Xothnagel's  Handbuch  is  a 
masterly  and  systematic  consideration  of  the  disease. 

Etiology. — What  relation  has  the  epidemic  influenza  to  the  ordinary  in- 
fluenza cold  or  catarrhal  fever  (commonly  also  called  the  grippe),  which  is 
constantly  present  in  the  community?  Leichtenstern  answers  this  question  by 
making  the  following  divisions:  (a)  Epidemic  influenza  vera;  {b)  endemic- 
epidemic  influenza  vera,  which  often  occurs  for  several  years  in  succession 
after  a  pandemic;  (c)  endemic  influenza  nostras,  pseudo-influenza  or  catarrhal 


INFLUENZA  119 

fever,  commonly  called  the  grippe,  is  caused  by  various  organisms,  alone  or  in 
combination^  and  bears  the  same  relation  to  the  true  influenza  as  cholera 
nostras  does  to  Asiatic  cholera. 

Since  the  pandemic  of  1889-'90  we  have  not  been  free  from  local  out- 
breaks ill  some  part  of  the  world.  In  some  places  the  disease  seems  to  have 
been  continually  present.  The  reports  are  sufficiently  numerous  to  show  that 
the  influenza  bacillus  is  constantly  with  us.  Many  observations  show  that  it 
is  a  frequent  invader  of  the  respiratory  tract  in  the  inter-epidemic  periods 
and  is  probably  responsible  for  many  of  the  cases  of  influenza  nostras.  It 
seems  to  bear  a  similar  relation  to  the  acute  infections  of  the  respiratory 
tract  as  other  common  organisms. 

The  disease  is  highly  infectious;  it  spreads  with  remarkable  rapidity, 
which,  however,  is  not  greater  than  modern  methods  of  conveyance.  In  the 
great  pandemics  some  of  the  large  prisons  escaped  entirely.  The  outbreak 
of  epidemics  is  independent  of  all  seasonal  and  meteorological  conditions. 
One  attack  does  not  necessarily  protect  from  a  subsequent  one.  A  few  persons 
appear  not  to  be  liable  to  the  disease. 

Bacteriology. — In  1893  Pfeiffer  isolated  a  bacillus  from  the  nasal  and 
bronchial  secretions,  which  by  some  is  recognized  as  the  cause  of  the  disease. 
It  is  a  small,  non-motile  organism,  which  stains  well  in  Loeffier's  methylene 
blue,  or  in  a  dilute,  pale-red  solution  of  carbol-fuchsin  in  water.  It  has  been 
found  in  the  blood  in  a  number  of  cases.  The  bacilli  are  present  in  enormous 
numbers  in  the  nasal  and  bronchial  secretions  of  patients,  in  the  latter  almost 
in  pure  cultures.  They  persist  often  after  the  severe  symptoms  have  sub- 
sided. The  experience  of  the  pandemic  of  1918  has  raised  the  question  as  to 
the  relation  of  the  influenza  bacillus  to  the  disease.  Is  it  the  responsible 
organism  or  a  secondary  invader?  The  evidence  is  conflicting  but  does  not 
seem  to  justify  the  conclusion  that  this  organism  is  not  causal.  There  are 
many  secondary  invading  organisms,  which  vary  in  prevalence  in  dilferent 
localities. 

Symptoms. — The  incubation  period  is  from  one  to  four  days  and  has  an 
average  of  two  days.  The  onset  is  usually  abrupt,  with  fever  and  its  associated 
phenomena,  headache,  general  pains,  prostration  and  sometimes  sore  throat 
and  an  irritating  cough. 

Types  of  the  Disease. — The  manifestations  are  so  extraordinarily  complex 
that  it  is  best  to  describe  them  under  types  of  the  disease. 

(a)  Eespieatory. — The  mucous  membrane  of  the  respiratory  tract  from 
the  nose  to  the  air-cells  of  the  lungs  may  be  regarded  as  the  seat  of  election 
of  the  infection.  In  the  simple  forms  the  disease  sets  in  with  coryza,  and 
presents  the  features  of  an  acute  catarrhal  fever,  with  perhaps  rather  more 
prostration  and  debility  than  is  usual.  In  other  cases  after  catarrhal  symp- 
toms bronchitis  occurs,  the  fever  increases,  there  is  delirium  and  much  pros- 
tration, and  the  picture  is  that  of  severe  toxgemia.  The  graver  respiratory 
conditions  are  bronchitis,  pleurisy,  and  pneumonia.  The  bronchitis  has  really 
no  special  peculiarities  but  the  sputum  is  supposed  by  many  to  be  distinctive. 
Sometimes  it  is  in  extraordinary  amounts,  very  thin,  and  containing  purulent 
masses.  Pfeiffer  regards  sputum  of  a  greenish-yellow  color  and  in  coin-like 
lumps  as  almost  characteristic  of  influenza.  In  other  cases  there  may  be  a 
dark  red,  bloody  sputum.     It  occasionally  happens  that  the  bronchitis  is  of 


120  SPECIFIC  INFECTIOUS  DISEASES 

great  intensity  and  reaches  the  finer  tuhes,  so  that  the  patient  becomes 
cvanosed  or  even  asphyxiated. 

Influenza  pneumonia  is  one  of  the  most  serious  manifestations,  and  may 
depend  upon  Pfeiffer's  bacillus  itself,  or  be  the  result  of  a  mixed  infection. 
The  true  influenza  pneumonia  is  lobular  and  probably  never  lobar.  It  was 
a  special  feature  of  the  1918  pandemic  and  responsible  for  many  of  the 
deaths.  It  may  be  present  from  the  onset  of  the  attack  or  develop  after 
some  days  of  general  infection.  The  clinical  course  is  often  atypical  and 
the  signs  obscure.  The  signs  were  often  atypical  for  several  days  and  sup- 
pression of  breath  sounds  with  fine  crackling  rales  were  the  common  early 
signs.  Severe  cough  with  bloody  sputum  or  hiemoptysis  is  common.  Cyanosis 
is  usually  marked.  There  is  a  special  tendency  to  the  secretion  of  fluid  so  that 
the  lungs  are  "water-logged.'^  Abscess  or  gangrene  follows  not  infrequently. 
The  toxaemia  is  often  extreme  but  the  circulation  shows  remarkably  little 
change  in  many  cases.  The  blood  pressure  is  usually  low.  Subcutaneous 
emphysema  was  common  in  the  1918  epidemic,  usually  over  the  neck  and 
upper  thorax  but  sometimes  very  widespread.  In  many  of  these  cases  there 
was  extreme  emphysema  of  the  lungs.  Probably  the  air  escaped,  after  rupture 
of  a  surface  bleb,  into  the  mediastinum  and  then  reached  the  tissues  of  the 
neck. 

Influenza  pAeurisy  is  more  rare,  but  cases  of  primary  involvement  of  the 
pleura  are  reported.  It  is  very  apt  to  lead  to  empyema.  Pulmonary  tuber- 
culosis is  usually  much  aggravated  by  an  attack  of  influenza. 

(&)  jSTervous  Form. — Without  any  catarrhal  symptoms  there  are  severe 
headache,  pain  in  the  back  and  Joints,  with  profound  prostration.  Among 
the  more  serious  complications  may  be  mentioned  meningitis  and  encephalitis, 
the  latter  leading  to  hemiplegia  or  monoplegia.  Abscess  of  the  brain  has 
followed  in  acute  cases.  j\Iyelitis,  with  symptoms  like  an  acute  Landry's 
paralysis,  has  occurred,  and  spastic  paraplegia  or  a  pseudo-tabes  may  follow 
an  attack.  In  the  recent  epidemic  there  were  cases  of  widespread  haemorrhage 
into  the  spinal  thecffi. 

The  influenza  bacillus  has  been  demonstrated  by  lumbar  puncture  during 
life  and  in  the  meninges  after  -death.  All  forms  of  neuritis  are  not 
uncommon,  and  in  some  eases  are  characterized  by  marked  disturbance  of 
motion  and  sensation.  Judging  from  the  accounts  in  the  literature,  almost 
every  form  of  disease  of  the  nervous  system  may  follow  influenza.  Among 
the  most  important  of  the  nervous  sequela  are  depression,  melancholia,  and  in 
some  cases  dementia. 

(c)  G ASTRO-INTESTINAL  FoRM. — AYith  the  onset  of  the  fever  there  may 
be  nausea  and  vomiting,  or  the  attack  may  set  in  with  abdominal  pain, 
profuse  diarrhoea,  and  collapse.  In  some  epidemics  jaundice  has  been  a  com- 
mon symptom.  In  a  considerable  number  of  the  cases  there  is  enlargement 
of  the  spleen,  depending  chiefly  upon  the  intensity  of  the  fever. 

{d)  Febrile  Form. — The  fever  in  influenza  is  very  variable,  but  it  is 
important  to  recognize  that  it  may  be  the  only  manifestation  of  the  disease. 
It  is  sometimes  markedly  remittent,  with  chills;  or  in  rare  cases  there  is  a 
protracted,  continued  fever  of  several  weeks'  duration,  which  simulates  typhoid 
closely.  The  blood  shows  a  leueopenia  which  is  often  marked.  Sometimes  the 
fever  resembles  that  of  a  tertian  malaria. 


INFLUENZA  121 

Complications. — The  pericarditis  is  apt  to  be  latent.  Of  endocarditis,  a 
number  of  cases  have  been  reported  in  Avhich  micro-organisms  morphologically 
like  influenza  bacilli  have  been  isolated  from  the  vegetations.  The  malignant 
form  may  occur.  Myocarditis  may  follow,  and  has  been  a  cause  of  sudden 
death.  Functional  disturbances  are  common,  palpitation,  bradycardia,  tachy- 
cardia, and  angina-like  attacks.  Phlebitis  and  thrombosis  of  various  vessels 
have  been  described.    Meningitis  occurs  occasionally. 

Peritonitis  is  rare.  Cholelithiasis  may  follow  an  attack.  The  increased 
prevalence  of  appendicitis  has  been  attributed  to  influenza. 

Various  renal  affections  have  been  noted,  but  nephritis  was  rare  in  the 
1918  pandemic.  Orchitis  has  been  seen.  Herpes  is  common.  A  diffuse 
erythema  sometimes  occurs,  occasionally  purpura.  Catarrhal  conjunctivitis  is 
a  frequent  event.  Iritis,  and  in  rare  instances  optic  neuritis,  have  been  met 
with.  Acute  otitis  media  is  a  common  complication  and  infection  of  the 
sinuses  is  not  rare.  Severe  and  persistent  vertigo  may  follow  influenza,  prob- 
ably from  involvement  of  the  labyrinth.  Bronchiectasis  may  follow.  We  have 
seen  several  cases;  in  a  fatal  one  of  three  years'  duration  the  influenza 
bacilli  were  present  in  the  sputum. 

Since  the  late  severe  epidemics  it  has  been  the  fashion  to  date  various 
ailments  or  chronic  ill  health  from  influenza.  In  many  cases  this  is  cor- 
rect. It  is  astonishing  the  number  of  people  who  have  been  crippled  in  health 
for  years  after  an  attack,  particularly  with  nervous  or  circulatory  disturb- 
ances.    Alopecia  is  a  common  sequel  but  is  rarely  permanent. 

Diagnosis. — During  a  pandemic  the  cases  offer  but  slight  difficulty.  The 
profoundness  of  the  prostration,  out  of  all  proportion  to  the  intensity  of  the 
disease,  is  one  of  the  most  characteristic  features.  In  the  respiratory  form 
the  diagnosis  may  be  made  by  the  bacteriological  examination  of  the  sputum, 
a  procedure  which  should  be  resorted  to  early  in  a  suspected  epidemic.  The 
more  chronic  pulmonary  infections  are  sometimes  mistaken  for  tuberculosis. 
The  differentiation  of  the  various  forms  has  been  sufficiently  considered. 

Treatment. — Isolation  should  be  practised  when  possible,  and  old  people 
should  be  guarded  against  ail  possible  sources  of  infection.  There  is  no 
conclusive  proof  that  vaccines  have  any  preventive  effect  or  that  they  are  useful 
in  treatment.  The  secretions,  nasal  and  bronchial,  should  be  thoroughly  dis- 
infected. In  every  case  the  disease  should  be  regarded  as  serious,  and  the 
patient  should  be  confined  to  bed  until  the  fever  has  completely  disappeared. 
In  this  way  alone  can  serious  complications  be  avoided.  From  the  outset  the 
treatment  should  be  supporting,  and  the  patient  carefully  fed  and  well 
nursed.  The  bowels  should  be  opened  by  a  dose  of  calomel  or  a  saline 
draught.  At  night  10  grains  (0.65  gm.)  of  Dover's  powder  may  be  given.  At 
the  onset  a  warm  bath  is  sometimes  grateful  in  relieving  the  pain  in  the 
Ijaek  and  limbs,  but  great  care  should  be  taken  to  have  the  bed  well  warmed, 
and  the  patient  should  be  given  a  hot  drink  after  it.  If  the  fever  is  high  and 
there  is  delirium,  acetyl-salicylic  acid  (gr.  x,  O.G  gm.)  may  be  given  and  an 
ice-cap  applied  to  the  head.  The  medicinal  antipyretics  should  be  used  with 
caution,  as  profound  prostration  sometimes  occurs  after  their  employment. 
An  alkali,  such  as  potassium  citrate  (gr.  xv,  1  gm.)  four  times  a  day  should 
be  given.    Too  much  stress  should  not  be  laid  upon  the  mental  features.    De- 


122  SPECIFIC  INFECTIOUS  DISEASES 

lirium  may  be  marked  even  with  slight  fever.  In  the  cases  with  great  cardiac 
weakness  stimulants  should  be  given  freely,  and  during  convalescence  strychnia 
in  full  doses. 

The  intense  bronchitis,  pneumonia,  and  other  complications  should  receive 
their  appropriate  treatment.  The  convalescence  requires  careful  manage- 
ment, and  it  may  be  w^eeks  or  months  before  the  patient  is  restored  to  full 
health.  A  good  nutritious  diet,  change  of  air,  and  pleasant  surroundings 
are  essential.  The  depression  following  this  disease  is  one  of  its  most 
unpleasant  and  obstinate  features. 


XI.     WHOOPING  COUGH 

Definition. — A  specific  affection  due  to  the  Bacillus  pertussis,  character- 
ized by  catarrh  of  the  respiratory  passages  and  a  series  of  convulsive  coughs 
which  end  in  a  long-drawn  insiDiration  or  "whoop.'' 

History. — Ballonius,  in  his  Ephenierides,  describes  the  disease  as  it  ap- 
peared in  1578.  Glisson  and  Sydenham  in  the  following  century  gave  brief 
accounts.  Willis  (Pharmaceutice  Eationalis,  second  part,  1674)  gave  a  much 
better  description  and  called  it  an  "epidemical  disorder." 

Etiology. — The  disease  occurs  in  epidemic  form,  but  sporadic  cases  appear 
in  a  community  from  time  to  time.  It  is  directly  contagious  from  person 
to  person ;  but  dwelling-rooms,  houses,  school-rooms,  and  other  localities  may 
be  infected  by  a  sick  child.  It  is,  however,  in  this  way  less  contagious  than 
other  diseases,  and  is  probably  most  often  taken  by  direct  contact.  Epidemics 
prevail  for  two  or  three  months,  usually  during  the  winter  and  spring,  and 
have  a  curious  relation  to  other  diseases,  often  preceding  or  following  epidemics 
of  measles,  less  frequently  of  scarlet  fever. 

Children  between  the  first  and  second  dentitions  are  most  liable  to  be 
attacked.  Sucklings  are  not  exempt,  and  there  may  be  very  severe  attacks 
in  infants  under  six  weeks.  Congenital  cases  are  described.  It  is  stated  that 
girls  are  more  subject  to  the  disease  than  boys.  Adults  and  old  people  are 
sometimes  attacked,  and  in  the  aged  it  may  be  a  very  serious  affection.  It 
appears  to  be  most  contagious  in  the  catarrhal  period.  A  natural  immunity 
has  been  mentioned,  but  it  must  be  remembered  that  a  child  may  have  the 
disease  in  a  very  mild  form.  As  a  rule,  one  attack  protects;  second  attacks 
are  rare.  The  disease  is  more  than  twice  as  fatal  in  the  negro  race  as  in 
others.    There  were  6,075  deaths  from  it  in  1916  in  England. 

The  Bacillus  pertussis  resembles  in  certain  features  the  influenza  bacillus. 
It  is  found  in  early  stages  of  the  disease  and  not  later  than  two  weeks  after 
the  appearance  of  the  "whoop."  In  convalescents  the  deviation  of  complement 
reaction  is  present  and  the  serum  is  stated  to  agglutinate  the  organism. 
The  complement  fixation  test  is  not  given  early  and  so  is  not  of  great  value  in 
diagnosis.  Apes  have  been  inoculated  with  the  production  of  a  characteristic 
pertussis. 

Morbid  Anatomy. — Whooping  coiigh  itself  has  no  special  pathological 
changes.  In  fatal  cases  pulmonary  complications,  particularly  broncho-pneu- 
monia, are  usually  present.  Collapse  and  compensatory  emphysema,  vesicular 
and  interstitial,  are  found,  and  the  tracheal  and  bronchial  glands  are  enlarged. 


WHOOPING  COUGH  123 

There  is  a  constant  lesion  of  the  trachea  with  the  presence  of  bacilli  between 
the  columnar  cells. 

Symptoms. — There  is  a  A^ariable  period  of  incubation  of  from  seven  to  ten 
days.  Catarrhal  and  paroxysmal  stages  can  be  recognized.  In  the  catarrhal 
stage  the  child  has  the  symptoms  of  an  ordinary  cold;,  which  may  begin  with 
slight  fever^,  running  at  the  nose,  injection  of  the  eyes,  and  a  bronchial  cough, 
usually  dry,  and  sometimes  giving  indications  of  a  spasmodic  character. 
Trousseau  calls  attention  to  the  incessant  character  of  the  early  cough.  The 
fever  is  usually  not  high,  and  slight  attention  is  paid  to  the  symptoms,  which 
are  thought  to  be  those  of  a  simple  catarrh.  After  a  week  or  ten  days, 
instead  of  subsiding,  the  cough  becomes  worse  and  more  convulsive  in  charac- 
ter. 

The  imroxysmal  stage,  marked  by  the  characteristic  cough,  dates  from  the 
first  appearance  of  the  "whoop.'^  The  fit  begins  with  a  series  of  from 
fifteen  to  twenty  forcible  short  coughs  of  increasing  intensity,  between  which 
no  inspiratory  effort  is  made.  The  child  gets  blue  in  the  face,  and  then 
with  a  deep  inspiration  the  air  is  drawn  into  the  lungs,  making  the  "whoop," 
which  may  be  heard  at  a  distance,  and  from  which  the  disease  takes  its  name. 
A  deep  inspiration  may  precede  the  series  of  spasmodic  expiratory  efforts. 
Several  coughing  fits  may  succeed  each  other  until  a  tenacious  mucus  is 
ejected,  usually  small  in  amount,  but  after  a  series  of  coughing  spells  a  con- 
siderable quantity  may  be  expectorated.  Vomiting  often  takes  place  at  the 
end  of  a  paroxysm,  and  may  recur  so  frequently  that  the  child  does  not  get 
enough  food  and  becomes  emaciated.  There  may  be  only  four  or  five  attacks 
in  the  day;  an  average  is  twenty  attacks  daily.  In  severe  and  fatal  cases  the 
paroxysms  may  exceed  one  hundred  daily.  During  the  paroxysm  the  thorax 
is  very  strongly  compressed  by  the  powerful  expiratory  efforts,  and,  as  very 
little  air  passes  in  through  the  glottis,  there  are  signs  of  defective  aeration  of 
the  blood ;  the  face  becomes  swollen  and  congested,  the  veins  are  prominent, 
the  eyeballs  protrude,  and  the  conjunctivae  become  deeply  engorged.  Suffoca- 
tion indeed  seems  imminent,  when  with  a  deep,  crowing  inspiration  air 
enters  the  lungs  and  the  color  is  quickly  restored.  The  child  knows  for  a  few 
moments  when  the  attack  is  coming  on,  and  tries  in  every  way  to  check  it, 
but  failing  to  do  so,  runs  terrified  to  the  nurse  or  mother  to  be  supported, 
or  clutches  anything  near  by.  Few  diseases  are  more  painful  to  witness.  In 
severe  paroxysms  the  sphincters  may  be  opened.  An  ulcer  may  form  under 
the  tongue  from  rubbing  on  the  teeth  (Eiga's  disease).  Among  circumstances 
which  precipitate  a  paroxysm  are  emotion,  such  as  crying,  and  any  irritation 
about  the  throat.  Even  the  act  of  .swallowing  sometimes  seems  sufficient.  In 
a  close  dusty  atmosphere  the  coughing  fits  are  more  frequent.  After  lasting 
for  three  or  four  weeks  the  attacks  become  lighter  and  finally  cease.  In  cases 
of  ordinary  severity  the  course  of  the  disease  is  rarely  under  six  weeks. 

During  the  attack,  if  the  chest  be  examiner!,  the  resonance  is  defective  in 
the  expiratory  stage,  full  and  clear  during  the  deep,  crowing  inspiration;  but 
on  auscultation  during  the  latter  there  may  be  no  vesicular  murmur  heard, 
owing  to  the  slowness  with  which  the  air  passes  the  narrowed  glottis.  Bron- 
chial rales  are  occasionally  heard. 

Complications  and  Sequelae. — During  the  extensive  venous  congestion 
hemorrhages  are  very  apt  to  occur  in  the  form  of  petechise,  particularly  about 


124  SPECIFIC  INFECTIOUS  DISEASES 

the  forehead,  ecchymosis  of  the  conjunctivse,  and  even  bleeding  tears  of  blood 
(Trousseau)  from  the  rupture  of  the  vessels,  epistaxis,  bleeding  from  the  ears, 
and  occasionally  hgemoptysis.  Ha?morrhage  from  the  bowels  is  rare.  Gly- 
cosuria occurs  occasionally.  Convulsions  are  not  ^ery  uncommon,  due  perhaps 
to  the  extreme  engorgement  of  the  cerebral  cortex.  Death  has  occurred  from 
spasm  of  the  glottis.  Sudden  death  has  been  caused  by  extensive  subdural 
haemorrhage.  Choked  disk,  relieved  by  decompression,  has  occurred.  Paralysis 
is  a  rare  event.  It  was  associated  with  3  in  a  series  of  120  cases,  but  in  none 
of  them  did  the  hemiplegia  come  on  during  the  paroxysm,  as  in  a  case  re- 
ported by  S.  AYest.  Valentine  (1901)  collected  79  cases,  chiefly  hemiplegias. 
A  spastic  paraplegia  may  follow.    Acute  polyneuritis  is  a  rare  sequel. 

The  persistent  vomiting  may  induce  marked  anemia  and  wasting.  The 
pulmonary  complications  are' extremely  serious.  During  the  severe  coughing 
spells  interstitial  emphysema  may  be  induced,  more  rarely  pneumothorax.  In 
one  instance  rupture  occurred,  evidently  near  the  root  of  the  lung,  and  the 
air  passed  along  the  trachea  and  reached  the  subcutaneous  tissues  of  the  neck, 
a  condition  which  has  been  known  to  become  general.  Capillary  bronchitis, 
lobular  and  pseudo-lobar  pneumonia  are  the  dangerous  complications,  respon- 
sible for  nine  out  of  ten  deaths  in  the  disease.  In  some  cases  the  process  is 
tuberculous.  Pleurisy  is  sometimes  met  with  and  occasionally  lobar  pneu- 
monia. Enlargement  of  the  bronchial  glands  is  very  common  in  whooping 
cough,  and  has  been  thought  to  cause  the  disease.  It  may  sometimes  be  suf- 
ficient to  produce  dulness  over  the  manubrium.  During  the  spasm  the  radial 
pulse  is  small,  the  right  heart  engorged,  and  during  and  after  the  attack  the 
cardiac  action  is  very  much  disturbed.  Serious  damage  may  result,  and 
possibly  some  of  the  cases  of  severe  valvular  disease  in  children  who  have  had 
neither  rheumatic  nor  scarlet  fever  may  be  attributed  to  the  terrible  heart 
strain  'during  a  prolonged  attack.  KoiDlik  regards  the  swelling  about  the  face 
and  eyes  as  an  important  sign  of  the  heart  strain.  Serious  renal  complica- 
tions are  very  uncommon,  but  albumin  sometimes  and  sugar  frequently  are 
found  in  the  urine.  A  distressing  sequel  in  adults  is  asthma,  which  may  re- 
cur at  intervals  for  a  year  or  more.  A  leucocytosis  sometimes  appears  early, 
chiefly  of  the  lymphocytes  (Meunier). 

Diagnosis. — So  distinctive  is  the  "whoop"  that  the  diagnosis  is  easy;  but 
occasionally  there  are  doubtful  cases,  particularly  during  epidemics,  in  which 
a  series  of  expiratory  coughs  occurs  without  any  inspiratory  crow.  The  spas- 
modic cough  due  to  enlarged  bronchial  glands  may  cause  difficulty. 

Prognosis. — If  we  include  its  complications,  whooping  cough  is  a  very 
fatal  affection,  ranking  one  of  the  first  among  the  acute  infections  as  a  cause 
of  death  in  children  under  five  years  of  age. 

Prophylaxis. — The  disease  should  be  placed  on  the  list  of.  reportable  infec- 
tions. When  possible  the  sputum  should  be  collected  and  disinfected.  As  the 
organism  usually  disappears  within  two  weeks  from  the  appearance  of  the 
characteristic  cough  there  seems  little  danger  of  contagion  in  the  later  stages. 
A  prophylactic  vaccine  has  been  used  with  success,  three  injections  of  500 
million,  2  and  3  billion,  being  given  every  third  day. 

Treatment. — The  gravity  of  the  disease  is  scarcely  appreciated  by  the  pub- 
lic. Children  with  the  disease  should  not  be  sent  to  school- or  exposed  in  public 
in  any  way.    There  is  more  reprehensible  neglect  in  connection  with  this  than 


GOXOCOCCUS  IXFECTIOX  125 

with  an}^  other  disease.  The  patient  should  be  isolated,  and  if  the  paroxysms 
are  at  all  severe,  at  rest  in  bed.  Fresh  air,  night  and  day,  is  important,  but 
in  cities  in  the  winter  this  is  not  easy  to  manage.  Stock  vaccine  has  been 
used  for  treatment  with  benefit;  some  patients' are  promptly  cured.  The  aver- 
age initial  dose  is  500  million  for  children  over  one  year.  With  two  day 
intervals  doses  of  1  and  2  billion  are  given.  Antiseptic  measures  have  been 
extensively  tried.  Quinine  holds  its  own  with  many  practitioners;  a  sixth  of 
a  grain  (0.01  gm.)  may  be  given  three  times  a  day  for  each  month  of  age, 
and  a  grain  and  a  half  (0.1  gm.)  for  each  year  in  children  under  five.  The 
use  of  benzoin  and  eucalyptus  inhalations  is  often  helpful.  Sedatives  are  by 
far  the  most  trustworthy  drugs  in  severe  cases,  and  paregoric  may  be  given 
freely,  particularly  to  give  rest  at  night.  Codein  and  heroin  in  doses  proper 
for  the  age  often  give  much  relief.  Jacobi  advised  belladonna  in  full  doses 
until  a  fiush  appears  on  the  cheeks.  Children  can  often  be  taught  to  inhibit 
an  attack.     The  wearing  of  a  tight  abdominal  binder  is  sometimes  of  value. 

Other  remedies,  such  an  antipyrin  and  chloral  hydrate,  may  be  tried.  In 
older  children  and  in  adults  it  would  be  worth  while  to  try  the  intratracheal 
injections  of  olive-oil  and  iodoform,  which  are  sometimes  so  useful  in  allaying 
severe  paroxysmal  cough. 

After  the  severity  of  the  attack  has  passed  and  convalescence  has  begun, 
the  child  should  be  watched  with  the  greatest  care.  It  is  just  at  this  period 
that  the  fatal  broncho-pneumonias  are  apt  to  develop.  The  cough  sometimes 
persists  for  months  and  the  child  remains  weak  and  delicate.  Change  of  air 
should  be  tried.  Such  a  patient  should  be  fed  with  care  and  given  tonics  and 
cod -liver  oil. 


XII.     GONOCOCCUS  INFECTION 

Definition. — An  acute  infection  with  a  primary  lesion,  usually  urethritis, 
and  numerous  secondary  and  systemic  manifestations,  of  which  prostatitis 
and  epididymitis,  salpingitis,  arthritis,  synovitis  and  endocarditis  are  the  most 
important.  The  Micrococcus  gonorrhme  (gonococcus)  was  described  by  ISTeis- 
ser,  in  1879. 

Gonorrhoea,  one  of  the  most  widespread  and  serious  of  infectious  diseases, 
presents  many  features  for  consideration.  It  is  not  a  killing  disease;  only  61 
fatal  cases  are  recorded  in  the  Eegistrar  General's  Eeport,  1915,  for  England 
and  Wales,  but  as  a  cause  of  ill-health  and  disability  the  gonococcus  occupies 
a  position  of  the  very  first  rank  among  its  fellows.  While  the  local  lesion  is 
too  often  thought  to  be  trifling,  in  its  singular  obstinacy,  in  the  possibilities 
of  permanent  sexual  damage  to  the  individual  himself  and  still  more  in  the 
"grisly  troop"  which  may  follow  in  its  train,  gonorrhoea  does  not  fall  very  far 
short  of  syphilis  in  importance. 

Etiolo^. — The  organism  is  a  biscuit-shaped  micrococcus,  occurring  in 
pairs,  usually  within  the  leucocytes,  and  is  always  found  in  the  primary  and 
systemic  lesions.  Two  types  of  gonococci  are  described,  corresponding  to  the 
adult  and  infant  forms  of  infection.  The  disease  has  been  reproduced  by 
inoculation  of  the  pure  culture. 

The  disease  is  seen  in  men  and  women  as  a  result  of  impure  sexual  inter- 


126  SPECIFIC  INFECTIOUS  DISEASES 

course,  in  the  new-born  from  vaginal  contamination,  and  in  older  children  cy 
accidental  infection.  Ophthalmia  neonatorum  is  one  of  the  great  causes  of 
blindness,  hut  an  active  campaign  of  education  is  rapidly  reducing  the  number 
of  cases.  The  gonococcus  vaginitis  and  the  ophthalmia  are  very  serious  dis- 
eases in  children's  hospitals  and  in  infants'  homes.  The  story  of  the  gono- 
coccus infection  in  the  Babies'  Hospital,  Xew  York,  for  eleven  years,  as  told 
by  Holt  (X.  Y.  Med.  Jour.,  March,  1905),  illustrates  the  singular  obstinacy 
of  the  infection.  In  spite  of  the  greatest  care  and  precaution,  there  were, 
in  1903,  65  cases  of  vaginitis,  with  2  of  ophthalmia  and  12  of  arthritis.  In 
1901^  there  were  52  cases  of  vaginitis,  only  16  of  which  would  have  been  rec- 
ognized without  the  bacteriological  examination.  In  all,  in  the  eleven  years, 
there  were  273  cases  of  vaginitis,  only  6  with  ophthalmia  and  26  with  arthritis. 
Other  institutions  have  had  equally  sad  experiences.  Isolation  and  pro- 
longed quarantine  are  the  only  measures  to  combat  the  disease  successfully. 

The  immediate  and  remote  effects  of  the  gonococcus  may  be  considered 
under — 

•  I.     The  primary  infection. 

II.  The  spread  in  the  genito-urinary  organs  by  direct  continuity. 

III.  Systemic  gonococcus  infection. 

The  primary  lesion  we  need  not  here  consider,  but  we  may  call  attention  to 
the  frequency  of  the  complications,  such  as  periurethral  abscess,  gonorrhoeal 
prostatitis  and  seminal  vesiculitis  in  the  male,  and  vaginitis,  endocervicitis,  and 
inflammation  of  the  glands  of  Bartholin  in  the  female. 

Perhaps  the  most  serious  of  all  the  sequels  are  those  which  result  from  the 
spread  by  direct  continuity  of  tissue.  Gonococcus  salpingitis  is  not  infrequent. 
Metritis  and  oyaritis  are  also  met  with,  and  peritonitis.  The  gonococcus  has 
been  found  in  pure  culture  in  cases  of  acute  general  peritonitis.  Equally 
important  is  the  cystitis,  which  is  probably  much  more  frequently  the  result 
of  a  mixed  infection  than  due  to  the  gonococcus  itself.  There  is  some  danger 
of  extension  upward  through  the  ureters  to  the  kidneys.  The  pyelitis,  like  the 
cystitis,  is  usually  a  mixed  infection. 

Systemic  Gonococcus  Infection. —  (1)  Goxococcus  Septicemia  and 
Pyemia. — Thayer  and  Blumer  first  cultivated  the  gonococci  from  the  blood 
in  a  case  in  the  senior  author's  wards,  and  the  septicemia  has  been  studied 
by  them  and  by  Cole,  who  divided  the  cases  into  four  groups :  (1)  Those  with 
endocarditis,  11  of  the  29  cases  collected  by  him.  The  clinical  features  are 
those  of  malignant  endocarditis;  two  recovered.  (2)  Cases  with  local  sup- 
puration and  the  general  features  of  a  pycemia — of  the  six  cases  three  died. 
The  septicgemia  associated  with  a  small  focus  of  suppuration  may  be  very  in- 
tense. A  man  ten  days  after  the  onset  of  urethritis  had  chills  and  high  fever ; 
he  became  profoundly  toxsemic  and  died  on  the  morning  of  the  fourth  day 
from  the  chill.  There  was  a  small  prostatic  abscess.  (3)  Cases  icith  no 
metastatic  local  affections  or  perhaps  only  slight  arthritis.  In  a  remarkable 
case  at  the  Johns  Hopkins  Hospital,  three  months  after  an  acute  gonorrhoea 
the  patient  had  a  fever  resembling  typhoid,  which  lasted  seven  weeks.  Gono- 
cocci were  cultivated  from  the  blood.  He  recovered  and,  as  Cole  suggests, 
such  cases  are  probably  more  common  than  we  suspect.  (1)  Cases  of  gon- 
orrhoml  puerperal  septicemia,  of  which  several  instances  have  been  reported. 
Of  the  29  cases  in  which  the  septicaemia  was  demonstrated  by  the  cultivation 


GONOCOCCUS  IN"FECTION  127 

of  the  organism  from  the  blood,  12  died.     The  endocarditis  will  be  consid- 
ered later. 

(2)  GoNOCOccus  Arthritis.— In  many  respects  this  is  the  most  damaging, 
disabling,  and  serious  of  all  the  complications  of  gonorrha:?a,  occurring  in  from 
2  to  5  per  cent,  of  the  cases.  It  occurs  more  frequently  in  males  than  in 
females;  43  to  7  in  one  series  at  the  Johns  Hopkins  Hospital  (Cole).  In  a 
series  of  252  cases  collected  by  Xorthrup,  230  were  in  males;  130  cases  were 
between  twenty  and  thirty  years  of  age.  It  occurS;,  as  a  rule,  during  an  acute 
attack  of  gonorrhoea.  In  208  of  Northrnp's  series  there  was  a  urethral  dis- 
charge while  in  hospital.  It  may  occur  as  the  attack  subsides,  or  even  when  it 
has  become  chronic.  A  gonorrhoeal- arthritis  of  great  intensity  may  occur  in 
a  newly  married  woman  infected  by  an  old  gleet  in  her  husband.  In  women 
it  is  not  always  easy  to  find  evidence  of  local  infection.  As  a  rule,  many  joints 
are  affected.  In  an  analysis  by  Cole  and  McCrae  of  the  involvement  of  the 
joints  in  gonococcus  arthritis  and  in  rheumatic  fever,  the  average  number  in 
the  former  was  double  that  in  the  latter.  In  Northrup's  series  three  or  more 
joints  were  affected  in  175  cases,  one  joint  in  56  cases. 

The  anatomical  changes  are  variable.  The  inflammation  is  often  jperi- 
articular,  and  extends  along  the  sheaths  of  the  tendons.  When  effusion  occurs 
in  the  joints  it  rarely  becomes  purulent.  It  has  more  commonly  the  characters 
of  a  synovitis.  About  the  wrist  and  hand  suppuration  sometimes  occurs 
in  the  sheaths.  The  gonococcus  itself  is  present  in  the  inflamed  joint  or  in 
the  peri -arthritic  exudate,  and  may  often  be  obtained  in  pure  culture.  Some- 
times the  cultures  are  negative.  Mixed  infection  with  staphylococci  or  strepto- 
cocci is  very  rare. 

Clinical  Course. — Variability  and  obstinacy  are  the  two  most  distinguish-! 
ing  features.     The  following  are  the  most  important  clinical  forms : 

(a)  Arthralgia  in  which  there  are  wandering  pains  about  the  joints,  with- 
out redness  or  swelling.     These  persist  for  a  long  time. 

(6)  Polyartliritic,  in  which  several  joints  become  affected.  The  fever  is 
slight;  the  local  inflammation  may  fix  itself  in  one  joint,  but  more  commonly 
several  become  swollen  and  tender.  In  this  form  cerebral  and  cardiac  complica- 
tions may  occur.  In  other  cases  one  joint  is  especially  involved,  the  others 
subsiding  rapidly.  The  pain  is  severe,  the  swelling  extensive,  and  due  chiefly 
to  peri-articular  oedema.  The  general  fever  is  not  at  all  proportionate  to  the 
intensity  of  the  local  signs.  The  exudate  usually  resolves,  though  suppura- 
tion occasionally  supervenes. 

{d)  Chronic  Hydrarthrosis. — This  is  usually  mono-articular,  and  is  par- 
ticularly apt  to  involve  the  knee.  It  comes  on  often  without  pain,  redness, 
or  swelling.  Formation  of  pus  is  rare.  It  occurred  only  twice  in  96  cases 
tabulated  by  Nolen. 

(e)  Bursal  and  Synovial  Form. — This  attacks  chiefly  the  tendons  and 
their  sheaths  and  the  bursaB  and  the  periosteum.  The  articulations  may  not 
be  affected.  The  bursae  of  the  patella,  the  olecranon,  and  the  tendo  Achillis, 
are  most  apt  to  be  involved.  vV  I  ^J 

(/)  Se'pticmmic. — In  this  the  gonococci  invade  the  blood,  and  the  picture 
is  that  of  an  intense  septico-pyasmia,  usually  witli  endocarditis. 

{g)   The  Painful  Ileel  of   Gonorrhcea.^This  is   due   to   local  periosteal 


V 


128  SPECIFIC  INFECTIOUS  DISEASES 

thickening  and  exostosis  on  the  os  calcis,  causing  pain  and  great  disability. 
Baer  has  demonstrated  the  gonococcus  in  the  periosteal  lesion. 

Complications. — Iritis  is  not  infrequent  and  may  recur  with  successive  at- 
tacks. The  visceral  complications  are  serious.  Endocarditis,  pericarditis,  and 
pleurisy  may  occur.  Eenal  infections  are  rare.  There  may  be  a  mixed  in- 
fection with  the  colon  bacillus. 

Treatment. — The  primary  infection — usually  urethritis — should  be  ac- 
tively treated.  Of  special  measures,  the  use  of  antigonococcus  serum  and 
vaccine  treatment  are  worthy  of  trial;  either  will  help  some  cases,  both  fail 
in  many.  Good  food,  fresh  air,  and  open  bowels  are  important.  Drugs  are 
of  little  value,  especially  sodium  salicylate  and  potassium  iodide.  Phenacetine 
or  acet^d-salicylic  acid  may  be  given  for  the  pain. 

The  local  treatment  is  very  important.  In  acute  cases,  fixation  of  the 
joints  for  a  short  period  is  beneficial,  and  in  the  chronic  forms,  massage  and 
passive  motion.  Counter-irritation  by  the  cautery  or  blisters,  active  hyperaemia 
by  baking  or  passive  by  the  Bier  method  are  all  useful.  A  distended  joint  may 
be  tapped  and  then  tightly  bandaged.  The  surgical  treatment  is  more  satis- 
factory in  severe  cases  and  good  results  usually  follow  incision  and  irrigation. 


XIII.     BACILLARY  DYSENTERY 

Definition. — A  form  of  intestinal  flux,  usually  of  an  acute  type,  occurring 
sporadically  and  in  severe  epidemics,  attacking  children  as  well  as  adults, 
characterized  by  pain,  frequent  passages  of  blood  and  mucus,  and  due  to 
the  action  of  a  specific  bacillus,  of  which  there  are  various  strains. 

Etiology. — Owing  to  improved  sanitation,  dysentery  has  become  less  fre- 
quent. In  temperate  climates  sporadic  cases  occur  from  time  to  time,  and  at 
intervals  epidemics  prevail,  particularly  in  overcrowded  institutions.  Eecords 
of  widespread  epidemics  have  been  collected  by  Woodward.  The  most  serious 
was  that  which  prevailed  from  1847  to  1856.  In  Great  Britain  and  Ireland 
epidemics  of  the  disease  have  become  less  frequent.  In  institutions,  particu- 
larly in  overcrowded  asylums,  dysentery  is  very  common,  and  this  form  has 
been  made  the  subject  of  a  valuable  report  by  Mott  and  Durham.  In  the 
tropics  "dysentery  is  a  destructive  giant  compared  to  which  strong  drink  is  a 
mere  phantom"  (Macgregor).  Dysentery  is  one  of  the  great  camp  diseases, 
and  it  has  been  more  destructive  to  armies  than  powder  and  shot.  In  the 
Federal  service  during  the  civil  war,  according  to  Woodward,*  there  were 
259,071  cases  of  acute  and  28,-±51  cases  of  chronic  dysentery.  The  disease 
prevails  in  Porto  Rico,  the  Philippines,  and  to  a  less  extent  in  Cuba.  In 
the  South  African  campaign  dysentery  prevailed  widely.  For  many  years  a 
very  fatal  form  of  dysentery  has  prevailed  in  Japan,  particularly  in  the 
summer  and  autumn  months,  having  a  mortality  of  from  26  to  27  per 
cent.;  in  1899  there  were  125,989  cases,  with  26.709  deaths  (Eldridge).  It  is 
now  generally  conceded  that  the  severe  epidemics  of  acute  dysentery  occurring' 


*  Medical  and  Surgical  History  of  the  War  of  the  Rebellion,  :Nredical,  vol.  ii.  The 
most  exhaustive  treatise  extant  on  intestinal  fluxes — an  enduring  monument  to  tlie 
industry  and  ability  of  the  author. 


BACILLARY  DYSEXTEEY  129 

in  the  tropics  are  of  the  bacillary  type,  and  the  same  form  prevails  in  tem- 
perate climates. 

Bacillus  Dysenteri.^. — In  1898,  Shiga,  a  Japanese  observer,  found  in 
the  dysentery  prevailing  in  his  country  a  bacillus  with  special  characters, 
which  he  considered  to  be  the  specific  cause  of  the  disease. 

Flexner  and  Barker,  of  the  Johns  Hopkins  Commission  for  the  Study  of 
Tropical  Diseases,  found  in  the  dysentery  in  the  Philippine  Islands  an  iden- 
tical organism,  and  it  has  been  made  the  subject  of  very  careful  study  by  Flex- 
ner, and  also  by  R.  P.  Strong,  Musgrave,  and  Craig,  of  the  United  States 
army.  The  organism  appears  to  be  constantly  present  in  the  acute  dysentery 
of  the  tropics.  In  Manila,  according  to  Strong  and  Musgrave,  of  1,328  cases, 
712  were  of  the  acute  specific  variety,  55  suspected  specific  cases,  and  561  of 
amoebic  dysentery.  Kruse,  in  an  outbreak  at  Laar,  in  Germany,  in  which 
300  persons  were  attacked,  isolated  an  identical  bacillus.  Vedder  and  Duval 
demonstrated  that  sporadic  cases  in  adults  in  Philadelphia,  as  well  as  epi- 
demics of  dysentery  in  the  Lancaster  County  Asylum,  Pennsylvania,  and  in 
the  almshouse  at  New  Haven,  were  due  to  this  organism.  Duval  and  Bas- 
sett  demonstrated  that  certain  forms  of  summer  diarrhoeas  of  infants  were 
due  to  infection  with  B.  dysenterice.  The  Rockefeller  Institute  conducted  a 
collective  investigation  into  the  cause  of  infantile  diarrhoeas;  several  observ- 
ers, under  Flexner's  direction,  studied  412  cases  and  found  the  dysentery 
bacillus  present  in  279  or  63.2  per  cent. 

The  strain  of  the  bacillus  most  frequently  found  in  the  United  States  is 
the  "Flexner-Harris"  type.  It  is  now  conceded  that  a  number  of  strains  of 
the  bacillus  occur.  This  fact  has  been  determined  by  the  relative  agglutina- 
tive power  of  immune  serum  upon  the  bacilli  isolated,  as  well  as  by  the  action 
of  the  latter  upon  various  sugars.  The  lesions  produced  by  the  different 
strains  are  identical.  The  organism  agglutinates  with  the  blood  serum  of 
cases  with  acute  dysentery  as  well  as  with  the  serum  of  immunized  animals. 

Infection  takes  place  by  the  mouth.  The  organisms  are  widely  distributed 
by  the  fseces  of  persons  suffering  with  the  disease  and  also  by  dysentery  "car- 
riers." In  institutions  food  and  drink  readily  become  contaminated.  Pos- 
sibly, too,  the  germs  are  distributed  by  flies  and  dust. 

Morbid  Anatomy. — In  the  acute  cases,  when  death  has  occurred  on  the 
fourth  to  the  seventh  day,  the  mucous  membrane  of  the  large  intestine  is 
swollen,  of  a  deep-red  color,  and  presents  elevated,  coarse  corrugations  and 
folds.  In  addition  to  the  intense  hyperemia  there  are  ha^morrhagic  areas. 
Over  the  surface  there  is  usually  a  superficial  necrotic  layer,  which  can  be 
brushed  off  lightly  with  the  finger.  This  may  be  in  patches,  or  uniform  over 
large  areas.  There  is  no  ulceration,  only  the  superficial,  general  necrosis  of 
the  mucosa.  The  solitary  follicles  are  swollen  and  red,  but  the  prominence 
is  obscured  in  the  involvement  of  the  entire  mucosa.  In  cases  of  great  in- 
tensity the  entire  coats  of  the  colon  may  be  stiff  and  thick,  and  the  mucous 
membrane  enormously  increased  in  thickness,  grayish  black,  extensively  necro- 
tic, and,  in  places,  gangrenous.  The  serous  surface  is  often  deeply  injected. 
The  ileum  may  be  involved,  having  a  deeply  hsemorrhagic  mucosa,  with  a 
superficial  necrosis.  In  the  subacute  cases  there  is  not  the  same  great  thicken- 
ing of  the  intestinal  wall,  the  solitary  follicles  are  more  swollen,  there  is  less 
necrosis,  and,  while  there  are  no  ulcers,  there  are  superficial  erosions. 


130  SPECIFIC  IXFECTIOUS  DISEASES 

Symptoms. — According  to  Strong  and  Musgrave^  the  period  of  incuba- 
tion is  not  more  than  forty-eight  hours.  The  onset,  which  is  usually  sudden, 
is  characterized  by  slight  fever,  pain  in  the  abdomen,  and  frequent  stools. 
At  first  mucus  is  passed,  but  within  twenty-four  hours  blood  appears  with  it, 
or  there  is  pure  blood.  There  is  a  constant  desire  to  go  to  stool,  with  great 
straining  and  tenesmus ;  every  hour  or  half  hour  there  may  be  a  small  amount 
of  blood  and  mucus  passed.  The  temperature  rises  and  may  reach  103°  or 
104°.  The  pulse  increases  in  frequency,  and  in  the  severer  cases  becomes 
very  small.  The  tongue  is  coated  with  a  white  fur,  and  there  is  excessive 
thirst.  In  the  very  acute  cases  the  patient  becomes  seriously  ill  within  forty- 
eight  hours,  the  movements  increase  in  frequency,  the  pain  is  of  great  inten- 
sity, the  patient  becomes  delirious,  and  death  may  occur  on  the  third  or 
fourth  day.  In  cases  of  moderate  severity  the  urgency  of  the  symptoms 
abates,  the  stools  lessen,  the  temperature  falls,  and  within  two  or  three  weeks 
the  patient  is  convalescent.  The  mortality  in  the  severe  forms  is  very  high. 
There  is  a  subacute  form  which  lasts  for  many  weeks  or  months.  The  pa- 
tients become  greatly  emaciated,  having  from  three  to  five  stools  in  the  twenty- 
four  hours.  The  BaciUtis  dysenterke  is  found  in  the  stools,  and  it  aggluti- 
nates readily  Avith  the  blood  serum. 

Other  Clinical  Types. — The  foregoing  account  describes  the  essential  fea- 
tures of  bacillary  dysentery  as  seen  in  Japan,  the  Philippines,  and  the  tropics. 
The  clinical  features  of  bacillary  dysentery  in  adults  in  temperate  climates 
differ  in  no  essential  manner  from  those  already  described.  Although  the 
evidence  hardly  warrants  us  at  present  in  making  the  sweeping  statement  that 
all  non-amcebic  cases  of  dysentery  are  bacillary  in  origi-n,  yet  experience  will 
probably  demonstrate  eventually  that  this  is  the  case.  What  is  known  as  the 
acute  catarrhal  dysentery  is  probably  a  sporadic  form  due  to  the  Bacillus 
dysenterm.  Diphtheritic  dysentery  is  a  type  of  the  bacillary  form  with  great 
necrosis  and  infiltration  of  the  mucosa.  There  may  be  rapid  gangrene  and 
a  fatal  termination  within  twenty-four  hours.  A  secondary  diphtheritic  dys- 
entery is  a  common  terminal  event  in  many  acute  and  chronic  diseases,  and 
a  bacillus  of  the  Shiga  type  has  been  isolated  from  these  cases. 

Complications  and  Sequelae. — Peritonitis  is  rare,  due  either  to  extension 
through  the  wall  of  the  bowel  or  to  perforation.  When  this  occurs  about  the 
cfEcal  region,  perityphlitis  results;  when  low  down  in  the  rectum,  periproc- 
titis. In  108  autopsies  collected  by  Woodward  perforation  occurred  in  11. 
Abscess  of  the  liver,  so  common  in  the  amcebic  form,  is  very  rare.  It  is  in- 
teresting to  note,  as  illustrating  the  probable  type  of  the  disease,  how  com- 
paratively rare  abscess  of  the  liver  was  during  the  American  civil  war.  Very 
few  cases  occurred  in  the  South  African  War  (Eolleston). 

In  the  tropics  malaria  and  acute  dysentery  very  often  coexist.  With  refer- 
ence to  typhoid  fever,  as  a  complication.  Woodward  mentions  that  the  com- 
bination was  exceedingly  frequent  during  the  civil  war,  and  characteristic 
lesions  of  both  diseases  coexisted.     In  civil  practice  it  is  extremely  rare. 

Sydenham  noted  that  dysentery  was  sometimes  associated  with  rheumatic 
pains,  and  in  certain  epidemics  a  secondary  arthritis  has  been  especially  preva- 
lent. In  severe  cases  there  may  be  pleurisy,  thrombosis,  pericarditis,  endo- 
carditis, and  occasionally  pysemic  manifestations,  among  which  may  be  men- 
tioned  pylephlebitis.      Chronic   nephritis   is    also   an   occasional   sequel.      In 


BACILLAEY  DYSENTEEY  131 

protracted  cases  there  may  be  an  anaemic  oedema.  An  interesting  sequel  of 
dysentery  is  paralysis.  Woodward  reports  8  cases.  Weir  Mitchell  men- 
tioned it  as  not  uncommon,  occurring  chiefly  in  the  form  of  paraplegia.  As 
in  other  acute  fevers,  this  is  due  probably  to  a  neuritis.  Eemlinger.  in  two 
cases  of  non-amoebic  dysentery  in  Tunis,  observed  an  epididymitis  during 
convalescence ;  gonorrhoea  was  excluded.  In  a  third  case  the  dysentery  was 
complicated  by  an  abscess  of  the  spleen,  which  ruptured,  causing  death.  In- 
testinal stricture  is  a  rare  sequence— so  rare  that  no  case  was  reported  at  the 
Surgeon-General's  office  during  the  civil  war.  It  appears  to  be  not  uncommon 
in  the  East.  Among  the  sequelae  of  chronic  dysentery,  in  persons  who  have 
recovered  a  certain  measure  of  health,  may  be  mentioned  persistent  dyspepsia 
and  irritability  of  the  bowels. 

Diagnosis. — In  the  acute  specific  form  the  blood  serum  agglutinates  the 
dysentery  bacillus.  The  "Flexner-Harris"  type  of  the  organism  agglutinates 
in  dilutions  of  from  1  to  1,000  up  to  1  to  1,500.  The  "Shiga"  type  aggluti- 
nates less  readily.  The  blood  serum  of  a  dysenteric  patient  will  agglutinate 
both  types,  but  the  former  more  readily  than  the  latter.  In  all  non-amoebic 
dysenteries  efforts  should  be  made  to  isolate  the  dysentery  bacillus  from  the 
stools. 

Treatment. — Flint  showed  that  sporadic  dysentery  is,  in  its  slighter  grades 
at  least,  a  self-limited  disease,  Avhich  runs  its  course  in  eight  or  nine  days. 
Eeading  the  report  of  his  cases,  one  is  struck,  however,  with  their  comparative 
mildness. 

Prophylactic. — The  same  precautions  should  be  followed  as  are  adopted 
in  typhoid  fever.  Elexner  and  Gay  have  shown  that  animals  can  be  pro- 
tected from  infection  by  a  previoiis  treatment  with  immune  serum.  Protec- 
tive and  curative  serums  have  been  prepared. 

I.  Acute  Dysentery. — The  patient  should  be  absolutely  at  rest  in  bed. 
He  should  be  kept  warm  and  have  a  flannel  abdominal  binder  applied.  The 
diet  should  be  very  simple — whey,  egg  albumen,  barley  or  rice  water,  and 
strained  gruels.  Milk  and  lactose  may  be  added  later.  Enough  water  should 
be  given  to  relieve  thirst.  If  vomiting  occurs,  nothing  should  be  given  by 
mouth  for  some  hours,  antl  if  the  patient  requires  fluid  this  can  be  given 
subcutaneously.  Hot  applications  to  the  abdomen  are  useful.  If  the  patient 
is  seen  early  in  the  attack,  free  purgation  is  advisable,  for  which  sodium  sul- 
phate and  Eochelle  salts  are  best.  Either  may  be  given  in  doses  of  two  drams 
(8  gm.)  for  two  doses  an  hour  apart  and  later  half  the  amount  every  three 
hours  until  the  bowels  have  moved  freely.  By  this  treatment  the  course  is 
sometimes  cut  short.  If  tlie  attack  is  well  established,  the  use  of  purgatives 
must  be  determined  by  the  conditions  present.  If  solid  faecal  matter  is  being 
passed,  a  purgative  is  indicated,  castor  oil  being  the  best  (3  vi,  25  c,  c).  Un- 
til the  bowels  have  been  thoroughly  cleared,  purgation  is  indicated. 

Medicinal. — Bismuth  in  large  doses  often  has  a  beneficial  effect.  Thirty 
to  sixty  grains  (2  to  4  gm.)  should  be  given  every  hour.  Minute  doses  of  bi- 
chloride of  mercury,  gr.  1/100  (O.OOOG  gm.)  every  two  hours,  were  recom- 
mended l;y  Einger.  For  the  relief  of  pain  and  to  quiet  the  bowel,  morphia 
is  the  most  useful  drug  and  is  to  be  preferred  to  opium  by  mouth.  It  should 
be  given  hypodermically  in  large  doses  (gr.  1-4  to  1-3,  0.016  to  0.022  gm.), 
and  repeated  according  to  the  needs   of  the  patient.     If  tenesmus  is  not 


132  SPECIFIC  IXFECTIOUS  DISEASES 

marked,  opium  can  be  given  as  the  starch  and  laudanum  enema,  in  which 
thirty  minims  (2  c.  c.)  of  laudanum  are  given. 

Local  Treatment. — During  the  acute  stages  this  may  be  out  of  the  ques- 
tion, but  should  be  employed  whenever  possible.  Normal  saline  or  ^.'odium 
bicarbonate  (1  per  cent.)  solution  at  the  body  temperature  can  be  used  as  an 
irrigation.  This  should  be  given  very  gently  and  with  the  hips  elevated.  If 
there  is  rectal  irritation,  a  cocaine  or  morphia  suppository  should  be  given  be- 
forehand. As  the  symptoms  lessen,  the  quantity  of  fluid  can  be  increased  and 
other  solutions  used,  such  as  boric  acid  (5  per  cent.),  salicylic  acid  (1  per 
cent.)   or  alum  (1  to  200). 

With  convalescence  the  diet  should  be  increased  very  gradually  and  only 
simple  foods  allowed.  The  patient  should  be  kept  quiet  until  all  danger  of  a 
relapse  is  over.  This  is  most  important  in  the  prevention  of  a  chronic 
dysentery. 

Serum  Therapy. — Shiga  produced  a  polyvalent  serum  by  immunizing 
horses,  by  which  he  claims  to  have  reduced  the  mortality  in  "endemic"  dys- 
entery in  Japan  from  about  35  per  cent,  to  9  per  cent.  Good  results  have 
been  reported  from  the  use  of  the  Pasteur  Institute  and  Lister  Institute 
serums,  which  should  be  given  in.  doses  of  20  c.  c.  two  or  three  times  a  day. 

11.  Chronic  Dysentery. — The  patient  should  be  at  rest  in  bed  and  on 
simple  diet,  milk,  boiled,  peptonized  or  fermented,  whey,  beef  juice,  and  eggs. 
In  some  cases  milk  may  have  to  be  given  well  diluted  or  in  small  amounts, 
but  it  usually  agrees  well.  It  is  well  to  give  an  occasional  purge  (castor  oil, 
§  ss,  15  c.  c.)  to  empty  the  bowels.  Drugs  by  mouth  are  not  of  great  value. 
Bismuth,  if  used,  should  be  in  large  doses  (3  i,  4  gm.)  every  three  hours 
while  the  patient  is  awake.  Opium  should  not  be  given  as  a  routine  measure, 
as  there  is  great  danger  of  forming  a  habit.  If  employed,  it  is  best  given  in 
the  starch  and  laudanum  enema. 

Local  Treatment. — This  is  most  rational  and  should  be  carried  out  thor- 
oughly. If  the  rectum  is  irritable,  a  cocaine  or  morphine  suppository  should 
be  given  half'  an  hour  previously.  The  irrigation,  at  the  body  temperature, 
should  be  given  very  gently,  the  patient  encouraged  to  retain  it  as  long  as 
possible,  and  the  amount  gradually  increased  up  to  -two  litres  if  possible.  One 
irrigation  a  day  is  usually  enough.  Silver  nitrate  solution  is  probably  the 
best  (1  to  5,000  at  first  and  increased  to  1  to  500).  Boric  acid  (5  per  cent), 
salicylic  acid  (2  per  cent.),  alum,  or  tannic  acid  (3  per  cent.)  may  also  be 
used.  With  any  of  these  an  occasional  irrigation  of  saline  solution  is  useful. 
With  improvement  the  frequency  of  the  irrigations  should  be  reduced.  To  any 
ulcers  in  the  bowel  which  can  be  reached  silver  nitrate  solution  (25  per  cent.) 
should  be  applied.  In  the  obstinate  cases  an  appendicostomy  may  be  done  and 
the  bowel  irrigated  through  the  opening. 


XIV.     MALTA  FEVER 

(Undulant  Fever,  Mediterranean  Fever,  Goat  Fever) 

Definition. — A  specific  fever,  caused  by  the  Micrococcus  melitensis  (and 
M.   paramelitensis)    characterized  by  undulatory   pyrexial   relapses,   profuse 


MALTA  FEVER  133 

sweats,  arthritis,  and  an  enlarged  spleen.  It  is  spread,  as  a  rule,  through  the 
agency  of  goat's  milk. 

Distribution. — The  disease  prevails  in  the  Mediterranean  littoral,  and  en- 
demic foci  exist  in  India,  Africa,  China,  and  Manila.  In  the  goat  raising 
sections  of  Texas  the  disease  is  endemic  (Gentry  and  Ferenbaugh).  In  the 
Malta  garrison  in  the  seven  years  1898-1904,  there  were  2,229  cases,  with 
an  average  case  duration  of  one  hundred  and  twenty  days  and  with  77  deaths. 
About  the  same  number  of  cases  occurred  in  the  fleet.  Since  the  introduction 
of  prophylactic  measures  the  disease  has  practically  disappeared  from  the 
Army  and  Navy,  and  has  diminished  greatly  in  the  civil  population. 

Etiolo^. — The  greater  part  of  our  knowledge  of  this  remarkable  disease 
we  owe  to  the  work  of  British  army  surgeons,  particularly  to  Marston,  Bruce, 
and  Hughes.  In  1886  Bruce  isolated  an  organism,  Micrococcus  melitensis, 
from  the  spleen  and  blood.  Hughes,  Wright,  Semple,  and  others  confirmed 
this.  In  1901-1905  a  Government  Commission  began  a  study  of  the  problems 
of  the  disease.  It  was  shown  to  be  a  septicsemia,  due  to  the  above-named 
organism,  which  had  an  unusually  prolonged  saprophytic  existence.  Zamit 
showed  that  the  goats,  the  most  important  animals  in  the  domestic  life  of 
^lalta,  were  largely  infected,  from  10  to  15  per  cent,  having  the  micrococcus 
in  their  milk.  Monkeys  were  successfully  infected  with  milk  which  contained 
the  organisms.  Steps  were  at  once  taken  to  stop  the  use  of  goat's  milk 
for  the  troops,  with  the  result  that  the  disease  has  disappeared  in  the  garrison 
and  in  the  fleet. 

The  micrococcus  enters  the  system  through  the  gastro-intestinal  tract.  It 
may  spread  by  the  inf-ection  of  food  by  flies  or  by  the  fingers.  Ambulant 
carriers  may  pass  organisms  by  the  urine. 

Symptoms. — There  is  no  specific  fever  which  presents  the  same  remarkable 
group  of  phenomena.  The  period  of  incubation  is  from  six  to  ten  days. 
"Clinically  the  fever  has  a  peculiar  irregular  temperature  curve,  consisting 
of  intermittent  waves  or  undulations' of  pyrexia,  of  a  distinctly  remittent  char- 
acter. These  pyrexial  waves  or  undulations  last,  as  a  rule,  from  one  to  three 
weeks,  with  an  apyrexial  interval  lasting  for  two  or  more  days.  In  rare 
cases  the  remissions  may  become  so  marked  as  to  give  an  almost  intermittent 
character  to  the  febrile  curve,  clearly  distinguishable,  however,  from  the  par- 
oxysms of  paludic  infection.  This  pyrexial  condition  is  usually  much  pro- 
longed, having  an  uncertain  duration,  lasting  for  even  six  months  or  more. 
Unlike  paludism,  its  course  is  not  markedly  affected  by  the  administration  of 
quinine.  Its  course  is  often  irregular  and  even  erratic  in  nature.  This  py- 
rexia is  usually  accompanied  by  obstinate  constipation,  progressive  anaemia, 
and  debility.  It  is  often  complicated  with  and  followed  by  neuralgic  symp- 
toms referred  to  the  peripheral  or  central  nervous  system,  arthritic  effusions, 
painful  inflammatory  conditions  of  certain  fibrous  structures,  of  a  localized 
nature,  or  swelling  of  the  testicles"  (Hughes).  There  is  a  malignant  type, 
in  which  the  disease  may  prove  fatal  within  a  week  or  ten  days ;  an  undulatory 
type — the  common  variety — in  which  the  fever  is  marked  by  intermittent 
Avaves  or  undulations  of  variable  length,  separated  by  periods  of  apyrexia  and 
freedom  from  symptoms.  In  this  really  lie  the  peculiar  features  of  the  dis- 
ease, and  the  victim  may  suffer  a  series  of  relapses  which  may  extend  from 
three  months,  the  average  time,  to  two  years.     Lastly,  there  is  an  intermittent 


134  SPECIFIC  INFECTIOUS  DISEASES 

type,  in  which  the  patient  may  simply  have  daily  pyrexia  toward  evening,  with- 
out any  special  complications,  and  may  do  well  and  be  able  to  work,  and  yet 
at  any  time  the  other  serious  features  of  the  disease  may  develop.  The  mor- 
tality is  slight,  only  about  2  per  cent. 

Diagnosis. — In  early  cases  the  organism  can  usually  be  cultivated  from 
the  blood.  The  agglutination  reaction  and  urine  cultures  are  of  value.  Clini- 
cally the  disease  may  be  diagnosed  as  typhoid  fever,  infective  arthritis  or 
gastro-intestinal  catarrh. 

The  prophylaxis  is  self-evident,  and  the  brilliant  work  of  the  commission 
has  reduced  the  incidence  of  the  disease  to  a  minimum.  The  disease  has  disap- 
peared from  Gibraltar  since  the  importation  of  goats  from  Malta  has  been 
stopped. 

Treatment. — General  measures  suitable  to  typhoid  fever  are  indicated. 
Fluid  food  should  be  given  during  the  febrile  period.  Vaccines  may  be  used 
and  good  results  have  been  reported.  Hydrotherapy,  either  the  bath  or  the 
cold  pack,  should  be  used  every  third  hour  when  the  temperature  is  above 
103°  F.  Otherwise  the  treatment  is  symptomatic.  No  drugs  appear  to  have 
any  special  influence  on  the  fever.  A  change  of  climate  seems  to  promote 
convalescence. 

XV.    CHOLERA  ASIATICA 

Definition. — A  specific,  infectious  disease,  caused  by  the  comma  bacillus 
of  Koch,  and  characterized  clinically  by  violent  purging  and  rapid  collapse. 

Historical  Summary. — Cholera  has  been  endemic  in  India  from  a  remote 
period,  but  only  within  the  last  century  did  it  make  inroads  into  Europe  and 
America.  An  extensive  epidemic  occurred  in  1832,  in  which  year  it  was 
brought  in  immigrant  ships  from  Great  Britain  to  Quebec.  It  travelled  along 
the  lines  of  traffic  up  the  Great  Lakes,  and  finally  reached  as  far  west  as  the 
military  posts  of  the  upper  Mississippi.  In  the  same  year  it  entered  the 
United  States  by  way  of  New  York.  There  were  recurrences  of  the  disease 
in  183o-'36.  In  1848  it  entered  the  country  through  New  Orleans,  and  spread 
widely  up  the  Mississippi  Valley  and  across  the  continent  to  California.  In 
1819  it  again  appeared.  In  1854  it  was  introduced  by  immigrant  ships  into 
New  York  and  prevailed  widely  throughout  the  country.  In  18G6  and  in 
1867  there  were  less  serious  epidemics.  In  1873  it  again  appeared  in  the 
United  States,  but  did  not  prevail  widely.  In  1884  there  was  an  outbreak 
in  Europe,  and  again  in  1892  and  1893.  Although  occasional  cases  have 
been  brought  by  ship  to  the  quarantine  stations  of  Great  Britain  and  the 
United  States,  the  disease  has  not  gained  a  foothold  in  either  country  since 
1873.  It  has  prevailed  extensively  in  the  Philippines.  For  the  past  fifteen 
years  it  has  prevailed  widely  in  the  near  and  far  East.  In  1911  cholera  pre- 
vailed in  Italy,  North  Africa  and  Madeira.  There  were  outbreaks  in  Asia 
Minor,  Arabia  and  Turkey,  and  the  usual  prevalence  in  India.  To  the  United 
States,  during  1911,  cholera  was  frequently  conveyed  by  ships  from  Italy, 
but  there  was  no  difficulty  in  controlling  it.  A  number  of  cholera  "carriers'' 
were  found. 

Etiology. — In  1884  Koch  announced  the  discovery  of  the  specific  organ- 
ism.    Subsequent  observations  have  confirmed  his  statement  that  the  comma 


CHOLERA  ASIATICA  135 

bacillus,  as  it  is  termed,  occurs  constantly  in  the  true  cholera,  and  in  no  other 
disease.  It  has  the  form  of  a  slightly  bent  rod,  which  is  thicker,  but  not  more 
than  about  half  the  length  of  the  tubercle  bacillus,  and  sometimes  occurs  in 
corkscrew-like  or  S  forms.  The  organisms  grow  upon  a  great  variety  of  media 
and  display  distinctive  and  characteristic  appearances.  Koch  found  them  in 
the  water  tanks  in  India,  and  they  were  isolated  from  the  Elbe  water  during 
the  Hamburg  epidemic  of  1892.  During  epidemics  virulent  bacilli  may  be 
found  in  the  fgeces  of  healthy  persons.  The  bacilli  are  found  in  the  intestine, 
in  the  stools  from  the  earliest  period  of  the  disease,  and  very  abundantly  in 
the  characteristic  rice-water  evacuations,  in  which  they  may  be  seen  as  an 
almost  pure  culture.  They  very  rarely  occur  in  the  vomit.  Post  mortem,  they 
are  found  in  enormous  numbers  in  the  intestine.  In  acutely  fatal  cases  they  do 
not  seem  to  invade  the  intestinal  wall,  but  in  those  with  a  more  protracted 
course  they  are  found  in  the  depths  of  the  glands  and  in  the  still  deeper 
tissues.  Experimental  animals  are  not  susceptil^le  to  cholera  germs  admin- 
istered per  OS.  But  if  introduced  after  neutralization  of  the  gastric  contents, 
and  if  kept  in  contact  with  the  intestinal  mucosa  by  controlling  peristalsis  with 
opium,  guinea-pigs  succumb  after  showing  cholera-like  symptoms. 

Cholera  Toxin. — Koch  in  his  studies 'of  cholera  failed  to  find  the  spirilla 
in  the  internal  organs.  He  concluded  that  the  constitutional  symptoms  of  the 
disease  resulted  from  the  absorption  of  toxic  bodies  from  the  intestine.  E. 
Pfeiffer  has  shoAvn  that  the  cholera  toxin  is  intimately  associated  with  the 
protein  of  the  bacterial  cells,  and,  being  of  a  very  labile  nature,  can  not  be 
separated.  Dead  cultures  are  toxic;  and  the  symptoms  produced  by  the  in- 
troduction of  even  minimal  amounts  are  often  comparable  with  those  of  the 
algid  stage  of  cholera  asiatica.  The  symptoms  occur  very  rapidly,  and  death 
often  results  in  eight  to  twelve  hours;  in  non-fatal  cases  recovery  is  often  as 
rapid.  The  intracellular  cholera  toxin  is  poisonous  to  animals  if  introduced 
into  the  blood,  -peritoneal  cavity,  or  subcutaneously.  No  absorption  takes  place 
from  the  intestine  unless  the  epithelial  layer  is  injured. 

Immunity. — Animals  may  be  immunized  by  repeated  injections  of  non- 
fatal doses  of  the  dead  and  later  of  the  living  organisms.  The  serum  of  an 
animal  thus  immunized  has  a  protective  power  when  injected  into  a  guinea 
pig  along  with  five  or  ten  times  the  fatal  dose.  This  serum  has  also  agglutina- 
tive and  other  antibacterial  properties.  The  blood  serum  of  convalescent  pa- 
tients also  possesses  these  properties,  and  for  therapeutic  purposes  anti-serums 
have  been  introduced  and  used  widely  in  India,  the  Philippines  and  in  Eussia. 

Modes  of  Infection. — As  in  other  diseases,  individual  peculiarities  count 
for  much,  and  during  epidemics  virulent  cholera  bacilli  have  been  isolated 
from  the  normal  stools  of  healthy  men.  Cholera  cultures  have  also  been 
swallowed  with  impunity. 

The  disease  is  not  highly  infectious;  physicians,  nurses,  and  others  in 
close  contact  with  patients  are  not  often  affected.  On  the  other  hand,  washer- 
Avomen  and  those  who  are  brought  into  very  close  contact  Avith  the  linen  of 
the  cholera  patients,  or  Avith  their  stools,  are  particularly  prone  to  catch  the 
disease.  There  have  been  several  instances  of  so-called  "laboratory  cholera," 
in  Avhich  students,  having  been  accidentally  infected  while  working  Avith  the 
cultures,  have  taken  the  disease,  and  at  least  one  death  has  resulted. 

Vegetables  Avhicli  have  been  Avashed  in  infected  Avator,  particularly  lettuce 


136  SPECIFIC  INFECTIOUS  DISEASES 

and  cress,  may  convey  the  disease.  Milk  may  also  be  contaminated.  The 
bacilli  live  on  fresh  bread,  butter,  and  meat,  for  from  six  to  eight  days.  In 
regions  in  which  the  disease  prevails  the  possibility  of  the  infection  of  food 
by  flies  should  be  borne  in  mind,  since  it  has  been  shown  that  the  bacilli 
may  live  for  at  least  three  days  in  their  intestines. 

The  disease  is  propagated  chiefly  by  contaminated  water  used  for  drink- 
ing, cooking,  and  washing.  The  virulence  of  an  epidemic  in  any  region  is  in 
direct  proportion  to  the  imperfection  of  its  water-supply.  In  India  the  dem- 
onstration of  the  connection  between  drinking-water  and  cholera  infection  is 
complete.  The  Hamburg  epidemic  is  a  most  remarkable  illustration.  The 
unfiltered  water  of  the  Elbe  was  the  chief  supply,  although  taken  from  the 
river  in  such  a  situation  that  it  was  directly  contaminated  by  sewage.  In 
August,  1892,  there  was  a  sudden  explosive  epidemic,  and  within  three  months 
nearly  18,000  persons  were  attacked,  with  a  mortality  of  42.3  per  cent.  The 
neighboring  city  of  Altona,  which  also  took  its  water  from  the  Elbe,  but  which 
had  a  thoroughly  well-equipped  modern  filtration  system,  had  in  the  same 
period  only  516  cases. 

Two  main  types  of  epidemics  are  recognized :  the  first,  in  whick  many 
individuals  are  attacked  simultaneously,  as  in  the  Hamburg  outbreak,  and 
in  which  no  direct  connection  can  be  traced  between  the  individual  cases.  In 
this  type  there  is  widespread  contamination  of  the  drinking-water.  In  the 
other  the  cases  occur  in  groups,  so-called  cholera  nests;  individuals  are  not 
attacked  simultaneously,  but  successively.  A  direct  connection  between  the 
cases  may  be  very  difficult  to  trace.  Both  these  types  may  be  combined,  and 
in  an  epidemic  which  has  started  in  a  widespread  infection  through  water, 
there  may  be  other  outbreaks,  examples  of  the  second  or  chain-like  type. 
The  disease  always  follows  the  lines  of  human  travel.  In  India  it  has,  in 
many  notable  cases,  been  widely  spread  by  pilgrims.  It  is  carried  also  by 
caravans  and  in  ships.     It  is  not  conveyed  through  the  atmosphere. 

Cholera  '^carriers"  have  an  important  influence.  In  Manila  nearly  8 
per  cent,  of  376  healthy  persons  harbored  the  bacilli.  The  perennial  outbreaks 
in  the  Manila  prison  were  due  to  carriers,  17  of  whom  were  found  among  those 
who  had  to  do  with  the  preparation  of  the  food  and  drink  of  3,000  prisoners. 

Places  situated  at  the  sea-level  are  more  prone  to  the  disease  than  inland 
towns.  In  high  altitudes  the  disease  does  not  prevail  so  extensively.  A  high 
temperature  favors  the  development  of  cholera,  but  in  Europe  and  America 
the  epidemics  have  been  chiefly  in  the  late  summer  and  in  the  autumn. 

The  disease  affects  persons  of  all  ages.  It  is  particularly  prone  to  attack 
the  intemperate  and  those  debilitated  by  want  of  food  and  by  bad  surround- 
ings. Depressing  emotions,  such  as  fear,  undoubtedly  have  an  influence. 
It  is  doubtful  whether  an  attack  furnishes  immunity  against  a  second  one. 

Morbid  Anatomy.— A  post  mortem  diagnosis  can  be  made  by  any  com- 
petent bacteriologist,  as  the  organism  is  distinctive.  The  body  has  the  ap- 
pearances associated  with  profound  collapse.  There  is  often  marked  post 
mortem  elevation  of  temperature.  The  rigor  mortis  sets  in  early  and  may 
produce  displacement  of  the  limbs.  The  lower  jaw  has  been  seen  to  move 
and  the  eyes  to  rotate.  Various  movements  of  the  arms  and  legs  have  also 
been  noted.  The  blood  is  thick  and  dark,  and  there  is  a  remarkable  diminution 
in  the  amount  of  its  water  and  salts,    The  peritoneum  is  sticky,  and  the  coil;'^ 


CHOLERA  ASIATICA  137 

of  intestines  are  congested  and  look  thin  and  shrunken.  The  small  intestine 
usually  contains  a  turbid  serum,  similar  to  that  passed  in  the  stools.  The 
mucosa  is,  as  a  rule,  swollen,  and  in  very  acute  cases  slightly  hypersemic; 
later  the  congestion,  which  is  not  uniform,  is  more  marked,  especially  about 
the  Peyer's  patches.  Post  mortem  the  epithelial  lining  is  sometimes  denuded, 
but  this  is  probably  not  a  change  which  takes  place  freely  during  life.  The 
bacilli  are  found  in  the  contents  of  the  intestine  and  in  the  mucous  mem- 
brane. The  spleen  is  usually  small.  The  liver  and  kidneys  show  cloudy 
swelling,  and  the  latter  extensive  coagulation-necrosis  and  destruction  of  the 
epithelial  cells. 

Symptoms. — A  period  of  incubation  of  uncertain  length,  probably  not 
more  than  from  two  to  five  days,  precedes  the  onset  of  the  symptoms. 

Three  stages  may  be  recognized  in  the  attack :  the  preliminary  diarrhoea, 
the  collapse  stage,  and  the  period  of  reaction. 

(a)  The  preliminary  diarrhosa  may  set  in  abruptly  without  any  pre- 
vious indications.  More  commonly  there  are,  for  one  or  two  days,  colicky 
pains  in  the  abdomen,  with  looseness  of  the  bowels,  perhaps  vomiting,  with 
headache  and  depression  of  spirits.    There  may  be  no  fever. 

(b)  Collapse  Stage. — The  diarrhoea  increases,  or,  without  any  of  the 
preliminary  symptoms,  sets  in  with  the  greatest  intensity,  and  profuse  liquid 
evacuations  succeed  each  other  rapidly.  There  are  in  some  instances  griping 
pains  and  tenesmus.  More  commonly  there  is  a  sense  of  exhaustion  and  col- 
lapse. The  thirst  becomes  extreme,  the  tongue  is  white;  cramps  of  great 
severity  occur  in  the  legs  and  feet.  Within  a  few  hours  vomiting  sets  in  and 
becomes  incessant.  The  patient  rapidly  sinks  into  a  condition  of  collapse, 
the  features  are  shrunken,  the  skin  has  an  ashy-gray  hue,  the  eyeballs  sink 
in  the  sockets,  the  nose  is  pinched,  the  cheeks  are  hollow,  the  voice  becomes 
husky,  the  extremities  are  cyanosed,  and  the  skin  is  shriveled,  wrinkled,  and 
covered  with  a  clammy  perspiration.  The  temperature  sinks.  In  the  axilla 
or  in  the  mouth  it  may  be  from  five  to  ten  degrees  below  normal,  but  in  the 
rectum  and  in  the  internal  parts  it  may  be  103°  or  104°.  The  blood  pressure 
falls  greatly  and  is  often  below  70  mm.  Hg.  The  pulse  becomes  extremely 
feeble  and  flickering,  and  the  patient  gradually  passes  into  a  condition  of 
coma,  though  consciousness  is  often  retained  until  near  the  end. 

The  faces  are  at  first  yellowish  in  color,  from  the  bile  pigment,  but  soon 
they  become  grayish-Avhite  and  look  like  turbid  whey  or  rice-water;  whence 
the  term  "rice-water  stools."  ISTumerous  small  flakes  of  mucus  and  granular 
matter,  and  at  times  blood  are  found  in  them.  The  reaction  is  usually 
alkaline.  The  fluid  contains  albumin  and  the  chief  mineral  ingredient  is 
chloride  of  sodium.  Microscopically,  mucus  and  epithelial  cells  and  innu- 
merable bacteria  are  seen,  the  majority  of  the  latter  being  the  comma  bacilli. 

The  condition  of  the  patient  is  largely  the  result  of  the  concentration  of 
the  blood  consequent  upon  the  loss  of  serum  in  the  stools.  Acidosis  probably 
has  some  influence.  The  specific  gravity  of  the  blood  rises  to  1.060  to  1.073. 
There  is  almost  complete  arrest  of  secretion,  particularly  of  the  saliva  and 
the  urine.  On  the  other  hand,  the  sweat-glands  increase  in  activity,  and  in 
nursing  women  it  has  been  stated  that  the  lacteal  flow  is  unaffected.  This 
stage  sometimes  lasts  not  more  than  tv;o  or  three  hours,  but  more  commonly 
froni  twelve  to  twenty-four. 


138  SPECIFIC  INFECTIOUS  DISEASES 

(c)  Eeaction  Stage. — When  the  patient  survives  the  collapse,  the  cyano- 
sis gradually  disappears,  the  warmth  returns  to  the  skin,  which  may  have  for 
a  time  a  mottled  color  or  present  a  definite  erythematous  rash.  The  heart's 
action  becomes  stronger,  the  urine  increases  in  quantity,  the  irritability  of  the 
stomach  disappears,  the  stools  are  at  longer  intervals,  and  there  is  no  abdom- 
inal pain.  In  the  reaction  the  temperature  may  not  rise  above  normal.  Not 
infrequently  this  is  interrupted  by  a  recurrence  of  severe  diarrhcea  and  the 
patient  is  carried  off  in  a  relapse.  Other  cases  pass  into  the  condition  of  what 
has  been  called  cholera-typhoid,  in  which  the  patient  is  delirious,  the  pulse 
rapid  and  feeble,  and  the  tongue  dry.  Death  finally  occurs  with  coma. 
These  symptoms  have  been  attributed  to  urgemia  and  acidosis. 

During  epidemics  attacks  are  found  of  all  grades  of  severity.  There  are 
cases  of  diarrhoea  with  griping  pains,  liquid,  copious  stools,  vomiting,  and 
cramps,  with  slight  collapse.  They  resemble  the  milder  cases  of  cholera 
nostras.  At  the  opposite  end  of  the  series  there  are  the  instances  of  cholera 
sicca,  in  which  death  may  occur  in  a  few  hours  after  the  onset,  without  diar- 
rhoea. There  are  also  cases  in  which  the  patients  are  overwhelmed  with  the 
poison  and  die  comatose,  without  the  preliminary  stage  of  collapse. 

Complications  and  Sequelae. — The  consecutive  nephritis  rarely  induces 
dropsy.  Diphtheritic  colitis  has  been  described.  There  is  a  special  tendency 
to  diphtheritic  inflammation  of  the  mucous  membranes,  particularly  of  the 
throat  and  genitals.  Pneumonia  and  pleurisy  may  follow,  and  destructive 
abscesses  may  occur  in  different  parts.  Suppurative  parotitis  is  not  very 
uncommon.  In  rare  instances  local  gangrene  may  occur.  A  troublesome 
symptom  of  convalescence  is  cramps  in  the  muscles  of  the  arms  and  legs. 

Diagnosis. — The  only  affection  with  which  Asiatic  cholera  could  be  con- 
founded is  the  cliolera  nostras,  the  severe  choleraic  diarrhoea  which  occurs 
during  the  summer  months  in  temperate  climates.  The  clinical  picture  of  the 
two  affections  is  identical.  The  extreme  collapse,  vomiting,  and  rice-water 
stools,  the  cramps,  the  cyanosed  appearance,  are  all  seen  in  the  worst  forms 
of  cholera  nostras.  In  enfeebled  persons  death  may  occur  within  twelve 
hours.    The  diagnosis  has  to  be  made  by  bacteriological  methods. 

Attacks  very  similar  to  Asiatic  cholera  are  produced  in  poisoning  by 
arsenic,  corrosive  sublimate,  and  certain  fungi;  but  a  difficulty  in  diagnosis 
could  scarcely  arise. 

The  prognosis  is  always  uncertain,  as  the  mortality  ranges  in  different 
epidemics  from  30  to  80  per  cent.  Intemperance,  debility,  and  old  age  are 
unfavorable  conditions.  The  more  rapidly  the  collapse  sets  in,  the  greater  is 
the  danger,  and  as  Andral  truly  says  of  the  malignant  form,  "It  begins  where 
other  diseases  end— in  death."  Patients  with  marked  cyanosis  and  very  low 
temperature  rarely  recover. 

Prophylaxis. — Preventive  measures  are  all-important,  and  isolation  of 
Mie  sick  and  thorough  disinfection  have  effectually  prevented  the  disease  enter- 
ing England  or  the  United  States  since  1873.  During  epidemics  the  greatest 
care  should  be  exercised  in  the  disinfection  of  the  stools  and  linen  of  the 
patients.  When  an  epidemic  prevails,  persons  should  be  warned  not  to  drink 
water  unless  previously  boiled.  The  milk  should  be  boiled  and  all  food  and 
drinks  carefully  protected  from  flies.  Errors  in  diet  should  be  avoided.  Un- 
cooked vegetables  and  salads  should  not  be  eaten.    As  the  disease  is  not  more 


THE  PLAGUE  139 

infectious  than  typhoid  fever,  the  chance  of  a  person  passing  safely  through 
an  epidemic  depends  very  much  upon  how  far  he  is  ahle  to  carry  out  prophy- 
lactic measures  thoroughly.  Digestive  disturbances  are  to  be  treated  promptly, 
and  particularly  diarrhoea,  -which  so  often  is  a  preliminary  symptom.  For 
this,  opium  and  acetate  of  lead  and  large  doses  of  bismuth  should  be  given. 
Protective  inoculation  has  been  carried  out  extensively. 

Treatment. — The  patient  should  be  at  rest  in  bed,  kept  warm,  and  given 
boiled  milk,  whey  and  egg  albumen.  Water  may  be  given  freely.  If  vomiting 
occurs  food  should  be  withheld  and  the  stomach  washed  with  an  alkaline 
solution.  Hot  applications  to  the  abdomen  should  be  used  and  hot  baths  given 
if  they  prove  helpful.  Early  in  the  course  the  bowels  should  be 
moved  by  castor  oil  or  calomel.  During  the  initial  stage,  when  the 
diarrhoea  is  not  excessive  but  the  abdominal  pain  is  marked,  opium 
is  the  most  efficient  remedy,  and  it  should  be  given  hypodermically 
as  morphia.  It  is  advisable  to  give  a  full  dose  at  once  which  may 
be  repeated  on  the  return  of  the  pain.  It  is  best  not  to  attempt  to  give 
remedies  by  the  mouth,  as  they  disturb  the  stomach.  In  the  collapse  stage, 
writers  speak  strongly  against  the  use  of  opium.  Undoubtedly  it  must  be' 
given  with  caution,  but,  judging  from  its  effects  in  cholera  nostras,  it  would 
seem  that  collapse  per  se  was  not  a  contraindication.  Potassium  permanganate 
(gr.  ii,  0.13  gm.  in  keratin  coated  pills)  is  given  every  15  minutes  for  two 
to  four  hours  and  then  every  half  hour  until  the  color  of  the  stools  is  green 
or  yellow.     For  collapse  pituitary  extract  and  caffeine  are  useful. 

Owing  to  the  profuse  serous  discharges  the  blood  becomes  concentrated, 
and  absorption  takes  place  rapidly  from  the  lymph-spaces.  To  meet  this, 
intravenous  injections  were  introduced  by  Latta,  of  Leith,  in  the  epidemic 
of  1832.  Bovell  first  practised  the  intravenous  injections  of  milk  m  Toronto, 
in  the  epidemic  of  1854. 

Saline  injections,  intravenous  and  into  the  bowel,  have  been  much  used 
and  with  great  success  by  the  method  introduced  l)y  Leonard  Rogers.  The 
hypertonic  solution  is  composed  of  sodium  chloride,  grains  120;  potassium 
chloride,  grains  6;  calcium  chloride,  grains  4;  water,  1  pint.  If  the  blood 
pressure  is  below  70  or  the  specific  gravity  of  the  blood  1.0G3  or  over  the 
hypertonic  solution  is  given  intravenously  (1500-3000  c.  c.)  and  repeated  as 
often  as  required  to  keep  the  blood  pressure  above  70  and  the  specific  gravity 
below  1.063.  Normal  saline  solution  (500  c.  c.)  with  glucose  (5  per  cent.)  is 
given  by  the  bowel  every  two  hours  and  at  longer  intervals  if  the  urine  in- 
creases. If  there  is  suppression  of  urine  with  the  danger  of  acidosis,  sodium 
chloride  4  gm.  and  sodium  bicarbonate  10  gm.  in  500  c.  c.  of  water  are  given 
intravenously.     This  treatment  has  markedly  reduced  the  mortality. 

In  the  stage  of  reaction  special  pains  should  be  taken  to  regulate  the  diet 
and  to  guard  against  recurrences  of  the  severe  diarrhoea. 


XVI.     THE  PLAGUE 

Definition. — A  specific,  infectious  disease,  caused  by  Bacillus  pestis,  and 
occurring  in  two  chief  forms :  a  bubonic,  involving  the  lymphatic  glands,  and 
a  pneumonic,  causing  an  acute  and  rai)idly  fatal  inflammatio]i  of  the  lungs. 


140  SPECIFIC  INFECTIOUS  DISEASES 

History  and  Geographical  Distribution,. — The  disease  was  probably  not 
known  to  the  classical  Greek  writers.  The  earliest  positive  account  dates 
from  the  second  century  of  our  era.  The  plague  of  Athens  and  the  pestilence 
of  the  reign  of  Marcus  Aurelius  were  apparently  not  this  disease  (Payne). 
From  the  great  plague  in  the  days  of  Justinian  (sixth  century)  to  the  middle 
of  the  seventeenth  century  epidemics  of  varying  severity  occurred  in  Europe. 
Among  the  most  disastrous  was  the  famous  "black  death"  of  the  fourteenth 
century,  which  overran  Europe  and  destroyed  a  fourth  of  the  population.  In 
the  seventeenth  century  it  raged  virulently,  and  during  the  great  plague  of 
London,  in  1665,  about  70,000  people  died.  During  the  eighteenth  and  nine- 
teenth centuries  the  ravages  of  the  disease  lessened. 

The  revival  of  the  plague  is  the  most  important  single  fact  in  modern 
epidemiology.  Throughout  the  nineteenth  century  it  waned  progressively, 
outbreaks  of  some  extent  occurring  in  Turkey  and  Asia  Minor  and  Astra- 
kan;  but  we  had  begun  to  place  it  with  sweating  sickness  and  typhus  among 
the  diseases  of  the  past.  We  knew  that  it  slumbered  in  parts  of  China,  and  in 
northwest  India,  but  the  outbreak  in  1894  at  Hong-Kong  startled  the  world 
and  showed  that  the  "black  death"  was  still  virulent.  Since  then  it  has 
spread  in  an  ominous  manner,  reaching  India,  China,  French  Indo-China, 
Japan,  Formosa,  Australia,  the  Philippine  Islands,  South  America,  the  West 
Indies,  the  United  States,  Cape  Colony,  Madagascar,  Egypt,  Asia  Minor,  and 
Russia  in  Asia.  In  Europe,  cases  have  been  carried  to  Marseilles  and  other 
Mediterranean  ports  and  to  Hamburg  and  Glasgow.  In  the  latter  city  there 
was  a  small  outbreak  in  1900,  36  cases.  In  the  next  year  there  were  two 
cases  and  in  1907  two  cases — this  without  fresh  importation.  There  have 
been  small  outbreaks  in  the  United  States  at  intervals  from  1907  to  the  present 
with  infection  of  rats  and  ground  squirrels. 

In  England  there  have  been  four  sets  of  human  cases  in  East  Suffolk; 
at  Shotley  in  1906-07,  8  cases  and  6  deaths;  at  Trimley,  in  December,  1909, 
and  January,  1910,  8  cases  and  5  deaths;  at  Freston  in  the  autumn  of  1910, 
4  fatal  cases;  and  a  fourth  case  occurred  in  the  autumn  of  1911.  The  ma- 
jority of  these  were  of  the  pneumonic  type.  There  was  an  infection  of  the 
rats  in  East  Anglia,  beginning  in  the  region  between  Ipswich  and  the  coast. 
The  rats  were  entirely  of  the  species  Mus  decumanus  except  in  part  of  Ipswich. 
The  infection  was  not  very  widespread  as  of  568  rats  examined  only  17  were 
found  infected.  The  disease  extended  to  rabbits,  but  not  to  any  great  extent. 
Some  fleas  from  the  rats  were  found  to  contain  bacilli  indistinguishable  from 
plague.  The  disease  was  introduced  into  Suffolk  by  ship  rats  from  plague 
infected  countries.  More  serious  is  the  fact  that  rats  infected  with  the 
plague  have  been  occasionally  discovered  at  Wapping,  but  there  does  not  seem 
to  have  been  any  widespread  epidemic  among  them.  The  immunity  of  the 
human  population  seems  to  be  due  to  the  fact  that  50  per  cent,  of  the  rat 
fleas  are  of  the  variety  Pulex  cheopis,  which  rarely  bites  man,  and  the  other 
rat  flea,  the  Ceratophyllus  fasciatus,  does  not  bite  man  very  freely.  The  com- 
mon brown  rat  is  not  a  house  resident  to  any  extent,  so  that  conditions  in 
England  are  not  favorable  for  an  epidemic. 

The  distribution  in  India  is  remarkable,  chiefly  in  the  Punjab,  Bombay, 
and  the  United  Provinces,  which  have  a  combined  population  of  about  100 
millions.     In  these  three  provinces  between  1896  and  the  middle  of  1911, 


THE  PLAGUE  141 

about  five  and  a  half  million  deaths  from  plague  have  occurred.  In  the 
remaining  provinces  of  India,  with  a  population  of  some  200  millions, 
only  about  two  millions  of  plague  deaths  have  occurred.  In  the  Presi- 
dency of  Madras  the  disease  has  not  been  very  severe,  while  Eastern 
Bengal  and  Assam  have  remained  free,  though  cases  have  been  repeatedly 
imported.  There  have  been  recent  outbreaks  in  China,  a  sharp  outbreak  in 
Hong-Kong,  and  the  disease  has  been  reported  in  Egypt,  Japan,  Straits  Set- 
tlements, Java  and  Sumatra,  Persia,  Turkey  in  Asia,  Astrakan,  the  Mauritius, 
and  several  of  the  South  American  countries.  The  Manchurian  outbreak  of 
pnemnonic  plague  in  the  wrinter  of  1910-11  was  one  of  the  most  virulent  on 
record,  carrying  off  more  than  45,000  persons  in  a  few  months. 

Etiology. — The  specific  organism  of  the  disease  is  a  bacillus  discovered 
by  Kitasato.  It  resembles  somewhat  the  bacillus  of  chicken  cholera,  and 
grows  in  a  characteristic  manner.  B.  pestis  occurs  in  the  blood,  in  the  organs 
of  the  body  and  in  the  sputum,  and  has  also  been  found  in  the  dust  and  in 
the  soil  of  houses  in  which  the  patients  have  lived,  but  outside  the  body, 
the  life  of  the  bacillus  is  thought  to  be  short.     Bed-bugs  may  harbor  it. 

The  disease  prevails  most  frequently  in  hot  seasons,  though  an  outbreak 
may  occur  during  the  coldest  weather.  Persons  of  all  ages  are  attacked.  It 
spreads  chiefly  among  the  poor,  in  the  slums  of  the  great  cities. 

The  following  conclusions  of  the  Plague  Commission  (1908)  relate  to 
bubonic  plague :  {a)  Contagion  occurs  in  less  than  3  per  cent,  of  the  cases, 
playing  a  very  small  part  in  the  general  spread  of  the  disease.  (6)  Bubonic 
plague  in  man  is  entirely  dependent  on  the  disease  in  the  rat.  (c)  The 
infection  is  conveyed  from  rat  to  rat  and  from  rat  to  man  solely  by  means  of 
fleas,  {d)  A  case  in  man  is  not  in  itself  infectious,  (e)  A  large  majority 
of  cases  occur  singly  in  houses.  When  more  than  on^  case  occurs  in  a  house, 
the  attacks  are  generally  nearly  simultaneous.  (/)  Plague  is  usually  con- 
veyed from  place  to  place  by  imported  fleas,  which  are  carried  by  people  on 
their  persons  or  in  their  baggage.  The  human  agent  may  himself  escape 
infection,  {g)  Insanitary  conditions  have  no  relation  to  the  occurrence  of 
plague,  except  in  so  far  as  they  favor  infestation  by  rats,  {h)  The  non- 
epidemic  season  is  bridged  over  by  acute  plague  in  the  rat,  accompanied  by  a 
few  cases  among  human  beings. 

In  the  pneumonic  form  personal  infection  from  one  person  to  another  is 
the  common  way,  as  the  bacilli  are  sprayed  into  the  air  by  coughing.  The 
possibility  of  the  human  flea  as  a  carrier  must  be  considered. 

Clinical  Forms. — Pestis  Minor. — In  this  variety,  also  known  as  the  am- 
bulant, the  patient  has  a  few  days  of  fever,  with  swelling  of  the  glands  of 
the  groin,  and  possibly  suppuration.  He  may  not  be  ill  enough  to  seek  med- 
ical relief.  These  cases,  often  found  at  the  beginning  and  end  of  an  epidemic, 
are  a  very  serious  danger,  as  the  urine  and  f^ces  contain  bacilli. 

Bubonic  Plague. — This  constitutes  the  common  variety,  77.65  per  cent, 
of  11,600  cases  of  plague  treated  in  the  Arthur  Road  Hospital,  Bombay  (N.  H. 
Choksy).  The  stage  of  invasion  is  characterized  by  headache,  backache, 
stiffness  of  the  limbs,  a  feeling  of  anxiety  and  restlessness,  and  great  depres- 
sion of  spirits.  There  is  a  steady  rise  in  the  fever  until  the  third  or  fourth 
day,  when  there  is  a  drop  of  two  or  three  degrees.  There  is  then  a  secondary 
fever,  as  some  writers  describe  it,  in  which  the  temperature  reaches  a  still 


142  SPECIFIC  IXFECTIOrS  DISEASES 

higher  point.  The  tongue  hecomes  brown,  collapse  symptams  are  apt  to 
supervene,  and  in  very  severe  infections  the  patient  may  die  at  this  stage. 
In  at  least  two-thirds  of  all  cases  there  are  glandular  swellings  or  buboes. 
An  analysis  of  9,500  cases  of  buboes  gave  more'  than  54  per  cent,  with  the 
glands  of  the  groin  affected.  The  swelling  appears  usually  from  the  third 
to  the  fifth  day.  Eesolution  may  occur,  or  suppuration,  or  in  rare  cases 
gangrene.  Suppuration  is  a  favorable  feature,  as  noted  by  De  Foe  in  his 
graphic  account  of  the  London  plague.    There  is  a  high  leucocytosis. 

Petechia  very  commonly  show  themselves,  and  may  be  very  extensive. 
These  have  been  called  the  "plague  spots,"  or  the  "tokens  of  the  disease,"  and 
gave  to  it  in  the  middle  ages  the  name  of  the  Black  Death.  Hsemorrhages 
from  the  mucous  membranes  may  also  occur;  in  some  epidemics  haemoptysis 
has  been  especially  frequent. 

Septicemic  Plague. — In  this,  the  most  rapid  form,  the  patient  succumbs 
in  three  or  four  days  with  a  virulent  infection  before  the  buboes  appear. 
This  form  constituted  14.25  per  cent,  of  the  11,600  cases.  Haemorrhages  are 
common.     The  bacilli  can  be  obtained  from  the  blood. 

PxEUMOXic  Plague. — In  the  ordinary  bubonic  type,  inflammation  of  the 
lungs  is  not  an  uncommon  complication,  but  the  true  pneumonic  plague 
begins  abruptly  with  fever,  shortness  of  breath,  cough,  and  sometimes  pain 
in  the  chest.  The  fever  increases,  the  signs  of  the  involvement  of  the  lung 
occur  early:  there  may  be  impaired  resonance  at  both  bases  with  harsh  and 
tubular  breathing;  the  sputum  becomes  bloody  and  stained  and  more  fluid 
than  in  ordinary  pneumonia.  Cyanosis  is  an  early  feature;  the  pulse  is  small 
and  rapid,  the  patient  becomes  profoundly  prostrate;  the  spleen  enlarges 
rapidly,  as  early  as  the  second  day,  and  a  fatal  result  follows  in  from  two  to 
four  days.     Eeeovery  is  very  rare. 

In  other  varieties  the  chief  manifestations  may  be  in  the  skin  and  sub- 
cutaneous tissues,  or  in  the  intestiries,  causing  diarrhoea  and  sometimes  the 
features  of  typhoid  fever. 

Diagnosis. — At  the  early  stage  of  an  outbreak  plague  cases  are  easily 
overlooked,  but  if  the  suspicious  cases  are  carefully  studied  by  a  competent 
bacteriologist,  there  is  no  disease  which  can  be  more  positively  identified. 
The  San  Francisco  epidemic  illustrates  this.  The  nature  of  the  cases  was 
recognized  by  Kellog  and  by  Kinyoun,  but  with  an  amazing  stupidity  (which 
was  shared  by  not  a  few  physicians,  who  should  have  known  better)  the  Gov- 
ernor of  the  State  refused  to  recognize  the  presence  of  jDlague,  and  the  United 
States  Government  had  to  intervene  and  send  a  board  of  exiaerts  to  settle 
the  question.  The  widespread  prevalence  of  the  disease  makes  it  the  impera- 
tive duty  of  the  health  authorities  to  have  on  hanct,  in  connection  with  large 
ports,  skilled  men  who  can  promptly  make  the  bacteriological  diagnosis.  There 
are  dangers  from  the  cultures  in  laboratories,  but  with  proper  precautions 
they  may  be  reduced  to  a  minimum.  Acute,  rapidly  fatal  pneumonia  should 
arouse  suspicion  as  in  the  Suffolk  cases. 

Prophylaxis. — Wherever  plague  exists  an  organized  staff,  an  intelligent 
policy,  and  a  long  purse  are  needed.  In  India,  where  fifteenth-century  con- 
ditions prevail,  and  where  the  scale  of  the  epidemic  is  so  enormous,  the  prob- 
lem of  prophylaxis  looks  hopeless.  Simpson's  recommendation  of  a  specially 
trained   plague   service,   organized  on   proper   lines  and  on   a  liberal  basis. 


TETANUS  US 

should  be  carried  out.  A  careful  watch  should  be  kept  on  the  mortality  of 
rats.  When  found  infected,  energetic  measures  should  be  taken  to  stamp  out 
the  disease  in  them.  Three  things  are  necessary — the  cleansing  of  premises, 
particularly  stables  and  outhouses,  so  that  the  rats  cannot  find  nesting  places 
or  food;  systematic  rat  destruction;  and  making  houses  rat  proof.  Certain 
measures  prevent  the  access  of  plague  to  healthy  ports;  fumigation  of  ships 
to  destroy  the  rats,  careful  inspection  of  passengers  and  crew,  and  detention 
over  a  period  which  covers  the  incubation  of  the  disease. 

When  a  centre  becomes  infected,  the  sanitary  organization  should  carry 
out  the  segregation  of  the  sick  in  hospitals,  the  disinfection  of  infected  rooms 
with  sulphur,  destruction  of  infected  bedding,  and  thorough  cleansing  of  the 
entire  district;  old,  badly  infected  buildings  should  be  destrayed. 

Treatment. — In  a  disease  the  mortality  of  which  may  reach  as  high  as  80 
or  90  per  cent,  the  question  of  treatment  resolves  itself  into  making  the  patient 
as  comfortable  as  possible,  and  following  out  certain  general  principles  such 
as  guide  us  in  the  care  of  fever  patients.  Cantlie  recommends  purgation  and 
stimulation  from  the  outset,  and  the  use  of  morphia  for  the  pain.  The  local 
treatment  of  the  buboes  is  important.  Ice  may  be  applied  to  them,  and 
good  results  apparently  follow  the  injection  of  the  bichloride  of  mercury. 
The  pyrexia  of  the  disease  is  best  treated  by  systematic  hydrotherapy. 

A  plague  serum,  chiefly  the  Lustig  and  the  Yersin-Eoux,  has  been  used. 
Choksy  concludes  that  a  reduction  of  20-25  per  cent,  in  the  mortality  may  be 
obtained  by  its  use. 

Preventive  Inoculation. — With  Haffkine's  serum  in  12  districts  of 
224,228  persons  inoculated,  3,399  took  the  disease;  of  639,600  uninoculated, 
49,430  were  attacked.  C.  J.  Martin  concludes  that  the  chances  of  infection 
are  reduced  four-fifths,  and  the  chances  of  recovery  are  two  and  a  half  times 
as  great  as  in  the  uninoculated.  The  reports  from  India  are  most  favorable 
and  in  South  America  the  value  of  this  plan  has  been  demonstrated.  It  is 
interesting  to  note  that  the  laboratory  staff  at  Bombay,  116  in  number,  have 
remained  immune  though  in  constant  contact  with  plague  infested  rats. 


XVII.     TETANUS 

{Loci- jaw) 

Definition. — An  infectious  malady  characterized  by  tonic  spasms  of  the 
muscles  with  marked  exacerbations.  The  virus  is  produced  by  a  bacillus, 
B.  tetani  of  Nicolaier,  which  occurs  in  earth,  in  putrefying  fluids,  and  manure, 
and  is  a  normal  inhabitant  of  the  intestines  of  many  ruminants. 

Etiology. — In  the  United  States,  according  to  Anders  and  Morgan,  it  is 
most  frequent  in  the  Hudson  valley,  in  Long  Island  and  in  the  Atlantic 
States.  In  1917  there  were  1.329  deaths  from  tetanus  in  the  registration  area, 
of  which  329  were  in  children  under  one  year.  An  extraordinary  number  of 
cases  have  followed  the  accidents  of  the  July  4th  celebrations,  but  the  propa- 
ganda of  the  Journal  of  the  American  ]\ledical  Association  has  succeeded  in 
reducing  these  fatalities  in  a  remarkable  way. 

In  England  the  disease  is  not  very  common.     There  were  166  deaths  in 


144  spEcinc  i:ntectious  diseases 

191.6,  It  is  more  prevalent  in  certain  districts,  e.  g.  the  Tliames  valley.  It  is 
more  frequent  in  the  EadclifEe  Infirmary,  Ozford,  than  in  any  hospital  with 
which  the  senior  author  was  connected.  It  is  more  common  in  the  summer 
months  and  males  are  more  frequently  attacked  than  females.  In  E.  W. 
Hill's  analysis  of  3,038  cases  in  temperate  climates  22.31  per  cent,  were  in 
children  under  one  year,  21  per  cent,  in  the  third  and  fourth  decades. 

In  the  tropics  tetanus  is  a  much  more  severe  and  common  disease.  In 
Jamaica  and  Cuba  it  is  from  five  to  six  times  more  frequent  as  a  cause  of 
death  than  in  the  United  States,  and  above  80  per  cent  of  the  deaths  are  in 
infants.  In  the  Canal  Zone  the  disease  has  not  been  common,  only  25  cases 
have  been  admitted  to  the  Ancon  and  Colon  Hospital  (E.  W.  Hill)  to  1910. 
It  is  not  only  in  the  tropics  that  tetanus  is  a  very  fatal  disease  in  infants.  On 
an  island  near  Iceland  all  the  children  born  died;  and  for  years  the  island  of 
St.  Kilda,  one  of  the  "Western  Hebrides,  had  been  scourged  by  the  "eight  days 
sickness"  among  the  new  born.  Of  125  children,  84  died  within  fourteen 
days  of  birth.  Since  the  introduction  of  proper  methods  of  treating  the  um- 
bilical cord  the  disease  has  practically  disappeared. 

The  tetanus  bacillus  has  contaminated  vaccines,  and  its  presence  in  com- 
mercial gelatine  is  a  grave  danger.  Outbreaks  have  occurred  in  general  hos- 
pitals following  the  use  of  catgut.  The  disease  has  occurred  after  prolonged 
use  of  the  hypodermic  needle  to  inject  morphia  or  quinine,  and  has  followed 
the  use  of  gelatine  as  a  hsemostatic. 

The  disease  usually  follows  an  injury,  often  of  a  most  trifling  character, 
and  particularly  lacerated  wounds  of  the  hands  which  have  been  contaminated 
by  dirt  and  splinters.  It  may  occur  without  any  recognizable  wound,  so- 
called  idiopathic  tetanus. 

The  Tetanus  Bacillus. — The  organism  is  widely  diffused  in  nature,  in 
garden  mould,  in  and  about  stables  and  farmyards,  and  is  a  normal  inhabi- 
tant of  the  intestines  of  many  horses  and  of  the  herbivora.  The  disease  has 
been  produced  by  inoculating  animals  with  garden  earth.  Living  bacilli  occur 
in  the  intestines  of  5  per  cent,  of  healthy  men  and  up  to  20  per  cent,  of  hostlers 
and  dairymen.  It  is  a  slender  motile  bacillus,  one  end  of  which  is  swollen  and 
occupied  by  a  spore.  It  is  anaerobic  and  grows  at  ordinary  temperatures.  The 
spores  are  the  most  resistant  known.  From  two  steel  nibs  dipped  in  a  tetanus 
culture  in  1891  a  growth  of  virulent  bacilli  was  obtained  from  one  in  1902 
and  from  the  other  in  1909  (Semple).  The  toxin  is  perhaps  the  most  virulent 
of  known  poisons.  "Whereas  the  fatal  dose  of  strychnine  for  a  man  weighing 
70  kilos  is  from  30  to  100  milligrammes,  that  of  the  tetanus  toxin  is  esti- 
mated at  0.23  milligramme.  Every  feature  of  the  disease  can  be  produced 
by  it  experimentally  without  the  presence  of  the  bacilli.  The  symptoms  do  not 
arise  immediately,  but  slowly,  and  it  has  been  found  to  be  absorbed  by  the 
end  plates  in  the  muscles  and  to  pass  up  the  motor  nerves  to  the  spinal  cord. 
The  bacilli  have  been  found  in  a  few  cases.  The  period  of  incubation  is  the 
time  required  for  the  toxins  to  travel  along  the  nerves  to  the  centres.  A 
high  degree  of  antitoxic  immunity  can  be  conferred  on  animals,  which  then 
yield  a  protective  serum.  It  is,  however,  difficult  to  cure  animals  with  this 
serum  on  account  of  the  combination  of  the  toxin  with  nerve-cells  by  the  time 
symptoms  appear. 

Morbid  Anatomy. — Xo  characteristic  lesions  have  been  found  in  the  cord 


TETANUS  145 

or  in  the  brain.  Congestions  occur  in  different  parts,  and  perivascular  exu- 
dations and  granular  changes  in  the  nerve-cells  have  been  found.  The  con- 
dition of  the  wound  is  variable.  The  nerves  are  often  found  injured,  red- 
dened, and  swollen.     In  tetanus  neonatorum  the  umbilicus  may  be  inflamed. 

Symptoms. — The  incubation  period  is  from  one  to  twenty  days.  Of  1,092 
cases  analyzed  by  E.  W.  Hill,  in  17.49  per  cent,  it  was  from  one  to  five  days 
and  in  55.06  per  cent,  from  five  to  ten  days.  In  only  8  cases  was  the  incu- 
bation as  long  as  twenty  days.  The  patient  complains  at  first  of  slight  stiff- 
ness in  the  neck,  or  a  feeling  of  tightness  in  the  Jaws,  or  difficulty  in  mastica- 
tion. Occasionally  chilly  feelings  or  actual  rigors  may  precede  these  symp- 
toms. Gradually  a  tonic  spasm  of  the  muscles  of  these  parts  produces  the 
condition  of  trismus  or  lockjaw.  The  e5''ebrows  may  be  raised  and  the  angles 
of  the  mouth  drawn  out,  causing  the  so-called  sardonic  grin — risus  sardonicus. 
In  children  the  spasm  may  be  confined  to  these  parts.  Sometimes  the  attack 
is  associated  with  paralysis  of  the  facial  muscles  and  difficulty  in  swallowing 
— the  head-tetaniTS  of  Eose,  which  has  most  commonly  followed  injuries  in  the 
neighborhood  of  the  fifth  nerve.  Gradually  the  process  extends  and  involves 
the  muscles  of  the  body.  Those  of  the  back  are  most  affected,  so  that  during 
the  spasm  the  unfortunate  victim  may  rest  upon  the  head  and  heels — a  position 
known  as  opisthotonos.  The  rectus  abdominis  muscle  has  been  torn  across 
in  the  spasm.  The  entire  trunk  and  limbs  may  be  perfectly  rigid — orthotonos. 
Flexion  to  one  side  is  less  common — phurothotonos ;  while  spasm  of  the  mus- 
cles of  the  abdomen  may  cause  the  body  to  be  bent  forward — emprostJiotonos. 
In  very  violent  attacks  the  thorax  is  compressed,  the  respirations  are  rapid,  and 
spasm  of  the  glottis  may  occur,  causing  asphyxia.  The  paroxysms  last  for 
a  variable  period,  but  even  in  the  intervals  the  relaxation  is  not  complete. 
The  slightest  irritation  is  sufficient  to  cause  a  spasm.  The  paroxysms  are 
associated  with  agonizing  pain,  and  the  patient  may  be  held  as  in  a  vise,  un- 
able to  utter  a  word.  Usually  he  is  bathed  in  a  profuse  sweat.  The  tempera- 
ture may  remain  normal  throughout,  or  show  only  a  slight  elevation  toward 
the  close.  In  other  cases  the  pyrexia  is  marked  from  the  outset;  the  tempera- 
ture reaches  105°  or  106°  F.,  and  before  death  109°  or  110°  F.  In  rare 
instances  it  may  go  still  higher.  The  course  is  sometimes  very  rapid,  with 
fever  and  general  spasms;  death  may  take  place  on  the  third  day.  Death 
either  occurs  during  the  paroxysm  from  heart-failure  or  asphyxia,  or  is  due 
to  exhaustion. 

The  cephalic  tetanus  (Kopftetanus  of  Eose)  originates  usually  from  a 
wound  of  the  head,  and  is  characterized  by  stiffness  of  the  muscles  of  the 
jaw  and  paralysis  of  the  facial  muscles  on  the  same  side  as  the  wound,  with 
difficulty  in  swallowing.  There  may  be  no  other  symptoms.  This  form  has 
been  called  hydrophobic  because  of  the  spasm  of  the  throat.  The  prognosis 
is  good  in  the  chronic  cases,  which  may  show  slight  symptoms  only.  Tetanus 
of  one  extremity  has  been  observed. 

Tetanus  neonatorum. — This  is  a  common  form,  particularly  in  hot  cli- 
mates and  in  districts  where  the  tetanus  bacillus  is  very  prevalent,  as  in 
the  island  of  St.  Kilda.  The  infection  follows  imperfect  treatment  of  the 
navel.  The  s}inptoms  may  come  on  in  a  few  'days  or  be  delayed  for  ten 
days.  Trismus  and  difficulty  in  crying  and  taking  food  are  the  earliest 
symptoms,  followed  in  a  few  days  by  more  general  spasms.     It  is  a  very  fatal 


146  SPECIFIC  INFECTIOUS  DISEASES 

form.  A  form  known  as  visceral  tetanus  is  described  by  the  French  in  which 
the  disease  originates  in  the  intestines,  and  the  possibility  of  this  must  be 
considered,  as  the  spores  have  been  found  in  human  faeces.  Post-operative 
tetanus  occurs  particularly  after  peritoneal  operations.  Paterson  collected 
150  cases  in  a  large  proportion  of  which  catgut  had  been  used.  It  is  a  very 
fatal  form,  with  a  short  incubation  and  rapid  course.  Operation  on  an  indi- 
vidual who  has  recovered  from  tetanus  a  short  time  before,  may  cause  a 
relapse. 

Diagnosis. — ^Yell-ma^ked  cases  following  a  trauma  could  not  be  mistaken 
for  any  other  disease.  The  spasms  are  not  unlike  those  of  strychnia-poison- 
ing, and  in  the  celebrated  Palmer  murder  trial  this  was  the  plea  for  the 
defence.  The  jaw-muscles,  however,  are  never  involved  early,  if  at  all,  and 
between  the  paroxysms  in  strychnia-poisoning  there  is  no  rigidity.  In  tetany 
the  distribution  of  the  spasm  at  the  extremities,  the  peculiar  position,  the 
greater  involvement  of  the  hands,  and  the  condition  under  which  it  occurs 
are  sufficient  to  make  the  diagnosis  clear.  In  doubtful  cases  cultures  should 
be  made  from  the  pus  of  the  wound.  A  mild  trismus  may  occur  with  throat 
infection  and  should  not  be  mistaken  for  head  tetanus. 

Escherich  has  described  in  children  a  form  of  generalized  tonic  contrac- 
tures of  the  muscles  of  the  jaw,  neck,  back,  and  limbs,  usually  a  sequel  of 
some  acute  infection,  occasionally  occurring  as  an  independent  malady.  The 
contractures  may  be  either  intermittent  or  persistent.  The  condition  may 
last  from  a  week  to  a  couple  of  months.     The  cases  as  a  rule  recover. 

Prognosis. — Two  of  the  Hippocratic  aphorisms  express  tersely  the  general 
prognosis  even  at  the  present  day :  "The  spasm  supervening  on  a  wound  is 
fatal,"  and  "such  persons  as  are  seized  with  tetanus  die  within  four  days, 
or  if  they  pass  these  they  recover."  Of  1,264  cases  analyzed  by  E.  W.  Hill 
only  414  recovered.  If  the  disease  lasts  beyond  the  tenth  day  the  patient 
has  an  even  chance,  and  from  this  time  the  prognosis  improves. 

The  mortality  is  greatest  in  children.  Favorable  indications  are :  late 
onset  of  the  attack,  localization  of  the  spasms  to  the  muscles  of  the  neck  and 
jaw,  and  an  absence  of  fever. 

Prophylaxis. — Suspicious  wounds  should  be  freely  opened,  thoroughly  dis- 
infected by  hydrogen  peroxide  and  cauterized  with  pure  phenol.  In  dis- 
tricts where  the  disease  prevails,  special  precautions  should  be  taken  with 
all  injuries,  and  a  prophylactic  dose  of  anti-tetanic  serum  (500  to  1,500 
units)  administered.  The  experience  in  the  United  States  with  this  treatment 
in  the  Fourth  of  July  accidents  has  been  most  satisfactory.  It  should  be 
carried  out  promptly  in  all  street  and  infected  injuries.  As  the  serum  is 
expensive.  Boards  of  Health  should  arrange,  if  necessary,  to  provide  it. 

Treatment. — The  patient  should  be  kept  in  a  darkened  room,  absolutely 
quiet,  and  attended  by  only  one  person.  All  possible  sources  of  irritation 
should  be  avoided.  Veterinarians  appreciate  the  importance  of  this  complete 
seclusion  in  treating  horses. 

When  the  lockjaw  is  extreme  the  patient  may  not  be  able  to  take  food  by 
the  mouth,  under  which  circumstances  it  is  best  to  use  rectal  injections,  or 
to  feed  by  a  catheter  passed  through  the  nose.  The  spasm  should  be  con- 
trolled by  chloroform,  which  may  be  repeatedly  exhibited  at  intervals.  It  is 
more  satisfactory  to  keep  the  patient  thoroughly  under  the  influence  of  mor- 


GLANDERS  147 

phia  giveii  hypodermically.  Chloral  hydrate,  chloretone,  bromide  of  potas- 
sium, and  other  drugs  have  been  recommended,  and  recovery  occasionally 
follows  their  use.  Intraspinal  injections  of  a  solution  of  magnesium  sulphate 
(25  per  cent.)  have  been  used  (Meltzer)  ;  1  c.  c.  is  injected  for  every  25 
pounds  weight  of  the  patient.  Eesection  of  the  nerve  and  amputation  of 
the  limb  have  been  advised.  Although  tetanus  antitoxin  of  great  strength 
can  be  obtained,  its  use  in  the  treatment  of  human  tetanus  very  often  fails 
because  it  is  given  too  late.  Given  at  once  and  in  sufficient  doses,  it  should 
prove  a  specific.  It  may  be  given  in  various  ways.  The  administration  of 
3,000  to  -5.000  imits  intraspinally  (repeated  in  24  hours)  and  10,000  units 
intravenously  and  10,000  units  subcutaneously  three  or  four  days  later  has 
given  good  results  (^Ticoll).  Intramuscular  injections  about  the  site  of  the 
wound  and  intraneural  into  the  large  nerve  trunk  leadnig  from  the  wounded 
area  have  seemed  useful  in  some  cases. 


XVIII.     GLANDERS 

{Farcy) 

Definition. — An  infectious  disease  of  the  horse  and  ass,  caused  by  Bacillus 
mallei,  communicated  occasionally  to  man.  In  the  horse  it  is  characterized  by 
the  formation  of  nodules,  chiefly  in  the  nares  (glanders)  and  beneath  the 
skin  (farcy). 

Etiology. — The  disease  belongs  to  the  infective  granulomata.  The  local 
manifestations  in  the  nostrils  and  the  skin  of  the  horse  are  due  to  the  same 
cause.  The  specific  germ  was  discovered  by  Loeffler  and  Schutz.  It  is  a  short, 
non-motile  bacillus,  not  unlike  that  of  tubercle,  but  exhibits  different  stain- 
ing reactions.  It  grows  readily  on  the  ordinary  culture  media.  For  the  full 
recognition  of  glanders  in  man  we  a-re  indebted  to  the  labors  of  Rayer,  whose 
monograph  remains  one  of  the  best  descriptions  of  the  disease.  Man  becomes 
infected  by  contact  with  diseased  animals,  and  usually  by  inoculation  on  an 
abraded  surface  of  the  skin.  The  contagion  may  also  be  received  on  the  mucous 
membrane.  In  a  Montreal  case  a  gentleman  was  probably  infected  by  the 
material  expelled  from  the  nostril  of  his  horse,  which  was  not  suspected  of 
having  the  disease.  It  is  a  rare  disease.  Only  3  deaths  were  registered  from 
this  cause  in  England  and  Wales  in  1916  and  none  in  1915.  Among  labora- 
tory workers  the  Bacillus  mallei  has  caused  more  deaths  than  any  other  germ, 
and  in  working  with  it  the  greatest  precautions  should  be  taken. 

Morbid  Anatomy. — As  in  the  horse,  the  disease  may  be  localized  in  the 
nose  (glanders)  or  beneath  the  skin  (farcy).  The  essential  lesion  is  the 
granulomatous  tumor,  characterized  by  the  presence  of  numerous  lymphoid 
and  epithelioid  cells,  among  and  in  which  are  seen  the  glanders  bacilli.  These 
nodular  masses  tend  to  break  down  rapidly,  and  on  the  mucous  membrane 
result  in  ulcers,  while  beneath  the  skin  they  form  abscesses.  The  glanders 
nodules  may  also  occur  in  the  internal  organs. 

Symptoms. — An  acute  and  a  chronic  form  of  glanders  may  be  recognized 
in  man,  and  an  acute  and  a  chronic  form  of  farcy. 

Acute  Glandkiss. — The  period  of  incubation  is  rarely  more  than  three  or 


148  SPECIFIC  IXFECTIOUS  DISEASES 

four  days.  There  are  signs  of  general  febrile  disturbance.  At  the  site  of  in- 
fection there  are  swelling,  redness,  and  lymphangitis.  "Within  two  or  three 
days  there  is  involvement  of  the  mucous  membrane  of  the  nose,  the  nodules 
break  down  rapidly  to  ulcers,  and  there  is  a  muco-purulent  discharge.  An 
eruption  of  papules,  which  rapidly  become  pustules,  breaks  out  over  the  face 
and  about  the  joints.  It  has  been  mistaken  for  variola.  In  a  Montreal  case 
this  copious  eruption  led  the  attending  physician  to  suspect  smallpox,  and 
the  patient  was  isolated.  There  is  a  great  swelling  of  the  nose.  There  may  be 
an  eruption  like  erysipelas.  The  ulceration  may  go  on  to  necrosis,  in  which 
case  the  discharge  is  very  offensive.  The  lymph  glands  of  the  neck  are  usually 
much  enlarged.  Subacute  pneumonia  is  very  apt  to  occur.  This  form  runs 
its  course  in  about  eight  or  ten  days,  and  is  invariably  fatal.  Glanders  piieu- 
monia  may  appear  after  subcutaneous  infection  (one  case  from  infection  with 
a  hypodermic  syringe  stuck  into  the  thumb).  Grossly  the  lung  appeared  like 
a  caseous  pneumonia. 

Cheoxic  glandees  is  rare  and  difficult  to  diagnose,  as  it  is  usually  mis- 
taken for  a  chronic  coryza.  There  are  ulcers  in  the  nose  and  often  laryngeal 
symptoms.  It  may  last  for  months,  or  even  longer,  and  recovery  sometimes 
takes  place.  Tedeschi  described  a  case  of  chronic  osteomyelitis,  due  to  the 
Bacillus  mallei,  which  was  followed  by  a  fatal  glanders  meningitis.  The 
diagnosis  may  be  extremely  difficult.  In  such  cases  a  suspension  of  the  secre- 
tion, or  of  cultures  upon  agar-agar  made  from  the  secretion,  should  be  in- 
jected into  the  peritoneal  cavity  of  a  male  guinea-pig.  At  the  end  of  two 
days,  in  positive  cases,  the  testicles  are  found  to  be  swollen  and  the  skin  of 
the  scrotum  reddened.  The  testicles  continue  to  increase  in  size,  and  finally 
suppurate.  Death  takes  place  after  the  lajDse  of  two  or  three  weeks,  and  gen- 
eralized glanders  nodules  are  found  in  the  viscera.  The  use  of  mallein  for 
diagnostic  purposes  is  highly  recommended.  The  principles  and  methods  of 
application  are  the  same  as  for  tuberculin.  McFadyean  and  others  have 
shown  that,  while  the  glanders  bacilli  are  agglutinated  in  a  dilution  of  1  to 
200  by  normal  horse  serum,  that  of  a  glanders  horse  will  agglutinate  at  1 
to  1,000.    The  test  must  be  made  before  mallein  is  given. 

Acute  faecy  in  man  results  usually  from  the  inoculation  of  the  virus 
into  the  skin.  There  is  an  intense  local  reaction  with  a  phlegmonous  inflam- 
mation. The  lymphatics  are  early  affected,  and  along  their  course  there  are 
nodular  subcutaneous  enlargements,  the  so-called  farcy  buds,  which  may  rap- 
idly go  on  to  suppuration.  There  are  pains  and  swelling  in  the  joints,  and 
abscesses  may  form  in  the  muscles.  The  symptoms  are  those  of  an  acute  in- 
fection, almost  like  an  acute  septicaemia.  The  nose  is  not  involved  and  the 
superficial  skin  eruption  is  not  common.  The  bacilli  have  been  found  in  the 
urine  in  acute  cases  in  man  and  animals. 

The  disease  is  fatal  in  a  large  proportion  of  the  cases,  usually  in  from 
twelve  to  fifteen  days. 

Cheoxic  faecy  is  characterized  by  the  presence  of  localized  tumors  which 
break  down  into  abscesses,  and  sometimes  form  deep  ulcers,  without  much  in- 
flammatory reaction  and  without  special  involvement  of  the  lymphatics.  The 
disease  may  last  for  months  or  even  years.  Death  may  result  from  pyaemia, 
or  occasionally  acute  glanders  develops.  The  celebrated  French  veterinarian 
Boulev  had  it  and  recovered. 


ANTHEAX  149 

The  disease  is  transmissible  also  from  man  to  man.  Washerwomen  have 
been  infected  from  the  clothes  of  a  patient.  In  the  diagnosis  the  occupation 
is  very  important.  In  cases  of  doubt  the  inoculation  should  be  made  in  ani- 
mals or  the  complement  fixation  test  used.  Mallein,  a  product  of  the  growth 
of  the  bacilli,  is  used  for  the  purpose  of  diagnosing  glanders  in  animals.  Sev- 
eral instances  of  cured  glanders  have  been  reported  in  animals  treated  with 
small  and  repeated  doses  of  mallein  (Pilavios,  Babes).  In  the  acute  cases 
there  is  ver}^  little  hope.  In  the  chronic  cases  recovery  is  possible,  though  often 
tedious.  Vaccine  treatment  may  be  tried  cautiously  with  doses  from  10  to 
100  millions  given  every  two  to  four  days.  Increase  in  dosage  must  be 
governed  by  the  reaction. 

Treatment.— -If  seen  early,  the  wound  should  be  either  cut  out  or  thor- 
oughly destroyed  by  caustics  and  an  antiseptic  dressing  applied.  The  farcy 
buds  should  be  early  opened.  Antiseptic  solutions  such  as  potassium  perman- 
ganate and  hydrogen  peroxide  should  be  used. 


XIX.     ANTHRAX 

(Splenic  Fever;  Charhon;  Wool-sorter's  Disease) 

Definition.^ — An  acute  infectious  disease  caused  by  Bacillus  anthracis, 
occurring  in  three  forms,  cutaneous  (malignant  pustule),  pulmonary,  and 
intestinal.  In  animals,  particularly  in  sheep  and  cattle,  the  disease  has  the 
character  of  an  acute  septicgemia  with  enlargement  of  the  spleen — hence  the 
name  splenic  fever.  In  man  it  occurs  sporadically  or  as  a  result  of  acci- 
dental inoculations  with  the  virus. 

Etiology. — The  infectious  agent  is  a  non-motile,  rod-shaped  organism, 
Bacillus  anthracis,  which  has,  by  the  researches  of  Pollender,  Davaine,  Koch, 
and  Pasteur,  become  the  best  known  ^perhaps  of  all  pathogenic  microbes.  The 
l)acillus  has  a  length  of  from  2  to  25  /x;  the  rods  are  often  united.  The  bacilli 
themselves  are  readily  destroyed,  but  the  spores  are  very  resistant,  and  sur- 
vive after  prolonged  immersion  in  a  o-per-cent.  solution  of  carbolic  acid,  or 
withstand  for  some  minutes  a  temperature  of  212°  F.  They  are  capable  also 
of  resisting  gastric  digestion.  Outside  the  body  the  spores  are  in  all  proba- 
bility very  durable. 

In  Animals. — Geographically  and  zoologically  the  disease  is  the  most 
Avidespread  of  all  infections.  It  is  much  more  prevalent  in  Europe  and  in 
Asia  than  in  America.  Its  ravages  among  the  herds  of  cattle  in  Russia  and 
Siberia,  and  among  sheep  in  certain  parts  of  Europe,  are  not  equalled  by  any 
other  animal  plague.  In  the  United  States  anthrax  is  not  very  widespread. 
In  France  from  6  to  10  per  cent,  of  the  sheep  and  about  5  per  cent,  of  the 
cattle  formerly  died  of  it. 

The  disease  is  conveyed  sometimes  by  direct  inoculation,  as  by  the  bites 
and  .stings  of  insects,  by  feeding  on  carcasses  of  animals  which  have  died  of 
the  disease,  but  more  commonly  by  grazing  in  pastures  contaminated  by  the 
germs.  Pasteur  thought  that  the  earthworm  played  an  important  part  in 
bringing  to  the  surface  and  distributing  the  bacilli  from  the  buried  carcass 
of  an  infected  animal.     Certain  fields,  or  even  farms,  may  thus  be  infected 


150  SPECIFIC  INFECTIOUS  DISEASES 

for  an  indefinite  period.  It  seems  probable  that,  if  the  carcass  is  not  opened 
or  the  blood  spilt,  spores  are  not  formed  in  the  buried  animal  and  the  bacilli 
quickly  die. 

In  man  the  disease  does  not  occur  spontaneously.  It  results  always  from 
infection,  either  through  the  skin  or  intestines,  or  in  rare  instances  through 
the  lungs.  Workers  in  wool  and  hair,  and  persons  whose  occupations  bring . 
them  into  contact  with  animals  or  animal  products,  as  stablemen,  shepherds, 
tanners,  and  butchers,  are  specially  liable  to  the  disease.  In  the  United  States 
the  disease  is  usually  found  in  the  workers  in  hides,  in  butchers,  and  in  veteri- 
narians. It  is  rare  in  general  hospital  work.  In  the  United  States  there  were 
63  deaths  from  anthrax  in  1917  in  the  registration  area.  In  England  and 
Wales  in  1916  there  were  28  deaths  from  this  cause  in  man.  Ponder  states 
that  40  per  cent,  of  all  the  cases  of  anthrax  in  British  leather  workers  are 
due  to  handling  Chinese  or  East  Indian  goods;  80  per  cent,  of  the  cases  are 
malignant  pustule  from  skin  infection  while  handling  hides  at  the  docks  or 
in  the  tanneries. 

Various  forms  of  the  disease  have  been  described,  and  two  chief  groups 
may  be  recognized :  the  external  anthrax  and  the  internal  anthrax,  of  which 
there  are  pulmonary  and  intestinal  forms. 

Symptoms. —  (a)  External  Anthrax. —  (1)  Malignant  Pustule. — At  the 
site  of  inoculation,  usually  on  an  exposed  surface — the  hands,  arms,  or  face — 
there  are,  within  a  few  hours,  itching  and  uneasiness,  and  the  gradual  forma- 
tion of  a  small  papule,  which  soon  becomes  vesicular.  Inflammatory  indura- 
tion extends  around  this,  and  within  thirty-six  hours  at  the  site  of  inocula- 
tion there  is  a  dark  brownish  eschar,  at  a  little  distance  from  which  there  may 
be  a  series  of  small  vesicles.  The  brawny  induration  may  be  extreme.  The 
oedema  produces  very  great  swelling  of  the  parts.  The  inflammation  extends 
along  the  lymphatics,  and  the  neighboring  lymph-glands  are  swollen  and  sore. 
The  fever  at  first  rises  rapidly,  and  the  concomitant  phenomena  are  marked. 
Subsequently  the  temperature  falls,  and  in  many  cases  becomes  subnormal. 
Death  may  take  place  in  from  three  to  five  days.  In  cases  which  recover  the 
constitutional  symptoms  are  slighter,  the  eschar  gradually  sloughs  out,  and  the 
wound  heals.  The  cases  vary  much  in  severity.  In  the  mildest  form  there 
may  be  only  slight  swelling.  At  the  site  of  inoculation  a  papule  is  formed, 
which  rapidly  becomes  vesicular  and  dries  into  a  scab,  which  separates  in  the 
course  of  a  few  days. 

(2)  Malignant  Anthrax  CEdema. — This  form  occurs  in  the  eyelid,  and 
also  in  the  head,  hand,  and  arm,  and  is  characterized  by  the  absence  of  the 
papule  and  vesicle  forms,  and  by  the  most  extensive  oedema,  which  may  fol- 
low rather  than  precede  the  constitutional  symptoms.  The  oedema  reaches 
such  a  grade  of  intensity  that  gangrene  results,  and  may  involve  a  consider- 
able surface.  The  constitutional  symptoms  then  become  extremely  grave, 
and  the  cases  invariably  prove  fatal.  The  greatest  fatality  is  seen  in  cases 
of  inoculation  about  the  head  and  face,  where  the  mortality,  according  to 
Nasarow,  is  26  per  cent.;  the  least  in  infection  of  the  lower  extremities,  where 
it  is  5  per  cent. 

In  a  case  at  the  Johns  Hopkins  Hospital  in  1895,  in  a  hair-picker,  there 
were  most  extensive  enteritis,  peritonitis,  and  endocarditis,  which  last  lesion 
has  been  described  by  Eppinger. 


ANTHRAX  151 

A  feature  in  both  these  forms  of  malignant  pustule  is  the  absence  of  feel- 
ing of  distress  or  anxiety  on  the  part  of  the  patient,  whose  mental  condition 
may  be  perfectly  clear.  He  may  be  without  any  apprehension,  even  though 
the  condition  be  most  critical. 

The  diagnosis  in  most  instances  is  readily  made  from  the  character  of  the 
lesion  and  the  occupation  of  the  patient.  There  is  a  remarkable  freedom  from 
pain  Avhich  distinguishes  anthrax  from  furuncle,  carbuncle  and  cellulitis. 
When  in  doubt,  the  examination  of  the  fluid  from  the  pustule  may  show  the 
presence  of  the  anthrax  bacilli.  Cultures  should  be  made,  or  a  mouse  or 
guinea-pig  inoculated  from  the  local  lesion.  The  blood  may  not  show  the 
bacilli  in  numbers  until  shortly  before  death. 

(b)  Internal  Anthrax. —  (1)  Intestinal  Form,  Alijcosis  Intestinalis. — 
In  these  cases  the  infection  usually  is  through  the  stomach  and  intestines, 
and  results  from  eating  the  flesh  or  drinking  the  milk  of  diseased  animals; 
it  may,  however,  follow  an  external  infection  if  the  germs  are  carried  to  the 
mouth.  The  symptoms  are  those  of  intense  poisoning.  The  disease  may  set 
in  with  a  chill,  followed  by  vomiting,  diarrhoea,  moderate  fever,  and  pains  in 
the  legs  and  back.  It  may  be  mistaken  for  intestinal  obstruction.  In  acute 
cases  there  are  dyspnoea,  cyanosis,  great  anxiety  and  restlessness,  and  toward 
the  end  convulsions  or  spasms  of  the  muscles.  Haemorrhage  may  occur  from 
the  mucous  membranes.  Occasionally  there  are  small  phlegmonous  areas  or 
petechige  on  the  skin.  The  spleen  is  enlarged.  The  blood  is  dark  and  remains 
fluid  for  a  long  time  after  death.  Late  in  the  disease  the  bacilli  may  be 
found  in  the  blood. 

This  is  one  of  the  forms  of  acute  poisoning  which  may  affect  many  indi- 
viduals together.  Butler  and  Huber  described  an  epidemic  in  which  twenty- 
five  persons  were  attacked  after  eating  the  flesh  of  an  animal  which  had  had 
anthrax.     Six  died  in  from  forty-eight  hours  to  seven  days. 

(2)  Wool-so7-ie7-'s  Disease,  Pulmonary  Anthrax,  Anthraccemia. — This  im- 
portant form  occurs  in  the  large  establishments  in  which  wool  or  hair  is  sorted 
and  cleansed.  The  hair  and  wool  imported  into  Europe  from  Eussia  and 
KSouth  America  appear  to  have  induced  the  largest  number  of  cases.  Many 
of  these  show  no  external  lesion.  The  infective  material  has  been  swallowed 
or  inhaled  with  the  dust.  There  are  rarely  premonitory  symptoms.  The 
patient  is  seized  with  a  chill,  becomes  faint  and  prostrated,  has  pains  in  the 
back  and  legs,  and  the  temperature  rises  to  103°  or  103°.  The  breathing  is 
rapid,  and  he  complains  of  much  pain  in  the  chest.  There  may  be  a  cough 
and  signs  of  bronchitis.  So  prominent  in  some  instances  are  these  bronchial 
symptoms  that  a  pulmonary  form  of  the  disease  has  been  described.  The 
pulse  is  feeble  and  very  rapid.  There  may  be  vomiting,  and  death  may  occur 
within  twenty-four  hours  with  symptoms  of  profound  collapse  and  prostra- 
tion. Other  cases  are  more  protracted,  aud  there  may  be  diarrhcca,  delirium, 
and  unconsciousness.  The  cerebral  symptoms  may  be  most  intense;  in  at 
least  four  cases  the  brain  seems  to  have  been  chiefly  affected,  and  its  capil- 
laries stuffed  with  bacilli  (Merkel).  The  recognition  of  wool-sorter's  disease 
as  a  form  of  anthrax  is  due  to  J.  H.  Bell,  of  Bradford. 

In  certain  instances  these  profound  constitutional  symptoms  of  internal 
anthrax  are  associated  with  the  external  lesions  of  malignant  pustule. 

The  rag-picker's  disease  has  been  made  the  subject  of  an  exhaustive  study 


153  SPECIFIC  IXFECTIOUS  DISEASES 

by  Eppinger  (Die  Hadernkrankheit,  Jena,  189-i),  who  has  shown  that  it  is 
a  local  anthrax  of  the  lungs  and  pleura,  with  general  infection. 

Prophylaxis. — This  is  important,  and  should  be  carried  out  by  a  most  rigid 
disinfection  of  the  hides,  hair,  and  rags  before  they  are  placed  in  the  hands 
of  the  workmen.  Those  handling  infected  material  should  have  the  arms  and 
neck  covered,  and  wear  gloves.  Animals  may  be  immunized  against  the  dis- 
ease and  Pasteur's  method  of  vaccination  has  been  extensively  employed  in 
France  with  good  results.  The  immunity  is  lost  within  a  year  in  nearly  5U 
per  cent,  of  the  animals. 

Treatment. — In  malignant  pustule  the  site  of  inoculation  should  be  excised 
and,  after  the  cautery  or  pure  phenol  is  applied,  powdered  bichloride  of  mer- 
cury sprinkled  over  the  exposed  surface.  The  local  development  of  the  bacilli 
about  the  site  of  inoculation  may  be  prevented  by  the  subcutaneous  injections 
of  solutions  of  carbolic  acid  (3  per  cent.)  or  bichloride  of  mercury  (1  to 
1,000).  The  injections  should  be  made  at  various  points  around  the  pustule, 
and  may  be  repeated  two  or  three  times  a  day.  The  internal  treatment  should 
be  confined  to  the  administration  of  stimulants  and  plenty  of  nutritious  food. 
In  malignant  forms,  particularly  the  intestinal  cases,  little  can  be  done. 
Active  purgatives  may  be  given  at  the  outset,  so  as  to  remove  the  infecting 
material.  The  anti-anthrax  serum  has  given  good  results  in  some  cases.  An 
initial  dose  of  80  to  100  c.  c.  is  given  intravenously  and  20  e.  c.  daily  after  this. 
The  use  of  normal  bovine  serum  (20-30  c.  c.  heated  twice  for  half  an  hour) 
intravenously  has  been  advised. 


XX.     LEPROSY 

Definition. — A  chronic  infectious  disease  caused  by  Bacillus  leprce,  charac- 
terized by  the  presence  of  tubercular  nodules  in  the  skin  and  mucous  mem- 
branes (tubercular  leprosy)  or  by  changes  in  the  nerves  (anesthetic  leprosy). 
At  first  these  forms  may  be  separate,  but  ultimately  both  are  combined,  and 
in  the  characteristic  tubercular  form  there  are  disturbances  of  sensation. 

History. — The  disease  appears  to  have'  prevailed  in  Egypt  even  so  far 
back  as  three  or  four  thousand  years  before  Christ.  The  Hebrew  writers  make 
many  references  to  it,  but,  as  is  evident  from  the  description  in  Leviticus, 
many  different  forms  of  skin  disease  were  embraced  under  the  term  leprosy. 
Both  in  India  and  in  China  the  affection  was  also  known  many  centuries 
before  the  Christian  era.  The  old  Greek  and  Eoman  physicians  were  per- 
fectly familiar  with  its  manifestations.  Evidence  of  a  pre-Columbian  exist- 
ence of  leprosy  in  America  has  been  sought  in  the  old  pieces  of  Peruvian  pot- 
tery representing  deformities  suggestive  of  this  disease,  but  Ashmead  denies 
their  significance.  Throughout  the  middle  ages  leprosy  prevailed  extensively 
in  Europe,  and  the  number  of  leper  asylums  has  been  estimated  as  at  least 
20,000.     During  the  sixteenth  century  it  gradually  declined. 

Geographical  Distribution. — In  Europe  leprosy  prevails  in  Iceland,  N"or- 
way  and  Sweden,  parts  of  Russia,  particularly  about  Dorpat,  Eiga,  and  the 
Caucasus,  and  in  certain  provinces  of  Spain  and  Portugal.  In  Great  Britain 
the  cases  are  all  imported.  In  the  United  States  it  is  estimated  that  there  are 
about  250  recognized  cases.     In  Canada  there  are  foci  of  leprosy  in  two  or 


LEPROSY  153 

three  comities  of  'New  Brunswick,  settled  by  French  Canadians,  and  in  Cape 
Breton,  Xova  Scotia.  The  number  has  gradually  lessened.  The  disease  ap- 
pears to  have  been  imported  from  Xormandy  about  the  end  of  the  18th  cen- 
tury. 

Leprosy  is  endemic  in  the  "West  India  Islands  and  also  occurs  in  Mexico. 
In  the  Sandwich  Islands  it  spread  rapidly  after  1860,  and  strenuous  attempts 
have  been  made  to  stamp  it  out  by  segregating  all  lepers  on  the  island  of 
Molokai.  In  the  Philippine  Islands,  in  a  population  of  over  six  millions, 
there  are  about  5,000  lepers. 

In  British  India,  according  to  the  Leprosy  Commission,  there  are  100,000 
lepers.  This  is  probably  a  low  estimate.  In  China  leprosy  prevails  exten- 
sively. In  South  Africa  it  has  increased  rapidly.  In  Australia,  Xew  Zealand, 
and  the  Australasian  islands  it  also  prevails,  chiefly  among  the  Chinese.  The 
essays  of  Ashburton  Thompson  and  James  Cantlie  deal  fully  with  leprosy  in 
China,  Australia,  and  the  Pacific  islands. 

Etiology. — Bacillus  leprce,  discovered  by  Hansen,  of  Bergen,  in  1871.  is 
universally  recognized  as  the  cause  of  the  disease.  It  has  many  points  of  re- 
semblance to  the  tubercle  bacillus,  but  can  be  readily  differentiated.  It  has 
been  cultivated,  but  with  difficulty,  and  is  stated  to  have  a  pleomorphism  of 
which  the  bacillus  as  seen  in  the  tissues  is  only  one  phase. 

Modes  of  Ixfectiox. —  (a)  Inoculation. — \Yhile  it  is  highly  probable 
that  leprosy  may  be  contracted  by  accidental  inoculation,  the  experimental  evi- 
dence is  as  yet  inconclusive.  With  one  possible  exception,  negative  results 
have  followed  the  attempts  to  reproduce  the  disease  in  man.  The  Hawaiian 
convict,  under  sentence  of  death,  who  was  inoculated  on  September  30,  1881, 
by  Arning,  four  weeks  later  had  rheumatoid  pains  and  gradual  painful  swell- 
ing of  the  ulnar  and  median  nerves.  The  neuritis  gradually  subsided,  but 
there  developed  a  small  lepra  tubercle  at  the  site  of  the  inoculation.  In  188T 
the  disease  was  manifest,  and  the  man  died  of  it  six  years  after  inoculation. 
The  case  is  not  regarded  as  conclusive,  as  he  had  leprous  relatives  and  lived 
in  a  leprous  country.     The  bed  bug  may  take  up  the  bacilli. 

(6)  Heredity. — For  years  it  was  thought  that  the  disease  was  transmitted 
from  parent  to  child,  but  the  general  opinion  is  now  decidedly  against  this 
view.  The  possibility  of  its  transmission  cannot  be  denied,  and  in  this  re- 
spect leprosy  and  tuberculosis  occupy  very  much  the  same  position,  though 
men  with  very  wide  experience  have  never  seen  a  new-born  leper.  The  young- 
est cases  are  rarely  under  three  or  four  years  of  age. 

(c)  Bij  Contagion. — The  bacilli  are  given  off  from  the  open  sores;  they 
are  found  in  the  saliva  and  expectoration  of  the  cases  with  leprous  lesions  in. 
the  mouth  and  throat,  and  occur  in  very  large  numbers  in  the  nasal  secre- 
tion. Sticker  found  in  153  lepers,  subjects  of  both  forms  of  the  disease, 
bacilli  in  the  nasal  secretion  in  128,  and  herein,  he  thinks,  lies  the  chief 
source  of  danger.  Schaffer  collected  lepra  bacilli  on  clean  slides  placed  on 
tables  and  floors  near  to  lepers  whom  he  had  caused  to  read  aloud.  The 
bacilli  have  also  been  isolated  from  the  urine  and  the  milk  of  patients.  It 
seems  probable  that  they  may  enter  the  body  in  many  ways  through  the 
mucous  membranes  and  through  the  skin.  Sticker  believes  that  the  initial 
lesion  is  in  an  ulcer  above  the  cartilaginous  part  of  the  nasal  septum.  One 
of  the  most  striking  examples  of  the  contagiousness  of  leprosy  is  the  follow- 


154  SPECIFIC  IXFECTIOrS  DISEASES 

ing:  "In  1860,  a  girl  who  had  hitherto  lived  at  Holstiershof,  where  no  lep- 
rosy existed,  married  and  went  to  live  at  Tarwast  with  her  mother-in-law, 
who  was  a  leper.  She  remained  healthy,  but  her  three  children  (1,  2,  3)  be- 
came leprous,  as  also  her  younger  sister  (4),  who  came  on  a  visit  to  Tarwast 
and  slept  with  the  children.  The  younger  sister  developed  leprosy  after  re- 
turning to  Holstfershof.  At  the  latter  place  a  man  (5),  fifty-two  years  old, 
who  married  one  of  the  'younger  sister's"  children,  acquired  leprosy;  also  a 
relative  (G),  thirty-six  years  old,  a  tailor  by  occupation,  who  frequented  the 
house,  and  his  wife  (7),  who  came  from  a  place  where  no  leprosy  existed."' 
There  is  evidence  to  show  that  the  disease  may  be  spread  through  infected 
clothing,  and  the  high  percentage  of  washerwomen  among  lepers  is  suggestive. 

CoxDiTioxs  IxFLUEXCixG  IxFECTiox. — The  disease  attacks  persons  of  all 
ages.  We  do  not  yet  understand  all  the  conditions  necessary.  Evidently  the 
closest  and  most  intimate  contact  is  essential.  The  doctors,  nurses,  and  Sisters 
of  Charity  who  care  for  the  patients  are  very  rarely  attacked.  In  the  lazaretto 
at  Tracadie  not  one  of  the  Sisters  who  for  more  than  fifty  years  have  so 
faithfully  nursed  the  lepers  has  contracted  the  disease.  Father  Damian,  in 
tlie  Sandwich  Islands,  and  Father  Boblioli,  in  Xew  Orleans,  both  fell  victims 
in  the  discharge  of  their  priestly  duties. 

Morbid  Anatomy. — The  leprosy  tubercles  consist  of  granulomatous  tissue 
made  up  of  cells  of  various  sizes  in  a  connective-tissue  matrix.  The  bacilli 
in  extraordinary  numbers  lie  partly  between  and  partly  in  the  cells.  The 
process  gradually  involves  the  skin,  giving  rise  to  tuberous  outgrowths  with 
intervening  areas  of  ulceration  or  cicatrization,  which  in  the  face  may  grad- 
ually produce  the  so-called  fades  leontina.  The  mucous  membranes,  partic- 
ularly the  conjunctiva,  the  cornea,  and  the  larynx,  may  gradually  be  involved. 
In  many  cases  deep  ulcers  form  which  result  in  extensive  loss  of  substance 
or  loss  of  fingers  or  toes,  the  so-called  lepra  mutilans.  In  anesthetic  leprosy 
there  is  a  peripheral  neuritis  due  to  the  development  of  the  bacilli  in  the  nerve- 
fibres.  Indeed,  this  involvement  of  the  nerves'  plays  a  primary  part  in  the 
etiology  of  many  of  the  important  features,  particularly  the  trophic  changes 
in  the  skin  and  the  disturbances  of  sensation. 

Clinical  Forms. —  (a)  Tubercular  Leprosy. — Prior  to  the  appearance  of 
the  nodules  there  are  areas  of  cutaneous  erythema  which  may  be  sharply 
defined  and  often  hyperaesthetic.  This  is  sometimes  known  as  macular  leprosy. 
The  affected  spots  in  time  become  pigmented.  In  some  instances  this  super- 
ficial change  continues  without  the  development  of  nodules,  the  areas  become 
anaesthetic,  the  pigment  gradually  disappears,  and  the  skin  gets  perfectly 
white — the  lepra  alha.  Among  the  patients  at  Tracadie  it  was  particularly 
interesting  to  see  three  or  four  in  this  early  stage  presenting  on  the  face  and 
forearms  a  patchy  erythema  with  slight  SAvelling  of  the  skin.  The  diagnosis 
of  the  condition  is  perfectly  clear,  though  it  may  be  a  long  time  before  any 
other  than  sensory  changes  develop.  The  eyelashes  and  eyebrows  and  the  hairs 
on  the  face  fall  out.  The  mucous  membranes  finally  become  involved,  partic- 
ularly of  the  mouth,  throat,  and  larynx ;  the  voice  becomes  harsh  and  finally 
aphonic.  Death  results  not  infrequently  from  the  laryngeal  complications 
and  aspiration  pneumonia.  The  conjunctiva  are  frequently  attacked,  and  the 
sight  is  lost  by  a  leprous  keratitis. 

(6)   Anaesthetic  Leprosy. — This  remarkable  form  has,  in  characteristic 


TUBEECULOSIS  155 

cases,  no  external  resemblance  whatever  to  the  other  variety.  It  usually  begins 
with  pains  in  the  limbs  and  areas  of  hyperaesthesia  or  of  numbness.  Very 
early  there  may  be  trophic  changes,  seen  in  the  formation  of  small  bullae 
(Hillis).  Maculae  appear  upon  the  trunk  and  extremities,  and  after  persist- 
ing for  a  variable  time  gradually  disappear,  leaving  areas  of  anaesthesia,  but 
the  loss  of  sensation  may  come  on  independently  of  the  outbreak  of  maculafe. 
The  nerve-trunks,  where  superficial,  may  be  felt  to  be  large  and  nodular.  The 
trophic  disturbances  are  usually  marked.  Pemphigus-like  bullae  develop  in 
the  affected  areas,  which  break  and  leave  ulcers  which  may  be  very  destructive. 
The  fingers  and  toes  are  liable  to  contractures  and  to  necroshs,  so  that  in 
chronic  cases  the  phalanges  are  lost.  The  course  of  anaesthetic  leprosy  is  ex- 
traordinarily chronic  and  may  persist  for  years  without  leading  to  much  de- 
formity. We  knew  a  prominent  clergyman  who  had  anaesthetic  leprosy  for 
more  than  thirty  years,  which  did  not  seriously  interfere  with  his  usefulness, 
and  not  in  the  slightest  with  his  career. 

Diagnosis. — Even  in  the  early  stage  the  dusky  erythematous  maculae  with 
hyperaesthesia  or  areas  of  anaesthesia  are  very  characteristic.  In  an  advanced 
grade  neither  the  tubercular  nor  anaesthetic  forms  could  possibly  be  mistaken 
for  any  other  aifeetion.  In  a  doubtful  case  the  microscopic  examination  of  an 
excised  nodule  is  decisive. 

Treatment. — Vaccines  have  been  prepared  and  good  results  are  claimed 
by  various  observers.  The  Finsen  light,  X-rays,  and  radium  do  good  to  the 
local  lesions.  Chaulmoogra  oil  has  been  extensively  used.  Heiser  advises 
chaulmoogra  oil  60  c.  c,  camphorated  oil  60  c.  c,  and  resorcin  4  gm. ;  this  is 
sterilised  and  1  c.  c.  given  subcutaneously  once  a  week.  The  dose  is  gradually 
increased  to  3  c.  c.  Eogers  advises  the  intravenous  injection  of  gynocardate  of 
soda  (prepared  from  the  fatty  acids  of  chaulmoogra  oil)  gr.  1/10  to  4/5  (0.006 
to  0.05  gm.),  in  a  2  per  cent,  saline  solution  and  0.5  per  cent,  phenol. 

Segregation  should  be  compulsory  in  all  cases  except  where  the  friends  can 
show  that  they  have  ample  provision  in  their  own  home  for  the  complete 
isolation  and  proper  care  of  the  patient. 


XXI.     TUBERCULOSIS 

I.     GENERAL    ETIOLOGY    AND    MORBID    ANATOMY 

Definition. — An  infection  caused  by  Bacillus  tuberculosis,  the  lesions  of 
which  are  characterized  by  nodular  bodies,  tubercles,  and  diffuse  infiltrations, 
which  either  undergo  caseation,  necrosis,  and  ulceration,  or  heal  with  sclerosis 
and  calcification. 

The  very  varied  clinical  features  depend  upon  the  organ  involved,  the  in- 
tensity of  the  infection,  and  the  degree  of  resistance  offered  by  the  body. 

History. — The  Greek  physicians  made  many  observations  upon  the  clinical 
features  of  pulmonary  tuberculosis,  and  our  description  of  the  symptoms  and 
of  the  consumptive  "type"  dates  from  Hippocrates.  Galen  recognized  its  con- 
tagious nature.  In  the  17th  century  F.  Sylvius  indicated  the  connection  be- 
tween the  tuberculous  nodule  and  phthisis,  and  Eichard  Morton,  a  friend  and 
contemporary  of  Sydenham,  wrote   (16S9)   the  first  modern  treatise  on  the 


156  SPECIFIC  INFECTIOUS  DISEASES  ~       ~" 

subject,  in  which  the  clinical  side  of  the  disease  was  well  considered.  He 
regarded  it  as  contagious.  Pierre  Desault,  William  Stark,  and  Matthew 
Baillie  laid  the  foundation  of  our  knowledge  of  the  coarse  characters  of  tu- 
bercle as  the  anatomical  basis  of  tuberculosis.  Our  real  knowledge  of  the 
disease  is  a  19th  century  contribution,  beginning  with  the  work  of  Bayle  on 
the  structure  of  the  tubercle  and  on  its  identity  in  the  widely  distributed  le- 
sions. With  the  Traite.  d' Auscultation  Mediate  (1819)  Laennec  laid  the 
foundation  not  only  of  our  modern  knowledge  of  tuberculosis,  but  of  modern 
clinical  medicine.  This  work  (easily  to  be  had  in  an  English  translation) 
should  be  read  from  cover  to  cover  by  every  young  doctor,  and,  when  possible, 
by  every  senior  student.  The  unity  of  the  forms  of  the  tubercle — the  miliary 
granule,  the  infiltration,  and  the  caseous  mass — ^was  recognized,  and  for  the 
first  time  physical  signs  and  anatomical  features  were  correlated,  and  the 
course  of  the  disease  carefully  studied.  Virchow  led  a  battle  against  the 
unity  of  tuberculous  lesions,  and  held  that  the  products  of  any  simple  inflam- 
mation might  become  caseous,  and  that  the  ordinary  so-called  catarrhal  pneu- 
monia might  terminate  in  phthisis. 

The  contagiousness  of  the  disease,  a  belief  in  which  had  all  along  been 
held  by  individuals,  and  was  widely  spread  in  certain  countries — as  in  Italy — 
was  emphasized  and  confirmed  by  the  brilliant  work  of  Villemin,  who  first 
placed  the  infective  nature  of  the  disease  on  a  solid  experimental  basis.  There 
is  nothing  more  masterly  in  the  literature  of  experimental  medicine  than  his 
work.  Then  came  the  demonstration  by  Eobert  Koch  (in  1882)  of  the  Bacil- 
lus tuberculosis.  The  preliminary  article  in  the  Berliner  klin.  Wochenschrift 
(1882)  and  the  more  complete  work  (Mitteilungen  a.  d.  k.  Gesundheitsamte, 
Bd.  2)  should  be  studied  by  all  who  wish  to  appreciate  the  value  of  scientific 
methods.  The  thoroughness  of  Koch's  work  is  manifested  by  the  fact  that,  in 
the  years  thut  have  elapsed,  the  innumerable  workers  have  amplified  and  ex- 
tended, but  in  no  way  essentially  modified  his  original  position. 

During  the  past  thirty  years  we  have  been  gradually  getting  accommodated 
to  the  new  views,  the  most  important  single  effect  of  which  has  been  a  world- 
wide crusade  against  tuberculosis  as  a  preventable  disease. 

Distribution. — The  disease  is  widely  spread  zoologically. 

(a)  In  Aximals. — Of  animals  the  cold-blooded  are  rarely  affected.  In 
birds  the  disease  is  not  uncommon,  particularly  in  fowls,  but  there  are  minor 
differences  between  the  avian  and  mammalian  forms.  In  the  domestic  ani- 
mals tuberculosis  is  a  common  disease,  particularly  in  cattle.  In  sheep,  goats, 
and  horses  it  is  rare.  In  pigs  it  is  not  uncommon  in  certain  parts  of  Europe. 
Cats  and  dogs  are  not  prone  to  the  disease.  In  monkeys  in  confinement  it  is 
very  common.  The  most  important  single  fact  in  the  distribution  of  the  dis- 
ease in  animals  is  its  widespread  prevalence  in  bovines,  from  which  nearly 
all  the  milk  and  a  large  proportion  of  our  meat  are  derived. 

(b)  In  Man. — Tuberculosis  is  his  most  universal  scourge,  well  deserving 
the  epithet  bestowed  upon  it  by  Bunyan  of  the  "Captain  of  the  Men  of  Death." 
It  is  estimated  that  at  least  one-eighth  of  all  deaths  are  due  to  it.  In  Eng- 
land and  Wales  there  were  53,858  deaths  from  tuberculosis  in  1916.  In  the 
United  States  it  is  responsible  for  about  one-tenth  of  all  deaths.  The  rate 
in  the  registration  areas  was  201.9  per  100^000  in  1900  and  116.4  in  1917. 


TUBERCULOSIS  157 

There  has  been  a  remarkable  reduction  in  England  in  the  death-rate  within 
the  past  fifty  years. 

In  London  the  death-rate  from  consumption  declined  33  per  cent,  be- 
tween 1901  and  1910^  and  other  forms  of  tuberculosis  show  a  similar  fall.  To 
a  less  striking  degree,  but  practically  everywhere  in  the  civilized  world,  there 
has  been  a  reduction  in  the  death-rate-^the  most  encouraging  feature  of 
modern  sanitation.  To  what  is  this  to  be  attributed?  First.,  To  the  im- 
proved social  condition  of  the  people,  better  housing,  better  food,  better  habits. 
The  falling  death-rate  began  before  the  present  campaign  against  the  disease. 
Secondly.  The  education  of  the  people,  which  has  made  great  strides,  and 
a  larger  proportion  are  striving  to  lead  hygienic  lives.  There  are  less  drunk- 
enness, less  overcrowding,  better  air,  and  better  food.  The  habit  of  spitting 
in  public  has  been  checked  and  the  seeds  of  the  disease  are  not  spread  so 
broadcast.  Thirdly.  As  ISTewsholme  points  out,  segregation  has  done  much 
to  protect  the  healthy  from  the  sick.  In  the  year  1910,  20.5  per  cent,  of  the 
deaths  in  England  and  Wales  and  43.4  per  cent,  of  the  deaths  in  London  oc- 
curred in  piiblic  institutions  for  the  sick.  Fourthly.  The  cases  are  seen 
earlier  and  the  condition  is  recognized  before  it  is  hopeless.  In  a  larger  num- 
ber of  persons  with  pulmonary  disease  the  diagnosis  is  made  at  a  stage  when 
complete  healing  is  possible.  The  two  important  elements  then  are,  fewer 
seeds,  more  stony  soil.  The  economic  loss  from  tuberculosis  has  been  esti- 
mated by  various  writers.  Baldwin  puts  it  for  the  United  States  at  from  150 
to  200  millions  of  dollars  annually. 

Etiolo^:  the  Bacillus  tuberculosis. —  (a)  The  Seed. — The  Bacillus  tuber- 
culosis is  a  minute  rod-shaped  organism  slightly  bent  or  curved,  with  an  aver- 
age length  of  from  3  to  4  fi.  When  stained  it  may  present  a  beaded  appear- 
ance; whether  due  to  spores  or  vacuoles  is  doubtful.  Aberrant  forms  are  not 
uncommon,  i.  e.,  long  filaments  or  branched  forms.  It  stains  in  a  character-- 
istic  way  with  aniline  dyes,  and  in  cultures  the  growth  is  distinctive. 

Specific  varieties  are  recognized.  The  avian  form  has  well-marked  pe- 
culiarities, but  the  great  point  of  discussion  has  been  the  relation  of  the 
bacillus  causing  human  to  that  which  causes  bovine  tuberculosis.  Differences 
in  the  character  of  the  tubercles  of  these  two  classes  had  long  been  recog- 
nized, and  Theobald  Smith  pointed  out  special  differences  between  the  human 
and  the  bovine  bacilli.  But  the  matter  was  brought  to  a  focus  in  1901  by 
Koch's  statement  that  the  bacilli  of  bovine  tuberculosis  did  not  cause  human 
tuberculosis,  and  vice  versa.  The  question  has  been  submitted  to  the  test 
and  it  is  generally  recognized  that  there  are  differences  between  the  two  forms. 
The  report  of  the  English  commission  confirms  the  view  that  the  bovine  or- 
ganism is  capable  of  producing  the  disease  in  man.  in  whom  it  may  often  be 
recognized  as  a  special  form. 

The  virulence  of  the  individual  strains  varies,  a  factor  of  great  importance 
in  all  specific  infections. 

In  the  Body. — The  bacilli  are  found  in  all  tuberculous  lesions,  particularly 
in  those  actively  growing,  but  in  the  chronic  disease  of  the  lymph  glands  and 
of  the  joints  they  are  scanty.  In  all  caseous  foci  they  are  few  in  number. 
In  the  sputum  in  pulmonary  tuberculosis  they  may  be  present  in  countless 
myriads.  They  are  sometimes  found  in  the  blood,  particularly  in  cases  of 
miliary  tuberculosis. 


158  SPECIFIC  INFECTIOUS  DISEASES 

Outside  the  Body. — The  tubercle  bacilli  are  widely  scattered  and  are 
found  in  varying  numbers  wherever  human  beings  are  crowded  together. 
There  are  two  chief  sources — the  expectoration  of  persons  Avith  advanced 
disease  of  the  lungs  and  the  milk  of  tuberculous  cows. 

From  a  patient  in  the  Johns  Hopkins  Hospital,  with  moderately  advanced 
disease,  Xuttall  estimated  that  from  1^  to  4  1-3  billions  of  bacilli  were 
thrown  off  each  twenty-four  hours.  Allowed  to  dry,  the  sputum  becomes  dust 
and  is  distributed  far  and  wide.  Experiments  have  shown  the  presence  of  the 
bacilli  in  dust  samples  from  hospital  wards,  from  public  buildings,  streets, 
railway  carriages,  and  various  localities.  So  widely  spread  are  the  bacilli  that 
in  cities  at  least  few  individuals  pass  a  week  without  affording  opportunity 
for  their  lodgment,  usually  in  the  throat  or  air  passages,  inhaled  with  dust. 
They  may  readily  contaminate  food.  The  hands  of  tuberculous  subjects  are 
almost  always  contaminated.  From  the  street,  tuberculous  sputum  may  be 
brought  into  the  house  on  shoes,  on  the  long  skirts  of  women,  on  the  hair  of 
dogs,  etc.  It  is  interesting  to  note  that  in  some  of  the  places  most  frequented 
by  tuberculous  subjects,  e.  g.,  the  sanatoria,  the  dust  (as  shown  by  experi- 
ments at  Saranac)    may  be  free  from  bacilli. 

Bovine  bacilli  are  distributed  by  means  of  the  milk,  rarely  by  the  flesh, 
and  still  more  rarely  by  contact  with  the  animals.  A  proportion  of  all  cases 
of  infection  in  childhood  are  with  this  variety.  A  study  by  Park  and  Krum- 
wiede  showed  that  bovine  tuberculosis  is  practically  negligible  in  adults  but 
in  young  children  causes  about  10  per  cent,  of  the  deaths  from  tuberculosis. 

So  widely  spread  everywhere  is  the  seed,  that  the  soil,  the  conditions  suit- 
able for  its  growth,  is  practically  of  equal  moment. 

(&)  The  Soil. — Many  years  ago  the  senior  author  drew  the  parallel  be- 
tween infection  in  tuberculosis  and  the  parable  of  the  sower,  which  though 
now  somewhat  hackneyed  illustrates  in  an  effective  way  the  importance  of  the 
nature  of  the  ground  upon  which  the  seed  falls.  ''Some  seeds  fell  by  the  way- 
side and  the  fowls  of  the  air  came  and  d&voured  them  up."  These  are  the 
bacilli  scattered  broadcast  outside  the  body,  an  immense  majority  of  which 
die.  "Some  fell  upon  stony  places."  These  are  the  bacilli  that  find  lodg- 
ment in  many  of  us,  perhaps,  with  the  production  of  a  small  focus,  but  noth- 
ing comes  of  it;  they  wither  away  "because  they  have  no  root."  "'Some  fell 
among  thorns,  and  the  thorns  sprang  up  and  cliol-ed  them."  This  represents 
the  cases  of  tuberculosis,  latent  or  active,  in  which  the  seed  finds  the  soil  suit- 
able and  grows,  but  the  conditions  are  not  favorable,  as  the  thorns,  represent- 
ing the  protecting  force  of  the  body,  get, the  better  in  the  struggle.  "But 
others  fell  on  good  ground  and  sprang  up  and  hare  fruit  an-  hundredfold." 
Of  this  fourth  group  were  the  53,858  who  died  of  the  disease  in  1916  in  Eng- 
land— the  soil  suitable,  the  protecting  forces  feeble. 

What  makes  a  good  soil?  Fortunately  the  human  body  is  not  a  very  good 
culture  medium  for  the  tubercle  bacillus.  The  adult  human  individual  in 
normal  health  seems  to  be  practically  immune  to  natural  infection  (Baldwin). 
And  yet  about  one-eighth  of  the  human  race  dies  of  tuberculosis,  but  a  large 
proportion  of  all  individuals  become  infected  before  reaching  adult  life  and 
never  have  the  disease.  The  studies  of  Xaegli,  Burkhardt,  and  others  show  that 
in  fully  90  per  cent,  of  the  bodies  of  city-dwellers  who  have  died  of  disease 
other  than  tuberculosis  small  tuberculous  lesions  are  present.    This  is  probably 


TUBEECULOSIS  159 

too  high  an  estimate  for  England  or  the  United  States.  Franz  has  shown  that 
over  60  per  cent,  of  healthy  young  adults  react  to  the  subcutaneous  tuberculin 
test.  Using  more  delicate  tuberculin  tests,  it  is  found  that  nearly  all  adults 
react,  and  according  to  Hamburger,  who  has  employed  the  subcutaneous-local 
reaction,  over  90  per  cent,  of  children  are  infected  before  reaching  the  twelfth 
year  of  life.  This  means,  of  course,  that  in  a  very  small  proportion  of  those 
upon  whom  the  seed  falls  is  the  soil  suitable  for  active  growth — only  a  natural 
immunity  keeps  the  race  alive. 

What  this  suitable  soil  is  has  been  the  subject  of  much  discussion.  From 
the  time  of  Hippocrates  the  profession  has  recognized  a  tuberculous  habitus, 
which  has  been  variously  described  as  disposition,  diathesis,  dyscrasia,  tem- 
perament, constitution,  or  by  the  German  word  "Anlage."  These  terms  are 
not  always  regarded  as  interchangeable,  but  here  for  practical  purposes  Eib- 
bert's  definition  suffices,  that  a  disposition  is  "that  peculiarity  in  the  organ- 
ism Avhich  allows  of  the  effective  working  of  the  exciting  causes  of  a  disease." 
jManifestly,  such  a  disposition  or  constitution  of  the  body  may  be  inherited  or 
acquired.  Pearson  concludes  that  "the  diathesis  of  pulmonary  tuberculosis  is 
certainly  inherited,  and  the  intensity  of  the  inheritance  is  sensibly  the  same 
as  that  of  any  normal  physical  character  yet  investigated  in  man.  Infec- 
tion probably  plays  a  necessary  part,  but  in  the  artisan  classes  of  the  urban 
populations  of  this  country  (England)  it  is  doubtful  if  their  members  can 
escape  the  risks  of  infection,  except  by  the  absence  of  diathesis — i.  e.,  the  in- 
heritance of  what  amounts  to  a  counter-disposition." 

Hippocrates  defines  the  habittis  phthisicus  in  the  following  words:  ^^The 
form  of  body  peculiar  to  subjects  of  phthisical  complaints  was  the  smooth, 
the  whitish,  that  resembled  the  lentil;  the  reddish,  the  blue-eyed,  the  leuco- 
phlegmatic,  and  that  with  the  scapulse  having  the  appearance  of  wings."  The 
so-called  scrofulous  type  has  broad  coarse  features,  opaque  skin,  large  thick 
bones,  and  heavy  figure. 

Acquired  disposition  may  arise  through  a  lowering  of  the  resistance  of 
the  body  forces.  Dwellers  in  cities  in  the  dark,  close  alleys,  and  tenement 
houses,  workers  in  cellars  and  ill-ventilated  rooms,  persons  addicted  to  drink, 
are  much  more  prone  to  the  disease.  The  influence  of  environment  was  never 
better  demonstrated  than  in  the  well-known  experiment  of  Trudeau,  who  found 
that  rabbits  inoculated  with  tuberculosis  if  confined  in  a  dark,  damp  place, 
without  sunlight  and  fresh  air,  rapidly  succumbed,  while  others  treated  in 
the  same  way,  but  allowed  to  run  wild,  either  recovered  or  showed  very  slight 
lesions.  The  occupants  of  prisons,  asylums,  and  poorhouses,  too  often,  indeed, 
in  barracks  and  large  workshops,  are  in  the  position  of  Trudeau's  rabbits  in 
the  cellar,  and  under  the  conditions  most  favorable  to  foster  the  development 
of  the  bacilli  which  may  have  lodged  in  their  tissues. 

No  age  is  exempt.  The  disease  is  met  with  in  the  suckling  and  in  the 
octogenarian,  but  fatal  tuberculosis  is,  as  Hippocrates  pointed  out,  more  com- 
mon between  the  eighteenth  and  thirty-fifth  year.  The  influence  of  sex  is 
very  slight.  On  the  other  hand  the  influence  of  7-ace  is  important.  It  is  a 
very  fatal  disease  in  the  negroes,  particularly  in  the  southern  United  States, 
and  in  the  ISTorth  American  Indians,  among  whom  in  1915,  35  per  cent,  of  the 
deaths  were  due  to  tuberculosis.     The  Irish,  both  at  home  and  in  the  United 


160  SPECIFIC  INFECTIOUS  DISEASES 

States,  are  more  prone  to  the  disease  than  other  European  races.  The  Jews 
everywhere  have  a  low  mortality  from  tuberculosis. 

Occupation  has  an  influence,  in  so  far  as  insanitary  surroundings,  expo- 
sure to  dust,  close  confinement,  long,  irregular  hours,  and  low  rates  of  wages, 
favor  the  prevalence  of  the  disease.  The  home  conditions  should  be  con- 
sidered in  estimating  the  influence  of  occupation.  Certain  local  conditions 
influence  the  soil  very  greatly.  Cat-arrh  of  the  respiratory  passages  appears 
to  lower  the  resistance  and  favor  the  conditions  which  enable  the  bacilli  to 
enter  the  system,  or  to  grow  in  the  tissues.  The  specific  fevers,  particularly 
measles  and  whooping-cough,  predispose  to  tuberculosis;  and  any  lowering 
disease  may  do  so,  but  in  such  cases  it  is  very  often  not  a  fresh  infection,  but 
the  blazing  of  a  smouldering  fire.  The  soil  of  diabetes  is  favorable  to  the 
growth  of  the  tubercle  bacilli.  Many  chronic  affections  lower  the  resistance 
and  it  is  notorious  in  hospital  practice  how  often  the  fatal  event  in  arterio- 
scleroeis,  cirrhosis  of  the  liver,  etc.,  is  a  terminal  acute  tuberculosis. 

Trauma,  as  for  example  a  blow  on  the  chest,  injury  to  the  knee,  a  blow 
upon  the  head,  may  be  followed  by  local  tuberculosis.  The  injured  part  for  a 
time  is  a  locus  minoris  resistentice,  and  the  bacilli  already  present  grow  in 
the  favorable  conditions  caused  by  the  injury. 

(c)  Specific  Eeactions  of  the  Bacilli. — In  its  growth  the  bacillus  so 
far  as  we  know  does  not  form  soluble  toxins,  at  least  not  in  the  cultures.  It 
causes  (1)  a  local  tissue  reaction  which  results  in  the  formation  of  a  new 
growth,  the  tubercle;  (2)  changes  in  the  metabolism  of  the  body  fluids.  The 
local  tissue  reactions  will  be  considered  later;  here  we  may  speak  of  the  phe- 
nomena grouped  under  the  term  immunity. 

(1)  Tuberculin  Reaction. — An  animal  inoculated  subcutaneously  with  tu- 
bercle bacilli,  or  with  dead  cultures,  has  a  local  reaction  associated  with  the 
formation  of  a  tubercle;  the  neighboring  lymph  glands  become  involved,  and 
in  susceptible  animals  the  disease  generalizes  and  causes  death.  Koch  found 
that  if  to  a  guinea-pig  with  a  subcutaneous  focus  of  tuberculosis  so  caused  a 
second  injection  of  •the  bacillus  was  given,  healing  occurred  in  the  primary 
nodule,  and  the  animal  did  not  die.  Upon  these  facts  his  tuberculin  treat- 
ment was  based.  Tuberculin  consists  of  the  dead  and  macerated  bacilli  to- 
gether with  any  substances  formed  in  the  cultures.  If  into  a  healthy  person 
.025  c.  c.  of  original  tuberculin  is  injected,  there  is  a  slight  fever  with  a  feel- 
ing of  uneasiness  which  passes  off  in  from  twelve  to  twenty-four  hours.  If 
into  an  individual  with  a  focus  of  tuberculosis  doses  of  .015  c.  c.  of  tuberculin 
are  injected  subcutaneously,  there  is  an  active  local  reaction  about  the  tu- 
berculous focus  and  a  constitutional  reaction  (fever,  general  pains,  etc.). 
This  process,  known  as  the  "tuberculin  reaction,^'  is  used  extensively  for  pur- 
poses of  diagnosis.  The  reaction  may  be  local,  focal  or  constitutional.  The 
skin  reactions  are  the  safest  because  the  reaction  is  local.  The  chief  methods 
are  the  ophthalmo-reaction  of  Calmette  and  the  cutaneous  of  von  Pirquet. 
A  drop  of  the  solution,  placed  on  the  conjunctiva  of  a  person  with  a  focus 
of  tuberculosis  anywhere  in  the  body,  is  followed  in  a  few  hours  by  deep  in- 
jection of  the  blood-vessels,  increased  lachrymation,  and  a  slight  swelling  of 
the  membrane.  This  lasts  for  from  twenty-four  to  thirty-six  hours.  This 
method  is  not  without  danger. 

For  the  sHn  reaction  of  von  Pirquet  a  couple  of  drops  of  tuberculin  are 


TUBERCULOSIS  161 

placed  on  a  disinfected  region  of  the  skin,  and  the  epidermis  is  scarified  through 
the  drops  without  drawing  blood.  If  positive,  at  the  end  of  twenty-four  hours 
there  is  an  inflammatory  reaction  which  reaches  its  maximum  in  from  thirty- 
six  to  forty-eight  hours.  For  clinical  purposes  the  tuberculin  reaction  is  to 
be  relied  on,  but  that  it  may  be  given  by  a  small  focus  of  latent  disease  in  a 
healthy  person  and  that  it  has  been  found  to  be  positive  in  as  large  a  propor- 
tion as  60  per  cent,  of  apparently  normal  individuals  are  facts  which  diminish 
its  practical  value. 

(2)  Immunity  Changes. — In  an  infected  person  certain  changes  occur  in 
the  blood  serum,  depending  upon  the  development  of  so-called  antibodies,  the 
presence  of  which  may  be  demonstrated  by  the  method  of  complement  fixa- 
tion; and  the  serum  also  contains  agglutinins  which  possess  an  agglutinating 
action  on  the  tubercle  bacilli.  Either  directly  themselves  or  through  the  toxic 
products  there  are  brought  into  play  certain  cellular  and  humoral  reactions 
which  are  capable  of  destroying  the  infecting  agents  or  of  neutralizing  their 
effects  or  of  limiting  their  activities.  Experimentally  in  animals,  according 
to  the  virulence  of  the  organism  and  the  dose,  all  gradations  of  symptoms  may 
be  produced,  from  the  slightest  local  reaction  to  the  profoundest  septicaemia 
with  high  fever  and  death.  In  a  local  tuberculous  infection,  such  as  happens 
to  the  great  majority  of  us  in  some  part  of  our  bodies  at  some  time  in  our  lives, 
happily  the  protective  mechanism  suffices  to  localize  and  limit  the  invaders. 
It  may  amount  only  to  a  skirmish,  such  as  is  constantly  going  on  at  the 
frontiers  of  a  great  empire,  but  if  the  local  infection  is  more  virulent,  or 
becomes  wider  spread,  the  products  of  the  growth  of  the  bacilli  or  the  bacilli 
themselves  enter  the  circulation,  an  auto-inoculation,  in  which  case  the  gen- 
eral metabolism  is  disturbed,  fever  is  produced,  and  antibodies  are  formed  to 
counteract  the  infective  products.  The  rationale  of  the  use  of  tuberculin  is 
to  stimulate  the  fighting  forces  of  the  body — to  mobilize  them,  so  to  speak — 
in  the  fight  that  is  going  on  in  an  infected  area. 

Studies  on  anaphylaxis  or  hypersensitiveness  to  foreign  proteins  have  an 
important  bearing  on  the  question  of  immunity  in  tuberculosis.  Baldwin  of 
Saranac  Lake  has  demonstrated  that  sensitization  to  and  subsequent  intoxica- 
tion by  tubercle  bacillus  protein  follow  the  general  laws  of  anaphylaxis  estab- 
lished for  the  parenteral  introduction  of  horse  serum.  From  his  experiments 
we  may  reasonably  interpret  the  tuberculin  reaction  as  an  anaphylactic  phe- 
nomenon. LTndoubtedly  hypersensitiveness  to  the  tubercle  bacillus  protein  is 
directly  responsible  for  the  so-called  toxic  symptoms  of  tuberculous  disease. 
Koch  in  his  original  experiments  that  led  up  to  the  introduction  of  tuberculin 
observed  a  marked  difference  in  the  reaction  of  healthy  and  tuberculous  ani- 
mals to  cutaneous  inoculation  with  tubercle  bacilli.  In  healthy  animals  the 
wound  closes  and  fcr  a  few  days  seems  to  heal,  but  in  from  ten  to  fourteen 
days  a  hard  nodule  appears,  which  soon  breaks  down.  General  infection  oc- 
curs and  the  ulcer  remains  open  to  the  time  of  the  death  of  the  animal.  In 
tuberculous  animals  extensive  ulceration  occurs  on  the  second  or  third  day 
after  vaccination,  but  the  ulcer  heals  quickly  and  permanently,  without  even 
the  neighboring  lymph  glands  becoming  infected.  Eoemer  extended  Koch's 
observations  and  demonstrated  that  tuberculous  animals  may  react  in  one  of 
three  ways  to  injections  of  tubercle  bacilli:  (1)  If  a  small  dose  be  given,  a 
dose,   however,   surely   fatal   for   healthy   animals,   infection   does   not  occur. 


162  SPECIFIC  INFECTIOUS  DISEASES 

The  animals  are  therefore  highly  resistant  to  re-infection.  (2)  If  a  large 
dose  be  given,  the  animals  die  promptly,  with  the  symptoms  of  an  intense 
intoxication.  The  condition  is  analogous  to  the  anaphylactic  shock.  (3)  If  a 
moderate  dose  be  given,  the  animals  display  the  symptoms  of  a  profound  in- 
toxication, but  gradually  recover,  and,  although  infection  follows,  a  mild  and 
chronic  form  of  the  disease  is  produced.  Upon  the  same  principle  depends 
the  protective  inoculation  of  calves,  practised  by  v.  Behring  and  Koch.  The 
animals  receive  injections  of  human  tubercle  bacilli  and,  although  anatomically 
disease  does  not  follow  their  introduction,  the  calves  become  highly  sensitive 
to  tuberculin  and  at  the  same  time  immune  to  doses  of  bovine  tubercle  bacilli 
fatal  to  unprotected  calves.  At  the  end  of  a  year  the  tuberculin  hypersensi- 
tiveness  disappears,  and  the  calves  again  become  susceptible  to  infection. 
While  we  are  not  in  a  position  to  state  that  protection  depends  upon  the  same 
mechanism  that  produces  hypersensitiveness  to  the  tubercle  bacillus  protein, 
the  two  phenomena  are  undoubtedly  closely  related. 

(d)  Modes  of  Infection. —  (1)  Hereditary  Transmission. — In  order  that 
the  disease  could  be  transmitted  by  the  sperm  it  would  be  necessary  that  the 
tubercle  bacilli  should  lodge  in  the  individual  spermatozoon  which  fecundates 
an  ovum.  The  chances  that  such  a  thing  could  occur  are  extremely  small, 
looking  at  the  subject  from  a  numerical  point  of  view,  although  we  know  that 
bacilli -do  occasionally  exist  in  the  semen;  they  become  still  smaller  when  we 
consider  that  the  spermatozoon  is  made  up  of  nuclear  material,  which  the 
tubercle  bacillus  is  never  known  to  attack.  The  possibility  of  transmission 
by  the  ovum  must  be  accepted.  Baumgarten  was  able  in  one  instance  to  de- 
tect the  tubercle  bacillus  in  the  ovum  of  a  female  rabbit  which  had  been 
artificially  fecundated  with  tuberculous  semen. 

The  almost  constant  method  of  transmission  in  congenital  tuberculosis  is 
through  the  blood  current,  the  tubercle  bacilli  penetrating  by  way  of  the 
placenta.  In  these  cases  the  placenta  itself  is  usually  the  seat  of  tuberculosis ; 
but  there  are  undoubted  instances  in  which,  with  an  apparently  sound  pla- 
centa, both  the  placental  blood  and  the  fetal  organs  contained  tubercle  bacilli, 
although  the  organs  appeared  normal.  The  number  of  cases  of  congenital 
tuberculosis  in  man  is  very  small  (about  50)  ;  it  is  more  common  in  cattle. 

Latency  of  the  Tubercle  Germs. — Baumgarten  and  his  followers  assume 
that  the  tubercle  bacilli,  present  in  the  new-born  child,  lie  latent  in  the  tissues 
and  subsequently  develop  when,  for  some  reason  or  other,  the  individual  re- 
sistance is  loAvered.  He  likens  such  cases  of  latent  tuberculosis  to  the  late 
congenital  forms  of  syphilis,  and  explains  the  lack  of  development  of  the 
germs  by  the  greater  resisting  power  of  the  tissues  of  children.  The  small 
number  of  congenital  cases  is  against  this  view. 

>(2)  Inocidation. — Cutaneous. — The  infective  nature  of  tuberculosis  was 
first  demonstrated  by  A'^illemin,  who  showed  in  1865  that  it  could  be  trans- 
mitted to  animals  by  inoculation.  The  experiments  of  Cohnheim  and  Salo- 
monsen,  who  produced  tuberculosis  in  the  eyes  of  guinea-pigs  and  rabbits  by 
inoculating  fresh  tubercle  into  the  anterior  chamber,  confirmed  and  extended 
Yillemin's  original  observations  and  paved  the  way  for  the  reception  of  Koch's 
announcement.  This  mode  of  infection  is  seen  in  persons  whose  occupation 
brings  them  in  contact  with  dead  bodies  or  animal  products.  Demonstrators 
of  morbid  anatomy,  butchers,  and  handlers  of  hides  are  subject  to  a  local 


TUBEECULOSIS  163 

tubercle  of  the  skin,  which  forms  a  reddened  mass  of  granulation  tissue, 
usually  capping  the  dorsal  surface  of  the  hand  or  a  finger.  This  is  the  so- 
called  post  mortem  wart,  the  verruca  necrogenica  of  Wilks.  The  demonstra- 
tion of  its  nature  is  shown  by  the  presence  of  tubercle  bacilli,  and  by  inocu- 
lation experiments  in  animals.' 

In  the  performance  of  the  rite  of  circumcision  children  have  been  acci- 
dentally inoculated.  Infection  in  these  cases  is  probably  always  associated 
with  disease  in  the  operator,  and  occurs  in  connection  with  the  habit  of  cleans- 
ing the  wound  by  suction.  Other  means  of  inoculation  have  been  described: 
as  the  wearing  of  earrings,  washing  the  clothes  of  tuberculous  patients,  the 
bite  of  a  tuberculous  subject,  or  inoculation  from  a  cut  by  a  broken  spit-glass 
of  a  consumptive;  and  Czerny  reported  two  cases  of  infection  by  transplanta- 
tion of  skin. 

It  has  been  urged  by  the  opponents  of  vaccination  that  tuberculosis  may 
be  thus  conveyed,  but  of  this  there  is  no  evidence.  Lymph  of  revaccinated 
consumptives,  is  non-infective.  Lupus  has  originated  at  the  site  of  vaccina- 
tion in  a  few  cases  (C.  Fox,  Graham  Little).  It  may  be  said  that  inocula- 
tion in  man  plays  a  trifling  role  in  the  transmission  of  tuberculosis. 

Mucous  membrane  inoculation  is  probably  important  in  childhood  through 
abrasions  of  the  lips,  tongue  or  gums,  though  a  primary  focus  is  not  often 
seen.  The  open  door  in  the  mouth  and  throat  is  more  often  by  loss  of  the 
protective  epithelium  due  to  catarrhal  and  ulcerative  processes. 

(3)  Infection  in  Childhood. — The  special  points  favoring  this  are:  (a) 
The  intimate  contact  between  children  and  parents  and  other  adults  in  house- 
holds where  tuberculosis  exists.  (&)  The  habit  of  playing  about  the  floor  and 
putting  objects  in  the  mouth,  (c)  The  influence  of  certain  infections,  such 
as  measles  and  whooping  cough,  (d)  The  large  place  which  milk  takes  in  the 
dietary,  (e)  The  close  contact  with  other  children  in  school.  The  result  may 
be:  (a)  Acute  tuberculosis  and  death,  (b)  An  infection  of  short  duration 
with  slight  symptoms  and  recovery,  (c)  A  more  chronic  condition,  (d) 
Latency  of  the  disease  until  adult  life,  when,  as  the  result  of  lowered  resistance 
by  many  factors,  the  infection  becomes  active.  Present  opinion  places  great 
stress  on  the  importance  of  infection  by  ingestion  early  in  life  with  the  de- 
velopment of  the  clinical  disease  many  years  later.  It  is  exceptional  not  to 
find  a  focus  somewhere  in  the  body  of  a  child,  no  matter  what  disease  caused 
death, 

(4)  Infection  by  Inhalation. — A  belief  in  the  contagiousness  of  pulmo- 
nary'- tuberculosis  originated  with  the  early  Greek  physicians,  and  has  per^ 
sisted  among  the  Latin  races.  The  investigations  of  Cornet  afford  conclusive 
proof  that  the  dust  of  a  room  or  other  locality  frequented  by  patients  with 
pulmonary  tuberculosis  is  infective.  The  bacilli  attached  to  fine  particles  of 
dust  are  inhaled  and  gain  entrance  to  the  system  through  the  lungs. 

Fliigge  denies  that  the  bacillus-containing  dust  is  the  dangerous  element 
in  infection.  Experimentally  he  has  only  succeeded  in  producing  the  disease 
when  there  is  some  lesion  in  the  respiratory  tract.  He  thinks  tliat  the  danger 
of  infection  by  the  dry  sputum  is  very  improbable.  On  the  other  hand,  he 
thinks  that  the  infection  is  chiefly  conveyed  by  the  free,  finely  divided  par- 
ticles of  sputum  produced  in  the  act  of  coughing,  and  that  these  tinv  fraff- 


164  SPECIFIC  INFECTIOUS  DISEASES 

ments  are  suspended  in  the  atmosphere.  Those  who  cough  very  much  and 
with  the  mouth  open  are  most  liable  to  infect  the  surrounding  air. 

It  is  well  remarked  by  Cornet^  "The  consumptive  in  himself  is  almost 
harmless^  and  only  becomes  harmful  through  bad  habits."  It  has  been  fully 
shown  that  the  expired  air  of  consumptives  is  not  infective.  The  virus  is 
contained  in  the  sputum,  which  when  dry  is  widely  disseminated  in  the  form 
of  dust,  and  constitutes  the  great  medium  for  the  transmission  of  the  disease. 
Among  the  points  urged  in  favor  of  the  inhalation  view  are : 

(i)  Primary  tuberculous  lesions  are  in  a  majority  of  all  cases  connected 
with  the  respiratory  system.  The  frequency  with  which  foci  are  met  with 
in  the  lungs  and  in  the  bronchial  glands  is  extraordinary,  and  the  statistics 
of  the  Paris  morgue  show  that  a  considerable  proportion  of  all  persons  dying 
of  accident  or  by  suicide  present  evidences  of  the  disease  in  these  parts.  The 
post  mortem  statistics  of  hospitals  show  the  same  widespread  prevalence  of 
infection  through  the  air  passages.  Biggs  reports  that  more  than  60  per  cent. 
of  his  post  mortems  showed  lesions  of  pulmonary  tuberculosis.  In  125  autop- 
sies at  the  Foundling  Hospital,  New  York,  the  bronchial  glands  were  tuber- 
culous in  every  case.  In  adults  the  bronchial  glands  may  be  infected  and  the 
individual  remain  in  good  health. 

(u)  The  greater  prevalence  of  tuberculosis  in  institutions  in  which  the 
residents  are  confined  and  restricted  in  the  matter  of  fresh  air  and  a  free 
open  life — conditions  which  would  favor,  on  the  one  hand,  the  presence  of  the 
bacilli  in  the  atmosphere,  and,  on  the  other,  lower  the  vital  resistance  of  the 
individual.  The  investigations  of  Cornet  upon  the  death-rate  from  consump- 
tion among  certain  religious  orders  devoted  to  nursing  give  some  striking 
facts  in  illustration  of  this.  In  a  review  of  38  cloisters,  embracing  the  average 
number  of  4,028  residents,  among  2,099  deaths  in  the  course  of  twenty-five 
years,  1,320  (62.88  per  cent.)  were  from  tuberculosis.  In  some  cloisters 
more  than  three-fourths  of  the  deaths  are  from  this  disease,  and  the  mortality 
in  all  the  residents,  up  to  the  fortieth  year,  is  greatly  above  the  average,  the 
increase  being  due  entirely  to  tuberculosis.  The  more  perfect  the  prophylaxis 
and  hygienic  arrangements  of  an  institution,  the  lower  the  death-rate  from 
tuberculosis.  The  mortality  in  prisons  has  been  shown  by  Baer  to  be  four 
times  as  great  as  outside.  The  death-rate  from  tuberculosis  in  prisons  con- 
stitutes from  40  to  50  per  cent.,  and  in  some  countries,  as  Austria,  over  60 
per  cent,  of  the  total  mortality.  Flick  studied  the  distribution  of  the  deaths 
from  tuberculosis  in  a  single  city  ward  in  Philadelphia  for  twenty-five  years. 
His  researches  go  far  to  show  that  it  is  a  house  disease.  About  33  per  cent. 
of  infected  houses  have  had  more  than  one  case.  There  are,  however,  oppos- 
ing facts.  The  statistics  of  the  Brompton  Consumption  Hospital  show  that 
doctors,  nurses,  and  attendants  are  rarely  attacked.  Dettweiler  claims  that 
no  case  of  tuberculosis  has  been  contracted  among  his  nurses  or  attendants 
at  Falkenstein.  Among  174  previously  healthy  sanitarium  physicians  whose 
average  term  of  service  was  three  years  only  two  became  tuberculous  (Sang- 
mann) .  On  the  other  hand,  in  the  Paris  hospitals  tuberculosis  decimates  the 
attendants. 

(w)  Special  danger  was  believed  to  exist  when  the  contact  is  very  intimate, 
as  between  man  and  wife,  but  upon  the  figures  of  the  late  Ernest  Pope,  of 
Saranac,  Karl  Pearson  bases  the  following  conclusions:     (a)  There  is  some 


TtJBEECULOSIS  165 

sensible  but  slight  infection  between  married  couples;  (6)  this  is  largely  ob- 
scured or  forestalled  by  the  fact  of  infection  from  outside  sources;  (c)  the 
liability  to  the  infection  depends  on  the  presence  of  the  necessary  diathesis; 
(d)  assortative  mating  probably  accounts  for  at  least  two-thirds,  and  infective 
action  not  more  than  one-third  of  the  whole  correlation  in  these  cases.  There 
are  cases  in  which  this  source  of  infection  seems  to  play  a  role. 

(5)  Infection  by  Ingestion. — There  are  two  other  channels,  the  tonsils  and 
the  intestines,  both  of  great  importance. 

(t)  Tonsillar  Infection. — The  frequency  of  involvement  of  these  glands 
has  been  shown  by  Schlenker,  Arthur  Latham,  and  "Walsham.  The  bacilli 
pass  to  the  glands  of  the  neck  and  of  the  mediastinum,  and  reach  the  circu- 
lation through  the  lymph-channels.  Or  an  infected  bronchial  gland  becomes 
adherent  to  a  branch  of  the  pulmonary  artery;  if  a  large  number  of  bacilli 
escape,  miliary  tuberculosis  follows;  if  only  a  small  number,  they  reach  the 
lungs,  at  the  apices  of  which  they  find  conditions  suitable  for  their  growth. 
Through  this  tonsillar-cervical  route  bacilli  may  gain  entrance  without  caus- 
ing local  disease  at  the  portal  of  entry.  It  is  a  common  method  of  infection 
in  children,  causing  the  "scrofulous"  glands  of  the  neck. 

(n)  Intestinal  Infection. — Behring  announced  in  1903  that  pulmonary 
tuberculosis  could  be  induced  through  intestinal  infection,  and  he  further  main- 
tained that  milk  fed  to  infants  was  the  chief  cause  of  consumption  in  adults, 
the  infection  remaining  latent.  Behring's  first  contention  was  supported  by 
Eavenel  and  others,  who  produced  pulmonary  tuberculosis  in  animals  by  feed^ 
ing  experiments,  and  it  was  demonstrated  that  the  intestinal  surface  itself 
might  remain  intact.  This  does  away  with  the  objection  raised  by  Koch  that, 
if  infection  through  the  milk  of  tuberculous  cattle  were  common,  primary  in- 
testinal tuberculosis  should  be  more  frequent,  whereas  in  ten  years  among 
3,104  cases  of  tuberculosis  in  children  there  were  only  16  of  primary  bowel 
infection.  Experiments  have  shown  in  a  striking  manner  how  the  lungs  act 
as  filters  for  particles  absorbed  from  the  intestines.  Vansteenberghe  and 
Grysez  produced  anthracosis  of  the  lungs  by  introducing  china-ink  emulsion 
directly  into  the  stomach  (see  Anthracosis).  They  found  a  remarkable  dif- 
ference in  young  and  adult  guinea-pigs;  in  the  former  the  carbon  particles 
were  filtered  out  by  the  mesenteric  glands,  while  the  lungs  remained  free ;  in 
the  latter  the  glands  were  unaffected,  but  the  lungs  were  carbonized.  Calmette 
and  Guerin  have  shown  how  easily  the  lungs  may  be  infected  through  the  in- 
testinal route  without  leaving  the  slightest  trace  of  disease  of  the  bowel  itself. 
Behring's  view  of  the  importance  of  infection  through  the  intestinal  route  has 
thus  received  the  strongest  support,  and  many  go  so  far  as  to  maintain  that 
a  majority  of  all  cases  of  tuberculosis  originate  in  this  manner.  The  truth  is 
that  this  ubiquitous  bacillus  is  not  particular,  and  gains  entrance  through 
either  portal,  preferring  the  throat  and  intestines  in  childhood,  the  bronchi  and 
lungs  in  adults.  The  important  matter  for  the  individual  is  the  nature  of  the 
soil  on  which  it  falls. 

Milk  alone  is  a  common  source  of  intestinal  infection,  particularly  in  the 
large  cities.  In  New  York,  Hess  found  tubercle  bacilli  in  16  per  cent,  of 
107  specimens !     The  ordinary  commercial  pasteurization  does  not  kill  them. 

The  flesh  of  tuberculous  animals  is  rarely  dangerous. 


166  SPECIFIC  IXFECTIOrS  DISEASES 

(6)  Re-infection. — This  is  a  possibility  in  adult  life  but  its  frequency  is 
difficult  to  state. 

General  Morbid  Anatomy  and  Histology  of  Tuberculous  Lesions. — (a) 
DiSTEiBUTiox  OF  THE  TuBEECLES  IX  THE  BoDY. — The  primary  localization  of 
the  tubercle  bacillus  in  the  vast  majority  of  cases,  if  not  in  all,  is  in  the  lym- 
phatic structures;  involvement  of  the  lungs  is  secondary.  Clinically  in  adults, 
the  lungs  may  be  regarded  as  the  seat  of  election;  in  children,  the  lymph-nodes, 
bones,  and  joints.  In  1,000  autopsies  there  were  275  cases  with  tuberculous 
lesions.  With  but  two  or  three  exceptions  the  lungs  were  affected.  The  dis- 
tribution in  the  other  organs  was  as  follows :  Pericardium,  7 ;  peritoneum, 
36;  brain,  31;  spleen,  23;  liver,  12;  kidneys,  32;  intestines,  65;  heart,  4;  and 
generative  organs,  8. 

Among  8,873  surgical  patients  at  the  AViirzburg  clinic,  1,287  were  tubercu- 
lous, with  the  following  distribution  of  lesions:  Bones  and  joints,  1,037; 
lymph-nodes,  196;  skin  and  connective  tissues,  77;  mucous  membranes,  10; 
genito-urinary  organs,  20. 

(6)  The  Changes  Produced  by  the  Tubercle  Bacilli. — The  Nodular 
Tubercle. — A  "tubercle"  presents  in  its  early  formation  nothing  distinctive  or 
peculiar^,  either  in  its  components  or  in  their  arrangement.  Identical  struc- 
tures are  produced  by  other  parasites,  such  as  the  actinomyces,  and  by  the 
strongylus  in  the  lungs  of  sheep. 

The  following  changes  occur  in  the  evolution  of  a  tubercle: 

(1)  The  tubercle  bacilli  multiply  and  disseminate  in  the  surrounding  tis- 
sues, partly  by  growth,  partly  in  the  lymph  currents. 

(2)  The  fixed  cells,  especially  those  of  connective  tissue  and  the  endothe- 
lium of  the  capillaries,  multiply  and  form  rounded,  cuboidal,  or  polygonal 
bodies  with  vesicular  nuclei — the  epithelioid  cells — inside  some  of  which  the 
bacilli  are  soon  seen. 

(3)  Leucocytes,  chiefly  polynuclear,  migrate  in  numbers  and  accumulate 
about  the  focus  of  infection.  They  do  not  survive.  Many  undergo  rapid 
destruction.  Later,  as  the  little  tubercle  grows,  the  leucocytes  are  chiefly  of 
the  mononuclear  variety  (lymphocytes),  which  do  not  undergo  the  rapid  de- 
generation of  the  polynuclear  forms. 

(4)  A  reticulum  of  fibres  is  formed  by  the  fibrillation  and  rarefaction  of 
the  connective-tissue  jnatrix.  This  is  most  apparent,  as  a  rule,  at  the  margin 
of  the  growth. 

(5)  In  some,  but  not  all,  tubercles  giant  cells  are  formed  by  an  increase 
in  the  protoplasm  and  in  the  nuclei  of  an  individual  cell,  or  possibly  by  the 
fusion  of  several  cells.  The  giant  cells  seem  to  be  in  inverse  ratio  to  the 
number  and  virulence  of  the  bacilli. 

(c)  The  Degeneratiox  of  Tubercle. —  (1)  Caseation. — At  the  central 
part  of  the  growth,  owing  to  the  direct  action  of  the  bacilli  or  their  products, 
a  process  of  coagulation  necrosis  goes  on  in  the  cells,  which  lose  their  outline, 
become  irregular,  no  longer  take  stains,  and  are  finally  converted  into  a  homo- 
geneous, structureless  substance.  This  may  be  due  to  the  blood  supply  being 
cut  off  or  to  the  toxins  of  the  tubercle  bacillus.  Proceeding  from  the  centre 
outward,  the  tubercle  may  be  gradually  converted  into  a  yellowish-gray  body, 
in  which  the  bacilli  are  still  abundant.     Ko  blood  vessels  are  found  in  them. 


TUBERCULOSIS  167 

Aggregated  together  these  form  cheesy  masses  which  may  undergo  softening, 
fibroid  limitation  (encapsulation),  or  calcification. 

(2)  Sclerosis. — With  the  necrosis  of  the  cell  elements  at  the  centre  of  the 
tubercle,  hyaline  transformation  proceeds,  together  with  great  increase  in  the 
fibroid  elements;  so  that  the  tubercle  is  converted  into  a  firm,  hard  structure. 
Often  the  change  is  rather  of  a  fibro-caseous  nature;  but  the  sclerosis  pre- 
dominates. In  some  situations,  as  in  the  peritoneum,  this  seems  to  be  the 
natural  transformation  and  it  is  by  no  means  rare  in  the  lungs. 

In  all  tubercles  two  processes  go  on:  the  one — caseation — destructive  and 
dangerous;  and  the  other — sclerosis — conservative  and  healing.  The  ultimate 
result  in  a  given  case  depends  upon  the  capabilities  of  the  body  to  fight  the 
invaders.  There  are  tissue-soils  in  which  the  bacilli  are,  in  all  probability, 
killed  at  once.  There  are  others  in  which  a  lodgment  is  gained  and  more  or 
less  damage  done,  but  finally  the  day  is  with  the  protecting  forces.  Thirdly, 
there  are  tissue-soils  in  which  the  bacilli  grow  luxuriantly,  caseation  and  soft- 
ening, not  limitation  and  sclerosis,  prevail,  and  the  day  is  with  the  invaders. 

The  action  of  the  bacilli  injected  directly  into  the  blood-vessels  illustrates 
many  points  in  the  histology  and  pathology  of  tuberculosis.  If  into  the  vein 
of  a  rabbit  a  pure  culture  of  the  bacilli  is  injected,  the  microbes  accumulate 
chiefly  in  the  liver  and  spleen.  The  animal  dies  usually  within  two  weeks, 
and  the  organs  apparently  show  no  trace  of  tubercles.  Microscopically,  in  both 
spleen  and  liver  the  young  tubercles  in  process  of  formation  are  very  numerous, 
and  karyokinesis  is  going  on  in  the  liver-cells.  After  an  injection  of  a  more 
dilute  culture,  or  one  of  less  virulence,  instead  of  dying  within  a  fortnight  the 
animal  survives  for  five  or  six  weeks,  by  which  time  the  tubercles  are  apparent 
in  the  spleen  and  liver,  and  often  in  the  other  organs. 

(d)  The  Diffused  Inflammatory  TuBERCLE.^This  is  most  frequently 
seen  in  the  lungs  and  results  from  the  fusion  of  many  small  foci  of  infection 
— so  small  indeed  that  they  may  not  be  visible  to  the  naked  eye,  but  which 
histologically  are  seen  to  be  composed  of  scattered  centres,  surrounded  by  areas 
in  which  the  air-cells  are  filled  with  the  products  of  exudation  and  of  the 
proliferation  of  the  alveolar  epithelium.  Under  the  influence  of  the  bacilli, 
caseation  takes  place,  usually  in  small  groups  of  lobules,  occasionally  in  an 
entire  lobe,  or  even  the  greater  part  of  a  lung.  In  the  early  stage  of  the 
process,  the  tissue  has  a  gray  gelatinous  appearance,  the  gray  infiltration  of 
Laennec.  The  alveoli  contain  a  sero-fibrinous  fluid  with  cells,  and  the  septa 
are  also  infiltrated.  These  cells  accumulate  and  undergo  coagulation  necrosis, 
forming  areas  of  caseation,  the  infiltration  tuberculeuse  jaune  of  Laennec,  the 
scrofulous  or  cheesy  pneumonia  of  later  writers.  There  may  also  be  a  diffuse 
infiltration  and  caseation  without  any  special  foci,  a  widespread  tuberculous 
pneumonia  induced  by  the  bacilli. 

After  all,  the  two  processes  are  identical.  As  Baumgarten  states:  "There 
is  no  well-marked  difference  between  miliary  tubercle  and  chronic  ceaseous 
pneumonia.  Speaking  histologically,  miliary  tuberculosis  is  nothing  else  than 
a  chronic  caseous  miliary  pneumonia,  and  chronic  caseous  pneumonia  is  noth- 
ing but  a  tuberculosis  of  the  lungs." 

(e)  Secoxdary  Inflammatory  Processes. —  (1)  The  irritation  caused 
by  the  bacilli  produces  an  inflammation  which  may,  as  has  been  described, 
be  limited  to  exudation  of  leucocytes  and  serum,  but  may  also  be  much  more 


168  SPECIFIC  INFECTIOUS  DISEASES 

extensive,  and  vary  with  changing  conditions.  We  find,  for  example,  about 
the  smaller  tubercles  in  the  lungs,  pneumonia — either  catarrhal  or  fibrinous — 
proliferation  of  the  connective-tissue  elements  in  the  septa  (which  also  become 
infiltrated  with  round  cells),  and  changes  in  the  blood  and  lymph-vessels. 

(2)  In  processes  of  minor  intensity  the  inflammation  is  of  the  slow  reac- 
tive nature,  which  results  in  the  production  of  a  cicatricial  connective  tissue 
which  limits  and  restricts  the  development  of  the  tubercles  and  is  the  essen- 
tial conservative  element  in  the  disease.  It  is  to  be  remembered  that  in  chronic 
pulmonary  tuberculosis  much  of  the  fibroid  tissue  which  is  present  is  not  in  any 
way  associated  with  the  action  of  the  bacilli. 

(3)  Suppuration.  Do  the  bacilli  themselves  induce  suppuration?  In 
so-called  cold  tuberculous  abscess  the  material  is  not  histologically  pus,  but 
a  dehrk  consisting  of  broken-down  cells  and  cheesy  material.  It  is  moreover 
sterile — that  is,  does  not  contain  the  usual  pus  organisms.  The  products  of 
the  tubercle  bacilli  are  probably  able  to  induce  suppuration,  as  in  joint  and 
bone  tuberculosis  pus  is  frequently  produced,  although  this  may  be  due  to  a 
mixed  infection.  Tuberculin  is  one  of  the  best  agents  for  the  production  of 
experimental  suppuration.  In  tuberculosis  of  the  lungs  the  suppuration  is 
largely  the  result  of  an  infection  with  pus  organisms. 

11.     ACUTE  MILIARY  TUBERCULOSIS 

The  modern  knowledge  of  this  remarkable  form  dates  from  the  statement 
of  Buhl  (1856),  that  miliary  tuberculosis  is  a  specific  infection  dependent  on 
the  presence  in  the  body  of  an  unencapsulated  yellow  tubercle,  or  a  tubercu- 
lous cavity  in  the  lung;  and  that  it  bears  the  same  relation  to  the  primary 
lesion  as  pygemia  does  to  a  focus  of  suppuration. 

Carl  Weigert  established  the  truth  of  this  brilliant  conception  by  demon- 
strating the  association  of  miliary  tuberculosis  with  tuberculosis  of  the  blood- 
vessels. There  are  two  groups  of  vessel  tubercle — the  tuberculous  periangitis 
in  which  there  is  invasion  of  the  adventitia,  and  the  endangitis  in  which  the 
tubercles  start  in  the  intima.  The  parts  most  frequently  affected  are  the 
pulmonary  veins  and  the  thoracic  duct,  less  often  the  jugular  vein,  the  supra- 
renal and  the  vena  cava  superior,  and  the  sinuses  of  the  dura  mater,  the  aorta, 
and  the  endocardium.  To  the  branches  of  the  pulmonary  veins  it  is  not 
uncommon  to  find  caseous  glands  adherent,  penetrating  the  walls  and  show- 
ing a  growth  of  miliary  tubercles  in  the  intima.  A  special  interest  belongs 
to  tuberculosis  of  the  thoracic  duct,  first  accurately  described  by  Sir  Astley 
Cooper.  Benda  in  a  series  of  19  cases  of  vessel  tuberculosis  found  in  many 
instances  an  enormous  number  of  bacilli,  particularly  in  the  ceasous  tubercles 
of  the  thoracic  duct. 

The  bacilli  do  not  increase  in  the  blood,  but  settle  in  the  different  organs, 
producing  a  generalized  tuberculosis,  of  which  Weigert  recognized  three  types 
or  grades:  I.  The  acute  general  miliary  tuberculosis,  in  which  the  various 
organs  of  the  body  are  stuffed  with  miliary  and  submiliary  nodules.  II.  A 
second  form  characterized  by  a  small  number  of  tubercles  in  one  or  many 
organs.  III.  The  occurrence  of  numerous  tuberculous  foci  widely  spread 
throughout  the  body,  but  in  a  more  chronic  form ;  the  tubercles  are  larger  and 
many  are  caseous.     It  is  the  chronic  generalized  tuberculosis  of  children. 


TUBEECULOSIS  169 

Transitional  forms  between  these  groni^s  occur.  In  the  fi^st  variety,  which  wc 
are  here  considering,  there  is  an  eruption  into  the  circulation  of  an  enormous 
number  of  bacilli.  Benda  suggests  in  explanation  of  the  profound  toxaemia 
seen  in  certain  cases  (the  typhoid  form)  that  in  addition  the  blood  is  sur- 
charged with  toxins  from  a  large  caseous  focus  which  has  eroded  the  vessel. 

Clinical  Forms 

The  cases  may  be  grouped  into  those  with  the  symptoms  of  an  acute  gen- 
eral infection — the  typhoid  form;  cases  in  which  pulmonary  symptoms  pre- 
dominate; and  cases  in  which  the  cerehral  or  cerebrospinal  symptoms  are 
marked — tuberculous  meningitis.  Other  forms  have  been  recognized,  but  this 
division  covers  a  large  majority  of  the  cases.  Taking  any  series  of  cases  it 
will  be  found  that  the  meningeal  form  of  acute  tuberculosis  exceeds  in  num- 
bers the  cases  with  general  or  marked  pulmonary  symptoms. 

General  or  Typhoid  Form. — Symptoms. — The  patient  presents  the  symp- 
toms of  a  profound  infection  which  simulates  and  is  frequently  mistaken  for 
typhoid  fever.  After  a  period  of  failing  health,  with  loss  of  appetite,  he 
becomes  feverish  and  weak.  Occasionally  the  disease  sets  in  more  abruptly, 
but  in  many  instances  the  anamnesis  closely  resembles  that  of  typhoid  fever. 
Kose-bleeding,  however,  is  rare.  The  temperature  increases,  the  pulse  be- 
comes rapid  and  feeble,  the  tongue  dry;  delirium  becomes  marked  and  the 
cheeks  are  flushed.  The  pulmonary  symptoms  may  be  very  slight;  usually 
bronchitis  exists,  but  is  not  more  severe  than  is  common  with  typhoid  fever. 
The  pulse  is  seldom  dicrotic,  but  is  rapid  in  proportion  to  the  pyrexia.  Per- 
haps the  most  striking  feature  of  the  temperature  is  the  irregularity;  and  if 
seen  from  the  outset  there  is  not  the  steady  ascent  noted  in  typhoid  fever. 
There  is  usually  an  evening  rise  to  103°  F.,  sometimes  104°  P.,  and  a  morn- 
ing remission  of  from  two  to  three  degrees.  Sometimes  the  pyrexia  is  inter- 
mittent, and  the  thermometer  may  register  below  normal  during  the  early 
morning  hours.  The  inverse  type  of  temperature,  in  which  the  rise  takes 
place  in  the  morning,  is  held  by  some  writers  to  be  more  frequent  in  general 
tuberculosis  than  in  other  diseases.  In  rare  instances  there  may  be  little  or  no 
fever.  On  three  occasions  we  have  had  a  patient  admitted  in  a  condition  of 
profound  debility,  with  a  history  of  illness  of  from  three  to  four  weeks'  dura- 
tion, with  rapid  pulse,  flushed  cheeks,  dry  tongue,  and  very  slight  elevation  in 
temperature,  in  whom  (post  mortem)  the  condition  proved  to  be  general 
tuberculosis.  Eeinhold,  from  Baumler's  clinic,  called  attention  to  these 
afebrile  forms  of  acute  tuberculosis.  In  9  of  52  cases  there  was  no  fever,  or 
only  a  transient  rise. 

In  a  considerable  number  of  the  cases  the  respirations  are  increased  in 
frequency,  particularly  in  the  early  stage,  and  there  may  be  signs  of  diffuse 
bronchitis  and  slight  cyanosis.  Cheyne-Stokes  breathing  occurs  toward  the 
close.  Active  delirium  is  rare.  More  commonly  there  are  torpor  and  dullness, 
gradually  deepening  into  coma,  in  which  the  patient  dies.  In  some  cases 
the  pulmonary  symptoms  become  more  marked;  in  others  meningeal  or  cere- 
bral features  occur. 

Diagnosis. — The  differential  diagnosis  between  general  miliary  tubercu- 
losis without  local  manifestations  and  typhoid  fever  is  extremely  difficult.  A 
point  of  importance  is  the  irregularity  of  the  temperature  curve.    The  greater 


170  SPECIFIC  INFECTIOUS  DISEASES 

frequency  of  the  respirations  and  the  tendency  to  slight  cyanosis  are  much 
more  common  in  tuberculosis.  There  are  cases,  however,  of  typhoid  fever  in 
which  the  initial  bronchitis  is  severe  and  may  lead  to  dyspnoea  and  disturbed 
oxygenation.  The  cough  may  be  slight  or  absent.  Diarrhoea  is  rare  in  tuber- 
culosis; the  bowels  are  usually  constipated;  but  diarrhoea  may  occur  and 
persist  for  days.  In  certain  cases  the  diagnosis  has  been  complicated  still  fur- 
ther by  the  occurrence  of  blood  in  the  stools.  Enlargement  of  the  spleen 
occurs  in  general  tuberculosis,  but  is  neither  so  early  nor  so  marked  as  in 
typhoid  fever.  In  children,  however,  the  enlargement  may  be  considerable. 
The  urine  may  show  traces  of  albumin  and  contains  tubercle  bacilli  in  a  con- 
siderable number  of  cases'.  The  absence  of  the  characteristic  roseola  is  an 
important  feature.  Occasionally  in  acute  tuberculosis  reddish  spots  may  occur 
and  for  a  time  cause  difficulty,  but  they  do  not  come  out  in  crops,  and  rarely 
have  the  characters  of  the  true  typhoid  eruption.  Herpes  is  perhaps  more 
common  in  tuberculosis.  Toward  the  close,  petechise  may  appear  on  the  skin, 
particularly  about  the  wrists.  A  rare  event  is  jaundice,  due  possibly  to  the 
eruption  of  tubercles  in  the  liver.  It  is  to  be  remembered  that  the  lesions 
of  acute  tuberculosis  and  of  typhoid  fever  have  been  demonstrated  in  the  same 
body. 

A  negative  Widal  test  and  the  absence  of  typhoid  bacilli  in  blood-cultures 
may  be  of  decisive  importance  in  these  doubtful  cases.  In  rare  instances 
tubercle  bacilli  have  been  found  in  the  blood.  Leucocytosis  is  more  common 
in  miliary  tuberculosis  than  in  typhoid  fever,  in  which  leucopenia  is  the  rule. 
Careful  examination  of  the  eyes  may  show  choroidal  tubercles,  though  we  have 
never  known  a  diagnosis  made  on  their  presence  alone.  In  the  fluid  obtained 
by  lumbar  puncture  the  tubercle  bacilli  may  be  abundant,  even  when  there  is 
no  active  meningitis. 

Pulmonary  Form. — Symptoms. — From  the  outset  the  pulmonary  symp- 
toms are  marked.  The  patient  may  have  had  a  cough  for  months  or  for 
years  without  much  impairment  of  health,  or  he  may  be  known  to  be  the 
subject  of  chronic  pulmonary  tuberculosis.  In  other  instances,  particularly 
in  children,  the  affection  follows  measles  or  whooping  cough,  and  is  of  a  dis- 
tinctly broncho-pneumonic  type.  The  disease  begins  with  the  symptoms  of 
diffuse  bronchitis.  The  cough  is  marked,  the  expectoration  muco-purulent, 
occasionally  rusty.  Haemoptysis  has  been  noted  in  a  few  instances.  From 
the  outset  dyspnoea  is  a  striking  feature  and  may  be  out  of  proportion  to  the 
intensity  of  the  physical  signs.  There  is  more  or  less  cyanosis  of  the  lips  and 
finger-tips,  and  the  cheeks  are  suffused.  Apart  from  emphysema  and  the  later 
stages  of  severe  pneumonia,  there  is  no  other  pulmonary  condition  in  which 
the  cyanosis  is  so  marked.  The  physical  signs  are  those  of  bronchitis.  In 
children  there  may  be  defective  resonance  at  the  bases,  from  scattered  areas  of 
broncho-pneumonia;  or,  what  is  equally  suggestive,  areas  of  hyper-resonance. 
Indeed,  the  percussion  note,  particularly  in  the  front  of  the  chest,  in  some 
cases  of  miliary  tuberculosis,  is  full  and  clear,  and  it  will  be  noted  (post  mor- 
tem) that  the  lungs  are  unusually  voluminous.  This  is  probably  the  result 
of  more  or  less  widespread  acute  emphysema.  On  auscultation,  the  rales 
are  either  sibilant  and  sonorous  or  small,  fine,  and  crepitant.  There  may  be 
fine  crepitation  from  the  occurrence  of  tubercles  on  the  pleura  (Jiirgensen). 
In   children  there  may   be  high-pitched   tubular   breathing  at  the   bases   or 


TUBERCULOSIS  171 

toward  the  root  of  the  lung.  Toward  the  close  the  rales  may  be  larger  and 
more  mucous.  The  temperature  rises  to  102°  or  103°  F.,  and  may  present 
the  inverse  type.  The  pulse  is  rapid  and  feeble.  In  the  A^ery  acute  cases  the 
spleen  is  always  enlarged.  The  disease  may  prove  fatal  in  ten  or  twelve  days, 
or  may  be  protracted  for  weeks  or  even  months. 

Diagnosis. — The  diagnosis  of  this  form  offers  less  difficulty  and  is  more 
frequently  made.  There  is  often  a  history  of  previous  cough,  or  the  patient 
is  known  to  be  the  subject  of  local  disease  of  the  lung,  of  the  lymph  glands, 
or  of  the  bones.  In  children  these  symptoms  following  measles  or  whooping 
cough  indicate  in  the  majority  of  cases  acute  miliary  tuberculosis,  with 
or  without  broncho-pneumonia.  Occasionally  the  sputum  contains  tubercle 
bacilli. 

The  choroidal  tubercle  occurs  in  a  limited  number  of  cases  and  may  help 
the  diagnosis.  More  important  in  an  adult  is  the  combination  of  dyspnoea 
with  cyanosis  and  the  signs  of  a  diffuse  bronchitis.  In  some  instances  the 
occurrence  of  cerebral  symptoms  at  once  gives  a  clew  to  the  diagnosis. 

Meningeal  Form  {Tuberculous  Meningitis). — This  affection,  also  known 
as  acute  hydrocephalus  or  "water  on  the  brain,^'  is  essentially  an  acute  tuber- 
culosis in  which  the  membranes  of  the  brain,  sometimes  of  the  cord,  bear  the 
brunt  of  the  attack.  Our  first  accurate  knowledge  of  it  dates  from  the  publica- 
tion of  Eobert  Whytt's  Observations  on  the  Dropsy  of  the  Brain,  Edinburgh, 
1768.  He  studied  20  cases  and  divided  the  disease  into  three  stages,  accord- 
ing to  the  condition  of  the  pulse. 

Though  Guersant  had  as  early  as  1827  used  the  name  granular  menin- 
gitis for  this  form  of  inflammation  of  the  meninges,  it  was  not  until  1830 
that  Papavoine  demonstrated  the  nature  of  the  graniiles  and  noted  their 
occurrence  with  tubercles  in  other  parts.  In  1832  and  1833,  W.  W.  Gerhard, 
of  Philadelphia,  made  a  very  careful  study  of  the  disease  in  the  Children's  Hos- 
pital at  Paris,  and  his  publications,  more  than  those  of  any  other  author, 
served  to  place  the  disease  on  a  firm  anatomical  and  clinical  basis. 

There  are  several  special  etiological  factors  in  connection  with  this  form. 
It  is  much  more  common  in  children  than  in  adults.  It  occurs  during  the 
first  year  of  life,  but  is  more  frequent  between  the  second  and  the  fifth  years. 
In  a  majority  of  the  cases  a  focus  of  old  tuberculous  disease  will  be  found, 
commonly  in  the  bronchial  or  mesenteric  glands.  In  a  few  instances  the 
affection  seems  to  be  primary  in  the  meninges.  It  is  very  difficult,  however, 
in  an  ordinary  post  mortem  to  make  an  exhaustive  search,  and  the  lesion  may 
be  in  the  bones,  sometimes  in  the  middle  ear,  or  in  the  genito-urinary  organs. 
In  cases  in  which  no  primary  focus  has  been  discovered  it  has  been  suggested 
that  the  bacilli  reach  the  meninges  through  the  cribriform  plate  of  the  ethmoid 
from  the  upper  part  of  the  nostrils,  but  this  is  not  probable. 

Morbid  Axatomy. — The  meninges  at  the  base  are  most  involved,  hence 
the  term  basilar  meningitis.  The  parts  about  the  optic  chiasm,  the  Sylvian 
fissures,  and  the  interpeduncular  space  are  affected.  There  may  be  only  slight 
turbidity  and  matting  of  the  membranes,  and  a  certain  stickiness  with  serous 
infiltration;  but  more  commonly  there  is  a  turbid  exudate,  fibrino-purulent 
in  character,  which  covers  the  structures  at  the  base,  surrounds  the  nerves, 
extends  into  the  Sylvian  fissures,  and  appears  on  the  lateral,  rarely  on  the 
upper,   surfaces   of  the  hemispheres.     The  tubercles  may  be  very  apparent. 


172  SPECIFIC  INFECTIOUS  DISEASES 

particularly  in  tli6  Sylvian  fissures,  appearing  as  small,  whitish  nodules  on 
the  membranes.  They  vary  much  in  number  and  size,  and  may  be  difficult 
to  find.  The  amount  of  exudate  bears  no  definite  relation  to  the  abundance 
of  tubercles.  The  arteries  of  the  anterior  and  posterior  perforated  spaces 
should  be  carefully  withdrawn  and  searched,  as  upon  them  nodular  tubercles 
may  be  found  when  not  present  elsewhere.  In  doubtful  cases  the  middle  cere- 
bral arteries  should  be  very  carefully  removed,  spread  on  a  glass  plate  with 
a  black  background,  and  examined  with  a  lenS.  The  tubercles  are  then  seen 
as  nodular  enlargements  on  the  smaller  arteries.  The  lateral  ventricles  are 
dilated  (acute  hydrocephalus)  and  contain  a  turbid  fluid;  the  ependyma  may 
be  softened,  and  the  septum  lucidum  and  fornix  are  usually  broken  down. 
The  convolutions  are  often  flattened  and  the  sulci  obliterated  owing  to  the 
increased  intra-ventricular  pressure.  The  meninges  are  not  alone  involved, 
but  the  contiguous  cerebral  substance  is  more  or  less  oedematous  and  infll- 
trated  with  leucocytes,  so  that  anatomically  the  condition  is  in  reality  a 
meningo-enceplialitis. 

There  are  instances  in  which  the  acute  process  is  associated  with  chronic 
meningeal  tuberculosis;  cases  which  may  for  months  present  the  clinical  pic- 
ture of  brain  tumor.  Although  in  a  majority  of  instances  the  process  is  cere- 
bral, the  spinal  meninges  may  also  be  involved,  particularly  those  of  the  cer- 
vical cord.    There  are  cases,  indeed,  in  which  the  symptoms  are  chiefly  spinal. 

Symptoms. — Tuberculous  meningitis  presents  an  extremely  complex 
clinical  picture.     It  will  be  best  to  describe  the  form  found  in  children. 

Prodromal  symptoms  are  common.  The  child  may  have  been  in  failing 
health  for  some  weeks,  or  may  be  convalescent  from  measles  or  whooping 
cough.  In  many  instances  there  is  a  history  of  a  fall.  The  child  gets  thin, 
is  restless,  peevish,  irritable,  loses  its  appetite,  and  the  disposition  may  com- 
pletely change.  Symptoms  pointing  to  the  disease  may  then  set  in,  either 
quite  suddenly  with  a  convulsion,  or  more  commonly  with  headache,  vomit- 
ing, and  fever,  three  essential  symptoms  of  the  onset  which  are  rarely  absent. 
The  pain  may  be  intense  and  agonizing.  The  child  puts  its  hand  to  its  head 
and  occasionally,  when  the  pain  becomes  worse,  gives  a  short,  sudden  cry,  the 
so-called  hydrocephalic  cry.  Sometimes  the  child  screams  continuously  until 
utterly  exhausted.  The  vomiting  is  without  apparent  cause,  and  is  independ- 
ent of  taking  of  food.  Constipation  is  usually  present.  The  fever  is  slight, 
but  gradually  rises  to  102°  to  103°  F.  The  pulse  is  at  flrst  rapid,  subse- 
quently irregular  and  slow.  The  respirations  are  rarely  altered.  During 
sleep  the  child  is  restless  and  disturbed.  There  may  be  twitchings  of  the 
muscles,  or  sudden  startings;  or  the  child  may  wake  up  from  sleep  in  great 
terror.  In  this  early  stage  the  pupils  are  usually  contracted.  These  are  the 
chief  symptoms  of  the  initial  stage,  or,  as  it  is  termed,  the  stage  of  irritation. 

In  the  second  period  of  the  disease  these  irritative  symptoms  subside; 
vomiting  is  no  longer  marked,  the  abdomen  becomes  retracted,  boat-shaped, 
or  carinated.  The  bowels  are  obstinately  constipated,  the  child  no  longer 
complains  of  headache,  but  is  dull  and  apathetic,  and  when  roused  is  more  or 
less  delirious.  The  head  is  often  retracted  and  the  child  utters  an  occasional 
cry.  The  pupils  are  dilated  or  irregular,  and  a  squint  may  develop.  Sighing 
respiration  is  common.  Convulsions  may  occur,  or  rigidity  of  the  muscles  of 
one  side  or  of  one  limb.     The  temperature  is  variable,  ranging  from  100°  to 


TUBERCULOSIS  173 

102.5°  F.  A  blotchy  erythema  is  not  uncommon  on  the  skin.  If  the  finger- 
nail is  drawn  across  the  skin  of  any  region  a  red  line  comes  out  quickly,  the 
so-called  iaclie  cerehrale,  which,  however,  has  no  diagnostic  significance. 

In  the  final  period,  or  stage  of  ■paralysis^  the  coma  increases  and  the  child 
c-an  not  be  roused.  Convulsions  are  not  infrequent,  and  there  are  spasmodic 
contractions  of  the  muscles  of  the  back  and  neck.  Spasms  may  occur  in  the 
limbs  of  one  side.  Optic  neuritis  and  paralysis  of  the  ocular  muscles  may  be 
present.  The  pupils  become  dilated,  the  eyelids  are  only  partially  closed,  and 
the  eyeballs  are  rolled  up  so  that  the  corneae  are  only  uncovered  in  part  by 
the  upper  eyelids.  Diarrhoea  may  occur,  the  pulse  becomes  rapid,  and  the 
child  may  sink  into  a  typhoid  state  with  dry  tongue,  low  delirium,  and  invol- 
untary passages  of  urine  and  faeces.  The  temperature  often  becomes  sub- 
normal, sinking  in  TLve  instances  to  93°  or  94°  F.  In  some  cases  there  is  an 
ante-mortem  elevation  of  temperature,  the  fever  rising  to  106°  F.  The  entire 
duration  of  the  disease  is  from  a  fortnight  to  several  weeks.  A  leucocytosis 
is  not  infrequently  present  throughout  the  disease. 

There  are  cases  of  tuberculous  meningitis  which  pursue  a  more  rapid 
course.  They  set  in  with  great  violence,  often  in  persons  apparently  in  good 
health,  and  may  prove  fatal  within  a  few  days.  In  these  instances,  more 
commonly  seen  in  adults,  the  convex  surface  of  the  brain  is  usually  involved. 
There  are  again  instances  which  are  essentially  chronic  and  display  symptoms 
of  a  limited  meningitis,  sometimes  with  pronounced  psychical  symptoms,  and 
sometimes  with  those  of  cerebral  tumor.  The  symptoms  may  vary  from  time 
to  time;  some  are  probably  due  to  toxemia  rather  than  to  the  local  lesion. 

There  are  certain  features  which  call  for  special  comment. 

The  irregularity  and  slowness  of  the  pulse  in  the  earty  and  middle  stages 
of  the  disease  are  points  upon  which  all  authors  agree.  Toward  the  close,  as 
the  heart's  action  becomes  weaker,  the  pulsations  are  more  frequent.  The 
temperature  is  usually  elevated,  but  there  are  instances  in  which  it  does  not 
rise  in  the  whole  course  of  the  disease  much  above  100°  F.  It  may  be  ex- 
tremely irregular,  and  the  oscillations  are  often  as  much  as  three  or  four 
degrees  in  the  day.  Toward  the  close  the  temperature  may  sink  to  95°  F., 
occasionally  to  94°  F.,  or  there  may  be  hyperpyrexia.  In  a  case  of  Baum- 
ler's  the  temperature  rose  before  death  to  43.7°  C.  (110.7°  F.). 

The  ocvlar  symptoms  are  of  special  importance.  In  the  early  stages  nar- 
rowing of  the  pupils  is  the  rule.  Toward  the  close,  with  increase  in  the 
intra-cranial  pressure,  the  pupils  dilate  and  are  irregular.  There  may  be  con- 
jugate deviation  of  the  eyes.  Of  ocular  nerves  the  third  is  most  frequently  in- 
volved, sometimes  with  paralysis  of  the  face,  limbs,  and  hypoglossal  nerve  on 
the  opposite  side  (syndrome  of  Weber),  due  to  a  lesion  limited  to  the  inferior 
and  internal  part  of  the  crus.  The  changes  in  the  retinse  are  very  important. 
Xeuritis  is  the  most  common.  According  to  Gowers,  the  disk  at  first  becomes 
full  colored  and  has  hazy  outlines,  and  the  veins  are  dilated.  Swelling  and 
striation  become  pronounced,  but  the  neuritis  is  rarely  intense.  Of  26  cases 
studied  by  Garlick,  in  6  the  condition  was  of  diagnostic  value.  The  tubercles 
in  the  choroid  are  rare  and  much  less  frequently  seen  during  life  than  post 
mortem  figures  would  indicate.  Ihus,  Litten  found  them  (post  mortem)  in 
39  out  of  52  cases.    They  were  present  in  only  1  of  the  26  cases  of  tuberculous 


174  SPECIFIC  IXFECTIOUS  DISEASES 

meningitis  examined  by  Garlick.  Heinzel  examined  41  eases  with  negative 
results. 

Among  the  motor  symptoms  convulsions  are  most  common,  but  there  are 
other  changes  which  deserve  special  mention.  A  tetanic  contraction  of  one 
limb  may  persist  for  several  days,  or  a  cataleptic  condition.  Tremor  and 
athetoid  movements  are  sometimes  seen.  The  paralyses  are  either  hemiplegias 
or  monoplegias.  Hemiplegia  may  result  from  disturbance  in  the  cortical 
branches  of  the  middle  cerebral  artery,  occasionally  from  softening  in  the 
internal  capsule,  due  to  involvement  of  the  central  branches.  Of  monoplegias, 
that  of  the  face  is  perhaps  most  common,  and  if  on  the  right  side  it  may  occur 
with  aphasia.  In  two  of  our  cases  in  adults  aphasia  occurred.  Brachial  mono- 
plegia may  be  associated  with  it.  In  the  more  chronic  cases  the  symptom^ 
persist  for  months,  and  there  may  be  a  characteristic  Jacksonian  epilepsy. 
Kernig's  sign  may  be  present,  but  is  not  constant.  The  Babinski  reflex  is 
sometimes  found. 

The  DIAGNOSIS  of  tuberculous  meningitis  is  rarely  difficult,  and  points 
upon  which  special  stress  is  to  be  laid  are  the  existence  of  a  tuberculous  focus 
in  the  body,  the  mode  of  onset  and  the  s5^mptoms,  and  the  evidence  obtained 
on  lumbar  puncture.  The  cerebro-spinal  fluid  is  usually  clear  or  slightly 
turbid,  and  after  standing  for  12  to  2-4  hours,  a  feathery  clot  of  fibrin  forms 
down  the  centre  of  the  fluid,  the  presence  of  which  indicates  that  it  is  not 
normal.  In  this  clot  the  tubercle  bacilli  are  usually  found.  By  centrifugaliza- 
tion,  careful  staining,  and  long  search,  tubercle  bacilli  can  be  found  in  a  large 
proportion  of  cases — in  135  of  137  in  one  series  (Hemenway).  The  cells  are 
usually  much  increased  in  number  and  a  large  percentage  (over  90  per  cent.) 
are  small  lymphocytes,  though  occasionally  an  excess  of  polymorphonuclear 
leucocytes  is  found. 

The  PEOGXOSis  in  this  form  of  meningitis  is  always  most  serious.  We  have 
neither  seen  a  case  proved  to  be  tuberculous  recover,  nor  post  mortem  evidence 
of  past  disease  of  this  nature.  Cases  of  recovery  have  been  reported  by  reliable 
authorities,  but  they  are  extremely  rare.  Pitfield  collected  29  undoubted  cases 
in  1913. 

Treatment. — In  a  disease  whicii  is  practically  always  fatal  this  does  not 
offer  much.  The  patients  should  be  nourished  as  well  as  possible  and  given 
sedatives  to  control  restlessness  or  pain.  In  the  meningeal  form,  lumbar  punc- 
ture should  be  done  and  repeated  if  it  relieves  the  symptoms. 

III.     TUBERCULOSIS  OF  THE  LY]\rPHATIC  SYSTEM 

1.  Tuberculosis  of  the  Lymph-glands  {Scrofula) 

Scrofula  is  tubercle,  as  it  has  been  shown  that  the  bacillus  of  Koch  is  the 
essential  element.  It  is  not  definitely  settled  whether  the  organism  which 
produces  the  chronic  tuberculous  adenitis  differs  from  that  which  produces 
tuberculosis  in  other  parts,  or  \vhether  it  is  the  local  conditions  in  the  glands 
which  account  for  the  slow  development  and  milder  course.  The  observations 
of  Lingard  are  important  as  showing  a  variation  in  the  virulence  of  the 
tubercle  bacillus.  Guinea-pigs  inoculated  with  ordinaiT  tubercle  showed 
lymphatic  infection  Nvithin  the  first  week  and  died  within  three  months; 
infected    with     material     from     tuberculous     glands,     the     lymphatic     en- 


TUBEECULOSIS  175 

largement  did  not  appear  until  the  second  or  third  week,  and  the  animals 
survived  for  six  or  seven  months.  In  68  cases  examined  by  A.  S.  Griffith,  in 
35  human  and  in  33  bovine,  infection  was  found.  The  proportion  is  higher 
in  children  under  five,  but  of  17  cases  twenty  years  old  and  upwards  4  were 
bovine.  The  cases  of  bovine  infection  in  cervical  gland  tuberculosis  in  different 
countries  analysed  by  Griffith  show  that  the  proportion  is  lowest  in  Germany 
and  highest  in  Scotland. 

Tuberculous  adenitis,  met  with  at  all  ages,  is  more  common  in  children 
than  in  adults,  and  may  occur  in  old  age. 

Tubercle  bacilli  are  ubiquitous;  all  are  exposed  to  infection,  and  upon  the 
local  conditions,  whether  favorable  or  unfavorable,  depends  the  fate  of  those 
organisms  which  find  lodgment  in  our  bodies.  A  special  predisposing  factor 
in  lymphatic  tuberculosis  is  catarrh  of  the  mucous  membranes,  which  in  itself 
excites  slight  adenitis  of  the  neighboring  glands.  In  a  child  with  constantly 
recurring  naso-pharyngeal  catarrh,  the  bacilli  which  lodge  on  the  mucous 
membranes  find  in  all  probability  the  gateways  less  strictly  guarded  and  are 
taken  up  by  the  lymphatics  and  passed  to  the  nearest  glands.  The  impor- 
tance of  the  tonsils  as  an  infection-atrium  has  been  urged.  In  conditions  of 
health  the  local  resistance  is  active  enough  to  deal  with  the  invaders,  but  the 
irritation  of  a  chronic  catarrh  weakens  the  resistance  of  the  lymph-tissue,  and 
the  bacilli  are  enabled  to  grow  and  gradually  to  change  a  simple  into  a  tuber- 
culous adenitis.  The  frequent  association  of  tuberculous  adenitis  of  the  bron- 
chial glands  with  whooping  cough  and  measles,  and  the  association  of  tubercle 
in  the  mesenteric  glands  in  children  with  intestinal  catarrh,  find  in  this  way  a 
rational  explanation. 

The  following  are  some  of  the  features  of  interest  in  tuberculous  adenitis : 

(a)  The  local  character.  Thus,  the  glands  of  the  neck,  or  at  the  bifurca- 
tion of  the  bronchi,  or  those  of  the  mesentery,  may  be  alone  involved. 

(&)  The  tendency  to  spontaneous  healing.  In  a  large  proportion  of  the 
cases  the  battle  which  ensues  between  the  bacilli  and  the  protective  forces  is 
long;  but  the  latter  are  finally  successful,  and  we  find  in  the  calcified  rem- 
nants in  the  bronchial  and  mesenteric  lymph-glands  evidences  of  victory. 
Too  often  in  the  bronchial  glands  a  truce  only  is  declared  and  hostilities  may 
break  out  afresh  in  the  form  of  an  acute  tuberculosis. 

(c)  The  tendency  of  tuberculous  adenitis  to  pass  on  to  suppuration.  The 
frequency  with  which,  particularly  in  the  glands  of  the  neck,  we  find  the 
tuberculous  processes  associated  with  suppuration  is  a  special  feature  of  this 
form  of  adenitis.  In  nearly  all  instances  the  pus  is  sterile.  Whether  the 
suppuration  is  excited  by  the  bacilli  or  by  their  products,  or  whether  it  is  the 
result  of  a  mixed  infection  with  pus  organisms,  which  are  subsequently  de- 
stroyed, has  not  been  settled. 

{d)  The  existence  of  an  unhealed  tuberculous  adenitis  is  a  constant 
menace  to  the  organism.  It  is  safe  to  say  that  in  three-fourths  of  the  in- 
stances of  acute  tuberculosis  the  infection  is  derived  from  this  source.  On  the 
other  hand,  it  has  been  urged  that  tuberculous  adenitis  in  childhood  gives  im- 
munity in  adult  life.  There  is  evidence  in  favor  of  this.  Only  a  small  num- 
ber of  adults  with  pulmonary  tuberculosis  show  scars  from  adenitis — 3.2  per 
cent,  of  one  series  of  2,000  patients.     Certain  autopsy  studies  suggest  that  in 


1^6  SPECIFIC  INFECTIOUS  DISEASES 

the  bodies  of  adults  with  mesenteric  gland  tuberculosis,  pulmonary  tuberculosis 
is  less  frequent. 

Generalized  Tuberculous  Lymphadenitis. — In  exceptional  instances  we  find 
diffuse  tuberculosis  of  nearly  all  the  lymph-glands  of  the  body  with  little 
or  no  involvement  of  other  parts.  The  most  extreme  cases  of  it,  which  we  have 
seen,  have  been  in  negro  patients.  Two  well-marked  cases  occurred  at  the 
Philadelphia  Hospital.  In  a  woman,  the  chart  from  April,  1888,  until 
March,  1889,  showed  persistent  fever,  ranging  from  101°  to  103°  F.,  oc- 
casionally rising  to  104°  F.  On  December  IGth  the  glands  on  the  right  side 
of  the  neck  were  remcved.  After  an  attack  of  erysipelas,  on  February  17th, 
she  gradually  sank  and  died  March  5th.  The  lungs  presented  only  one  or 
two  puckered  spots  at  the  apices.  The  bronchial,  retro-peritoneal,  and  mesen- 
teric glands  were  greatly  enlarged  and  caseous.  There  was  no  intestinal, 
uterine,  or  bone  disease.  The  continuous  high  fever  in  this  case  depended 
apparently  upon  the  tuberculous  adenitis.  In  these  instances  the  enlarge- 
ment is  most  marked  in  the  retro-peritoneal,  bronchial,  and  mesenteric  glands, 
but  may  be  also  present  in  the  groups  of  external  glands.  Occurring  acutely, 
it  presents  a  picture  resembling  Hodgkin's  disease.  In  a  case  which  died  in  the 
Montreal  General  Hospital  this  diagnosis  was  made.  The  cervical  and  axillary 
glands  were  enortnously  enlarged,  and  death  was  caused  by  infiltration  of  the 
larynx.  In  infants  and  children  there  is  a  form  of  general  tuberculous  adenitis 
in  which  the  various  groups  of  glands  are  successively,  more  rarely  simultane- 
ously, involved,  and  in  which  death  is  caused  either  by  cachexia  or  by  an  acute 
infection  of  the  meninges. 

Local  Tuberculous  Adenitis. — {a)  Cervical. — This  is  the  most  common 
form  in  children.  It  is  seen  particularly  among  the  poor  and  those  who  live 
in  the  impure  atmosphere  of  badly  ventilated  lodgings.  Children  in  foundling 
hospitals  and  asylums  are  specially  prone  to  the  disease.  In  the  United  States 
it  is  most  common  in  the  negro  race.  It  is  often  met  with  in  catarrh  of  the 
nose  and  throat,  or  chronic  enlargement  of  the  tonsils;  or  the  child  may  have 
had  eczema  of  the  scalp  or  a  purulent  otitis. 

The  submaxillary  glands  are  first  involved,  and  are  popularly  spoken  of 
as  enlarged  Tcernels.  They  are  usually  larger  on  one  side  than  on  the  other. 
As  they  increase  in  size,  the  individual  tumors  can  be  felt;  the  surface  is 
smooth  and  the  consistence  firm.  They  may  remain  isolated,  but  more  com- 
monly they  form  large,  knotted  masses,  over  which  the  skin  is,  as  a  rule, 
freely  movable.  In  many  cases  the  skin  ultimately  becomes  adherent,  and 
inflammation  and  suppuration  occur.  An  abscess  points  and,  unless  opened, 
bursts,  leaving  a  sinus  which  heals  slowly.  The  disease  is  frequently  associated 
with  coryza,  with  eczema  of  the  scalp,  ear,  or  lips,  and  with  conjuncti- 
vitis or  keratitis.  When  the  glands  are  large  and  growing  actively  there  is 
fever.  The  subjects  are  usually  ansemic,  particularly  if  suppuration  has  oc- 
curred. The  progress  of  this  form  of  adenitis  is  slow  and  tedious.  Death, 
however,  rarely  follows,  and  many  aggravated  cases  in  children  get  well.  Not 
only  the  submaxillary  group,  but  the  glands  above  the  clavicle  and  in  the 
posterior  cervical  triangle,  may  be  involved.  In  other  instances  the  cervical 
and  axillary  glands  are  involved  together,  forming  a  continuous  chain  which 
extends  beneath  the  clavicle  and  the  pectoral  muscle.  "With  them  the  bron- 
chial glands  may  also  be  enlarged  and  caseous.     Not  infrequently  the  en- 


TUBERCULOSIS  177 

largement  of  the  supra-clavicular  and  axillary  group  of  glands  on  one  side 
precedes  a  tuberculous  pleurisy  or  pulmonary  tuberculosis. 

(h)  Tracheo-bronchial. — The  mediastinal  lymph-glands  constitute  fil- 
ters in  which  lodge  the  various  foreign  particles  which  escape  the  normal 
phagocytes  of  bronchi  and  lungs.  Among  these  foreign  particles,  and  proba- 
bly attached  to  them,  tubercle  bacilli  are  not  uncommon,  and  we  find  tubel"- 
cles  and  caseous  matter  with  great  frequency  in  this  group.  Northrup  found 
them  involved  in  every  one  of  125  cases  of  tuberculosis  at  the  New  York 
Foundling  Hospital.  This  tuberculous  adenitis  may,  in  the  bronchial  glands, 
attain  the  dimensions  of  a  tumor  of  large  size.  In  children  the  bronchial 
adenitis  is  apt  to  be  associated  with  suppuration.  The  glands  at  the  bifurca- 
tion of  the  trachea  are  first  involved  and  chiefly  on  the  right  side — in  74  per 
cent,  of  Wollstein's  cases.  Irregular  fever,  failure  of  nutrition,  loss  of  appe- 
tite, and  lassitude  may  be  caused  by  the  absorption  of  toxins;  pain  is  rare, 
though  it  is  complained  of  sometimes  in  the  mammary  region.  The  cough 
is  paroxysmal,  often  brassy,  so  that  it  has  been  mistaken  for  whooping  cough. 
Stridor,  when  present,  is  more  often  expiratory.  The  physical  signs  are  not 
very  definite.  Dilated  veins  over  the  anterior  aspect  of  the  thorax,  absence 
of  descent  of  the  larynx  during  inspiration,  and  pain  on  pressure  over  the 
upper  dorsal  vertebrse  are  mentioned.  Extension  of  the  normal  dulness  over 
the  upper  four  thoracic  vertebrae  to  the  fifth  and  sixth  is  of  importance,  and 
there  may  be  para-vertebral  dulness  on  delicate  percussion.  Some  writers 
lay  stress  upon  the  whispered  bronchophony  over  the  upper  thoracic  vertebrae, 
and  a  venous  hum  may  be  heard  sometimes  over  the  manubrium.  The  X-ray 
pictures  are  regarded  by  experts  as  distinctive,  showing  the  shadow  extending 
from  either  side  of  the  spine. 

Some  of  the  more  uncommon  effects  are  the  following:  Compression  of 
the  superior  cava,  of  the  pulmonary  artery,  and  of  the  azygos  vein.  The 
trachea  and  bronchi,  though  often  flattened,  are  rarely  seriously  compressed. 
The  vagus  nerve  may  be  involved,  particularly  the  recurrent  laryngeal  branch. 
More  important  are  the  perforations  of  the  enlarged  and  softened  glands  into 
the  bronchi  or  trachea,  or  a  sort  of  secondary  cyst  may  be  formed  between 
the  lung  and  the  trachea;  Asphyxia  has  been  caused  by  blocking  of  the 
larynx  by  a  caseous  gland  which  has  ulcerated  through  the  bronchus  (Voelcker), 
and  Cyril  Ogle  reported  a  case  in  which  the  ulcerated  gland  practically  occluded 
both  bronchi.  Perforations  of  the  vessels  are  much  less  common,  but  the  pul- 
monary artery  and  the  aorta  have  been  opened.  Perforation  of  the  oesophagus 
has  been  described.  One  of  the  most  serious  efl^ects  is  infection  of  the  lung 
or  pleura  by  the  caseous  glands  situated  deep  along  the  bronchi.  This  may, 
as  is  often  clearly  seen,  be  by  direct  contact,  and  it  may  be  difficult  to  deter- 
mine in  some  sections  where  the  caseous  bronchial  gland  terminates  and  the 
pulmonary  tissue  begins.  In  other  instances  it  takes  place  along  the  root  of 
the  lung  and  is  subpleural.  Among  other  sequences  may  be  mentioned  diver- 
ticulum of  the  oesophagus  following  adhesion  of  an  enlarged  gland  and  its 
subsequent  retraction;  and,  in  the  case  of  the  anterior  mediastinal  and  aortic 
groups,  the  frequent  production  of  pericarditis,  either  by  contact  or  by  rupture 
of  a  softened  gland  into  the  sac.  A  serious  danger  is  systemic  infection,  which 
takes  place  through  the  vessels. 

(c)  Mesenteric;  Tabes  mesentekica,^ — In  this  affection,  the  abdominal 


178  SPECIFIC  i:nfectious  diseases 

scrofula  of  old  writers,  the  glands  of  the  mesentery  and  retro-peritoneum 
become  enlarged  and  caseate;  more  rarely  they  suppurate  or  calcify.  A  slight 
tuberculous  adenitis  is  extremely  common  in  children,  and  is  often  acci- 
dentally found  (post  mortem)  when  they  have  died  of  other  diseases.  It  may 
be  a  primary  lesion  associated  with  intestinal  catarrh,  or  it  may  be  secondary 
to  tuberculous  disease  of  the  intestines. 

The  statistics  of  abdominal  tuberculosis  show  a  great  variation  in  different 
localities.  The  small  percentage  in  Kew  York,  less  than  one  per  cent,  of  all 
cases  (Bovaird  and  Mt.  Sinai  Hospital  figures),  contrasts  with  the  high  fig- 
ures given  for  Scotland  by  John  Thomson,  3.57  for  Edinburgh  and  4.51  for 
Glasgow.  "Scotland  enjoys  the  unenviable  distinction  of  having  more  abdom- 
inal tuberculosis  than  any  other  civilized  country — twice  as  much  at  least  as 
England  generally,  and  more  than  ten  times  as  much  as  Europe  and  North 
America.  It  accounts  for  one-half  of  the  medical  tuberculosis  admissions."  The 
general  involvement  of  the  glands  interferes  seriously  with  nutrition,  and  the 
patients  are  puny,  wasted,  and  ansemic.  The  abdomen  is  enlarged  and  tym- 
panitic; diarrhoea  is  a  constant  feature;  the  stools  are  thin  and  offensive. 
There  is  moderate  fever,  but  the  general  wasting  and  debility  are  the  most 
characteristic  features.  The  enlarged  glands  can  not  often  be  felt,  owing  to 
the  distended  condition  of  the  bowels.  These  cases  are  often  spoken  of  as 
"consumption  of  the  bowels,"  but  in  a  majority  of  them  the  intestines  do 
not  present  tuberculous  lesions.  In  a  considerable  number  of  the  cases  of 
tabes  mesenterica  the  peritoneum  is  also  involved,  and  in  such  the  abdomen 
is  large  and  hard,  and  nodules  may  be  felt. 

In  adults  tuberculous  disease  of  the  mesenteric  glands  may  occur  as  a 
primary  affection,  or  in  association  with  pulmonary  disease.  It  may  exist 
without  tuberculous  disease  in  the  intestines  or  in  any  other  part.  The  tumor 
mass  is  usually  a  little  to  the  right  of  the  umbilicus,  freely  movable.  The  gen- 
eral symptoms  are  loss  of  weight  and  slight  fever;  locally  there. is  pain,  some- 
times diarrhoea,  and  appendicitis  is  often  suspected. 

2.  Tuberculosis  of  the  Serous  Membranes 

General  Serous  Membrane  Tuberculosis  (PolyorrJiomenitis) . — The  serous 
membranes  may  be  chiefly  involved,  simultaneously  or  consecutively,  pre- 
senting a  distinctive  and  readily  recognizable  clinical  type  of  tuberculosis. 
There  are  three  groups  of  cases.  First,  those  in  which  an  acute  tuberculosis 
of  the  peritoneum  and  pleurge  occurs  rapidly,  caused  by  local  disease  of  the 
tubes  in  women,  or  of  the  mediastinal  or  bronchial  lymph-glands.  Secondly, 
cases  in  which  the  disease  is  more  chronic,  with  exudation  into  both  peritoneum 
and  pleuras,  the  formation  of  cheesy  masses,  and  the  occurrence  of  ulcerative 
and  suppurative  processes.  Thirdly,  there  are  cases  in  which  the  pleuro- 
peritoneal  affection  is  still  more  chronic,  the  tubercles  hard  and  fibroid,  the 
membranes  much  thickened,  and  with  little  or  no  exudate.  In  any  one  of 
these  three  forms  the  pericardium  may  be  involved  with  the  pleura  and  peri- 
toneum. It  is  important  to  bear  in  mind  that  there  may  be  no  visceral  tuber- 
culosis in  these  cases. 

Tuberculosis  of  the  Pleura. —  (a)  Acute  Tuberculous  Pleurisy. — It  is 
difficult  to  estimate  the  proportion  of  instances  of  acute  pleurisy  due  to  tuber- 
culosis   (see  Acute  Pleurisy).     The  cases  are  rarely  fatal.     There  are  three 


TUBEECULOSIS  179 

groups  of  cases :  ( 1 )  Acute  tuberculous  pleurisy  with  subsequent  chronic 
course.  (2)  Secondary  and  terminal  forms  of  acute  pleurisy  (these  are  not 
uncommon  in  hospital  practice).  And  (3)  a  form  of  acute  tuberculous  sup- 
purative pleurisy.  A  considerable  number  of  the  purulent  pleurisies,  desig- 
nated as  latent  and  chronic,  are  caused  by  tubercle  bacilli,  but  the  fact  is  not 
so  widely  recognized  that  there  is  an  acute,  ulcerative,  and  suppurative  disease 
which  may  run  a  very  rapid  course.  The  pleurisy  sets  in  abruptly,  with  pain  in 
the  side,  fever,  cough,  and  sometimes  with  a  chill.  There  may  be  nothing  to 
suggest  a  tuberculous  process,  and  the  subject  may  have  a  fine  physique  and 
come  of  healthy  stock. 

(b)  The  subacute  and  chronic  tuberculous  pleurisies  are  more 
common.  The  largest  group  of  cases  comprises  those  with  sero-fibrinous  effu- 
sion. The  onset  is  insidious,  the  true  character  of  the  disease  is  frequently 
overlooked,  and  in  almost  every  instance  there  are  tuberculous  foci  in  the 
lungs  and  in  the  bronchial  glands.  These  are  cases  in  which  the  termination 
is  often  in  pulmonary  tuberculosis  or  general  miliary  tuberculosis.  In  a  few 
cases  the  exudate  becomes  purulent. 

(c)  And,  lastly,  there  is  a  chronic  adhesive  pleurisy,  a  primary  proliferative 
form  which  is  of  long  standing,  and  may  lead  to  very  great  thickening  of  the 
membrane,  and  sometimes  to  invasion  of  the  lung. 

Secondary  tuberculous  pleurisy  is  very  common.  The  visceral  layer  is 
always  involved  in  pulmonary  tuberculosis.  Adhesions  usually  form  and  a 
chronic  pleurisy  results,  which  may  be  simple,  but  usually  tubercles  are  scat- 
tered through  the  adhesions.  An  acute  tuberculous  pleurisy  may  result  from 
direct  extension.  The  fluid  may  be  sero-fibrinous  or  hemorrhagic,  or  may 
become  purulent.  And,  lastly,  in  pulmonary  tuberculosis,  a  superficial  spot  of 
softening  may  perforate  with  the  production  of  pyo-pneumothoraa: 

The  general  symptomatology  of  these  forms  will  be  considered  under  dis- 
ease of  the  pl6ura. 

Tuberculosis  of  the  Pericardium. — Miliary  tubercles  may  occur  as  a  part 
of  a  general  infection,  but  the  term  is  properly  limited  to  those  cases  in  which, 
either  as  a  primary  or  secondary  process,  there  is  extensive  disease  of  the  mem- 
brane. Tuberculosis  is  not  so  common  in  the  pericardium  as  in  the  pleura 
and  peritoneum,  but  it  is  certainly  more  common  than  the  literature  would 
lead  us  to  suppose.  George  Norris  found  83  instances  among  1,780  post 
mortems  in  tuberculous  subjects. 

We  may  recognize  four  groups  of  cases :  First,  those  in  which  the  condi- 
tion is  entirely  latent,  and  the  disease  is  discovered  accidentally  in  individuals 
who  have  died  of  other  afi^ections  or  of  chronic  pulmonary  tuberculosis. 

A  second  group,  in  which  the  symptoms  are  those  of  cardiac  insufficiency 
following  the  dilatation  and  hypertrophy  consequent  upon  a  chronic  adhesive 
pericarditis.  The  symptoms  are  those  of  cardiac  dropsy,  and  suggest  either 
idiopathic  hypertrophy  and  dilatation,  or,  if  there  is  a  loud  blowing  systolic 
murmur  at  the  apex,  mitral  valve  disease,  either  insufficiency  or  stenosis.  The 
condition  of  adherent  pericardium  is  usually  overlooked. 

In  a  third  group  the  clinical  picture  is  that  of  an  acute  tuberculosis,  either 
general  or  with  cerebro-spinal  manifestations,  which  has  had  its  origin  from 
the  tuberculous  pericardium  or  tuberculous  mediastinal  lymph-glands. 

A  fourth  group,  with  symptoms  of  acute  pericarditis,  includes  cases  in 


180  SPECIFIC  I^'FECTIOUS  DISEASES 

Avhich  the  affection  is  ac-ute  and  accompanied  with  more  or  less  exudation  of 
a  sero-fibrinous,  haemorrhagic,  or  purulent  character.  There  may  be  no  sus- 
picion whatever  of  the  tuberculous  nature  of  the  trouble. 

Tuberculosis  of  the  Peritoneum. — In  connection  with  miliary  and  chronic 
pulmonary  tuberculosis  it  is  not  uncommon  to  find  the  peritoneum  studded 
with  small  gray  granulations.  They  are  constantly  present  on  the  serous  sur- 
face of  tuberculous  ulcers  of  the  intestines.  Apart  from  these  conditions  the 
membrane  is  often  the  seat  of  extensive  tuberculous  disease,  which  occurs  in 
the  following  forms : 

(a)  Acute  miliary  tuberculosis  with  sero-fibrinous  or  bloody  exudation. 

(b)  Chronic  tuberculosis,  characterized  by  larger  growths,  which  tend  to 
caseate  and  ulcerate.  The  exudate  is  purulent  or  sero-purulent,  and  is  often 
sacculated. 

(c)  Chronic  fibroid  tuberculosis,  which  may  be  subacute  from  the  onset, 
or  which  may  represent  the  final  stage  of  an  acute  miliary  eruption.  The 
tubercles  are  hard  and  pigmented.  There  is  little  or  no  exudation,  and  the 
serous  surfaces  are  matted  together  by  adhesions. 

The  process  may  be  primary  and  local,  which  was  the  case  m  5  of  17 
post  mortems.  In  children  the  infection  appears  to  pass  from  the  intestines, 
and  in  adults  this  is  the  source  in  the  cases  associated  with  chronic  tubercu- 
losis. In  women  the  disease  extends  commonly  from  the  Fallopian  tubes.  In  at 
least  30  or  40  per  cent,  of  the  instances  of  laparotomy  in  this  affection  the 
infection  was  from  them.  The  prostate  or  the  seminal  vesicles  may  be  the 
starting-point.  In  many  cases  the  peritoneum  is  involved  with  the  pleura  and 
pericardium,  particularly  with  the  former  membrane. 

It  is  interesting  to  note  that  certain  morbid  conditions  of  the  abdominal 
organs'  predispose  to  the  development  of  the  disease ;  thus  patients  with  cirrho- 
sis of  the  liver  very  often  die  of  an  acute  tuberculous  peritonitis.  The  fre- 
quency with  which  the  condition  is  met  with  in  operations  upon  ovarian 
tumors  has  been  commented  upon  by  gynaecologists.  Many  cases  have  fol- 
lowed trauma  of  the  abdomen.  An  interesting  feature  is  the  occurrence  of 
tuberculosis  in  hernial  sacs  which  is  not  very  uncommon.  In  a  majority  of 
the  instances  it  is  discovered  accidentally  during  the  operation  for  radical  cure 
or  for  strangulation.    In  7  instances  the  sac  alone  was  involved. 

It  is  generally  stated  that  males  are  attacked  oftener  than  females,  but 
in  the  collected  statistics  the  cases  are  twice  as  numerous  in  females  as  in 
males;  in  the  ratio,  indeed,  of  131  to  60. 

Tuberculous  peritonitis  occurs  at  all  ages.  It  is  common  in  children  asso- 
ciated with  intestinal  and  mesenteric  disease.  The  incidence  is  most  frequent 
between  the  ages  of  twenty  and  forty.  It  may  occur  in  advanced  life;  one 
patient  was  eighty-two  years  of  age.  Of  357  cases  collected  from  the  literature, 
there  were  under  ten  years,  27;  between  ten  and  twenty,  75;  from  twenty 
to  thirty,  87 ;  between  thirty  and  forty,  71 ;  from  forty  to  fifty,  61 ;  from  fifty 
to  sixty,  19;  from  sixty  to  seventy,  4;  above  seventy,  2.  In  America  it  is  more 
common  in  the  negro  than  in  the  white  race.  More  blacks  than  whites,  77  to 
i70,  were  admitted  to  the  Johns  Hopkins  Hospital  (Hamman). 

Symptoms. — In  certain  special  features  the  tuberculous  varies  consider- 
ably from  other  forms  of  peritonitis.  It  presents  a  symptom-complex  of  ex- 
traordinary diversity. 


TUBERCULOSIS  181 

In  the  first  place,  the  process  may  be  latent  and  met  with  accidentally  in 
the  operation  for  hernia  or  for  ovarian  tumor.  The  acute  onset  is  not  uncom- 
mon. Four  cases  in  our  records  were  diagnosed  appendicitis^  two  acute  chole- 
cystitis, and  six  had  symptoms  of  intestinal  obstruction,  in  two  of  these 
coming  on  with  great  abruptness  (Hamman)„  The  cases  have  been  mistaken 
for  strangulated  hernia.  Other  cases  set  in  acutely  with  fever,  abdominal 
tenderness,  and  the  symptoms  of  ordinary  acute  peritonitis.  Cases  with  a  slow 
onset,  abdominal  tenderness,  tympanites,  and  low  continuous  fever  are  often 
mistaken  for  typhoid  fever. 

Ascites  is  frequent,  but  the  effusion  is  rarely  large.  It  is  sometimes  hgem- 
orrhagic.  In  this  form  the  diagnosis  may  rest  between  an  acute  miliary  cancer, 
cirrhosis  of  the  liver,  and  a  chronic  simple  peritonitis — conditions  which  usually 
offer  no  special  difficulties  in  differentiation.  A  most  important  point  is  the 
simultaneous  presence  of  a  pleurisy.  The  tuberculin  test  may  be  used. 
Tympanites  may  be  present  in  the  very  acute  cases,  when  it  is  due  to  loss 
of  tone  in  the  intestines  owing  to  inflammatory  infiltration;  or  it  may  occur 
in  the  old,  long-standing  cases  when  universal  adhesion  has  taken  place 
between  the  parietal  and  visceral  layers.  Fever  is  a  marked  symptom  in 
the  acute  cases,  and  the  temperature  may  reach  103°  or  104°.  In  many 
instances  the  fever  is  slight.  In  the  more  chronic  cases  subnormal  tempera- 
tures are  common,  and  for  days  the  temperature  may  not  rise  above  97°, 
and  the  morning  record  may  be  as  low  as  95.5°.  An  occasional  symptom 
is  pigmentation  of  the  skin,  which  has  led  to  the  diagnosis  of  Addison's 
disease.  A  striking  peculiarity  of  tuberculous  peritonitis  is  the  frequency 
with  which  it  simulates  or  is  associated  with  tumor.    This  may  be : 

(a)  Omental,  due  to  puckering  and  rolling  of  this  membrane  until  it 
forms  an  elongated  firm  mass,  attached  to  the  transverse  colon  and  lying 
athwart  the  upper  part  of  the  abdomen.  This  cord-like  structure  is  foimd 
also  with  cancerous  peritonitis,  but  is  much  more  common  in  tuberculosis. 
Gairdner  called  special  attention  to  this  form  of  tumor,  and  in  children 
saw  it  undergo-  gradual  resolution.  A  resonant  percussion  note  may  some- 
times be  elicited  above  the  mass.  Though  usually  situated  near  the  umbilicus, 
the  omental  mass  may  form  a  prominent  tumor  in  the  right  iliac  region. 

(&)  Sacculated  exudation,  in  which  the  effusion  is  limited  and  confined 
by  adhesions  between  the  coils,  the  parietal  peritoneum,  the  mesentery,  and 
the  abdominal  or  pelvic  organs^  This  encysted  exudate  is  most  common  m 
the  middle  zone,  and  has  frequently  been  mistaken  for  ovarian  tumor.  It  may 
occupy  the  entire  anterior  portion  of  the  peritoneum,  or  there  may  be  a  more 
limited  saccular  exudate  on  one  side  or  the  other.  Within  the  pelvis  it  is 
associated  with  disease  of  the  Fallopian  tubes.  Eighteen  cases  in  the  gynaeco- 
logical wards  (J.  H.  H.)  were  operated  upon  for  pyosalpinx  (Hamman). 

(c)  In  rare  cases  the  tumor  formations  may  be  due  to  great  retraction 
or  thickening  of  the  intestinal  coils.  The  small  intestine  is  found  shortened, 
the  walls  enormously  thickened,  and  the  entire  coil  may  form  a  firm  knot  close 
against  the  spine,  giving  on  examination  the  idea  of  a  solid  mass.  Not 
the  small  intestine  only,  but  the  entire  bowel  from  the  duodenum  to  the 
rectum,  has  been  found  forming  such  a  hard  nodular  tumor. 

(d)  Mesenteric  glands,  which  occasionally  form  very  large,  tumor-like 
masses,  more  commonly  found  in  children  than  in  adults.     This  condition 


182  SPECIFIC  IJ^FECTIOUS  DISEASES 

may  be  confined  to  the  abdominal  glands.  Ascites  may  coexist.  The  condi- 
tion must  be  distinguished  from  that  in  children,  in  which,  with  ascites  or 
tympanites — sometimes  both — there  can  be  felt  irregular  nodular  masses,  due 
to  large  caseous  formations  between  the  intestinal  coils.  No  doubt  in  a  con- 
siderable number  of  eases  of  the  so-called  tabes  mesenterica,  particularly  in 
those  with  enlargement  and  hardness  of  the  abdomen — the  condition  which 
the-  French  call  carreau — there  is  involvement  also  of  the  peritoneum. 

The  diagnosis  of  these  peritoneal  tumors  is  sometimes  very  difficult.  The 
omental  mass  is  a  less  frequent  source  of  error  than  any  other;  but  a  similar 
condition  may  occur  in  cancer.  The  most  important  problem  is  the  diagnosis 
of  the  saccular  exudation  from  ovarian  tumor.  In  fully  one-third  of  the  re- 
corded cases  of  laparotomy  in  tuberculous  peritonitis  the  diagnosis  of  cystic 
ovarian  disease  had  been  made.  The  most  suggestive  points  for  consideration 
are  the  history  and  the  evidence  of  old  tuberculous  lesions.  The  physical 
condition  is  not  of  much  help,  as  in  many  instances  the  patients  have  been 
robust  and  well  nourished.  Irregular  febrile  attacks,  gastro-intestinal  dis- 
turbance, and  pains  are  more  common  in  tuberculous  disease.  Unless  inflamed 
there  is  usually  not  much  fever  with  ovarian  cysts.  The  local  signs  are  very 
deceptive,  and  in  certain  cases  have  conformed  in  every  particular  to  those  of 
cystic  disease.  The  outlines  in  saccular  exudation  are  rarely  so  well  defined. 
The  position  and  form  may  be  variable,  owing  to  alterations  in  the  size  of  the 
coils  of  which  in  parts  the  walls  are  composed.  Nodular  cheesy  masses  may 
sometimes  be  felt  at  the  periphery.  Depression  of  the  vaginal  wall  is  men- 
tioned as  occurring  in  encysted  peritonitis;  but  it  is  also  found  in  ovarian 
tumor.  The  condition  of  the  Fallopian  tubes,  of  the  lungs  and  the  pleurae, 
should  be  thoroughly  examined.  The  association  of  salpingitis  with  an  ill- 
defined  anomalous  mass  in  the  abdomen  should  arouse  suspicion,  as  should 
also  involvement  of  the  pleura,  the  apex  of  one  lung,  or  a  testis  or  seminal 
vesicle  in  the  male. 

Treatment. — General  measures  should  be  carried  out  as  in  pulmonary 
tuberculosis.  Direct  exposure  of  the  abdomen  to  sunlight  and  to  the  X-rays 
has  proved  useful  in  some  cases.  Surgical  treatment  is  most  helpful  in  the 
cases  with  ascites,  but  when  there  are  tuberculous  tumors  and  many  adhesions 
the  results  are  not  satisfactory.  In  some  cases  the  removal  of  a  focus  of 
infection,  such  as  tuberculous  mesenteric  glands,  a  diseased  appendix  or  a 
tuberculous  Fallopian  tube,  has  been  of  benefit. 

IV.     PULMONAEY  TUBERCULOSIS 

( Ph tliisis,  Co nsu nip tion) 

Three  clinical  groups  may  be  recognized:  (1)  acute  pneumonic  tubercu- 
losis— acute  phthisis;  (2)  chronic  ulcerative  tuberculosis;  and  (3)  fibroid 
tuberculosis. 

According  to  the  mode  of  infection  there  are  two  distinct  types  of  lesions : 
(a)  When  the  bacilli  reach  the  lungs  through  the  blood-vessels  or  lym- 
phatics the  primary  lesion  is  usually  in  the  tissues  of  the  alveolar  walls,  in 
the  capillary  vessels,  the  epithelium  of  the  air-cells,  and  in  the  connective- 
tissue  framework  of  the  septa.  The  irritation  of  the  bacilli  produces,  within 
a  few  days,  the  small,  gray  miliary  nodules,  involving  several  alveoli  and  con- 


TUBERCULOSIS  183 

sisting  largely  of  rounds,  cuboidal,  uninuclear  epithelioid  cells.  Depending 
upon  the  number  of  bacilli  which  reach  the  lung  in  this  way,  either  a  localized 
or  a  general  tuberculosis  is  excited.  The  tubercles  may  be  scattered  through 
both  lungs  and  form  part  of  a  general  miliary  tuberculosis,  or  be  confined 
to  the  lungs,  or  even  in  great  part  to  one  lung.  The  further  stages  may  be: 
(1)  Arrest  of  the  process  of  cell  division,  gradual  sclerosis  of  the  tubercle,  and 
ultimately  complete  fibroid  transformation.  (2)  Caseation  of  the  centre  of 
the  tubercle,  extension  at  the  periphery  by  proliferation  of  the  epithelioid  and 
lymphoid  cells,  so  that  the  individual  tubercles  or  small  groups  become  conflu- 
ent and  form  diffuse  areas  which  undergo  caseation  and  softening.  (3)  Occa- 
sionally as  a  result  of  intense  infection  of  a  localized  region  through  the  blood- 
vessels the  tubercles  are  thickly  set.  The  intervening  tissue  becomes  acutely 
inflamed,  the  air-cells  are  filled  with  the  products  of  a  desquamative  pneumonia, 
and  many  lobules  are  involved. 

(h)  When  the  bacilli  reach  the  lung  through  the  bronchi — inhalation  or 
aspiration  tuberculosis — the  picture  differs.  The  smaller  bronchi  and  bron- 
chioles are  more  extensively  affected;  the  process  is  hot  confined  to  single 
groups  of  alveoli,  but  has  a  more  lobular  arrangement,  and  the  tuberculous 
masses  from  the  onset  are  larger,  more  diffuse,  and  may  in  some  cases  involve 
an  entire  lobe  or  the  greater  part  of  a  lung.  It  is  in  this  mode  of  infection 
that  we  see  the  characteristic  peri-bronchial  granulations  and  the  areas  of 
the  so-called  nodular  broncho-pneumonia.  These  broncho-pneumonic  areas, 
with  on  the  one  hand  caseation,  ulceration,  and  cavity  formation,  and  on  the 
other  sclerosis  and  limitation,  make  up  the  essential  elements  in  the  anatom- 
ical picture  of  pulmonary  tuberculosis. 

1.  Acute  Pneumonic  Tulierculosis  of  the  Lungs 

This  form,  known  also  by  the  name  of  galloping  consumption,  is  met  with 
both  in  children  and  adults.  In  the  former  many  of  the  cases  are  mistaken 
for  simple  broncho-pneumonia. 

Two  types  may  be  recognized,  the  pneumonic  and  broncho-pneumonic. 

The  Pneumonic  Form. — In  the  pneumonic  form  one  lobe  may  be  involved, 
or  in  some  instances  an  entire  lung.  The  organ  is  heavy,  the  affected  portion 
airless;  the  pleura  is  usually  covered  with  a  thin  exudate,  and  on  section  the 
picture  resembles  closely  that  of  ordinary  hepatization.  The  following  is  an 
extract  from  the  post  mortem  report  of  a  case  in  which  death  occurred  twenty- 
nine  days  after  the  onset  of  the  illness,  having  all  the  characters  of  an  acute 
pneumonia:  "Left  lung  weighs  1,500  grams  (double  the  weight  of  the  other 
organ)  and  is  heavy  and  airless,  crepitant  only  at  the  anterior  margins. 
Section  shows  a  small  cavity  the  size  of  a  walnut  at  the  apex,  about  which 
are  scattered  tubercles  in  a  consolidated  tissue.  The  greater  part  of  the  lung 
presents  a  grayish-white  appearance  due  to  the  aggregation  of  tubercles  which 
in  some  places  have  a  continuous,  uniform  appearance,  in  others  are  sur- 
rounded by  an  injected  and  consolidated  lung-tissue.  Toward  the  margins  of 
the  lower  lobe  strands  of  this  firm  reddish  tissue  separate  anaemic,  dry  areas. 
There  are  in  the  right  lung  three  or  four  small  groups  of  tubercles  but  no 
caseous  masses.  The  bronchial  glands  are  not  tuberculous."  Here  the  intense 
local  infection  was  due  to  the  small  focus  at  the  apex  of  the  lung,  probably 
an  aspiration  process. 


184  SPECIFIC  ivJ^FECTIOUS  DISEASES 

Only  the  most  careful  inspection  may  reveal  the  jDresence  of  miliary  tuber- 
cles, or  the  attention  may  be  arrested  by  the  detection  of  tubercles  in  the  other 
lung  or  in  the  bronchial  glands.  The  process  may  involve  only  one  lobe. 
There  may  be  older  areas  which  are  of  a  peculiarly  yellowish-white  color  and 
distinctly  caseous.  The  most  remarkable  picture  is  presented  by  cases  of  this 
kind  in  which  the  disease  lasts  for  some  months.  A  lobe  or  an  entire  lung 
may  be  enlarged,  firm,  airless  throughout,  and  converted  into  a  dry,  yellowish- 
white,  cheesy  substance.  Cases  are  met  with  in  which  the  entire  lung  from 
apex  to  base  is  in  this  condition,  with  perhaps  only  a  small,  narrow  area  of 
air-containing  tissue  on  the  margin.  More  commonly,  if  the  disease  has  lasted 
for  two  or  three  months,  rapid  softening  has  taken  place  at  the  apes  with 
extensive  cavity  formation. 

Males  are  much  more  frequently  attacked  than  females.  Of  a  series  of 
15  cases,  11  were  males.  The  onset  was  acute  in  13,  with  a  chill  in  9.  Ba- 
cilli were  found  in  the  sputum  in  one  case  as  early  as  the  fourth  day.  Fraenkel 
and  Troje  believe  that  the  cases  are  of  bronchogenous  origin,  due  to  infection 
from  a  small  focus  somewhere  in  the  lung.  Tendeloo  regards  the  infection  as 
sometimes  hematogenous. 

Symptoms. — The  attack  sets  in  abruptly  with  a  chill,  usually  in  an  indi- 
vidual who  has  enjoyed  good  health,  although  in  many  cases  the  onset  has 
been  preceded  by  exposure  to  cold,  or  there  have  been  debilitating  circum- 
stances. The  temperature  rises  rapidly  after  the  chill,  there  are  pain  in  the 
side  and  cough,  with  at  first  mucoid,  subsequently  rusty-colored  expectoration 
which  may  contain  tubercle  bacilli.  The  dyspnoea  may  become  extreme 
and  the  patient  may  have  suffocative  attacks.  The  physical  examination  shows 
involvement  of  one  lobe  or  of  one  lung,  with  signs  of  consolidation,  dulness, 
increased  fremitus,  at  first  feeble  or  suppressed  vesicular  murmur,  and  subse- 
quently well-marked  bronchial  breathing.  The  upper  or  lower  lobe  may  be 
involved,  or  in  some  cases  the  entire  lung. 

At  this  time,  as  a  rule,  no  suspicion  enters  the  mind  of  the  practitioner 
that  the  case  is  an3'thing  but  one  of  frank  lobar  pneumonia.  Occasionally 
there  may  be  suspicious  circumstances  in  the  history  of  the  patient  or  in  his 
family;  but,  as  a  rule,  no  stress  is  laid  upon  them  in  view  of  the  intense  and 
characteristic  mode  of  onset.  Between  the  eighth  and  tenth  day,  instead  of 
the  expected  crisis,  the  condition  becomes  aggravated,  the  temperature  is 
irregular,  and  the  pulse  more  rapid.  There  may  be  sweating,  and  the  expec- 
toration becomes  muco-purulent  and  greenish  in  color — a  point  of  special 
importance,  to  which  Traube  called  attention.  Even  in  the  second  or  third 
week,  with  the  persistence  of  these  symptoms,  the  physician  tries  to  console 
himself  with  the  idea  that  the  case  is  one  of  unresolved  pneumonia,  and  that 
all  will  yet  be  well.  Gradually,  however,  the  severity  of  the  symptoms,  the 
presence  of  physical  signs  indicating  softening,  the  existence  of  elastic  tissue 
and  tubercle  bacilli  in  the  sputum  present  the  mournful  proofs  that  the  case  is 
one  of  acute  pneumonic  tuberculosis.  Death  may  occur  on  the  sixth  day,  as  m 
a  case  of  Tendeloo's.  The  earliest  death  in  our  series  was  on  the  thirteenth  day. 
A  majority  of  the  cases  drag  on,  and  death  does  not  occur  until  the  third 
month.  In  a  few  cases,  even  after  a  stormy  onset  and  active  course,  the 
symptoms  subside  and  the  patient  passes  into  the  chronic  stage. 

Diagnosis. — "Waters,  of  Liverpool,  who  gave  an  admirable  description  of 


TUBERCULOSIS  185 

these  cases,  called  attention  to  the  difficulty  in  distinguishing  them  from  or- 
dinary pneumonia.  Certainly  the  mode  of  onset  affords  no  criterion  whatever. 
A  healthy,  robust-looking  young  Irishman,  a  cab-driver,  who  had  been  kept 
waiting  on  a  cold,  blustering  night  until  three  in  the  morning,  was  seized  the 
next  afternoon  with  a  violent  chill,  and  the  following  day  was  admitted  to 
the  University  Hospital,  Philadelphia.  He  was  made  the  subject  of  a  clinical 
lecture  on  the  fifth  day,  when  there  was  absent  no  single  feature  in  history, 
symptoms,  or  physical  signs  of  acute  lobar  pneumonia  of  the  right  upper 
lobe.  It  was  not  until  ten  days  later,  when  bacilli  were  found  in  his  ex- 
pectoration, that  we  were  made  aware  of  the  true  nature  of  the  case.  There 
is  no  criterion  by  which  cases  of  this  kind  can  be  distinguished  in  the  early 
stage.  A  point  to  which  Traube  called  attention,  and  which  is  also  referred 
to  as  important  by  Herard  and  Cornil,  is  the  absence  of  breath-sounds 
in  the  consolidated  region;  but  this  does  not  hold  good  in  all  cases.  The 
tubular  breathing  may  be  intense  and  marked  as  early  as  the  fourth  day ;  and 
again,  how  common  it  is  to  have,  as  one  of  the  earliest  and  most  suggestive 
symptoms  of  lobar  pneumonia,  suppression  or  enfeeblement  of  the  vesicular 
murmur !  In  many  cases,  however,  there  are  suspicious  circumstances  in 
the  onset :  the  patient  has  been  in  bad  health,  or  may  have  had  previous 
pulmonar}'  trouble,  or  there  are  recurring  chills.  Careful  examination  of 
the  sputum  and  a  study  of  the  physical  signs  from  day  to  day  can  alone 
determine  the  true  nature  of  the  case.  A  point  of  some  moment  is  the  charac- 
ter of  the  fever,  which  in  true  pneumonia  is  more  continuous,  particularly 
in  severe  cases,  whereas  in  this  form  of  tuberculosis  remissions  of  1.5°  or  2° 
are  not  infrequent. 

Acute  Tuberculous  Broncho-pneumonia. — Acute  tuberculous  broncho-pneu- 
monia is  more  common,  particularly  in  children,  and  forms  a  majority  of  the 
cases  of  phthisis  florida,  or  "galloping  consumption.""  It  is  an  acute  caseous 
broncho-pneumonia,  starting  in  the  smaller  tubes,  which  become  blocked  with 
a  cheesy  substance,  while  the  air-cells  of  the  lobule  are  filled  with  the  products 
of  a  catarrhal  pneumonia.  In  the  early  stages  the  areas  have  a  grayish  red, 
later  an  opaque  white,  caseous  appearance.  By  the  fusion  of  contiguous  masses 
an  entire  lobe  may  be  rendered  nearly  solid,  but  areas  of  crepitant  air  tissue 
can  usually  be  seen  between  the  groups.  This  is  not  an  uncommon  picture 
in  the  acute  tuberculosis  of  adults,  but  it  is  still  more  frequent  in  children. 
The  following  is  an  extract  from  the  post  mortem  report  of  a  case  on  a  child 
aged  four  months,  who  died  in  the  sixth  week  of  illness :  "On  section,  the 
right  upper  lobe  is  occupied  with  caseous  masses  from  5  to  12  mm.  in  diameter, 
separated  from  each  other  by  an  intervening  tissue  of  a  deep  red  color.  The 
bronchi  are  filled  with  cheesy  substance.  The  middle  and  lower  lobes  are 
studded  with  tubercles,  many  of  which  are  becoming  caseous.  Toward  the 
diaphragmatic  surface  of  the  lower  lobe  there  is  a  small  cavity  the  size  of  a 
marble.  The  left  lung  is  more  crepitant  and  uniformly  studded  with  tubercles 
of  all  sizes,  some  as  large  as  peas.  The  bronchial  glands  are  very  large,  and 
one  contains  a  tuberculous  abscess." 

There  is  a  form  of  tuberculous  aspiration  pneumonia,  to  which  Biiumler 
called  attention,  occurring  as  a  sequence  of  haemoptysis,  and  due  to  the 
aspiration  of  blood  and  the  contents  of  pulmonary  cavities  into  the  finer  tubes. 
There  are  fever,  dyspnoea,  and  signs  of  a  diffuse  broncho-pneumonia.     Some 


186  SPECIFIC  I^NFECTIOUS  DISEASES 

of  these  cases  run  a  very  rapid  course.  This  accident  may  occur  early  in 
the  disease,  or  follow  hgemorrhage  in  a  well-marked  pulmonary  tuberculosis.. 

In  children  the  enlarged  bronchial  glands  usually  surround  the  root  of  the 
lung,  and  even  pass  deeply  into  the  substance,  and  the  lobules  are  often  in- 
volved by  direct  contact. 

In  other  cases  the  caseous  broncho-pneumonia  involves  groups  of  alveoli 
or  lobules  in  different  portions  of  the  lungs,  more  commonly  at  both  apices, 
forming  areas  from  1  to  3  cm.  in  diameter.  The  size  of  the  mass  depends 
largely  upon  that  of  the  bronchus  involved.  There  are  cases  which  probably 
should  come  in  this  category,  in  which,  with  a  history  of  an  acute  illness  of 
from  four  to  eight  weeks,  the  lungs  are  extensively  studded  with  large  gray 
tubercles,  ranging  in  size  from  5  to  10  mm.  In  some  instances  there  are 
cheesy  masses  the  size  of  a  cherry.  All  of  these  are  grayish-white  in  color, 
distinctly  cheesy,  and  between  the  adjacent  ones,  particularly  in  the  lower 
lobe,  there  may  be  recent  pneumonia,  or  the  condition  of  lung  which  has  been 
termed  splenization.  In  a  case  of  this  kind  at  the  Philadelphia  Hospital 
death  took  place  about  the  eighth  week  from  the  abrupt  onset  of  the  illness 
with  haemorrhage.  There  were  no  extensive  areas  of  consolidation,  but  the 
cheesy  nodules  were  uniformly  scattered  throughout  both  lungs.  Ko  softening 
had  taken  place. 

Secondary  infections  are  not  uncommon;  but  Prudden  was  able  to  show 
that  the  tubercle  bacillus  could  produce  not  only  distinct  tubercle  nodules,  but 
also  the  various  kinds  of  exudative  pneumonia,  the  exudates  varying  in  appear- 
ance in  different  cases,  which  phenomena  occurred  absolutely  without  the 
intervention  of  other  organisms.  The  fact  that  these  latter  had  not  sub- 
sequently crept  in  was  shown  by  cultures  at  the  autopsy  on  the  affected  animal. 

Symptoms. — The  symptoms  of  acute  broncho-pneumonic  tuberculosis  are 
very '  variable.  In  adults  the  disease  may  attack  persons  in  good  health,  but 
over-worked  or  "run  down"  from  any  cause.  Haemorrhage  initiates  the  attack 
in  a  few  cases.  There  may  be  repeated  chills;  the  temperature  is  high,  the 
pulse  rapid,  and  the  respirations  are  increased.  The  loss  of  flesh  and  strength 
is  very  striking. 

The  physical  signs  may  at  first  be  uncertain  and  indefinite,  but  finally 
there  are  areas  of  impaired  resonance,  usually  at  the  apices;  the  breath 
sounds  are  harsh  and  tubular,  with  numerous  rales.  The  sputum  may  early 
show  elastic  tissue  and  tubercle  bacilli.  In  the  acute  cases,  within  three 
weeks,  the  patient  may  be  in  a  marked  typhoid  state,  with  delirium,  dry 
tongue,  and  high  fever.  Death  may  occur  within  three  weeks.  In  other 
cases  the  onset  is  severe,  with  high  fever,  rapid  loss  of  flesh  and  strength, 
and  signs  of  extensive  unilateral  or  bilateral  disease.  Softening  takes  place; 
there  are  sweats,  chills,  and  progressive  emaciation,  and  all  the  features  of 
phthisis  florida.  Six  or  eight  weeks  later  the  patient  may  begin  to  improve, 
the  fever  lessens,  the  general  symptoms  abate,  and  a  case  which  looked  as  if  it 
would  terminate  fatally  within  a  few  weeks  drags  on  and  becomes  chronic. 

In  children  the  disease  most  commonly  follows  the  infectious  diseases, 
particularly  measles  and  whooping  cough.  At  least  three  groups  of  these 
tuberculous  broncho-pneumonias  may  be  recognized.  In  the  first  the  child 
is  taken  ill  suddenly  while  teething  or  during  convalescence  from  fever;  the 
temperature  rises  rapidly,  the  cough  is  severe,  and  there  may  be  signs  of  con- 


TUBEECULOSIS  187 

solidation  at  one  or  both  apices  with  rales.  Death  may  occur  within  a  few 
days,  and  the  lung  shows  areas  of  broncho-pneumonia,  with  perhaps  here  and 
there  scattered  opaque  grayish-yellow  nodules.  Macroscopically  the  affection 
does  not  look  tuberculous,  but  histologically  miliary  granulations  and  bacilli 
may  be  found.  Tubercles  are  usually  present  in  the  bronchial  glands,  but 
the  appearance  of  the  broncho-pneumonia  may  be  exceedingly  deceptive,  and 
it  may  require  careful  microscopic  examination  to  determine  its  tuberculous 
character.  The  second  group  is  represented  by  the  case  of  the  child  previously 
quoted,  who  died  at  the  sixth  week  with  the  ordinary  symptoms  of  severe 
broncho-pneumonia.  And  the  tliird  group  is  that  in  which,  during  the  con- 
valescence from  an  infectious  disease,  the  child  is  taken  ill  with  fever,  cough, 
and  shortness  of  breath.  The  severity  of  the  symptoms  abates  within  the 
first  fortnight ;  but  there  is  loss  of  flesh,  the  general  condition  is  bad,  and  the 
physical  examination  shows  the  presence  of  scattered  rales  throughout  the 
hmgs,  and  here  and  there  areas  of  defective  resonance.  The  child  has  sweats, 
the  fever  becomes  hectic  in  character,  and  in  many  cases  the  clinical  picture 
gradually  passes  into  that  of  chronic  phthisis. 

2.  Chronic  Ulcerative  Tuberculosis  of  the  Lungs 

Under  this  heading  may  be  grouped  the  great  majority  of  cases  of  pul- 
monary tuberculosis,  in  which  the  lesions  proceed  to  ulceration  and  softening. 

Morbid  Anatomy. — Inspection  of  the  lungs  shows  a  remarkable  variety  of 
lesions,  comprising  nodular  tubercles,  diffuse  tuberculous  infiltration,  caseous 
masses,  pneumonic  areas,  cavities  of  various  sizes,  with  changes  in  the  pleura, 
bronchi,  and  bronchial  glands. 

The  DiSTKiBUTiOiSr  of  the  Lesions. — For  years  it  has  been  recognized 
that  the  most  advanced  lesions  are  at  the  apices,  and  that  the  disease  pro- 
gresses downward,  usually  more  rapidly  in  one  of  the  lungs.  This  general 
statement,  which  has  passed  current  in  the  text-books  ever  since  the  masterly 
description  of  Laennec,  has  been  carefully  elaborated  by  Kingston  Fowler, 
who  finds  that  the  disease  in  its  onward  progress  through  the  lungs  follows, 
in  a  majority  of  the  cases,  distinct  routes.  In  the  upper  lobe  the  primary 
lesion  is  not,  as  a  rule,  at  the  extreme  apex,  but  from  an  inch  to  an  inch  and  a 
half  below  the  summit  of  the  lung,  and  nearer  to  the  posterior  and  external 
borders.  The  lesion  here  tends  to  spread  downward,  probably  from  inhala- 
tion of  the  virus,  and  this  accounts  for  the  frequent  circumstance  that  exami- 
nation behind,  in  the  supra-spinous  fossa,  will  give  indications  of  disease 
before  any  evidences  exist  at  the  apex  in  front.  Anteriorly  this  initial  focus 
corresponds  to  a  spot  just  below  the  centre  of  the  clavicle,  and  the  direction 
of  extension  in  front  is  along  the  anterior  aspect  of  the  upper  lobe,  along  a  line 
running  about  an  inch  and  a  half  from  the  inner  ends  of  the  first,  second, 
and  third  interspaces.  A  second  less  common  site  of  the  primary  lesion  in 
the  apex  "corresponds  on  the  chest  wall  with  the  first  and  second  interspaces 
below  the  outer  third  of  the  clavicle."  The  extension  is  downward,  so  that 
the  outer  part  of  the  upper  lobe  is  chiefly  involved. 

In  the  middle  lobe  of  the  right  lung  the  affection  usually  follows  disease 
of  the  upper  lobe  on  the  same  side.  In.  the  involvement  of  the  lower  lobe 
the  first  secondary  infiltration  is  about  an  inch  to  an  inch  and  a  half  below 
the  posterior  extremity  of  its  apex,  and  corresponds  on  the  chest  wall  to  a 


188  SPECIFIC  Ij;rFECTIOUS  DISEASES 

spot  opposite  the  fifth  dorsal  spine.  This  involvement  is  of  the  greatest  im- 
portance clinically,  as  "in  the  great  majority  of  cases,  when  the  physical  signs 
of  the  disease  at  the  apex  are  sufficiently  definite  to  allow  of  the  diagnosis  of 
phthisis  being  made,  the  lower  lobe  is  already  affected."  Examination,  there- 
fore, should  be  made  carefully  of  this  posterior  apex  in  all  suspicious  cases. 
In  this  situation  the  lesion  spreads  downward  and  laterally  along  the  line 
of  the  interlobular  septa,  a  line  which  is  marked  by  the  vertebral  border 
of  the  scapula,  when  the  hand  is  placed  on  the  opposite  scapula  and  the 
elbow  raised  above  the  level  of  the  shoulder.  Once  present  in  an  apex,  the 
disease  usually  extends  in  time  to  the  opposite  upper  lobe ;  but  not,  as  a  rule, 
until  the  apex  of  the  lower  lobe  of  the  lung  first  affected  has  been  attacked.  Of 
427  cases,  the  right  apex  was  involved  in  172,  the  left  in  130,  both  in  111. 

Lesions  of  the  base  may  be  primary,  though  this  is  rare.  Percy  Kidd 
makes  the  proportion  of  basic  to  apical  phthisis  1  to  500,  a  smaller  number 
than  existed  in  our  series.  In  very  chronic  cases  there  may  be  arrested  lesions 
at  the  apex  and  more  recent  lesions  at  the  base. 

Summary  of  the  Lesions  in  Chronic  Ulcerative  Tuberculosis. — (a) 
Miliary  Tubercles. — They  have  one  of  two  distributions:  (1)  A  dissemination 
due  to  aspiration  of  tuberculous  material,-  the  tubercles  being  situated  in  the 
air-cells  or  the  walls  of  the  smaller  bronchi;  (2)  the  distribution  due  to 
dissemination  of  tubercle  bacilli  by  the  lymph  current,  the  tubercles  being 
scattered  about  the  old  foci  in  a  radial  manner — the  secondary  crop  of  Laen- 
nec.  Much  more  rarely  there  is  a  scattered  dissemination  from  infection  here 
and  there  of  the  smaller  vessels,  the  tubercles  then  being  situated  in  the  vessel 
walls.  Sometimes,  in  cases  with  cavity  formation  at  the  apex,  the  greater 
part  of  the  lower  lobes  presents  many  gToups  of  firm,  sclerotic,  miliary  tuber- 
cles, which  may  indeed  form  the  distinguishing  anatomical  feature — a  chronic 
miliary  tuberculosis. 

(b)  Tuberculous  Broncho-pneumonia. — In  a  large  proportion  of  cases  of 
chronic  tuberculosis  the  terminal  bronchiole  is  the  point  of  origin  of  the  process, 
consequently  we  find  the  smaller  bronchi  and  their  alveolar  territories  blocked 
with  the  accumulated  products  of  inflammation  in  all  stages  of  caseation. 
At  an  early  period  a  cross-section  of  an  area  of  tuberculous  broncho-pneumonia 
gives  the  most  characteristic  appearance.  The  central  bronchiole  is  seen  as 
a  small  orifice,  or  it  is  plugged  with  cheesy  contents,  while  surrounding  it  is 
a  caseous  nodule,  the  so-called  peribronchial  tubercle.  The  longitudinal  sec- 
tion has  a  somewhat  dendritic  or  foliaceous  appearance.  The  condition  of  the 
picture  depends  much  upon  the  slowness  or  rapidity  with  which  the  process 
has  advanced.    The  following  changes  may  occur : 

Ulceration. — When  the  caseation  takes  place  rapidly  or  ulceration  occurs 
in  the  bronchial  wall,  the  mass  may  break  down  and  form  a  small  cavity. 

Sclerosis. — In  other  instances  the  process  is  more  chronic,  and  fibroid 
changes  gradually  produce  a  sclerosis  of  the  affected  area.  This  may  be  con- 
fined to  the  margin  of  the  mass,  forming  a  limiting  capsule,  within  which  is 
a  uniform,  firm,  cheesy  substance,  in  which  lime  salts  are  often  deposited. 
This  represents  the  healing  of  one  of  these  areas  of  caseous  broncho-pneumonia. 
It  is  only,  however,  when  complete  fibroid  transformation  or  calcification  has 
occurred  that  we  can  really  speak  of  healing.  In  many  instances  the  colonies 
of  miliary  tubercles  about  these  masses  show  that  the  process  is  still  active. 


TUBEECULOSIS  189 

Subsequently,  in  ulcerative  processes,  these  calcareous  bodies — lung-stones,  as 
they  are  sometimes  called — may  be  expectorated. 

(c)  Pneumonia. — An  important  though  secondary  place  is  occupied  by 
inflammation  of  the  alveoli  surrounding  the  tubercles,  which  become  filled,  with 
epithelioid  cells.  The  consolidation  may  extend  for  some  distance  about  the 
tuberculous  foci  and  unite  them  into  areas  of  uniform  consolidation.  Al- 
though in  some  instances  this  inflammatory  process  may  be  simple,  in  others 
it  is  undoubtedly  specific.  It  is  excited  by  the  tubercle  bacilli  and  is  a 
manifestation  of  their  action.  It  may  present  a  very  varied  appearance;  in 
some  instances  resembling  closely  ordinary  red  hepatization,  in  others  being 
more  homogeneous  and  infiltrated,  the  so-called  infiltration  tuh&rculeuse  of 
Laennec.  In  other  cases  the  contents  of  the  alveoli  undergo  fatty  degenera- 
tion, and  appear  on  the  cut  surface  as  opaque  white  or  yellowish-white  bodies. 
In  early  tuberculosis  much  of  the  consolidation  is  due  to  this  pneumonic  infil- 
tration, which  may  surround  the  smaller  foci  for  some  distance. 

{d)  Cavities. — A  vomica  is  a  cavity  in  the  lung  tissue,  produced  by  necro- 
sis and  ulceration.  The  process  usually  begins  in  the  wall  of  the  bronchus  in 
a  tuberculous  area.  Dilatation  is  produced  by  retained  secretion,  and  necrosis 
and  ulceration  of  the  wall  occur  with  gradual  destruction  of  the  contiguous 
tissues.  By  extension  of  the  necrosis  and  ulceration  the  cavity  increases,  con- 
tiguous ones  unite,  and  in  an  affected  region  there  may  be  a  series  of  small 
excavations  communicating  with  a  bronchus.  In  nearly  all  instances  the  proc- 
ess extends  from  the  bronchi,  though  it  is  possible  for  necrosis  and  softening 
to  take  place  in  the  centre  of  a  caseous  area  without  primary  involvement  of 
the  bronchial  wall.     Three  forms  may  be  recognized. 

The  fresh  ulcerative,  seen  in  acute  cases,  in  which  there  is  no  limiting 
membrane,  but  the  walls  are  made  up  of  softened,  necrotic,  and  caseous  masses. 
A  small  vomica  of  this  sort,  situated  just  beneath  the  pleura,  may  rupture  and 
cause  pneumothorax.  In  cases  of  acute  pneumonic  tuberculosis  they  may  be 
large,  occupying  the  greater  portion  of  the  upper  lobe.  In  the  chronic  ul- 
cerative form,  cavities  of  this  sort  are  invariably  present  in  those  portions 
of  the  lung  in  which  the  disease  is  advancing.  At  the  apex  there  may  be 
a  large  old  cavity  with  well-defined  walls,  while  at  the  anterior  margin  of 
the  upper  lobes,  or  in  the  apices  of  the  lower  lobes,  there  are  recent  ulcerating 
cavities  communicating  with  the  bronchi. 

Cavities  ivitli  iv ell-defined  Walls. — A  majority  of  the  cavities  in  the  chronic 
cases  have  a  well-defined  limiting  membrane,  the  inner  surface  of  which 
constantly  produces  pus.  The  walls  are  crossed  by  trabeculse  which  represent 
remnants  of  bronchi  and  blood-vessels.  Even  the  cavities  with  the  well-defined 
walls  extend  gradually  by  a  slow  necrosis  and  destruction  of  the  contiguous 
lung  tissue.  The  contents  are  usually  purulent,  similar  in  character  to  the 
grayish  nummular  sputa  coughed  up.  Xot  infrequently  the  membrane  is 
vascular  or  it  may  be  hemorrhagic.  Occasionally,  when  gangrene  has  oc- 
curred in  the  wall,  the  contents  are  horribly  fetid.  These  cavities  may  occupy 
the  greater  portion  of  the  apex,  forming  an  irregular  series  which  communicate 
with  each  other  and  with  the  bronchi,  or  the  entire  upper  lobe  except  the 
anterior  margin  may  be  excavated,  forming  a  thin-walled  cavity.  In  rare 
instances  the  process  has  proceeded  to  total  excavation  of  the  lung,  not  a  rem- 
nant of  which  remains,  except  perhaps  a  narrow  strip  at  the  anterior  mar- 


190  SPECIFIC  INFECTIOUS  DISEASES 

gin.  In  a  case  of  this  kind,  in  a  young  girl,  the  cavity  held  40  fluid  ounces, 
in  another  42  ounces. 

Quiescent  Cavities. — AYhen  quite  small  and  surrounded  by  dense  cicatricial 
tissue  communicating  with  the  bronchi  they  form  the  cicatrices  fistuleuses  of 
Laennec.  Occasionally  one  apex  may  be  represented  by  a  series  of  these  small 
cavities,  surrounded  by  dense  fibrous  tissue.  The  lining  membrane  of  these 
old  cavities  may  be  quite  smooth,  almost  like  a  mucous  membrane.  Cavities 
of  any  size  do  not  heal  completely.  Cases  are  often  seen  in  which  it  has  been 
supposed  that  a  cavity  has  healed;  but  the  signs  of  excavation  are  notoriously 
uncertain,  and  there  may  be  pectoriloquy  and  cavernous  sounds  with  gurgling 
resonant  rales  in  an  area  of  consolidation  close  to  a  large  bronchus. 

In  the  formation  of  cavities  the  blood-vessels  gradually  become  closed  by 
an  obliterating  inflammation.  They  are  the  last  structures  to  yield  and  may 
be  completely  exposed  in  a  cavity,  even  when  the  circulation  is  still  going  on 
in  them.  Unfortunately,  the  erosion  of  a  large  vessel  which  has  not  yet  been 
obliterated  is  by  no  means  infrequent,  and  causes  profuse  and  often  fatal 
haemorrhage.  xA.nother  common  event  is  the  formation  of  aneurisms  on  the  ar- 
teries running  in  the  walls  of  cavities.  These  may  be  small,  bunch-like  dilata- 
tions, or  they  may  form  sacs  the  size  of  a  walnut  or  even  larger.  They  are 
important  with  regard  to  haemoptysis. 

And,  finally,  about  cavities  of  all  sorts,  the  connective  tissue  grows,  tending 
to  limit  their  extent.  The  thickening  is  particularly  marked  beneath  the 
pleura,  and  in  chronic  cases  an  entire  apex  may  be  converted  into  a  mass  of 
fibrous  tissue,  inclosing  a  few  small  cavities. 

(e)  Pleura. — Practically,  in  all  cases  of  chronic  tuberculosis  the  pleura  is 
involved.  Adhesions  take  place  which  may  be  thin  and  readily  torn,  or  dense 
and  firm,  uniting  layers  of  from  2  to  5  mm.  in  thickness.  This  pleurisy  may 
be  simple,  but  in  many  cases  it  is  tuberculous,  and  miliary  tubercles  or  case- 
ous masses  are  seen  in  the  thickened  membrane.  Effusion  is  not  at  all  infre- 
quent, either  serous,  purulent,  or  hsemorrhagic.  Pneumothorax  is  a  common 
accident. 

(/)  Changes  in  the  smaller  bronchi  control  the  situation  in  the  early  stages 
of  pulmonary  tuberculosis,  and  play  an  important  role  throughout.  The  proc- 
ess very  often  begins  in  the  walls  of  the  smaller  tubes  and  leads  to  caseation, 
distention  with  products  of  inflammation,  and  broncho-pneumonia  of  the 
lobules.  In  many  cases  the  visible  implication  of  the  bronchus  is  an  extension 
upward  of  a  process  which  has  begun  in  the  smallest  bronchiole.  This  involve- 
ment weakens  the  wall,  leading  to  bronchiectasis,  not  an  uncommon  event.  The 
mucous  membrane  of  the  larger  bronchi,  which  is  usually  involved  in  a  chronic 
catarrh,  is  more  or  less  swollen,  and  in  some  instances  ulcerated.  Besides 
these  speciflc  lesions,  they  may  be  the  seat,  especially  in  children,  of  inflamma- 
tion due  to  secondary  invasion,  most  frequently  by  the  pneumo coccus  with  the 
production  of  a  broncho-pneumonia. 

(g)  The  bronchial  glands,  in  the  more  acute  cases,  are  swollen  and  oedema- 
tous.  Miliary  tubercles  and  caseous  foci  are  usually  present.  In  cases  of 
chronic  tuberculosis  the  caseous  areas  are  common,  calcification  may  occur, 
and  not  infrequently  purulent  softening. 

(h)  Changes  in  the  Other  Organs. — Of  these,  tuberculosis  is  the  most  com- 
mon.    In  275  autopsies  the  brain  presented  tuberculous  lesions  in  31,  the 


TUBERCULOSIS  191 

spleen  in  33,  the  liver  in  1"2,  the  kidneys  in  32,  the  intestines  in  65,  and  the 
pericardium  in  7.  Other  groups  of  lymphatic  glands  besides  the  bronchial 
may  be  affected. 

•  Amyloid  cliange  may  occur  in  the  liver,  spleen,  kidneys,  and  mucous  mem- 
brane of  the  intestines.  The  liver  is  often  the  seat  of  extensive  fatty  infiltra- 
tion, which  may  cause  marked  enlargement.  The  intestinal  tuberculosis 
occurs  in  advanced  cases  and  is  responsible  in  great  part  for  the  diarrhoea. 

Endocarditis  is  not  very  common,  and  was  present  in  13  of  275  post 
mortems  and  in  27  of  Percy  Kidd"s  500  cases.  Tubercle  bacilli  have  been 
found  in  the  vegetations.  Tubercles  may  be  present  on  the  endocardium,  par- 
ticularly of  the  right  ventricle. 

The  larynx  is  frequently  involved,  and  ulceration  of  the  vocal  cords  and 
destruction  of  the  epiglottis  are  not  at  all  uncommon. 

Modes  of  Onset. — We  have  already  seen  that  tuberculosis  of  the  lungs  may 
occur  as  the  chief  part  of  a  general  infection,  or  may  set  in  with  symptoms 
which  closely  simulate  acute  pneumonia.  In  the  ordinary  type  of  pulmonary 
tuberculosis  the  invasion  is  gradual  and  less  striking,  but  presents  an  extra- 
ordinarily diverse  picture,  so  that  the  practitioner  is  often  led  into  error. 
Among  the  most  characteristic  modes  of  onset  are  the  following: 

(a)  Latent  Types. — Many  such  cases  are  found  in  the  routine  examina- 
tion of  large  groups  of  people.  It  is  probable  that  many  slight,  ill-defined 
ailments  are  due  to  unrecognized  tuberculosis.  In  the  history  of  patients  with 
tuberculosis  such  attacks  are  not  infrequently  mentioned. 

The  disease  makes  considerable  progress  before  there  are  serious  symp- 
toms to  arouse  the  attention  of  the  patient.  In  workingmen  the  disease  may 
even  advance  to  excavation  of  an  apex  before  they  seek  advice.  It  is  not  a 
little  remarkable  how  slight  the  lung  symptoms  may  have  been. 

The  symptoms  may  be  masked  by  the  existence  of  serious  disease  in  other 
organs,  as  in  the  peritoneum,  intestines,  or  bones. 

(6)  With  Symptoms  of  Dyspepsia  and  Anemia. — The  gastric  mode  of 
onset  is  very  common,  and  the  early  manifestations  may  be  great  irritability 
of  the  stomach  with  vomiting  or  a  type  of  acid  dyspepsia  with  eructations. 
In  young  girls  (and  in  children)  with  this  dyspepsia  there  is  very  frequently 
a  pronounced  chloro-ansemia.  and  the  patient  complains  of  palpitation  of  the 
heart,  increasing  weakness,  slight  afternoon  fever,  and  amenorrhoea. 

(c)  Malarial  Symptoms. — In  a  considerable  number  of  cases  the  onset 
of  pulmonary  tuberculosis  is  with  symptoms  which  suggest  malarial  fever. 
The  patient  has  repeated  paroxysms  of  chills,  fevers,  and  sweats,  which  may 
recur  with  great  regularity.  In  districts  in  which  malaria  prevails  there  is 
no  more  common  mistake  than  to  confound  the  initial  rigors  of  pulmonary 
tuberculosis  with  it. 

{d)  Onset  with  Pleurisy. — The  first  symptoms  may  be  a  dry  pleurisy 
over  an  apex,  with  persistent  friction  murmur.  In  other  instances  the  pul- 
monary symptoms  have  followed  an  attack  of  pleurisy  with  effusion.  The 
exudate  gradually  disappears,  but  the  cough  persists  and  the  patient  becomes 
feverish,  and  signs  of  disease  at  one  apex  gradually  become  manifest.  About 
one-third  of  all  cases  of  pleurisy  with  effusion  subsequently  have  pulmonary 
tuberculosis. 

(e)  With  Laryngeal  Sympto^ms. — The  primary  localization  may  be  in 


192  SPECIFIC  INFECTIOUS  DISEASES 

the  larynx,  though  in  a  majority  of  the  instances  in  which  huskiness  and 
laryngeal  symptoms  are  the  first  noticeable  features  of  the  disease  there  are 
doubtless  foci  already  existing  in  the  lung.  The  group  of  cases  in  which  for 
many  months  throat  and  larynx  symptoms  precede  the  manifestations  of 
pulmonary  tuberculosis  is  a  very  important  one. 

(f)  Onset  with  Hemoptysis. — Frequently  the  very  first  symptom  is 
a  brisk  haemorrhage  from  the  lungs,  following  which  the  pulmonary  symptoms 
may  come  on  with  great  rapidity.  In  other  cases  the  haemoptysis  recurs,  and 
it  may  be  months  before  the  symptoms  become  well  established.  In  a  majority 
of  these  cases  the  local  tuberculous  lesion  exists  at  the  date  of  the  haemoptysis. 
Blood-streaked  sputum  may  have  the  same  significance. 

(g)  With  Tuberculosis  of  the  Cervico-axillaey  Glands. — Preceding 
the  onset  of  pulmonary  disease  for  months,  or  even  for  years,  the  lymph- 
glands  of  the  neck  or  of  the  neck  and  axilla  of  one  side  may  be  enlarged. 
These  cases  are  of  importance  because  of  the  latency  of  the  pulmonary  lesions 
and  it  is  well  to  bear  in  mind  that  in  such  patients  the  corresponding  apex  of 
the  lung  may  be  extensively  involved. 

(h)  With  Keevous  Symptoms. — Malaise,  fatigue  and  indefinite  nervous 
disturbances  with  loss  of  weight  may  be  the  marked  features  and  suggest 
neurasthenia. 

(i)  Bronchial  Symptoms. — In  by  far  the  largest  number  of  all  cases 
the  onset  is  with  a  bronchitis,  or,  as  the  patient  expresses  it,  a  neglected  cold. 
There  has  been,  perhaps,  a  liability  to  catch  cold  easily  or  the  patient  has 
been  subject  to  naso-pharyngeal  catarrh;  then,  following  some  unusual  expo- 
sure, a  cough  begins,  which  may  be  frequent  and  irritating.  The  examination 
of  the  lungs  may  reveal  localized  moist  sounds  at  one  apex  and  perhaps 
wheezing  bronchitic  rales  in  other  parts.  In  a  few  cases  the  early  symptoms 
are  often  suggestive  of  asthma  with  marked  wheezing  and  diffuse  piping 
rales. 

(;')  Miscellaneous  Group.  (1)  Following  ac;ite  infections,  such  as  in- 
fluenza. (2)  With  or  after  pregnancy.  (3)  After  an  operation  in  which 
ether  anaesthesia  was  used,  (i)  In  association  with  ischio-rectal  abscess  and 
fistula-in-ano.    In  all  of  these  an  inactive  process  may  be  rendered  active. 

Symptoms. — In  discussing  the  symptoms  it  is  usual  to  divide  the  disease 
into  three  periods :  the  first  embracing  the  time  of  the  growth  and  develop- 
ment of  the  tubercles ;  the  second,  when  they  soften ;  and  the  third,  when 
there  is  a  formation  of  cavities.  Unfortunately,  these  anatomical  stages  can 
not  be  satisfactorily  correlated  with  corresponding  clinical  periods,  and  we 
often  find  that  a  patient  in  the  third  stage  with  a  well-marked  cavity  is  in  a 
far  better  condition  and  has  greater  prospects  of  recovery  than  a  patient  in 
the  first  stage  with  diffuse  consolidation.  It  is  therefore  better  perhaps  to 
disregard  them  altogether. 

Local  Symptoms. — Pain  in  the  chest  may  be  early  and  troublesome  or 
absent  throughout.  It  is  usually  associated  with  pleurisy,  and  may  be  sharp 
and  stabbing  in  character,  and  either  constant  or  felt  only  during  coughing. 
Perhaps  the  commonest  situation  is  in  the  lower  thoracic  zone,  though  in  some 
instances  it  is  beneath  the  scapula  or  referred  to  the  apex.  The  attacks  may 
recur  at  long  intervals.  Intercostal  neuralgia  occasionally  occurs  in  the  course 
of  ordinary  pulmonary  tuberculosis. 


TUBERCULOSIS  193 

Cough  is  one  of  the  earliest  symptoms,  and  is  present  in  the  majority  of 
cases  from  beginning  to  end.  There  is  nothing  peculiar  or  distinctive  about 
it.  At  first  dry  and  hacking,  and  perhaps  scarcely  exciting  the  attention  of  the 
patient,  it  subsequently  becomes  looser,  more  constant,  and  associated  with  a 
glairy,  muco-purulent  expectoration.  In  the  early  stages  the  cough  is  bronchial 
in  its  origin.  When  cavities  have  formed  it  becomes  more  paroxysmal,  and  is 
most  marked  in  the  morning  or  after  a  sleep.  Cough  is  not  a  constant  symp- 
tom, however,  and  a  patient  may  present  himself  with  well-marked  excavation 
at  one  apex  who  declares  that  he  has  had  little  or  no  cough.  So,  too,  there 
may  be  well-marked  physical  signs,  dulness  and  moist  sounds,  without  either 
expectoration  or  cough.  In  well-established  cases  the  nocturnal  paroxysms  are 
most  distressing  and  prevent  sleep.  The  cough  may  be  of  such  persistence  and 
severity  as  to  cause  vomiting,  and  the  patient  becomes  rapidly  emaciated  from 
loss  of  food — Morton's  cough  (Phthisiologia,  1689,  p.  101).  The  laryngeal 
complications  give  a  peculiarly  husky  quality  to  the  cough,  and  when  erosion 
and  ulceration  have  proceeded  far  in  the  vocal  cords  the  coughing  becomes 
much  less  effective. 

Sputum. — This  varies  greatly  in  amount  and  character  with  the  different 
stages.  There  are  patients  with  well-marked  local  signs  at  one  apex,  with 
slight  cough  and  moderately  high  fever,  without  a  trace  of  expectoration.  So, 
also,  there  are  instances  with  the  most  extensive  consolidation  (caseous  pneu- 
monia) and  high  fever,  but  without  enough  expectoration  to  enable  an  exami- 
nation for  bacilli  to  be  made.  In  the  early  stage  of  pulmonary  tuberculosis  the 
sputum  is  chiefly  catarrhal  and  has  a  glairy,  sago-like  ap;  earance,  due  to  the 
presence  of  alveolar  cells  Avhich  have  undergone  the  myeline  degeneration. 
There  is  nothing  distinctive  or  peculiar  in  this  form  of  expectoration,  which 
may  persist  for  months  without  indicating  serious  trouble.  The  earliest  trace 
of  characteristic  sputum  may  show  the  presence  of  small  grayish  or  greenish- 
gray  purulent  masses.  These,  when  coughed  up,  are  always  suggestive  and 
should  be  the  portions  picked  out  for,  microscopic  examination.  As  softening 
comes  on,  the  expectoration  becomes  more  profuse  and  purulent,  but  may  still 
contain  a  considerable  quantity  of  alveolar  epithelium.  Finally,  when  cavities 
exist,  the  sputum  assumes  the  so-called  nummular  form ;  each  mass  is  isolated, 
flattened,  greenish-gray  in  color,  quite  airless,  and,  when  spat  into  water,  sinks 
to  the  bottojn. 

By  the  microscopic  examination  of  the  sputum  we  determine  whether  the 
process  is  tuberculous,  and  whether  softening  has  occurred.  The  bacilli  in 
stained  preparations  are  seen  as  elongated,  slightly  curved,  red  rods,  sometimes 
presenting  a  beaded  appearance.  They  are  frequently  in  groups  of  three  or 
four,  but  the  number  varies  considerably.  Only  one  or  two  may  be  found 
in  a  preparation,  or,  in  some  instances,  they  are  so  abundant  that  the  entire 
field  is  occupied.     Repeated  examinations  may  be  necessary. 

The  continued  presence  of  tubercle  dacilli  in  the  sputum  is  an  infallible 
indication  of  the  erxistence  of  tuberculosis.  One  or  two  may  possibly  be  due 
to  accidental  inhalation.  A  number  may  come  from  a  spot  of  softening  3  by  3 
cm.    In  the  nummular  sputa  of  later  stages  the  bacilli  are  very  abundant. 

Elastic  tissue  may  be  derived  from  the  bronchi,  the  alveoli,  or  from  the 
arterial  coats;  and  naturally  the  appearance  of  the  tissue  will  vary  Avith  the 
locality  from  which  it  comes.     In  the  examination  for  this  it  is  not  necessary 


194  SPECIFIC  INFECTIOUS  DISEASES 

to  boil  the  sputum  with  caustic  potash.  In  almost  all  instances  if  the  sputum 
is  spread  in  a  sufficiently  thin  layer  the  fragments  of  elastic  tissue  can  be  seen 
with  the  naked  eye.  The  thick,  purulent  portions  are  placed  upon  a  glass 
plate  15  X  15  cm.  and  flattened  into  a  thin  layer  by  a  second  glass  plate 
10  X  10  cm.  In  this  compressed  grayish  layer  between  the  glass  slips  any 
fragments  of  elastic  tissue  show  on  a  black  background  as  grayish-yellow 
spots  and  can  either  be  examined  at  once  under  a  low  power  or  the  uppermost 
piece  of  glass  is  slid  along  until  the  fragment  is  exposed,  when  it  is  picked 
out  and  placed  upon  the  ordinary  microscopic  slide.  Fragments  of  bread 
and  collections  of  milk-globules  may  also  present  an  opaque  white  appearance, 
but  with  a  little  practice  they  can  readily  be  recognized.  Fragments  of  epi- 
thelium from  the  tongue,  infiltrated  with  micrococci,  are  still  more  deceptive, 
but  the  miscroscope  at  once  shows  the  difference. 

The  bronchial  elastic  tissue  forms  an  elongated  network,  or  two  or  three 
long,  narrow  fibres  are  found  close  together.  From  the  blood-vessels  a  some- 
what similar  form  may  be  seen  and  occasionally  a  distinct  sheeting  is  found 
as  if  it  had  come  from  the  intima  of  a  good-sized  artery.  The  elastic  tissue 
of  the  alveolar  wall  is  quite  distinctive ;  the  fibres  are  branched  and  often  show 
the  outline  of  the  arrangement  of  the  air-cells.  The  elastic  tissue  from  bronchi 
or  alveoli  indicates  extensive  erosion  of  a  tube  and  softening  of  the  lung-tissue. 

Another  occasional  constituent  of  the  sputum  is  blood,  which  may  be  pres- 
ent as  the  chief  characteristic  of  the  expectoration  in  haemoptysis  or  may 
simply  tinge  the  sputum.  In  chronic  cases  with  large  cavities,  in  addition  to 
bacteria,  various  forms  of  fungi  may  be  found,  of  which  the  aspergillus  is  the 
most  important.     Sarcinae  may  also  occur. 

Calcareous  Fragments. — Formerly  a  good  deal  of  stress  was  laid  upon  their 
presence  in  the  sputum,  and  Morton  described  a  phthisis  a  adculis  in  puhnoni- 
bus  g-eneratvi.  Bayle  also  described  a  separate  form  of  phthisis  calculeuse. 
The  size  of  the  fragments  varies  from  a  small  pea  to  a  large  cherry.  As  a 
rule,  a  single  one  is  ejected;  sometimes  large  numbers  are  coughed  up  in  the 
course  of  the  disease.  They  are  formed  in  the  lung  by  the  calcification  of  case- 
ous masses,  and  it  is  said  also  occasionally  in  obstructed  bronchi.  They  may 
come  from  the  bronchial  glands  by  ulceration  into  the  bronchi,  and  there  is  a 
case  on  record  of  suffocation  in  a  child  from  this  cause. 

The  daily  amount  of  expectoration  varies.  In  rapidly  advancing  cases, 
with  much  cough,  it  may  reach  as  high  as  500  c.  c.  in  the  day.  In  cases  with 
large  cavities  the  chief  amount  is  brought  up  in  the  morning.  The  expectora- 
tion of  tuberculous  patients  usually  has  a  heavy,  sweetish  odor,  and  occasion- 
ally it  is  fetid,  owing  to  decomposition  in  the  cavities. 

Hcenioptysis. — One  of  the  most  famous  of  the  Hippocratic  axioms  says, 
"From  a  spitting  of  blood  there  is  a  spitting  of  pus."  The  older  writers 
thought  that  the  phthisis  was  directly  due  to  the  inflammatory  or  putrefactive 
changes  caused  by  the  hgemorrhage  into  the  lung.  Morton,  however,  in  his 
interesting  section,  Phithisis  ah  Hcemoptoe,  rather  doubted  this  sequence. 
Laennec  and  Louis,  and  later  in  the  century  Traube,  regarded  the  haemoptysis 
as  an  evidence  of  existing  disease  of  the  lung.  From  the  accurate  views  of 
Laennec  and  Louis  the  profession  was  led  away  by  Graves,  and  particularly 
by  Niemeyer,  who  held  that  the  blood  in  the  air-cells  set  up  an  inflammatory 
process,  a  common  termination  of  which  was  caseation.     Since  Koch's  dis- 


TUBEECULOSIS  195 

CO  very  vre  have  learned  that  many  cases  in  which  the  physical  examination  is 
negative  show,  either  during  the  period  of  haemorrhage  or  immediately  after  it, 
tubercle  bacilli  in  the  sputum,  so  that  opinion  has  veered  to  the  older  view, 
and  we  now  regard  the  appearance  of  haemoptysis  as  an  indication  pf  existing 
disease.  In  young,  apparently  healthy,  persons  cases  of  haemoptysis  may  be 
divided  into  three  groups.  In  the  first  the  bleeding  has  come  on  without  pre- 
monition, without  overexertion  or  injury,  and  there  is  no  family  history  of 
tuberculosis.  The  physical  examination  is  negative,  and  the  examination  of 
the  expectoraton  at  the  time  of  the  haemorrhage  and  subsequently  shows  no 
tubercle  bacilli.  Such  instances  are  not  uncommon,  and,  though  one  may 
suspect  strongly  the  presence  of  some  focus  of  tuberculosis,  yet  the  individuals 
may  retain  good  health  for  many  years,  and  have  no  further  trouble.  Of  the 
386  cases  of  haemoptysis  noted  by  "Ware  in  private  practice  68  recovered,  and 
pulmonar}'  disease  did  not  subsequently  occur. 

In  a  second  group  individuals  in  apparently  perfect  health  are  suddenly 
attacked,  perhaps  after  a  slight  exertion  or  during  some  athletic  exercises. 
The  physical  examination  is  also  negative,  but  tubercle  bacilli  are  found  some- 
times in  the  bloody  sputum,  more  frequently  a  few  days  later. 

In  a  third  set  of  cases  the  individuals  have  been  in  failing  health  for  a 
month  or  two,  but  the  symptoms  have  not  been  urgent  and  perhaps  not  noticed. 
Phj^sical  examination  shoAvs  the  presence  of  well-marked  tucerculous  disease, 
and  there  are  both  tubercle  bacilli  and  elastic  tissue  in  the  sputum. 

A  very  interesting  study  of  the  subject  of  haemoptysis,  particularly  in  its 
relation  to  tuberculosis,  was  made  in  the  Prussian  army  by  Strieker.  During 
the  five  years  1890-'95  there  were  900  cases  admitted  to  the  hospitals;  in  480 
the  haemorrhage  came  on  without  recognizable  cause.  Of  these,  417  cases,  86 
per  cent.,  were  certainly  or  probably  tuberculous.  In  only  221,  however,  was 
the  evidence  conclusive.  In  a  second  group  of  213  cases  the  haemorrhage  came 
on  during  the  military  exercise,  and  of  these  To  patients  were  shown  to  be 
tuberculous.  In  118  cases  the  haemorrhage  followed  special  exercises,  as  in  the 
g}'mnasium  or  riding  or  swimming.  In  24  cases  it  occurred  during  the  ex- 
ercise of  the  voice  in  singing  or  in  giving  command  or  in  the  use  of  wind  in- 
struments. A  group  of  24  cases  is  reported  in  which  the  hgemorrhage  followed 
trauma,  either  a  fall  or  a  blow  upon  the  thorax.  In  7  of  these  tuberculosis 
was  positively  present,  and  in  6  other  cases  there  was  a  strong  probability  of 
its  existence. 

Among  the  conclusions  which  Strieker  draws  the  following  are  the  most 
important:  namely,  that  soldiers  attacked  with  haemoptysis  without  special 
cause  are  in  at  least  86.8  per  cent,  tuberculous.  In  the  cases  in  which  the 
haemoptysis  follows  the  special  exercises,  etc.,  of  military  service  at  least  74.4 
per  cent,  are  tuberculous.  In  the  cases  which  come  on  during  swimming  or 
as  a  consequence  of  direct  injur}^  to  the  thorax  about  one-half  are  not  associ- 
ated Avith  tuberculosis. 

Hjemoptysis  occurs  in  from  60  to  80  per  cent,  of  all  cases  of  pulmonary 
tuberculosis.     It  is  more  frequent  in  males  than  in  females. 

In  a  majority  of  all  cases  the  bleeding  recurs.  Sometimes  it  is  a  special 
feature  throughout  the  disease,  so  that  a  hsemorrhagic  form  kas  been  recog- 
nized.    The  amount  of  blood  brought  up  varies  from  a  couple  of  drams  to  a 


196  SPECIFIC  WFECTIOUS  DISEASES 

pint  or  more.  In  69  per  cent,  of  4,125  cases  of  haemoptysis  at  the  Brompton 
Hospital  the  amount  brought  up  was  under  half  an  ounce. 

A  distinction  may  be  drawn  between  the  haemoptysis  early  in  the  disease 
and  that  which  occurs  in  the  later  periods.  In  the  former  the  bleeding  is 
usually  slight,  is  apt  to  recur,  and  fatal  hgemorrhage  is  very  rare.  In  these 
cases  the  bleeding  is  usually  from  small  areas  of  softening  or  from  early 
erosions  in  the  bronchial  mucosa.  In  the  later  periods,  after  ca:vities  have 
formed,  the  bleeding  is,  as  a  rule,  more  profuse  and  is  more  apt  to  be  fatal. 
Single  large  hsemorrhages,  proving  quickly  fatal,  are  very  rare,  except  in  the 
advanced  stages  of  the  disease.  In  these  cases  the  bleeding  comes  either  from 
an  erosion  of  a  good-sized  vessel  in  the  wall  of  a  cavity  or  from  the  rupture 
of  an  aneurism  of  the  pulmonary  artery. 

The  bleeding,  as  a  rule,  sets  in  suddenly.  Without  any  warning  the  pa- 
tient may  notice  a  warm  salt  taste  and  the  mouth  fills  with  blood.  It  may 
come  up  with  a  slight  cough.  The  total  amount  may  not  be  more  than  a  few 
drams,  and  for  a  day  or  two  the  patient  may  spit  up  small  quantities.  When 
a  large  vessel  is  eroded  or  an  aneurism  bursts,  the  amount  of  blood  brought 
up  is  large,  and  in  the  course  of  a  short  time  a  pint  or  two  may  be  expectorated. 
Fatal  haemorrhage  may  occur  into  a  very  large  cavity  without  any  blood 
being  coughed  up.  The  character  of  the  blood  is,  as  a  rule,  distinctive.  It 
is  frothy,  mixed  with  mucus,  generally  bright  red  in  color,  except  when  larg3 
amounts  are  expectorated,  and  then  it  may  be  dark.  The  sputum  may  remain 
blood-tinged  for  some  days,  or  there  are  brownish-black  streaks  in  it,  or 
friable  nodules  consisting  entirely  of  blood-corpuscles  may  be  coughed  up. 
Blood  moulds  of  the  smaller  bronchi  are  sometimes  expectorated. 

The  microscopic  examination  of  the  sputum  in  haemorrhage  cases  is  most 
important.  If  carefully  spread  out,  there  may  be  noted,  even  in  an  apparently 
pure  hgemorrhagic  mass,  little  portions  of  mucus  from  which  bacilli  or  elastic 
tissue  may  be  obtained.  Flick  and  others  have  called  attention  to  the  fre- 
quency with  which  haemoptysis  is  associated  with  the  appearance  or  an  in- 
crease of  pneumococci  and  influenza  bacilli  in  the  sputum. 

Dyspnoea,  is  not  a  common  accompaniment  of  ordinary  tuberculosis.  The 
greater  part  of  one  lung  may  be  diseased  and  local  trouble  exist  at  the  other 
apex  without  any  shortness  of  breath.  Even  in  the  paroxysms  of  very  high 
fever  the  respirations  may  not  be  much  increased.  Dyspnoea  occurs  (a)  with 
the  rapid  extension  in  both  lungs  of  a  broncho-pneumonia;  (&)  with  the  oc- 
currence of  miliary  tuberculosis;  (c)  sometimes  with  pneumothorax;  {d)  in 
old  cases  with  much  emphysema,  and  it  may  be  associated  with  cyanosis;  (e) 
in  cases  with  marked  adhesions  to  the  diaphragm  interfering  with  its  action ; 
(/)  and,  lastly,  in  long-standing  cases,  with  contracted  apices  or  great  thick- 
ening of  the  "pleura,  the  right  heart  is  enlarged,  and  the  dyspnoea  may  be 
cardiac. 

General  Symptoms. — Fever. — It  is  well  to  bear  in  mind  that  the  tem- 
perature varies  slightly  in  normal  individuals,  and  the  afternoon  range  may 
be  99°,  99.5°  or  even  100°  F.  The  difference  between  the  mouth  and  rectal 
temperature  may  be  a  full  degree,  and  in  young  full-blooded  persons,  in  the 
nervous,  and  after  exercise  the  normal  rectal  temperature  may  be  100.5°  or 
even  101°  F.  To  get  a  correct  idea  of  the  temperature  range  in  pulmonary 
tuberculosis  it  is  necessary  to  make  observations  every  two  hours  at  first.    The 


TUBERCULOSIS  19^ 

usual  8  A.  :\i.  and  8  r.  :\i.  record  is,  in  a  majority  of  the  cases,  vefy  deceptive, 
giving  neither  the  minimum  nor  maximum.  The  former  usually  occurs  be- 
tween 2  and  6  a.  m.,  and  the  latter  between  2  and  6  p.  m. 

Fever,  one  of  the  earliest  and  most  important  symptoms,  is  due  to  the 
effect  on  the  heat  centres  of  the  toxins  or  materials  absorbed  from  the  tuber- 
culous focus.  Later  in  the  disease  the  hectic  fever  is  caused  in  part  by  the 
absorption  of  the  bacterial  products  of  other  organisms.  From  a  small  spot 
of  disease  not  a  suflficient  amount  of  toxin  may  be  produced  to  disturb  the 
body  metabolism,  but  in  the  lymph  glands,  lungs,  and  bones,  from  progressing 
areas  of  infection  suflficient  absorption  takes  place  to  cause  fever.  It  is  an 
auto-inoculation  comparable  with  the  fever  produced  by  an  injection  of  tuber- 
culin. Anything  that  stimulates  the  local  lymph  and  blood  flow  favors  the 
discharge  of  the  toxins  and  causes  fever.  A  patient  at  rest  may  be  afebrile; 
after  exercise  the  temperature  may  be  102.5°,  due  to  an  auto-inoculation.  In 
acute  cases  the  fever  is  more  or  less  continuous,  resembling  that  of  typhoid 
fever  or  pneumonia,  with  slight  morning  remissions.  It  may  set  in  with  a 
chill  and  be  followed  by  sweats,  and  there  are  cases  with  a  marked  intermit- 
tent pyrexia  from  the  onset.  As  a  rule,  the  degree  of  activity  of  the  local  proc- 
ess may  be  gauged  by  the  persistency  and  the  range  of  the  fever;  and  fav- 
orable cases  are  those  in  which  the  temperature  yields  rapidly  to  rest.  In  a 
few  cases  progress  of  the  local  disease  continues  and  may  even  be  rapid 
without  fever.  The  temperature  of  consumptives  is  easily  influenced  by 
trivial  causes  which  would  not  affect  a  normal  person,  such  as  mental  excite- 
ment, exercise,  constipation,  etc.  The  patient  is  usually  aware  when  fever 
is  present  and  may  feel  more  comfortable  with  a  temperature  of  101°.  Except 
the  sweating,  there  are  rarely  any  unpleasant  feelings  connected  with  it. 

With  breaking  down  of  the  lung-tissue  and  formation  of  cavities,  asso- 
ciated as  these  processes  always  are  with  suppuration  and  mixed  infection, 
the  fever  assumes  a  characteristically  intermittent  or  hectic  type.  For  a  large 
part  of  the  day  the  patient  is  not  only  afebrile,  but  the  temperature  is  sub- 
normal. In  the  annexed  two-hourly  chart,  from  a  case  of  chronic  tuberculosis 
of  the  lungs,  it  will  be  seen  that,  from  10  p.  M.  to  8  a.  m.  or  noon,  the  tem- 
perature continuously  fell  and  went  as  low  as  95°.  A  slow  rise  then  took 
place  through  the  late  morning  and  early  afternoon  hours  and  reached  its 
maximum  between  6  and  10  p.  M.  As  shown  in  the  chart,  there  were  in  the 
three  days  about  forty-three  hours  of  pyrexia  and  twenty-nine  hours  of  apy- 
rexia.  The  rapid  fall  of  the  temperature  in  the  early  morning  hours  is  usually 
associated  with  sweating.  This  hectic,  as  it  is  called^  which  is  a  typical 
fever  of  septic  infection,  is  met  with  when  the  process  of  cavity  formation  and 
softening  is  advanced  and  extending. 

Sweating — Drenching  perspirations  are  common  and  are  one  of  the  most 
distressing  features  of  the  disease.  They  occur  usually  with  the  drop  in  the 
fever  in  the  early  morning,  or  at  any  time  in  the  day  when  the  patient  sleeps. 
They  may  come  on  early  in  the  disease,  but  are  more  persistent  and  frequent 
after  cavities  have  formed.     Some  patients  escape  altogether. 

The  pulse  is  increased  in  frequency  and  usually  in  proportion  to  the 
lieight  of  the  fever.  Even  when  at  rest  and  afebrile  the  pulse  may  be  rapid, 
but  the  excitement  of  counting  it  may  increase  the  rate  20  to  30  beats.  The 
pulse  is  often  remarkably  full,  soft  and  compressible;  even  after  recovery  it 


198 


SPECIFIC  I^^FECTIOUS  DISEASES 


may  remain  rapid.     Pulsation  may  sometimes  be  seen  in  the  capillaries  and 
in  the  veins  on  the  back  of  the  hand. 

Emaciation  is  a  pronounced  feature,  from  which  the  two  common  names 
of  the  disease  have  been  derived.  The  loss  of  weight  is  gradual  and,  if  the 
disease  is  extending,  progressive.  The  scales  give  one  of  the 'best  indications 
of  the  progress  of  the  patient.  It  is  most  rapid  early  in  the  disease,  when  the 
patient  may  lose  at  the  rate  of  five  or  six  pounds  a  week;  and  usually  is  in 
direct  relation  to  the  intensity  and  duration  of  the  fever.  With  the  arrest  of 
the  progress  and  the  fall  in  temperaure  the  patient  usually  begins  to  regain 

No.5  ^^  JN!ifc^.'tij^to^_  .^iieXi^^^ 


Chart  Y. — Three  Days.    Chronic  Tuberculosis 


weight.  The  average  gain  in  weight  of  901  patients  at  the  Adirondack  Sana- 
torium was  fourteen  pounds  (L.  Brown).  A  gain  of  two  pounds  a  week  is 
satisfactory.  Loss  of  strength  may  be  out  of  proportion  to  and  quite  inde- 
pendent of  loss  of  weight.     Early  debility  may  be  a  marked  feature. 

.  Physical  Sigxs. —  (a)  Inspection. — The  shape  of  the  chest  is  often  sug- 
gestive, though  it  is  to  be  remembered  that  the  disease  may  be  met  with  in 
chests  of  any  build.  Practically,  however,  in  a  considerable  proportion  of 
cases  the  thorax  is  long  and  narrow,  with  very  wide  intercostal  spaces,  the 
ribs  more  vertical  in  direction,  and  the  costal  angle  very  narrow.  The  scap- 
ulae are  "winged,"  a  point  noted  by  Hippocrates.    Another  type  of  chest  which 


TUBERCULOSIS  199 

is  very  common  is  that  which  is  flattened  in  the  antero-posterior  diameter. 
The  costal  cartilages  may  be  prominent  and  the  sternum  depressed.  Occa- 
sionally the  lower  sternum  forms  a  deep  concavity,  the  so-called  funnel  breast 
(Trichter-Brust).  Special  examination  should  be  made  of  the  clavicular 
regions  to  see  if  one  clavicle  stands  out  more  distinctly  than  the  other,  or  if 
the  spaces  above  or  below  it  are  more  marked.  Defective  expansion  at  one 
apex  is  an  early  and  important  sign.  The  condition  of  expansion  of  the  lower 
zone  of  the  thorax  may  be  well  estimated  by  inspection.  The  condition  of  the 
prcecordia  should  also  be  noted,  as  a  wide  area  of  impulse,  particularly  in  the 
second,  third,  and  fourth  interspaces,  often  results  from  disease  of  the  left 
apex.  From  a  point  behind  the  patient,  looking  over  the  shoulders,  one  can 
often  better  estimate  the  relative  expansion  of  the  apices.  Atrophy  of  the 
muscles  of  the  shoulder-girdle  on  the  affected  side  is  not  uncommon,  and  a 
slight  scoliosis  may  be  present.  Movement  may  be  restricted  on  the  affected 
side,  particularly  at  the  apex.  Pleurisy  with  adhesions  or  with  effusion, 
fibrosis,  and  pneumonic  consolidation  may  limit  the  movement  of  one  side. 
The  Litten  phenomenon  (seen  best  on  the  right  side)  may  be  restricted  in 
extent  or  absent.  The  chest  expansion  may  be  much  reduced.  It  should  be 
recorded  carefully  at  the  first  examination. 

(b)  Palpation. — Deficiency  in  expansion  at  the  apices  or  bases  is  perhaps 
best  gauged  by  placing  the  hands  in  the  subclavicular  spaces  and  then  in  the 
lateral  regions  of  the  chest  and  asking  the  patient  to  draw  slowly  a  full  breath. 
Standing  behind  the  patient  and  placing  the  thumbs  in  the  supraclavicular  and 
the  fingers  in  the  infraclavicular  spaces  one  can  judge  accurately  as  to  the 
relative'  mobility  of  the  two  sides.  Disease  at  an  apex,  though  early  and 
before  dulness  is  at  all  marked,  may  be  indicated  by  deficient  expansion.  The 
tactile  fremitus  is  increased  wherever  there  is  local  growth  of  tubercle  or  ex- 
tensive caseation.  In  comparing  the  apices  it  is  important  to  bear  in  mind 
that  normally  the  fremitus  is  stronger  over  the  right  than  the  left.  In  the 
later  stages,  when  cavities  form,  the  tactile  fremitus  is  usually  much  exag- 
gerated over  them.  When  the  pleura  is  greatly  thickened  the  fremitus  may  be 
diminished. 

(c)  Percussion. — Tubercles,  inflammatory  products,  fibroid  changes,  and 
cavities  produce  important  changes  in  the  pulmonary  resonance.  There  may 
be  localized  disease,  even  of  some  extent,  without  inducing  much  alteration, 
as  when  the  tubercles  are  scattered  there  is  air-containing  tissue  between  them. 
In  incipient  cases  percussion  may  be  negative,  28  out  of  201  in  L.  Brown's 
series.  It  requires  a  fair-sized  area  of  infiltration  to  cause  a  change  in  the 
percussion  note,  4x6  cm.,  according  to  Cornet.  One  of  the  earliest  and  most 
valuable  signs  is  defective  resonance  upon  and  above  a  clavicle.  In  a  consid- 
erable proportion  of  all  cases  the  dulness  is  first  noted  in  these  regions.  The 
comparison  between  the  two  sides  should  be  made  also  when  the  breath  is  held 
after  a  full  inspiration,  as  the  defective  resonance  may  then  be  more  clearly 
marked.  In  the  early  stages  the  percussion  note  is  usually  higher  in  pitch, 
and  it  may  require  an  experienced  ear  to  detect  the  difference.  In  recent  con- 
solidation from  caseous  pneumonia  the  percussion  note  often  has  a  tympanitic 
quality.  A  wooden  dulness  is  rarely  heard  except  in  old  cases  with  extensive 
fibroid  change  at  the  apex  or  base.  Over  large,  thin-walled  cavities  at  the 
apex  the  so-called  cracked-pot  sound  may  be  obtained.     Percussion  should  be 


200  SPECIFIC  INFECTIOUS  DISEASES 

carefully  done  in  the  supraspinous  fossee  and  the  interscapular  space,  as  they 
correspond  to  very  important  areas  early  involved  in  the  disease.  By  light 
percussion  along  the  border  of  the  trapezius  and  in  the  supraclavicular  and 
supraspinous  fossge,  areas  of  apical  resonance  may  be  mapped  out  (Kronig's 
apical  resonance  zones).  Under  normal  conditions  the  areas  are  equal  on  the 
two  sides.  Consolidation  or  retraction  of  an  apex  causes  definite  narrowing 
of  the  zone  on  the  affected  side.  The  procedure  requires  considerable  skill.  It 
gives  valuable  information  in  the  early  stage  of  infiltration.  Goldscheider 
uses  a  special  pleximeter  and  percusses  out  the  borders  of  the  apex  of  the  lung 
projecting  above  the  clavicle.  The  method  is  less  satisfactory  than  that  of 
Kronig.  In  cases  with  numerous  isolated  cavities  at  the  apex,  without  much 
fibroid  tissue  or  thickening  of  the  pleura,  the  percussion  note  may  show  little 
change,  and  the  contrast  between  the  signs  obtained  on  auscultation  and  per- 
cussion is  most  marked.  In  the  direct  percussion  of  the  chest,  particularly  in 
thin  patients  over  the  pectorals,  one  frequently  sees  the  phenomenon  known  as 
myoidema,  a  local  contraction  of  the  muscle  causing  bulging,  which  persists 
for  a  variable  period  and  gradually  subsides.    It  has  no  special  significance. 

{d)  Auscultation. — Feeble  breath-sounds  are  among  the  most  character- 
istic early  signs,  since  not  as  much  air  enters  the  tubes  and  vesicles  of  the 
affected  area.  It  is  well  at  first  always  to  compare  carefully  the  corresponding 
points  on  the  two  sides  of  the  chest  without  asking  the  patient  either  to  draw 
a  deep  breath  or  to  cough.  With  early  apical  disease  the  inspiration  on  quiet 
breathing  may  be  scarcely  audible.  Expiration  is  usually  prolonged.  On  the 
other  hand,  there  are  cases  in  which  the  earliest  sign  is  a  harsh,  rude,  respira- 
tory murmur.  On  deep  breathing  it  is  frequently  to  be  noted  that  inspiration 
is  jerking  or  wavy,  the  so-called  "cog-wheel''  rhythm ;  which,  however,  is  by  no 
means  confined  to  tuberculosis.  With  extension  of  the  disease  the  inspiratory 
murmur  is  harsh,  and,  when  consolidation  occurs,  whifiing  and  bronchial. 
With  these  changes  in  the  character  of  the  murmur  there  are  rales.  The  pa- 
tient should  first  breathe  quietly,  then  take  a  full  breath,  and  then  cough. 
When  heard  with  quiet  breathing,  if  they  persist  and  are  present  in  one  area 
only,  they  are  of  great  importance.  The  fine  rustling  crepitus  at  one  or  both 
apices  which  is  heard  when  the  patient  first  takes  a  deep  breath  is  of  no  mo- 
ment. It  may  also  be  present  at  the  bases.  Eales  at  the  end  of  deep  inspira- 
tion which  disappear  on  repeated  breathing  may  also  be  disregarded.  Eales 
which  are  brought  out  by  coughing  (most  useful  during  expiration),  which  per- 
sist, and  are  repeatedly  heard  at  the  same  spot  are  of  the  greatest  importance. 
It  is  of  equal  import  when  moist,  clicking  rales  are  present  with  change  in 
the  percussion  note.  Attention  to  these  rules  will  save  many  of  the  unneces- 
sary diagnoses  of  pulmonary  tuberculosis  made  on  auscultatory  signs  alone. 

When  softening  occurs  the  rales  are  louder  and  have  a  bubbling,  some- 
times a  characteristic  clicking  quality.  These  "moist  sounds,"  as  they  are 
called,  when  associated  with  change  in  the  percussion  resonance  are  extremely 
suggestive.  When  cavities  form  the  rales  are  louder,  more  gurgling,  and  reso- 
nant in  quality.  When  there  is  consolidation  of  any  extent  the  breath  sounds 
are  tul)ular,  and  in  the  large  excavations  loud  and  cavernous,  or  have  an  am- 
phoric quality.  In  the  unaffected  portions  of  the  lobe  and  in  the  opposite 
luno-  the  breath  sounds  may  be  harsh  and  even  puerile.  The  vocal  resonance 
is  usually  increased  in  all  stages  of  the  process,  and  bronchophony  and  pec- 


TUBERCULOSIS  201 

toriloquy  are  met  with  in  the  regions  of  consolidation  and  over  cavities.  Pleu- 
ritic friction  may  be.  present  at  any  stage  and,  as  mentioned  before,  occurs 
very  early.  There  are  cases  in  which  it  is  a  marked  feature  throughout. 
When  the  lappet  of  lung  over  the  heart  is  involved  there  may  be  a  pleuro- 
pericardial  friction,  and  when  this  area  is  consolidated  there  may  be  curious 
clicking  rales  synchronous  with  the  heart-beat,  due  to  the  compression  by  the 
heart  of  this  portion  with  expulsion  of  air  from  it.  An  interesting  ausculta- 
tory sign  met  with  in  thin-chested  persons,  in  nervous  patients,  and  often  in 
early  pulmonary  tuberculosis  is  the  so-called  cardio-respiratory  murmur,  a 
whiffing  systolic  bruit  due  to  the  propulsion  of  air  out  of  the  tubes  by  the 
impulse  of  the  heart.  It  is  best  heard  during  inspiration  and  in  the  antero- 
lateral regions  of  the  chest. 

A  systolic  murmur  is  frequently  heard  in  the  subclavian  artery  on  either 
side,  the  pulsation  of  which  may  be  very  visible.  The  murmur  is  in  all  prob- 
ability due  to  pressure  on  the  vessels  by  the  thickened  pleura. 

The  signs  of  cavity  may  be  here  briefly  enumerated. 

(1)  When  there  is  not  much  thickening  of  the  pleura  or  condensation  of 
the  surrounding  lung-tissue,  the  percussion  sound  may  be  full  and  clear,  re- 
sembling the  normal  note.  More  commonly  there  is  defective  resonance  or  a 
tympanitic  quality  which  may  at  times  be  purely  amphoric.  The  pitch  of  the 
percussion  note  changes  over  a  cavity  when  the  mouth  is  opened  or  closed 
(Wintrich's  sign),  or  it  may  be  brought  out  more  clearly  on  change  of  posi- 
tion. The  cracked-pot  sound  is  obtainable  over  tolerably  large  cavities  with 
thin  walls  or  M^hen  one  cavity  is  above  another.  It  is  best  elicited  by  a  firm, 
quick  stroke,  the  patient  at  the  time  having  the  mouth  open.  In  those  rare 
instances  of  almost  total  excavation  of  one  lung  the  percussion  note  may  be 
amphoric  in  quality.  (2)  On  auscultation  the  so-called  cavernous  sounds  are 
heard:  (i)  Various  grades  of  modified  breathing — blowing  or  tubular,  caver- 
nous or  amphoric.  There  may  be  a  curiously  sharp  hissing  sound,  as  if  the 
air  was  passing  from  a  narrow  opening  into  a  wide  space.  In  very  large 
cavities  both  inspiration  and  expiration  may  be  typically  amphoric,  (ii) 
There  are  coarse  bubbling  rales  which  have  a  resonant  quality,  and  on  cough- 
ing may  have  a  metallic  or  ringing  character.  On  coughing  they  are  often 
loud  and  gurgling.  In  very  large  thin-walled  cavities,  and  more  rarely  in 
medium-sized  cavities,  surrounded  by  recent  consolidation,  the  rales  may  have 
a  distinctly  amphoric  echo,  simulating  those  of  pneumothorax.  There  are  dry 
cavities  in  which  no  rales  are  heard,  (iii)  The  vocal  resonance  is  greatly  in- 
tensified, and  whispered  bronchophony  is  clearly  heard.  In  large  apical  cavities 
the  heart-sounds  are  well  heard,  and  occasionally  there  may  be  an  intense 
systolic  murmur,  probably  always  transmitted  to,  and  not  produced,  as  has 
been  supposed,  in  the  cavity  itself.  In  large  excavations  of  the  left  apex  the 
heart  impulse  may  cause  gurgling  sounds  or  clicks  synchronous  with  the 
systole.  They  may  even  be  loud  enough  to  be  heard  at  a  little  distance  from 
the  chest  wall.  A  large  cavity  with  smooth  walls  and  thin  fluid  contents  may 
give  the  succussion  sound  when  the  trunk  is  abruptly  shaken  (Walshe),  and 
even  the  coin  sound  may  be  obtained. 

Pseudo-cavernous  signs  may  be  caused  by  an  area  of  consolidation  near  a 
large  bronchus.     The  condition  may  be  most  deceptive — the  high-pitched  or 


W2  SPECIFIC  INFECTIOUS  DISEASES 

tympanitic   percussion   note,    the   tubular   or   cavernous   breathing,   and   the 
resonant  rales  simulate  closely  the  signs  of  cavity. 

3.  Fibroid  Tuberculosis 

In  their  monograph  on  Fibroid  Diseases  of  the  Lung,  Clark,  Hadley,  and 
'Chaplin  make  the  following  classification :  1.  Pure  fibroid — a  condition  in 
which  there  is  no  tubercle.  2.  Tuberculo-fibroid  disease — a  condition  pri- 
marily tuberculous,  but  which  has  run  a  fibroid  course.  3.  Fibro-tuberculous 
disease — a  condition  primarily  fibroid,  but  which  has  become  tuberculous. 
The  tuberculo-fibroid  form  may  come  on  gradually  as  a  sequence  of  a  chronic 
tuberculous  broncho-pneumonia  or  follow  a  chronic  tuberculous  pleurisy.  In 
other  instances  the  process  supervenes  upon  ordinary  ulcerative  tuberculosis. 
The  disease  becomes  limited  to  one  apex,  the  cavity  is  surrounded  by  layers  of 
dense  fibrous  tissue,  the  pleura  is  thickened,  and  the  lower  lobe  is  gradually 
invaded  by  the  sclerotic  change.  Ultimately  a  picture  is  produced  little  if  at 
all  different  from  the  condition  known  as  cirrhosis  of  the  lungs.  It  may  even 
be  difficult  to  say  that  the  process  is  tuberculous,  but  in  advanced  cases  the 
bacilli  are  usually  present  in  the  walls  of  the  cavity  at  the  apex,  or  old,  en- 
capsulated caseous  areas  are  present,  or  there  may  be  tubercles  at  the  apex 
of  the  other  lung  and  in  the  bronchial  glands.  Dilatation  of  the  bronchi  is 
present;  the  right  ventricle,  sometimes  the  entire  heart,  is  hypertrophied. 

The  disease  is  chronic,  lasting  from  ten  to  twenty  or  more  years,  during 
which  time  the  patient  may  have  fair  health.  The  chief  symptoms  are  cough, 
often  paroxysmal  in  character  and  most  marked  in  the  morning,  and  dyspnoea 
on  exertion.  The  expectoration  is  purulent,  and  in  some  instances,  when  the 
bronchiectasis  is  extensive,  fetid.    There  is  rarely  any  fever. 

The  physical  signs  are  very  characteristic.  The  chest  is  sunken  and  the 
shoulder  lower  on  the  affected  side;  the  heart  is  often  drawn  over  and  dis- 
placed. If  the  left  lung  is  involved  there  may  be  an  unusually  large  area 
of  cardiac  pulsation  in  the  third,  fourth,  and  fifth  interspaces.  Heart  mur- 
murs are  common.  There  are  dulness  and  deficient  tactile  fremitus  over  the 
affected  side,  except  over  cavities  where  fremitus  is  increased.  At  the  apex 
there  may  be  well-marked  cavernous  sounds;  at  the  base,  distant  bronchial 
breathing.  In  some  cases  the  other  lung  becomes  involved,  or  the  -patient  has 
repeated  attacks  of  haemoptysis,  in  one  of  which  he  dies.  As  a  result  of  the 
chronic  suppuration,  amyloid  degeneration  may  take  place;  dropsy  frequently 
supervenes  from  failure  of  the  right  heart. 

A  more  detailed  account  is  found  under  Cirrhosis  of  the  Lung,  with  which 
this  form  is  clinically  identical. 

Complications  of  Pulmonary  Tuberculosis 

In  the  Respiratory  System. — The  larynx  is  rarely  spared  in  chronic  pul- 
monary tuberculosis.  The  first  symptom  may  be  huskiness  of  the  voice.  There 
are  pain,  particularly  in  swallowing,  and  a  cough  which  is  often  wheezing,  and 
in  the  later  stages  very  ineffectual.  Aphonia  and  dysphagia  are  the  two  most 
distressing  symptoms  of  the  laryngeal  involvement'.  When  the  epiglottis  is 
seriously  diseased  and  the  ulceration  extends  to  the  lateral  wall  of  the  pliarynx, 
the  pain  in  swallowing  may  be  very  intense,  or,  owing  to  the  imperfect  closure 
of  the  glottis,  there  may  be  covighing  spells  and  regurgitation  of  food  through 


TUBERCULOSIS  203 

the  nostrils.     Bronchitis  and  tracheitis  are  ahnost  invariable  accompaniments. 

Pneumonia  is  a  not  infrequent  complication  of  pulmonary  tuberculosis. 
It  may  run  a  perfectly  normal  course,  while  in  other  instances  resolution  may 
be  delayed,  and  one  is  in  doubt,  in  spite  of  the  abruptness  of  the  onset,  as  to 
the  presence  of  a  simple  or  a  tuberculous  pneumonia.  In  some  cases  a  pneu- 
monia is  a  terminal  complication. 

Emphysema  of  the  uninvolved  portions  of  the  lung  is  common,  rarely  pro- 
ducing any  special  symptoms.  There  are,  however,  cases  of  chronic  tubercu- 
losis in  which  emphysema  dominates  the  picture,  and  in  which  the  condition 
comes  on  slowly  during  a  period  of  many  years.  General  subcutaneous  em- 
physema, met  with  in  a  few  rare  cases,  is  due  either  to  perforation  of  the 
trachea  or  to  the  rupture  of  a  cavity  adherent  to  the  chest  wall. 

Gangrene  of  the  lung  is  an  occasional  event,  due  in  almost  all  instances 
to  sphacelus  in  the  walls  of  the  cavity,  rarely  in  the  lung-tissue  itself. 

Complications  in  the  Pleura. — A  dry  pleurisy  is  a  very  common  accom- 
paniment of  the  early  stages  of  tuberculosis.  It  is  always  a  conservative,  use- 
ful process.  In  some  cases  it  is  very  extensive,  and  friction  murmurs  may  be 
heard  over  the  sides  and  back.  The  cases  with  dry  pleurisy  and  adhesions  are, 
of  course,  much  less  liable  to  the  dangers  of  pneumothorax.  Pleurisy  with 
effusion  more  commonly  precedes  than  occurs  in  the  course  of  pulmonary 
tuberculosis.  Still,  it  is  common  enough  to  meet  with  cases  in  which  a  sero- 
fibrinous effusion  arises  in  the  course  of  the  chronic  disease.  There  are  cases 
in  which  it  is  a  special  feature,  and  it  seems  to  favor  chronicity.  ■  A  patient  may 
during  a  period  of  four  or  five  years  have  signs  of  local  disease  at  one  apex  with 
recurring  effusion  in  the  same  side.  Owing  to  adhesions  in  different  parts  of 
the  pleura,  the  effusion  may  be  encapsulated.  Hemorrhagic  effusions,  not  un- 
common in  connection  with  tuberculous  pleurisy,  are  comparatively  rare  in 
pulmonary  tuberculosis.  Chyliform  or  milky  exudates  are  sometimes  found. 
Purulent  effusions  are  not  frequent  apart  from  pneumothorax.  An  empyema, 
however,  may  occur  in  the  course  of  the  disease  or  as  a  sequence  of  a  sero- 
fibrinous exudate.  Pneumothorax  is  an  extremely  common  complication. 
Of  49  cases  at  the  Johns  Hopkins  Hospital,  23  were  tuberculous  (Emerson). 
It  may  prove  fatal  in  twenty-four  hours.  In  other  instances  a  pyo-pneumo- 
thorax  follows  and  the  patient  lingers  for  weeks  or  months.  In  a  third  group 
of  cases  it  seems  to  have  a  beneficial  effect  and  is  sometimes  produced  for  the 
therapeutic  effect. 

Symptoms  Referable  to  the  Other  Organs. —  (a)  Cardio-vascular. — The 
retraction  of  the  left  upper  lobe  exposes  a  large  area  of  the  heart.  In  thin- 
chested  subjects  there  may  be  pulsation  in  the  second,  third,  and  fourth 
interspaces  close  to  the  sternum.  Sometimes  with  much  retraction  of  the  left 
upper  lobe  the  heart  is  drawn  up.  A  systolic  murmur  over  the  pulmonary 
area  and  in  the  subclavian  arteries  is  common  in  all  stages.  Apical  murmurs 
are  not  infrequent  and  may  be  extremely  rough  and  harsh  without  necessarily 
indicating  that  endocarditis  is  present.  The  association  of  heart  disease  -with 
tuberculosis  is  not,  however,  very  uncommon.  There  were  12  instances  of 
endocarditis  in  216  autopsies.  The  arterial  tension  is  usually  low  and  the 
capillary  resistance  lessened  so  that  the  pulse  is  often  full  and  soft  even  in 
the  later  stages.  The  capillary  pulse  is  not  infrequently  found,  and  pulsation 
of  the  veins  in  the  back  of  the  hand  is  occasionally^ seen. 


204  SPECIFIC  IXFECTIOUS  DISEASES 

(b)  Blood. — The  early  anaemia  is  often  more  apparent  than  real,  and  the 
blood-count  rarely  sinks  below  two  millions  per  c.  mm.  The  blood-plates  are, 
as  a  rule^  enormously  increased  and  are  seen  in  the  withdrawn  blood  as  the 
so-called  Schultze's  granule  masses.  Without  any  significance,  they  are  of 
interest  chiefly  from  the  fact  that  every  few  years  some  tyro  announces  their 
discovery  as  a  new  diagnostic  sign  of  tuberculosis.  The  leucocytes  are  greatly 
increased,  particularly  in  the  later  stages. 

(c)  Gastro-intestinal  System. — The  tongue  is  usually  furred,  but  may 
be  clean  and  red.  Small  aphthous  ulcers  are  sometimes  distressing.  A  red 
line  on  the  gums,  a  symptom  to  which  at  one  time  much  attention  was  paid 
as  a  special  feature  of  tuberculosis,  occurs  in  other  cachectic  states.  Extensive 
tuberculous  disease  of  the  pharynx,  associated  with  a  similar  affection  of  the 
larynx,  may  interfere  seriously  with  deglutition  and  prove  a  very  distressing 
and  intractable  symptom.    The  saliva  has  full  digestive  powers. 

Tuberculosis  of  the  stomach  is  rare.  L^lceration  may  occur  as  an  accidental 
complication  and  multiple  catarrhal  ulcers  are  not  uncommon.  Interstitial 
and  parenchymatous  changes  in  the  mucosa  are  common  (possibly  associated 
with  the  venous  stasis)  and  lead  to  atrophy,  but  these  cannot  always  be  con- 
nected with  the  symptoms,  and  they  may  be  found  when  not  expected.  On 
the  other  hand,  when  the  gastric  symptoms  have  been  most  persistent  the 
mucosa  may  show  very  little  change.  It  is  impossible  always  to  refer  the 
anorexia,  nausea,  and  vomiting  of  consumption  to  local  conditions.  The 
hectic  fever  and  the  neurotic  influences  must  be  taken  into  account,  as  they 
play  an  important  role.  There  is  interference  with  both  the  secretory  and 
motor  functions  early  in  the  course.    Hyperacidity  is  rare  (Mohler  and  Funk). 

Anorexia  is  often  a  marked  symptom  at  the  onset;  there  may  be  positive 
loathing  for  food,  and  even  small  quantities  cause  nausea.  Sometimes,  with- 
out any  nausea  or  distress  after  eating,  the  feeding  of  the  patient  is  a  daily 
battle.  When  practicable,  forced  alimentation  is  of  great  benefit  in  such 
cases.  Xausea  and  vomiting,  though  occasionally  troublesome  at  an  early 
period,  are  more  marked  in  the  later  stages.  The  latter  may  be  caused  by 
the  severe  attacks  of  coughing.  S.  H.  Habershon  refers  to  four  causes  of  vomit- 
ing: (1)  central,  as  from  tuberculous  meningitis;  (2)  pressure  on  the  vagi 
by  caseous  glands;  (3)  stimulation  from  the  peripheral  branches  of  the  vagus, 
either  pulmonary,  pharyngeal,  or  gastric;  and  (-4)  mechanical  causes. 

Of  the  intestinal  symptoms  diarrhoea  is  the  most  serious.  It  may  come 
on  early,  but  is  more  usually  a  symptom  of  the  later  stages,  and  is  associated 
with  ulceration,  particularly  of  the  large  bowel.  Extensive  ulceration  of  the 
ileum  may  exist  without  any  diarrhoea.  The  associated  catarrhal  condition 
may  account  in  part  for  it,  and  in  some  instances  the  amyloid  degeneration 
of  the  mucous  membrane.  Perforation  occurred  in  13  of  475  autopsies  in 
chronic  pulmonary  tuberculosis. 

{d)  Nervous  System. —  (1)  Focal  lesions  due  to  the  development  of 
coarse  tubercles  and  areas  of  tuberculous  meningo-encephalitis.  Aphasia,  for 
instance,  may  result  from  the  growth  of'  meningeal  tubercles  in  the  fissure  of 
Sylvius,  or  even  hemiplegia  may  occur.  The  solitary  tubercles  are  more  com- 
mon in  the  chronic  tuberculosis  of  children.  (2)  Basilar  meningitis  is  an 
occasional  complication.  It  may  be  confined  to  the  brain,  though  more  com- 
monly it  is  a   (3)    cerebrospinal  meningitis,  which  may  come  on  in  persons 


TUBERCULOSIS  205 

without  well-marked  local  signs  in  the  chest  so  that  the  existence  of  pulmonary 
disease  is  not  discovered  until  the  post  mortem.  (4)  Peripheral  neuritis, 
which  is  not  common,  may  cause  an  extensor  paralysis  of  the  arm  or  leg, 
more  commonly  the  latter,  with  foot-drop.  It  is  usually  a  late  manifestation. 
(5)  The  brachial  plexus,  close  to  the  pleuro-pulmonary  apex,  is  sometimes 
involved,  either  hy  adhesion  to  the  tuberculous  glands  in  the  neighborhood  or 
in  the  thickening  of  the  tissues  about  the  pleura  itself.  There  may  be  pains 
in  the  arm,  trophic  disturbances  and  occasionally  paralysis,  particularly  in  the 
distribution  of  the  lower  cord  in  the  plexus.  (6)  Mental  symptoms.  It  was 
noted,  even  1)y  the  older  writers,  that  consumptives  had  a  peculiarly  hope- 
ful temperament,  and  the  spes  pltthisica  forms  a  curious  characteristic  of  .the 
disease.  Patients  with  extensive  cavities,  high  fever,  and  too  weak  to  move 
will  often  make  plans  for  the  future  and  confidently  expect  to  recover. 

Apart  from  tuberculosis  of  the  brain,  there  is  sometimes  in  chronic  tuber- 
culosis a  form  of  insanity  not  unlike  that  which  occurs  in  the  convalescence 
from  acute  affections. 

(e)  Eyes. — The  conjunctiva  is  rarely  involved.  Iritis  may  occur  and  not 
always  of  the  tuberculous  variety.  The  pupils  are  often  unduly  dilated. 
With  the  common  apical  pleurisy,  irregularity  of  the  pupils  may  be  present. 
Myosis  with  narrowing  of  the  palpebral  fissure  and  retraction  of  the  eye  or 
mydriasis  with  associated  vaso-motor  features  may  be  found  with  small  lesions 
of  the  apex  with  pleural  involvement. 

(/)  Hypertrophy  of  the  mammary  gland  may  occur  in  pulmonary  tuber- 
culosis^ most  commonly  in  males.  It  may  be  only  on  the  affected  side.  It 
is  a  chronic  interstitial,  non-tuberculous  mammitis  (Allot).  Mastitis  adoles- 
centium,  not  very  uncommon,  is  not  necessarily  suggestive  of  pulmonary 
tuberculosis. 

(g)  Genito-urinary  System. — The  urine  presents  no  special  peculiarities 
in  amount  or  constituents.  Fever,  however,  has  a  marked  influence  upon  it. 
Albumin  is  met  with  frequently  and  may  be  associated  with  the  fever,  or  is 
the  result  of  definite  changes  in  the  kidneys.  Tubercle  bacilli  may  be  present 
without  any  disease  of  the  kidney.  Amyloid  disease  of  the  kidneys  is  not 
uncommon.  Its  presence  is  shown  by  albumin  and  tube  casts,  and  sometimes 
by  a  great  increase  in  the  amount  of  urine.  In  other  instances  there  is  dropsy, 
and  the  patients  have  all  the  characteristic  features  of  chronic  nephritis. 

Pus  in  the  urine  may  be  due  to  disease  of  the  bladder  or  of  the  pelves 
of  the  kidneys.  In  some  instances  the  entire  urinary  tract  is  involved.  In 
pulmonary  tuberculosis,  however,  extensive  tuberculous  disease  is  rarely  found 
in  the  urinary  organs.  Bacilli  may  occasionally  be  detected  in  the  urine. 
Haematuria  is  not  a  very  common  symptom.  It  may  occur  occasionally  as  a 
result  of  congestion  of  the  kidneys,  and  pass  off,  leaving  the  urine  albuminous. 
In  other  instances  it  results  from  disease  of  the  pelvis  or  of  the  bladder,  and 
is  associated  either  with  early  tuberculosis  of  the  mucous  membranes  or  more 
commonly  with  ulceration.  In  a  medical  clinic  the  routine  inspection  of  the 
testes  for  tubercle  will  save  two  or  three  mistakes  a  year. 

(/i)  Cutaneous  System. — The  skin  is  often  dry  and  harsh.  Local  tuber- 
cles occasionally  occur  on  the  hands.  There  may  be  pigmentary  staining, 
the  chloasma  pjhthisicorum,  which  is  more  common  when  the  peritoneum  is 
involved.    Upon  the  chest  and  the  back  the  brown  stains  of  pityriasis  versicolor 


206  SPECIFIC  INFECTIOUS  DISEASES 

are  very  frequent.  The  hair  of  the  head  and  beard  may  become  dry  and 
lanky.  The  terminal  phalanges,  in  chronic  cases,  become  clubbed  and  the 
nails  incurvated — the  Hippocratic  fingers.  Landouzy  called  attention  to  a 
curious  bending,  usually  of  the  ring  and  little  fingers,  which  permits  of 
flexion,  but  not  of  extension — a  condition  which  he  calls  camptodactaly.  A 
remarkable  and  unusual  complication  is  general  emphysema,  which  may  re- 
sult from  ulceration  of  an  adherent  lung  or  perforation  of  the  larynx. 

Diagnosis  of  Pulmonary  Tuberculosis 

With  fever,  well-marked  physical  signs  an,d  bacilli  in  the  sputum,  no  dis- 
ease is  more  easily  diagnosed.  Successful  treatment  depends  largely  upon 
early  diagnosis,  and  special  attention  must  be  paid  to  the  obscure,  variable, 
and  uncertain  symptoms  and  signs  of  the  initial  stage.  The  active  crusade 
against  the  disease  has  made  both  the  public  and  the  profession  more  alert, 
and  we  have,  as  so  often  happens,  gone  to  an  extreme,  and  are  apt  to  see 
early  tuberculosis  in  trivial  complaints.  This  is  based  on  the  experience  of 
cases  seen  in  consultation,  and  is  borne  out  by  the  records  of  institutions. 
Hamman,  in  charge  of  the  Phipps  Tuberculosis  Dispensary  of  the  Johns 
Hopkins  Hospital,  makes  the  interesting  confession  that  in  the  early  days, 
when  they  depended  on  slight  physical  signs  and  the  tuberculin  reaction, 
there  were  innumerable  early  cases,  but  with  a  wider  experience  and  greater 
confidence  in  clinical  symptoms  the  outlook  on  these  borderland  cases  has 
changed  completely,  and  they  are  found  to  keep  well  under  the  ordinary 
conditions  of  life,  in  spite  of  the  persistence  of  slight  abnormal  signs.  How 
important  this  feature  of  tuberculosis  work  has  become  is  also  indicated  by 
the  figures  for  the  first  year  at  the  Tuberculosis  Dispensary  of  the  Eadcliffe 
Infirmary.  Of  the  580  cases,  all  sent  by  physicians,  243  were  found  not  to 
be  tuberculous !  One  lesson  from  the  work  of  the  past  few  years  is  that  we 
should  pay  more  attention  to  symptoms  than  to  physical  signs.  The  follow- 
ing are  the  points  of  special  importance  in  the  diagnosis  of  early  cases: 

History. — Tuberculosis  in  the  family,  "Phthisical  habitus,"  unusual  ex- 
posure to  infection,  special  debilitating  circumstances,  as  worry,  grief,  dis- 
sipation, or  a  chronic  illness. 

Symptoms. — Loss  of  weight,  loss  of  strength,  marked  nervous  and  physical 
exhaustion,  and  anaemia,  if  progressive  and  not  otherwise  accounted  for,  are 
of  first  importance.  Fever  is  at  once  a  most  trustworthy  and  the  most  falla- 
cious symptom.  The  thermometer  has  needlessly  condemned  many  patients 
to  the  sanatorium.  Eegard  should  be  had  to  the  points  already  mentioned 
in  speaking  of  the  fever.  In  nervous  persons,  particularly  in  stout,  flabby 
young  girls,  a  temperature  from  99,5°  to  100.5°  may  mean  nothing,  and 
the  rectal  temperature  is  often  very  deceptive :  if  taken  after  exercise  or 
excitement  it  may  be  a  degree  and  a  half  above  normal.  In  the  case  of  a 
flabby,  fat  girl  of  ten,  with  an  anxious  mother,  a  foolish  nurse,  and  an  alarm- 
ist doctor,  for  months  the  rectal  temperature  was  taken  hourly  during  the 
day;  the  child  had  been  in  bed;  there  was  no  cough,  and  the  only  physical 
sign  a  few  rustling  rales  at  one  apex.  The  cure  followed  rapidly  on  the 
breaking  of  the  thermometer  and  getting  rid  of  the  nurse.  In  a  suspicious 
case  a  two-hour  temperature  record  should  be  taken  during  the  day  for  ten 
days  and  the  influence  of  exercise  upon  it  carefully  estimated. 


TUBERCULOSIS  207 

A  cough  is  always  suspicious  in  tiie  young,  more  in  the  winter  than  in 
the  summer,  and  more  in  the  morning  than  at  other  times  in  the  day.  Throat 
and  sinus  conditions  should  he  carefully  excluded,  particularly  the  irritation 
from  cigarette  smoking.  The  spitting  of  blood  has  been  considered  and  its 
importance  in  the  diagnosis  of  tuberculosis  is  universally  recognised.  A  brisk, 
early  hsemoptysis  is  often  helpful,  not  only  for  the  positive  information  it 
gives  us,  but  for  its  useful  moral  effect  on  the  patient.  The  greater  the  care 
with  which  the  bloody  sputum  is  examined  the  more  likely  will  it  be  that 
bacilli  are  found. 

Sputum. — The  patient  should  be  instructed  to  collect  what  is  expectorated, 
particularly  early  in  the  morning,  and  everything  brought  up  should  be  sent. 
The  difficulty  in  private  practice  is  that  it  requires  a  long  series  of  examina- 
tions to  exclude  positively  the  presence  of  tubercle  bacilli.  Time  and  again 
with  suspicious  cases,  or  in  pleurisy  with  effusion,  the  clinical  clerk  has  been 
asked  day  by  day  "Any  bacilli  yet?",  and  in  one  instance  there  were  none 
found  until  the  twentieth  examination !  Of  course,  in  private  practice  this  is 
impossible,  but  it  is  well  to  bear  in  mind  that  one  or  two  negative  examina- 
tions are  not  sufficient.  Various  methods  of  digesting  the  sputum  and  ex- 
amining the  centrifugalized  sediment  are  important  when  few  bacilli  are 
present.  The  antiformin  method  introduced  by  Uhlenhuth  is  simple  and 
often  reveals  tubercle  bacilli  missed  by  an  ordinary  examination. 

Physical  Signs. — These  raise  the  difficulty.  At  present,  so  far  as  the 
lungs  are  concerned,  the  position  resembles  that  of  twenty-five  years  ago  in 
respect  to  the  heart,  when  any  murmur  was  regarded  as  serious.  ISTow,  if  we 
see  the  apex  beat  within  the  nipple  line  and  there  is  no  shortness  of  breath, 
and  the  pulse  is  regular,  we  discount  physical  signs  and  tell  the  patient  to 
live  a  rational  life.  This  is  what  we  should  do  with  many  cases  of  suspected 
early  tuberculosis.  If  the  symptoms  above  dealt  with  are  not  present,  "dis- 
count" the  physical  signs.  These  have  already  been  considered  :  change  in  the 
character  of  the  respiratory  murmur  and  the  presence  of  rales  are  the  two 
most  important,  as  dulness  is  rarely  present  in  early  cases.  Altogether  too 
much  stress  has  been  laid  upon  roughened  or  impure  inspiration  associated 
with  a  few  dry  rales.  Only  upon  repeated  examination  should  a  decision 
be  reached.  Practically,  in  these  early  cases,  we  have  .two  groups — the  one 
with  symptoms  and  no  physical  signs,  and  the  other  with  physical  signs  and 
no  symptoms.     Of  the  two,  the  former  is  of  the  greater  importance. 

In  regard  to  the  extent  of  disease  in  the  lung,  caution  is  advisable  in 
patients  seen  for  the  first  time  with  fever  and  acute  symptoms.  Signs  may 
be  found  over  a  large  area,  but  these  may  be  due  principally  to  an  acute 
intercurrent  infection  and  lessen  materially  in  a  few  days. 

Certain  conditions  may  be  ivrongly  diagnosed  as  tuberculous.  Foreign 
bodies  in  the  bronchi  may  be  a  cause  of  error.  In  patients  with  infection  of 
the  mouth  or  throat,  tonsillitis,  sinusitis,  and  adenoids,  there  may  be  a  per- 
sistent cough  with  bronchitis  and  fever.  Recognition  and  proper  treatment 
of  the  cause  may  result  in  the  prompt  disappearance  of  the  pulmonary  signs. 
In  some  cases  these  non-tuberculous  infections  may  'Cause  some  fibroid  change. 
There  are  certain  non-tuberculous  chronic  bronchial  and  pulmonary  diseases 
which  may  be  mistaken  for  tuberculosis.  Actinomycosis,  streptothrix  infec- 
tion, syphilis,  chronic  bronchitis,  and  bronchiectasis  are  in  this  group.     It  is 


208  SPECIFIC  INFECTIOUS  DISEASES 

a  good  rule  that  with  signs  of  advanced  chronic  disease  in  the  lungs  and  no 
tubercle  bacilli  in  the  sputum,  the  condition  is  not  likely  to  be  tuberculous. 
A  diagnosis  of  tuberculosis  based  on  marked  lung  changes  without  finding 
tubercle  bacilli  in  the  siDutum  is  often  wrong.  Atypical  forms  of  pneumonia, 
disease  of  the  pleura,  especially  apical,  cardiac  disease  and  aneurism  may 
lead  one  astray. 

Specific  Reaction. — Tuberculin  Test. — The  experience  of  observers  in  dif- 
ferent parts  of  the  world  testifies  to  its  value.  But  we  must  remember  the  re- 
action simply  means  that  the  organism  has  developed  a  responsive  activity 
to  tuberculous  infection,  and  by  no  means  indicates  that  an  individual  has 
tuberculous  disease,  in  the  ordinary  sense  of  the  term  "disease."  From  the 
studies  made  at  the  Phipps  Dispensar}^,  the  conjunctival  test  was  found  of 
greater  value  in  indicating  the  presence  of  an  active  lesion.  The  following 
conclusions  reached  by  Hamman  and  his  colleagues  appear  to  be  sane :  "When 
a  patient  fails  to  react  to  either  test,  and  there  are  no  striking  symptoms  or 
physical  signs  of  pulmonary  disease,  we  feel  that  the  negative  diagnosis  has 
received  a  valuable  confirmation.  If  the  eye  reaction  is  positive,  this  is  a 
strong  indication  that  the  patient  has  an  active  tuberculous  focus;  if  symp- 
toms and  signs  are  present  it  is  an  important  aid  in  excluding  other  pulmo- 
nary conditions ;  if  they  are  absent  it  marks  the  patient  as  a  suspect.  *  *  * 
None  of  these  tests  can  replace  in  the  slightest  degree  a  carefully  taken  his- 
tory and  a  well-made  examination.  They  can  never  stand  censor  over  these; 
rather  their  value  must  ultimately  be  adjudged  by  them.  They  are  aids  and 
nothing  more." 

While  the  cutaneous  and  conjunctival  are  the  more  important  as  a  routine 
procedure,  still  in  special  instances  in  which  it  is  desired  to  elicit  a  focal 
reaction  the  subcutaneous  tuberculin  test  is  invaluable. 

Complement  fixation  Test. — This  may  be  of  much  value  in  doubtful  cases 
as  it  is  usually  positive  in  active  tuberculosis.  Several  negative  tests  are  im- 
portant and  it  is  useful  in  deciding  as  to  the  arrest  of  the  disease. 

X-ray  Diagnosis. — In  skilful  hands  the  study  of  cases  with  the  Rontgen 
rays  is  of  great  value.  In  a  normal  case  the  radiogram  shows  a  shadow  be- 
neath and  extending  beyond  the  sternum  due  to  the  contents  of  the  mediasti- 
num. Extending  from  the  mediastinum  and  radiating  out  into  the  various 
lobes  is  a  series  of  shadows  which  may  be  likened  to  the  branches  of  a  tree, 
the  thickest  shadow  being  at  the  hilus  and  thinning  toward  the  periphery 
of  the  lungs.  In  diseased  conditions  changes  are  seen  in  the  hilus,  shadows 
due  to  enlarged  or  calcified  glands  and  to  the  increase  in  the  fibrous  and 
lymphatic  tissues  in  the  mediastinum.  The  pulmonary  vessels  with  their 
contained  blood  play  an  important  part  in  the  production  of  the  shadow. 
The  X-rays  undoubtedly  show  very  early  changes  in  the  lungs,  but  they  can 
not  always  determine  the  etiological  factor.  In  the  majority  of  cases  the 
X-rays  tell  no  more  than  a  careful  clinical  examination,  and  they  do  not 
differentiate  an  active  from  a  healed  lesion.  More  than  any  others,  radio- 
graphers need  the  salutary  lessons  of  the  dead  house  to  correct  their  vision- 
ary interpretations  of  shadows,  particularly  of  those  radiating  from  the  roots  of 
the  lungs. 


TUBERCULOSIS  209 

Concurrent  Infections  and  Diseases  Associated  with  Pulmonary  Tuberculosis 

Concurrent  Infections  in  Pulmonary  Tuberculosis. — It  has  long  been 
known  that  in  pulmonary  tuberculosis  organisms  other  than  the  specific 
bacilli  are  present,  particularly  the  pneumococcus,  Streptococcus  pyogenes, 
the  influenza  bacillus,  Micrococcus  catarrhalis,  and  Staphylococcus  aureus; 
less  frequently  Bacillus  pyocyaneus. 

Many  cases  of  pulmonary  tuberculosis  are  combined  infections;  strepto- 
cocci and  pneumococci  may  be  found  in  the  sputum,  and  the  former  have  been 
isolated  from  the  blood.  Prudden  arrives  at  the  following  conclusions :  The 
pulmonary  lesions  of  tuberculosis  are  subject  to  variations  depending  largely 
on  the  different  modes  of  distribution  of  the  bacilli,  whether  by  the  blood  ves- 
sels or  through  the  bronchi,  and  also  whether  a  concurrent  infection  with 
other  organisms  has  taken  place.  The  pneumonia  complicating  tuberculosis 
may  be  the  direct  result  of  the  tubercle  bacillus  or  its  toxins,  or  it  may  follow 
secondary  infection  with  other  germs,  particularly  the  Streptococcus  pyogenes, 
the  Micrococcus  lanceolatus,  and  the  Staphylococcus  pyogenes.  An  infec- 
tion with  the  influenza  bacillus  or  Micrococcus  catarrhalis  may  be  followed 
by  increased  fever  and  an  aggravation  of  the  general  symptoms.  The  fre- 
quency of  these  secondary  infections  and  the  relative  significance  of  their 
germs  are  not  fully  decided.  It  is  probable  that  in  man  the  effect  of  con- 
tamination with  the  pus  organisms  is  important  in  hastening  necrosis  and 
softening,  and  also  in  the  chronic  cases  they  doubtless  jJroduce  in  large 
amounts  the  toxins  which  are  responsible  for  many  of  the  symptoms.  The 
work  of  Hastings  indicates  that  secondary  infections  are  not  so  important  as 
we  had  thought,  and  a  study  by  Eadcliffe  at  the  King  Edward  Sanatorium 
points  in  this  direction. 

Diseases  Associated  with  Pulmonary  Tuberculosis. — Lobar  pneumonia  is 
a  not  uncommon  cause  of  death.  It  is  met  with  as  a  terminal  dvent  in  the 
chronic  cases  or  may  occur  early,  and  be  difficult  to  distinguish  from  an  acute 
caseous  pneumonia.  The  sputum  in  the  latter  is  rarely  rusty,  while  the  fever 
in  the  former  is  more  continuous  and  higher,  but  in  many  cases  it  is  impossible 
to  differentiate  between  the  two  conditions. 

The   association   of   tuberculosis   and   typhoid  fever  has   been  discussed. 

Erysipelas  not  infrequently  attacks  old  poitrinaires  in  hospital  wards  and 
almshouses.  There  are  instances  in  which  the  attack  seems  to  be  beneficial, 
as  the  cough  lessens  and  the  symptoms  ameliorate.    It  may  prove  fatal. 

Erythema  nodosum. — Some  regard  it  as  a  symptom  of  the  disease,  a 
"tuberculide"  as  the  French  call  it.  Guinea  pigs  have  been  successfully  inocu- 
lated from  the  lesions  but  clinically  we  rarely  see  any  definite  association. 

The  eruptive  fevers,  particularly  measles,  frequently  precede  but  rarely 
occur  in  the  course  of  pulmonary  tuberculosis.  In  the  revaccination  of  a 
tuberculous  subject  the  vesicles  run  a  normal  course. 

Fistula  in  ano,  .so  often  associated  with  pulmonary  tuberculosis,  in  a  ma- 
jority of  such  cases  is  a  tuberculous  process.  Tlie  general  affection  may  pro- 
gress rapidly  after  an  operation. 

Heart  Disease. — Cardiac  hypoplasia  seems  imcommon  in  tuberculosis, 
though  it  was  much  referred  to  by  the  older  writers.  It  was  present  in  only 
3    cases   in   1,7C4   autopsies   on   tuberculous   patients    (Norris).     Rokitansky 


310  SPECIFIC  mFECTIOUS  DISEASES 

taught  that  there  was  an  antagonism  between  valvular  lesions  and  aneurisms 
and  tuberculosis.  All  forms  of  congenital  heart  disease  predispose  to  it,  par- 
ticularly stenosis  of  the  pulmonary  artery.  Mitral  stenosis,  on  the  other 
hand,  has  a  distinctly  inhibitory  influence.  The  two  conditions  are  rarely 
found  associated.  Endocarditis  has  already  been  mentioned.  A  terminal 
acute  tuberculosis,  particularly  of  the  serous  membranes,  is  not  at  all  uncom- 
mon in  cardio-vascular  diseases. 

In  chronic  and  arrested  tuberculosis  arteriosclerosis  and  phlebo-sclerosis 
are  not  uncommon.  Ormerod  noted  30  cases  of  chronic  renal  disease  in  100 
post  mortems. 

Diabetes  mellitus. — Among  31,834  cases  of  tuberculosis  there  were  151 
with  glycosuria,  and  in  1047  autopsies  there  were  6  cases  of  diabetes  mellitus. 
The  association  means  an  unfavorable  prognosis. 

Cancer — Not  often  associated  with  active  tuberculosis,  many  persons  dying 
of  cancer  show  foci  of  old  tuberculosis.  There  does  not  seem  to  be  any  active 
antagonism  between  the  diseases. 

Peculiarities  of  Pulmonary  Tuberculosis  at  the  Extremes  of  Life 

Old  Age. — It  is  remarkable  how  common  tuberculosis  is  in  the  aged,  par- 
ticularly in  institutions.  McLachlan  noted  145  cases  in  which  tuberculosis 
was  the  cause  of  death  in  old  persons  in  Chelsea  Hospital.  All  were  over 
sixty  years  of  age.  The  experience  at  the  Salpetriere  is  the  same.  Laennec 
met  with  a  case  in  a  person  over  ninety-nine  years  of  age. 

At  the  Philadelphia  Hospital,  in  the  bodies  of  aged  persons  sent  over  from 
the  almshouse,  it  was  extremely  common  to  find  either  old  or  recent  tuber- 
culosis. One  patient  died  at  the  age  of  eighty-two  with  extensive  peritoneal 
tuberculosis.  Pulmonary  tuberculosis  in  the  aged  is  usually  latent  and  runs 
a  slow  course.  The  physical  signs  are  often  masked  by  emphysema  and  by 
the  coexisting  chronic  bronchitis.  The  diagnosis  may  depend  entirely  upon 
the  discovery  of  the  bacilli  and  elastic  tissue.  Contrary  to  the  opinion  which 
was  held  some  years  ago,  tuberculosis  is  by  no  means  uncommon  with  senile 
emphysema.  Some  of  the  cases  of  tuberculosis  in  the  aged  are  instances  of 
quiescent  disease  which  may  have  dated  from  an  early  period. 

Infancy. — The  occurrence  of  acute  tuberculosis  in  children  has  been  men- 
tioned, and  also  that  the  disease  is  occasionally  congenital.  The  incidence 
is  variable,  from  13  to  42  per  cent,  in  collected  statistics.  In  Wollstein's 
study  from  the  New  York  Babies'  Hospital,  among  1,131  autopsies  in  chil- 
dren under  four  years  of  age,  in  192  tuberculosis  was  present;  the  percentage 
was:  first  year  1.8  per  cent.,  second  year  11  per  cent.,  third  year  16  per  cent., 
and  fourth  year  23  per  cent.  Chronic  ulcerative  tuberculosis  of  the  lungs 
is  much  more  rare  than  in  adults.  In  Parrot's  series  of  219  cases  in  children 
under  three  years  of  age,  in  only  57  were  cavities  found  in  the  lungs. 

Modes  of  Death  in  Pulmonary  Tuberculosis 

(a)  By  asthenia,  a  gradual  failure  of  the  strength.  The  end  is  usually 
peaceable  and  quiet,  occasionally  disturbed  by  paroxysms  of  cough.  Con- 
sciousness is  often  retained  until  near  the  close. 

(b)  By  asphyxia,  as  in  some  cases  of  acute  miliary  tuberculosis  and  in 


TUBERCULOSIS  211 

acute  pneumonic  tuberculosis.     In  chronic  pulmonary  tuberculosis  it  is  rarely 
seen,  even  when  pneumothorax  developa 

(c)  By  syncope.  This  is  not  common  but  may  happen  in  patients  who  in- 
sist upon  going  about  when  in  the  advanced  stages.  There  may  be,  but  not 
necessarily,  fatty  degeneration  of  the  heart.  Eapid  syncope  may  follow  haemor- 
rhage or  may  be  due  to  thrombosis  or  embolism  of  the  pulmonary  artery,  or  to 
pneumothorax. 

(d)  From  haemorrhage.  The  fatal  bleeding  in  chronic  tuberculosis  is  due 
to  erosion  of  a  large  vessel  or  rupture  of  an  aneurism  in  a  pulmonary  cavity, 
most  commonly  the  latter.  Of  26  cases  analyzed  by  S.  West,  in  11  the  fatal 
haemoptysis  was  due  to  aneurism,  and,  of  35  cases  collected  by  Percy  Kidd, 
aneurism  Avas  present  in  30.  In  a  case  of  Curtin's,  at  the  Philadelphia  Hos- 
pital, the  bleeding  proved  fatal  before  haemoptysis  occurred,  as  the  eroded 
vessel  opened  into  a  capacious  cavity. 

(e)  With  cerebral  symptoms.  Coma  may  be  due  to  meningitis,  less  often 
to  uraemia.  Death  in  convulsions  is  rare.  The  haemorrhagic  pachy-meningitis 
which  occurs  in  some  cases  occasionally  causes  loss  of  consciousness,  but  is 
rarely  a  direct  cause  of  death.  In  one  of  our  cases  death  resulted  from  throm- 
bosis of  the  cerebral  sinuses  with  symptoms  of  meningitis. 

V.  TUBEECULOSIS  OF  THE  ALIMENTARY  CANAL 

(a)  Lips. — Tuberculosis  of  the  lip  is  very  rare.  It  occurs  occasionally  in 
the  form  of  an  ulcer,  either  alone  or  more  commonly  with  laryngeal  or  pul- 
monary disease.  The  ulcer  is  usually  very  sensitive  and  may  be  mistaken  for 
a  chancre  or  an  epithelioma.  The  diagnosis  may  be  made  in  cases  of  doubt 
by  inoculation  or  the  examination  of  a  portion  for  tubercle  bacilli. 

(b)  Tongue. — The  disease  begins  by  an  aggregation  of  small  granular, 
bodies  on  the  edge  or  dorsum.  Ulceration  proceeds,  leaving  an  irregular  sore 
with  a  distinct  but  uneven  margin,  and  a  rough,  often  caseous  base.  The- 
disease  extends  slowly  and  may  form  an  ulcer  of  considerable  size.  It  may 
be  mistaken  for  epithelioma  and  the  tongue  excised.  It  is  rarely  met  with 
except  when  other  organs  are  involved.  The  glands  of  the  angle  of  the  jaw 
are  not  enlarged  and  the  sore  does  not  yield  to  iodide  of  potassium,  which 
are  points  of  distinction  between  the  tuberculous  and  the  syphilitic  ulcer.  In 
doubtful  cases  the  inoculation  test  should  be  made,  or  a  portion  excised  for 
microscopic  examination. 

(c)  Salivary  Glands.— The  salivary  glands  belong  to  that  small  group  of 
organs  of  the  body  which  seem  to  possess  an  immunity;  a  very  few  cases  have 
been  reported. 

(d)  Palate. — Tubercles  of  the  hard  or  soft  palate  nearly  always  follow 
extension  of  the  disease  from  neighboring  parts, 

(e)  Tuberculosis  of  the  Tonsils. — In  7  of  45  consecutive  cases  in  children 
from  three  months  to  fifteen  years,  A.  Latham  demonstrated,  by  inoculation, 
the  presence  of  tuberculosis  of  the  tonsils  either  in  organs  removed  by  oper- 
ation or  post  mortem.  The  observation  is  of  interest  in  connection  with  the 
views  of  Schlenker,  who  claims  that  the  majority  of  the  cases  of  tuberculous 
cervical  glands  result  from  infection  with  tubercle  bacilli  which  gain  admis- 
sion by  way  of  the  tonsil.    A  large  number  of  his  cases  of  tuberculous  cervical 


S12  SPECIFIC  INFECTIOUS  DISEASES 

adenitis  were  definitely  of  a  descending  variety  and  associated  with  tubercu- 
losis of  these  glands.  The  majority  also  had  pulmonary  tuberculosis,  and  he 
regards  surface  infection  of  the  tonsil  by  tuberculous  food  and  sputum  far 
more  common  than  infection  by  way  of  the  circulation.  The  disease  may 
occur  as  a  superficial  ulceration.  More  commonly  there  is  an  infiltration  of 
the  tonsil  with  miliary  tubercles,  which  produces  a  greater  or  less  hypertrophy 
which  it  is  practically  impossible  to  distinguish  from  an  ordinary  enlargement 
of  the  tonsil  without  a  microscopic  examination. 

(f)  Pharynx. — In  extensive  laryngeal  tuberculosis  an  eruption  of  miliary 
granules  on  the  posterior  wall  of  the  pharynx  is  not  very  uncommon.  In 
chronic  tuberculosis  an  ulcerative  pharyngitis,  due  to  extension  of  the  disease 
from  the  epiglottis  and  larynx,  is  a  most  distressing  complication,  rendering 
deglutition  acutely  painful.  Adenoids  of  the  naso-pharynx  may  be  tubercu- 
lous, as  shown  by  Lermoyez.  Macroscopically,  they  do  not  differ  from  the 
ordinary  vegetations  found  in  this  situation. 

(g)  OEsophagus. — A  few  instances  occur  in  the  literature  of  tuberculosis 
of  the  oesophagus.  The  condition  is  a  pathological  curiosity,  except  in  the 
slight  extension  from  the  larynx,  which  is  not  infrequent;  but  in  a  case  de- 
scribed by  Flexner,  the  ulcer  perforated  and  caused  purulent  pleurisy.  The 
condition  has  been  considered  by  Claribel  Cone,  who  described  a  second  case 
from  the  Johns  Hopkins  Hospital  (Bulletin,  Nov.,  1897). 

(h)  Stomach. — Many  cases  are  reported  which  are  doubtful.  In  2,501 
gastric  operations  at  the  Mayo  Clinic  in  four  years  only  one  instance  was  found. 
Broders,  in  a  study  of  the  literature  (1917),  accepts  49  proved  cases,  not 
one  of  which  was  primary.  Ulcer  is  the  most  common  lesion  and  occurred  in 
about  80  per  cent,  of  the  cases.  Miliary  tubercles,  pyloric  stenosis  and  the 
occurrence  of  a  nodule  are  the  other  lesions.  Perforation  of  the  stomach  oc- 
curred six  times  in  the  12  cases  collected  by  Marfan,  thrice  by  a  tuberculous 
gland.  Three  cases  were  described  from  the  Hopkins  clinic  by  Alice  Hamilton 
(J.  H.  H.  Bulletin,  April,  1897). 

(i)  Intestines. — The  tubercles  may  be  (1)  primary  in  the  mucous  mem- 
brane, or  more  commonly  (2)  secondary  to  disease  of  the  lungs,  or  in  rare 
cases  the  affection  may  (3)  pass  from  the  peritoneum. 

(1)  Primary  intestinal  tuberculosis  occurs  most  frequently  in  children, 
in  whom  it  may  be  associated  with  enlargement  and  caseation  of  the  mesen- 
teric glands,  or  with  peritonitis.  There  is  great  discrepancy  in  the  statistics 
on  this  point,  and  the  question  needs  careful  study.  Biedert  gives  16  cases 
in  3,104  instances  of  tuberculosis  in  children.  In  adults  primary  intestinal 
tuberculosis  is  rare,  occurring  in  but  1  instance  in  1,000  autopsies  upon  tuber- 
culous adults  at  the  Munich  Pathological  Institute;  but  now  and  then  cases 
occur  in  which  the  disease  sets  in  with  irregular  diarrhoea,  moderate  fever, 
and  colicky  pains.  In  a  few  cases  haemorrhage  has  been  the  initial  symptom. 
Eegarded  at  first  as  a  chronic  catarrh,  it  is  not  until  the  emaciation  becomes 
marked  or  the  signs  of  disease  appear  in  the  lungs  that  the  true  nature  is  ap- 
parent. Still  more  deceptive  are  the  cases  in  which  the  tuberculosis  begins  in 
the  ccBCum  and  there  are  symptoms  of  appendicitis — tenderness  in  the  right 
iliac  fossa,  constipation,  or  an  irregular  diarrhoea  and  fever.  These  signs  may 
gradually  disappear,  to  recur  in  a  few  weeks  and  still  further  complicate  the 
diagnosis.     Fatal  hasmorrhage  has  occurred.     Perforation  into  the  peritoneum 


TUBEECULOSIS  213 

may  take  place,  a  pericsecal  abscess  may  form,  or  in  very  rare  instances  there 
is  partial  healing  with  great  thickening  of  the  walls  and  narrowing  of  the 
lumen.  Tuberculosis  of  the  appendix  is  found  in  about  one  per  cent,  but 
often  can  only  be  diagnosed  microscopically.  The  symptoms  are  those  of  a 
suppurative  appendicitis. 

(2)  Secondary  involvement  of  the  bowels  is  very  common  in  chronic 
pulmonary  tuberculosis,  e.  g.,  in  566  of  the  1,000  Munich  autopsies  in  tuber- 
culosis. In  only  three  of  these  cases  were  the  lungs  not  involved.  The  lesions 
are  chiefly  in  the  ileum,  caecum,  and  colon.  The  affection  begins  in  the  soli- 
tary and  agminated  glands,  or  on  the  surface  of  or  within  the  mucosa.  The 
caseation  and  necrosis  lead  to  ulceration,  which  may  be  very  extensive  and 
involve  the  greater  portion  of  the  mucosa  of  the  large  and  small  bowels.  In 
the  ileum  the  Peyer's  patches  are  chiefly  involved  and  the  ulcers  may  be  ovoid, 
but  in  the  jejunum  and  colon  they  are  usually  round  or  transverse  to  the 
long  axis.  The  tuberculous  ulcer  has  the  following  characters :  {a)  It  is 
irregular,  rarely  ovoid  or  in  the  long  axis,  more  frequently  girdling  the  bowel ; 
(&)  the  edges  and  base  are  infiltrated,  often  caseous;  (c)  the  sub  mucosa  and 
muscularis  are  usually  involved;  and  {d)  on  the  serosa  may  be  seen  colonies 
of  young  tubercles  or  a  well-marked  tuberculous  lymphangitis.  Perforation 
and  peritonitis  are  not  uncommon  events  in  the  secondary  ulceration.  Sten- 
osis of  the  bowel  from  cicatrization  may  occur ;  the  strictures  may  be  multiple. 

Localized  chronic  tuberculosis  of  the  ileo-ccecal  region  is  of  great  impor- 
tance. The  caecum  may  present  a  chronic  hyperplastic  tuberculosis,  which  not 
uncommonly  extends  into  the  appendix.  As  a  consequence  of  the  changes 
produced  a  definite  tumor-like  mass  is  formed  in  the  right  iliac  fossa.  This 
varies  in  size,  is  usually  elongated  in  a  vertical  direction,  hard,  slightly  mov- 
able, or  bound  down  by  adhesions  and  very  sensitive  to  pressure.  The  tumor 
simulates  more  or  less  closely  a  true  neoplasm  of  this  region,  particularly  car- 
cinoma. The  condition  is  characterized  by  gradual  constriction  of  the  lumen 
of  the  bowel,  periodic  attacks  of  s'evere  pain,  and  alternating  diarrhoea  and 
constipation.  The  extremely  localized  character  of  the  disease  warrants  an  ex- 
ploratory operation,  as  the  results  of  enterectomy  are  favorable.  Of  11  cases 
reported  by  F.  M.  Caird,  7  recovered.  In  a  second  form  of  this  disease,  oc- 
curring less  frequently,  there  is  no  definite  tumor  mass,  but  a  general  indura- 
tion and  thickening  in  the  right  iliac  fossa  similar  to  the  local  changes  pro- 
duced by  a  recurring  appendicitis.  In  this  variety  a  fistula  discharging  faecal 
matter  occasionally  results.  Both  forms  may  be  distinguished  from  the  dis- 
eases they  simulate  by  tbe  finding  of  tubercle  bacilli  in  the  stools  or  in  the 
discharge  from  the  fistula  when  such  exists. 

Tuberculosis  of  the  rectum  has  a  special  interest  in  connection  with  fistula 
in  anOj  which  occurs  in  about  3.5  per  cent,  of  cases  of  pulmonary  disease.  In 
many  instances  the  lesion  has  been  shown  to  be  tuberculous.  It  is  very  rarely 
primary,  but  if  the  tissue  on  removal  contains  bacilli  and  is  infective  the  lungs 
are  almost  invariably  involved.  It  is  a  common  opinion  that  the  pulmonary 
symptoms  progress  rapidly  after  the  fistula  is  cut.  This  may  have  some 
basis  if  the  operation  consists  in  laying  the  tract  open,  and  not  in  a  free 
excision, 

(3)  Extension  from  the  peritoneum  may  excite  tuI)erculous  disease  in  the 
bowels.     The  affection  may  be  primary  in  the  peritoneum  or  extend  from  the 


214  SPECIFIC  I^Tj^ECTIOUS  DISEASES 

tubes  in  women  or  the  mesenteric  glands  in  children.  The  coils  of  intestines 
become  matted  together,  caseous  and  suppurating  foci  develop  between  the 
folds,  and  perforation  may  take  place  between  the  coils. 

VI.      TUBERCULOSIS    OF   THE    LIVER 

This  organ  is  very  constantly  involved  in  (a)  Miliary  tuberculosis.  This 
is  seen  in  acute  generalized  tuberculosis,  though  the  granules  may  be  small 
and  have  to  be  looked  for  very  carefully.  In  chronic  tuberculosis  miliary 
tubercles  are  not  at  all  uncommon  in  the  liver.  (6)  Solitary  tubercle.  Oc- 
casionally large  tuberculous  masses  are  found,  sometimes  associated  with  peri- 
hepatitis, sometimes  with  tuberculous  peritonitis,  and  in  children  with  tuber- 
culous adenitis.  In  a  few  cases  the  masses  are  large,  though  it  is  only  in 
exceptional  cases  that  the  tumor  can  be  felt  through  the  abdominal  wall.  The 
organ  may  be  enlarged  by  numerous  caseous  masses  and  present  the  clinical 
picture  of  an  enlarged  rough  tender  liver  with  jaundice,  as  in  a  case  reported 
by  Thayer.  The  solitary  tubercles  become  infected  with  pus  organisms,  soften, 
and  form  an  abscess,  (c)  Tuberculosis  of  the  bile  ducts.  This  is  the  most 
characteristic  tuberculous  change  in  the  organ,  and  is  not  uncommon.  It 
was  well  described  by  Bristowe  in  1858.  The  liver  is  enlarged,  and  section 
shows  numerous  small  cavities,  which  look  at  first  like  multiple  abscesses  in 
suppurative  pylephlebitis,  but  the  pus  is  bile-stained  and  the  whole  process 
is  a  local  tuberculous  cholangitis,  (d)  Tuberculous  cirrliosis.  With  the 
eruption  of  miliary  tubercles  there  may  be  slight  increase  in  the  connective 
tissue,  which  is  overshadowed  by  the  fatty  change.  In  all  the  chronic  forms 
of  tubercle  in  this  organ  there  may  be  fibrous  overgrowth.  Hanot,  who  de- 
scribed .several  varieties,  states  that  the  condition  may  be  primary.  Prac- 
tically it  is  very  rare,  except  in  connection  with  chronic  tuberculous  peritonitis 
and  perihepatitis,  when  the  organ  may  be  much  deformed  by  a  sclerosis  in- 
volving the  portal  canals  and  the  capsule,  which  may  be  greatly  involved  in  a 
polyserositis. 

Jaundice  is  not  common.  It  is  usually  due  to  some  form  of  tuberculosis 
of  the  liver,  either  solitary  tubercles  or  larger  nodules.  It  is  important  to  note 
its  frequency  in  acute  general  miliary  tuberculosis. 

VIL     TUBERCULOSIS  OF   THE  BRAIN  AND  CORD 

Ttiberculosis  of  the  brain  occurs  as  (a)  an  acute  miliary  infection  caus- 
ing meningitis  and  acute  hydrocephalus;  (b)  as  a  chronic  meningo-encepha- 
litis,  usually  localized,  and  containing  small  nodular  tubercles;  and  (c)  as 
the  so-called  solitary  tubercle.  Between  the  last  two  forms  there  are  all 
gradations,  and  it  is  rare  to  see  the  meninges  uninvolved.  The  acute  variety 
has  already  been  considered.  The  chronic  form,  which  comes  on  slowly  and 
has  the  clinical  characters  of  a  tumor,  is  more  common  in  the  young.  Of  148 
cases  collected  by  Pribram  118  were  under  fifteen  years  of  age.  Other  organs 
are  usually  involved,  particularly  the  lungs,  the  bronchial  glands,  or  the 
bones.  In  rare  instances  no  tubercles  are  found  elsewhere.  They  occur  most 
frequently  in  the  cerebellum ;  next  in  the  cerebrum,  and  then  in  the  pons.  The 
growths  are  often  multiple,  in  100  out  of  183  cases  (Cowers).     They  range 


TUBERCULOSIS  215 

in  size  from  a  pea  to  a  walnut;  large  tumors  occasionally  occur,  and  some- 
times an  entire  lobe  of  the  cerebellum  is  affected.  On  section  the  tubercle 
presents  a  grayish-yellow,  caseous  appearance,  usually  firm  and  hard,  and 
encircled  by  a  translucent,  softer  tissue.  The  centre  of  the  growth  may  be 
semi-diflfluent.  As  in  other  localities  the  tubercle  may  calcify.  The  tumors 
are  as  a  rule  attached  to  the  meninges,  often  to  the  pia  at  the  bottom  of  a 
sulcus  so  that  they  look  imbedded  in  the  brain-substance.  About  the  longitu- 
dinal fissure  there  may  be  an  aggregation  of  the  gro\v'ths,  with  compression 
of  the  sinus,  and  the  formation  of  a  thrombus.  The  tuberculous  tumor  not 
infrequently  excites  acute  meningitis.  In  localized  meningo-encephalitis  the 
pia  is  thickened,  tubercles  are  adherent  to  the  under  surface  and  grow  about 
the  arteries.  It  is  often  combined  with  cerebral  softening  from  interference 
with  the  circulation.  Several  of  the  most  characteristic  instances  are  on  the 
meninges  covering  the  insula.  This  form  may  occur  in  pulmonary  tubercu- 
losis, causing  hemiplegia  or  aphasia  which  may  persist  for  months. 

The  symptoms  of  tuberculous  growths  in  the  brain  are  those  of  tumor, 
and  will  be  considered  in  the  section  on  the  brain. 

In  the  spinal  cord  the  same  forms  are  found.  The  acute  tuberculous  men- 
ingitis is  almost  always  cerebro-spinal.  The  solitary  tubercle  of  the  cord  is 
rare  and  usually  secondary.  Herter  reported  3  cases  and  collected  24  from 
the  literature.     The  symptoms  are  those  of  spinal  tumor  or  meningitis. 

VIII.     TUBERCULOSIS  OF  THE  GENITO-URINARY  SYSTEM 

Eecent  studies,  and  particularly  the  work  of  surgeons  and  gynecologists, 
have  taught  as  the  great  importance  of  tuberculosis  of  this  tract.  Any  part 
of  the  genito-urinary  system  may  be  invaded.  The  successive  involvement  of 
the  organs  may  be  so  rapid  that  unless  the  case  has  been  seen  early  it  may  be 
impossible  to  state  with  any  degree  of  certainty  which  has  been  the  primary 
seat  of  infection.  There  may  be  simultaneous  involvement  of  various  portions 
of  the  tract.  In  tuberculosis  of  the  genito-urinary  system  one  always  has  to 
bear  in  mind  the  possibility  of  latent  disease  elsewhere.  As  Bollinger  says, 
tubercle  bacilli  may  gain  admission  at  some  part  of  the  respiratory  tract 
without  producing  any  lesion  at  the  point  of  entrance,  and  finally  reach  a 
bronchial  gland,  where  they  set  up  a  tuberculous  process  of  extremely  slow 
development  without  producing  any  symptoms.  From  this  point  bacilli  may 
enter  the  blood  stream  and  lodge  in  the  epididymis,  and  produce  nodules  which 
are  readily  discovered  owing  to  the  ease  with  which  this  part  is  examined. 
Such  a  case  might  be  easily  mistaken  for  one  of  primary  genital  tuberculosis, 
whereas  the  true  primary  tuberculous  focus  is  far  distant. 

Infection  of  the  genito-urinary  tract  occurs  in  various  ways: 

(a)  By  Hereditary  Transmission. — It  has  been  met  with  in  the  fetus. 
The  comparative  frequency  of  tuberculosis  of  the  testicle  in  very  young  chil- 
dren suggests  very  strongly  that  the  uro-genital  organs  may  be  involved  as  a 
result  of  direct  transmission  of  the  disease. 

(6)  By  Infection  from  Areas  of  Tuberculosis  Already  Existing. — 
(1)  Hcematogenous. — In  many  cases  uro-genital  tuberculosis  is  found  at 
autopsy  associated  with  disease  of  some  distant  organ,  particularly  the  lungs, 
and  it  would  appear  most  probable  that  in  them  infection  has  been  through 


216  SPECIFIC  INFECTIOUS  DISEASES 

the  blood-vessels.  Jani's  observations,  published  by  Weigert  after  the  author's 
death,  strongly  support  this  theory.  In  studying  sections  of  the  genital  organs 
of  patients  who  died  of  pulmonary  tuberculosis,  he  found  tubercle  bacilli  in 
5  out  of  8  cases  in  the  testicle,  and  in  4  out  of  6  cases  in  the  prostate,  without 
in  any  instance  finding  microscopic  evidences  of  tubercles  in  these  organs.  The 
bacilli  lay,  in  the  testis,  partly  within  and  partly  close  beside  the  cellular  and 
granular  contents  of  the  seminal  tubules,  while  in  the  prostate  they  were 
always   situated   in   the   neighborhood   of   the   glandular   epithelium. 

(2)  Infection  from  the  Peritoneum. — This  source  of  infection,  in  both 
men  and  women,  is  much  more  frequent  than  is  commonly  supposed.  The 
intimate  relationship  between  the  peritoneum  and  bladder  in  both  sexes, 
and  with  the  vesiculee  seminales  and  vasa  deferentia  in  the  male,  allows  a 
ready  way  of  invasion  of  these  organs  by  direct  extension  of  the  disease.  The 
peritoneum  is  a  frequent  source  of  genital  tuberculosis  in  the  female.  iSTo 
doubt  many  cases  of  tuberculosis  of  the  Fallopian  tubes  originate  from  this 
source.  The  fact  that  the  fimbriated  extremity  of  the  tube  is  often  most 
seriously  involved  points  in  this  direction,  although  the  fact  might  be  taken 
as  a  point  in  favor  of  blood  infection,  favored  by  its  greater  vascularity. 
Various  observations  go  to  show  that  the  action  of  the  cilia  lining  the  lumina 
of  the  Fallopian  tubes  tends  to  attract  particles  introduced  into  the  peritoneal 
cavity.  Jani's  observation  is  interesting  in  this  connection,  as  showing  the 
possibility  of  tubercle  bacilli  entering  the  tubes  from  the  peritoneal  cavity 
without  there  being  any  tuberculous  peritonitis.  He  found  typical  tubercle 
bacilli  in  the  lumen,  in  sections  of  a  normal  Fallopian  tube,  in  a  woman 
who  died  of  pulmonary  and  intestinal  tuberculosis.  The  explanation  advanced 
was  that  the  bacilli  made  their  way  through  the  thin  peritoneal  coat  from 
one  of  the  intestinal  ulcers,  thus  reaching  the  peritoneal  cavity,  and  thence' 
were  attracted  into  the  Fallopian  tube  by  the  current  produced  by  the  action 
of  the  cilia  lining  the  lumen.  The  intimate  relationship  between"  tuberculous 
peritonitis  and  tuberculosis  of  the  Fallopian  tubes  is  shown  in  the  fact  that 
the  latter  are  affected  in  from  30  to  40  per  cent,  of  the  cases. 

(3)  Infection  from  Otlier  Organs  ty  Direct  Extension. — The  occurrence 
of  direct  extension  from  the  peritoneum  has  already  been  mentioned.  In 
tuberculous  ulceration  of  the  intestine  or  rectum  adhesions  to  the  bladder 
in  the  male  or  to  the  uterus  and  vagina  in  the  female  may  occur,  with  result- 
ing fistulse  and  a  direct  extension  of  the  disease.  Perirectal  tuberculous 
abscesses-  may  lead  to  secondary  involvement  of  some  portion  of  the  genito- 
urinary tract.  Tuberculosis  of  the  vertebras  may  be  followed  by  tuberculosis 
of  the  kidney  as  a  result  of  direct  extension  of  the  disease. 

(c)  By  Infectiox  from  Without .^ — Whether  uro-genital  tuberculosis 
may  occur  as  a  result  of  the  entrance  of  tubercle  bacilli  into  the  urethra  or 
vagina  is  a  disputed  question.  That  bacilli  gain  admission  to  these  passages 
during  coitus  with  a  person  the  subject  of  uro-genital  tuberculosis,  or  by  the 
use  of  foul  instruments,  seems  quite  probable.  The  possibility  of  genital 
tuberculosis  occurring  in  the  female  as  a  result  of  coitus  with  a  male  the  sub- 
ject of  tuberculosis  in  some  portion  of  the  genito-urinary  system  was  first 
suggested  by  Cohnheim,  who  stated,  however,  that  it  rarely,  if  ever,  occurred. 
In  a  patient  with  intestinal  tuberculosis  the  tubercle  bacilli  might  accidentally 
reach  the  urethra  or  vagina  from  the  rectum. 


TUBERCULOSIS  "  217 

Uro-genital  tuberculosis  is  commonest  between  the  ages  of  twenty  and 
forty  years — that  is,  during  the  period  of  greatest  sexual  activity.  Males  are 
affected  much  more  freciuently  than  females,  the  proportion  being  3  to  1. 
This  great  difference  is  no  doubt  partly  due  to  the  more  intimate  relationship 
between  the  urinary  and  genital  systems  in  the  former  than  in  the  latter. 

Once  the  uro-genital  tract  has  been  invaded  the  disease  is  likely  to  spread 
rapidly,  and  the  method  of  extension  is  an  important  one.  Frequently  there 
is  direct  extension,  as  when  the  bladder  is  involved  secondarily  to  the  kidney 
by  passage  of  the  disease  along  the  ureter,  or  where  the  tuberculous  process 
extends  along  the  vas  deferens  to  the  vesiculas  seminales.  No  doubt  surface 
inoculation  occurs  in  some  instances,  and  to  this  cause  may  be  attributed  a 
certain  percentage  of  cases  of  vesical  and  prostatic  disease  following  tuber- 
culosis of  the  kidney.  Although  this  probability  is  acknowledged,  there  is 
an  element  of  doubt  as  to  the  possibility  of  the  kidney  becoming  affected  sec- 
ondarily to  the  bladder  or  prostate  by  the  direct  passage  of  the  bacilli  up  the 
lumen  of  one  ureter;  for  in  such  a  case  we  have  to  suppose  that  a  non-motile 
bacillus  ascends  against  an  almost  constant  current  of  urine  flowing  in  the 
opposite  direction.  The  lymphatics  may  afford  a  means  for  the  spreading  of 
the  disease,  but  in  the  majority  of  cases  the  infection  is  hsematogenous.  Cys- 
toscopic  examinations  of  the  bladder  not  infrequently  show  the  presence  of 
tubercles  beneath  the  mucous  membrane  before  there  is  any  evidence  of 
superficial  ulceration — a  fact  suggesting  strongly  a  blood  infection. 

The  discovery  of  tubercle  bacilli  in  the  urine  and  the  obtaining  of  tuber- 
culous lesions  in  animals  as  a  result  of  inoculation  with  the  urinary  sedi- 
ment afford  us  the  only  positive  evidence  of  genito-urinary  tuberculosis.  So 
far  there  are  no  authentic  accounts  of  tubercle  bacilli  having  been  found  in  the 
semen  of  men  with  tuberculosis  of  the  testicle  or  vesiculse  seminales.  Owing 
to  the  fact  that  the  smegma  bacillus  has  the  same  staining  reaction  as  the 
tubercle  bacillus,  and,  morphologically  is  practically  indistinguishable  from 
it,  the  greatest  care  must  be  used  in  obtaining  the  specimen  of  urine  for  exam- 
ination, to  eliminate,  if  possible,  all  chances  of  contamination.  One  or  more 
guinea-pigs  should  be  inoculated  with  some  of  the  suspected  urine.  If  tubercle 
bacilli  be  present  the  animals  will  manifest  tuberculous  lesions  in  from  three 
to  five  weeks. 

Tuberculosis  of  the  Kidneys. — In  general  tuberculosis  the  kidneys  fre- 
ciuently present  scattered  miliary  tubercles.  In  pulmonary  tuberculosis  it  is 
common  to  find  a  few  nodules  in  the  substance  of  the  organ,  or  there  may 
be  pyelitis.  In  the  first  17,000  admissions  to  the  medical  wards  of  the  Johns 
Hopkins  Hospital  there  were  1,085  cases  of  tuberculous  infection.  In  17  of 
these  a  clinical  diagnosis  of  renal  tuberculosis  was  made.  Walker  analyzed 
the  first  1,369  autopsies  in  the  same  hospital  and  found  that  78-i  had  tubercu- 
losis in  some  part  of  the  body.  In  all  there  were  61  cases  of  renal  tuberculosis. 
Of  -482  cases  of  pulmonary  tuberculosis  showing  symptoms  during  life,  one 
or  both  kidneys  were  involved  in  23.  There  were  36  cases  of  acute  general 
miliary  tuberculosis,  and  in  every  instance  the  kidney  was  affected.  The 
2  other  cases  of  renal  tuberculosis  occurred  in  patients  with  latent  disease. 
Primary  tuberculosis  of  the  kidneys  is  not  very  rare,  but  in  no  instance  in 
the  above  series  did  Walker  demonstrate  a  primary  infection  in  the  kidney. 
The  tuberculous  process  was  primary  in  some  other  part  of  the  genito-urinary 


218  SPECIFIC  mFECTIOUS  DISEASES 

tract  in  6  cases.  In  a  majority  of  the  cases  the  process  involves  the  pelvis 
and  the  ureter  as  well,  sometimes  the  bladder  and  prostate.  It  may  be 
difficult  to  say  in  advanced  cases  whether  the  disease  has  started  in  the 
bladder,  prostate,  or  vesicles,  or  whether  it  started  in  the  kidneys  and  pro- 
ceeded downward.  In  a  majority  of  cases  the  infection  is  through  the  blood. 
Walker  thinks  that  a  hsematogenous  infection  takes  place  in  90  per  cent,  of 
the  cases,  and  that  this  is  the  channel  of  infection  in  the  majority  of  instances 
where  renal  follows  vesical  tuberculosis  rather  than  along  the  ureter.  One 
kidney  alone  may  be  involved,  and  the  disease  creeps  down  the  ureter  and 
may  only  extend  a  few  millimetres  on  the  vesical  mucosa.  A  man  with  aortic 
insufficiency,  who  had  no  lesions  in  the  lungs,  presented  a  localized  patch  in' 
the  pelvis  of  the  kidney,  involving  a  pyramid,  while  the  ureter,  5  cm.  from  tho 
bladder  and  at  its  orifice,  was  thickened  and  tuberculous.  The  prostate 
showed  an  area  of  caseation.  The  process  is  most  common  between  twenty 
and  thirty  years  of  age,  but  it  may  occur  at  the  extremes  of  age.  In  a  series 
of  386  cases  collected  by  Walker  in  which  the  sex  was  stated  182  of  the 
patients  were  males  and  .20-1  females.  In  the  earliest  stage,  which  may  be 
met  with  accidentally,  the  disease  is  seen  to  begin  in  the  pyramids  and  calyces. 
Xecrosis  and  caseation  proceed  rapidty,  and  the  colonies  of  tubercles  start 
throughout  the  pyramids  aud  extend  upon  the  mucous  membrane  of  the  pel- 
vis. As  a  rule,  from  the  outset  it  is  a  tuberculous  pyo-nephrosis.  It  may 
be  confined  to  one  kidney,  or  progress  more  extensively  in  one  than  in  the 
other.  At  autopsy  both  organs  are  usually  found  enlarged.  In  only  3  of 
the  61  autopsies  previously  referred  to  was  the  disease  unilateral.  One  kidney 
may  be  completely  destroyed  and  converted  into  a  series  of  cysts  containing 
cheesy  substance — a  form  of  kidney  which  the  older  writers  called  scrofulous. 
In  the  putty-like  contents  of  these  cysts  lime  salts  may  be  deposited.  In  other 
instances  the  walls  of  the  pelvis  are  thickened  and  cheesy,  the  pyramids  eroded, 
and  caseous  nodules  are  scattered  through  the  organ,  even  to  the  capsule, 
which  may  be  thickened  and  adherent.  The  other  organ  is  usually  less  af- 
fected, and  shows  only  pyelitis  or  a  superficial  necrosis  of  one  or  two  pyramids. 
The  ureters  are  usually  thickened  and  the  mucous  membrane  ulcerated  and 
caseous.  Involvement  of  the  bladder,  vesiculte  seminales,  and  testes  is  not  un- 
common in  males. 

The  SYMPTOMS  are  those  of  pyelitis.  The  urine  may  be  purulent  for 
years,  and  there  may  be  little  or  no  distress.  Even  before  the  bladder  be- 
comes involved  micturition  is  frequent,  and  many  instances  are  mistaken 
for  cystitis.  The  frequent  micturition  is  in  part  due  to  an  initial  polyuria, 
in  part  to  reflex  irritation,  but  chiefly  to  a  non-tuberculous  inflammation 
over  the  trigone  of  the  bladder.  It  is  usually  the  earliest  and  most  constant 
symptom.  Hcematuria,  of  a  mild  grade,  occurs  at  some  time  during  the 
course  in  the  majority  of  cases.  Dull,  aching  pain  in  the  lumbar  region  on 
one  side  is  frequently  complained  of  and  may  he  the  first  symptom.  The 
condition  is  for  many  years  compatible  with  fair  health.  The  curability  is 
shown  by  the  accidental  discovery  of  the  so-called  scrofulous  kidney,  converted 
into  cysts  containing  a  putty-like  substance.  In  cases  in  which  the  disease 
becomes  advanced  and  both  organs  are  affected  constitutional  symptoms  are 
more  marked.  There  is  irregular  fever,  with  chills  and  loss  of  weight  and 
strength.     General  tuberculosis  is  common  and  the  lungs  are  usually  involved. 


TUBERCULOSIS  219 

In  a  case  at  the  Montreal  General  Hospital  a  cyst  perforated  and  caused  fatal 
peritonitis. 

Examination  may  detect  special  tenderness  on  one  side,  or  the  kidney 
may  be  palpable  in  front  on  deep  pressure;  but  tuberculous  pyelo-nephritis 
seldom  causes  a  large  tumor.  Occasionally  the  pelvis  becomes  enormously 
distended;  but  this  is  rare  in  comparison  with  its  frequency  in  calculous 
pyelitis.  The  urine  presents  changes  similar  to  those  of  ordinary  calculous 
pyelitis — pus-cells,  epithelium,  and  occasionally  definite  caseous  masses.  It 
is  nearly  always  acid  in  reaction..  Albumin  is  present  but  casts  are  rare. 
Tubercle  bacilli  may  be  demonstrated  and  should  be  searched  for  when  there 
are  any  unusual  sensations.    There  may  be  "showers"  of  bacilli  at  these  times. 

Diagnosis. — To  distinguish  the  condition  from  calculous  pyelitis  is  often 
difficult.  Hsemorrhage  may  be  present  in  both,  though  not  nearly  so  fre- 
quently in  the  tuberculous  disease.  The  appearance  of  the  ureteral  orifices 
on  cystoscopic  examination  is  often  characteristic.  The  diagnosis  rests  on : 
(1)  The  detection  of  some  focus  of  tuberculosis,  as  in  the  testis;  (2)  the 
presence  of  tubercle  bacilli  in  the  sediment;  (3)  the  use  of  tuberculin;  and 
(-t)  cystoscopic  examination  and  catheterization  of  the  ureters. 

Tuberculosis  of  the  suprarenal  glands  will  be  considered  under  Addison's 
Disease. 

Tuberculosis  of  the  Ureter  and  Bladder. — This  rarely  occurs  as  a  primary 
affection,  but  is  nearly  always  secondary  to  involvement  of  other  parts,  par- 
ticularly the  pelvis  of  the  kidney.  Protracted  cystitis  which  has  come  on  with- 
out apparent  cause  is  always  suggestive  of  tuberculosis.  The  renal  regions,  the 
testes,  the  seminal  vesicles,  and  the  prostate  should  be  examined  with  care. 
It  may  follow  a  pyelo-nephritis,  or  be  associated  with  primary  disease  of  the 
prostate  or  vesiculae  seminales.  Primary  tuberculosis  of  the  posterior  wall 
of  the  bladder  may  simulate  stone. 

Tuberculosis  of  the  Prostate  and  Vesiculae  Seminales. — The  prostate  is  fre- 
quently involved  in  tuberculosis  of  the  uro-genital  tract.  In  Krzyincki's 
cases,  of  15  males  the  prostate  was  involved  in  14  and  the  vesicul^  seminales 
in  11.  In  Orth's  cases  the  prostate  was  involved  in  18  of  the  37  cases  in 
males.  These  parts  are  much  more  frequently  involved  than  ordinary  post 
mortem  statistics  indicate.  The  prostatic  lobes  are  felt  to  be  occupied  by  hard 
nodules  varying  in  size  from  a  pea  to  a  bean.  There  is  great  irritability  of  the 
bladder,  and  agonizing  pain  in  catheterization.  An  extremely  rare  lesion  is 
primary  urethral  tuberculosis,  which  may  simulate  stricture. 

Tuberculosis  of  the  Testes. — This  somewhat  common  affection  may  be 
primary,  or,  more  frequently,  is  secondary  to  tuberculous  disease  elsewhere. 
Many  cases  occur  before  the  second  year,  and  it  is  stated  to  have  been  met 
with  in  the  fetus.  In  infants  it  is  serious  and  usually  associated  with  tubercu- 
lous disease  in  other  parts.  In  9  cases  reported  by  Hutinel  and  Deschamps, 
in  every  one  there  was  a  general  affection.  In  20  cases  reported  by  Jullien,  6 
were  under  one  year,  and  6  between  one  and  two  years  old.  In  5  of  the  cases 
both  testicles  were  affected.  Koplik  holds  that  most  of  the  instances  of 
this  kind  are  congenital,  in  Baumgarten's  sense.  In  the  adult  the  tubercles 
begin  within  the  substance  of  the  gland,  but  in  children  the  tunica  albuginea 
is  first  affected.  The  tubercle  does  not  always  undergo  caseation,  but  it  may 
present  a  number  of  embryonic  cells,  not  unlike  a  sarcoma. 


220  .  SPECIFIC  IJSTFECTIOUS  DISEASES 

Tubercle  of  the  testes  is  most  likely  to  be  confomided  with  syphilis.  In 
the  latter  the  body  of  the  organ  is  most  often  affected,  there  is  less  pain,  and 
the  outlines  of  the  growth  are  more  nodular  and  irregular.  In- obscure  peri- 
toneal disease  the  detection  of  tubercle  in  a  testis  has  not  infrequently  led  to 
a  correct  diagnosis.  The  association  of  the  two  conditions  is  not  uncom- 
mon. The  lesion  in  the  testis  may  heal  completely  or  the  disease  may  become 
generalized.  General  infection  has  followed  ojDeration.  Too  much  stress  can 
not  be  laid  on  the  importance  of  a  routine  examination  of  the  testes. 

Tuberculosis  of  the  Fallopian  Tubes,  Ovaries,  and  Uterus. — The  Fallopian 
tubes  are  by  far  the  most  frequent  seat  of  genital  tuberculosis.  The  disease 
may  be  primary  and  produce  a  most  characteristic  form  of  salpingitis,  in 
which  the  tubes  are  enlarged,  the  walls  thickened  and  infiltrated,  and  the  con- 
tents cheesy.  Adhesion  takes  place  between  the  fimbrise  and  the  ovaries,  or 
the  uterus  may  be  invaded.  The  condition  is  usually  bilateral.  It  may  occur 
in  young  children.  Although,  as  a  rule,  very  evident  to  the  naked  eye,  there 
are  specimens  resembling  ordinary  salpingitis,  which  show  on  microscopic 
examination  numerous  miliary  tubercles  (Welch  and  Williams).  Tuberculous 
salpingitis  may  cause  serious  local  disease  with  abscess  formation,  and  it  may 
be  the  starting-point  of  peritonitis.  Tuberculosis  of  the  ovary  is  always 
secondary.  There  may  be  an  eruption  of  tubercles  over  the  surface  in  an 
extensive  involvement  of  the  stroma  with  abscess  formation. 

Tuberculosis  of  the  uterus  is  very  rare.  Only  four  examples  have  come 
under  our  observation,  all  in  connection  with  pulmonary  tuberculosis.  It  may 
be  primary.  The  mucosa  of  the  fundus  is  thickened  and  caseous,  and  tubercles 
may  be  seen  in  the  muscular  tissue.  Occasionally  the  process  extends  to  the 
vagina.  Tuberculosis  of  the  placenta  is  more  common  than  has  been  sup- 
posed. Of  20  placentas  from  tuberculous  women,  9  were  affected;  5  of  these 
were  from  cases  of  advanced  disease  of  the  lung.  The  lesions  are  easily 
overlooked. 

IX.     TUBEECULOSIS   OF   THE   ]\rAiniARY  GLAND 

There  may  be.  solitary  or  disseminated  nodules,  a  sclerosing  mastitis  or 
caseation  with  abscess  formation.  The  disease  is  most  common  between  the 
fortieth  and  sixtieth  years.  The  breast  is  frequently  fistulous,  unevenly  in- 
durated, and  the  nipple  is  retracted.  The  fistulse  and  ulcers  present  a  charac- 
teristic tuberculous  aspect.  There  is  also  a  cold  tuberculous  abscess  of  the 
breast.  The  axillary  glands  are  affected  in  about  two-thirds  of  the  cases.  The 
disease  runs  a  chronic  course  of  months  or  years.  The  diagnosis  can  be  made 
by  the  general  appearance  of  the  fistula  and  ulcers,  and  by  the  existence  of 
tubercle  bacilli.  The  prognosis  is  not  serious,  if  total  eradication  of  the  dis- 
ease be  possible. 

In  1836  Bedor  described  an  hypertrophy  of  the  breast  in  the  subjects  of 
pulmonary  tuljerculosis.  As  a  rule,  if  one  gland  is  involved,  usually  on  the 
side  of  the  affected  lung,  as  already  mentioned,  the  condition  is  one  of  chronic 
interstitial  mammitis  and  is  not  tuberculous. 


TUBERCULOSIS  221 


X.     TUBEECULOSIS  OF  THE  CIRCULATORY  SYSTEM 

Myocardium. — Scattered  miliary  tubercles  are  sometimes  met  with  in  the 
acute  disease.  Larger  caseous  tubercles  are  excessively  rare.  A.  Moser  found 
46  cases  on  record.  There  is  also  a  sclerotic  tuberculous  myocarditis.  The 
infection  often  passes  from  a  mediastinal  gland. 

Endocardium. — In  216  autopsies  in  cases  of  chronic  tuberculosis  endocar- 
ditis was  found  in  12.  It  was  present  in  only  151  among  more  than  11,000 
autopsies  on  tuberculous  cases  (G.  W.  ISTorris).  As  a  rule,  it  is  a  secondary 
form,  the  result  of  a  mixed  infection,  so  common  in  pulmonary  tuberculosis. 
A  true  tuberculous  endocarditis  does,  however,  occur,  directly  dependent  upon 
infection  with  the  bacillus  of  Koch.  As  a  rule,  it  is  a  vegetative  endocarditis, 
not  to  be  distinguished  from  that  caused  by  a  streptococcus  or  staphylococcus. 
In  rare  cases,  however,  caseous  tubercles  develop. 

Arteries. — Primary  tuberculosis  of  the  larger  blood-vessels  is  very  rare 
and  is  usually  the  result  of  invasion  from  without.  The  disease  may,  how- 
ever, occur  in  a  large  artery  and  not  result  from  external  invasion.  In  a  case 
of  chronic  tuberculosis  Flexner  found  a  fresh  tuberculous  growth  in  the  aorta, 
which  had  no  connection  with  cheesy  masses  outside  the  vessel.  Simmitsky 
collected  18  cases  of  tuberculosis  of  the  aorta. 

In  the  lungs  and  other  organs  attacked  by  tuberculosis  the  arteries  are 
involved  in  an  acute  infiltration  which  usually  leads  to  thrombosis,  or  tuber- 
cles may  develop  in  the  walls  and  proceed  to  caseation  and  softening,  fre- 
quently with  a  resulting  hemorrhage.  By  extension  into  vessels,  particu- 
larly veins,  the  bacilli  are  widely  distributed  with  the  production  of  miliary 
tuberculosis. 

XI.     THE  PROGNOSIS  IN  TUBERCULOSIS 

The  parable  of  the  sower  already  referred  to  expresses  better  than  in  any 
other  way  the  question  of  individual  predisposition.  There  are  five  groups 
of  cases  of  tuberculous  infection.  L  Those  who  become  infected  and  recover 
spontaneously  without  knowing  they  have  been  infected.  2.  Mild  infections 
which  produce  slight  symptoms,  recovery  following  after  a  few  months  of 
change  of  air  or  special  treatment.  3.  Cases  with  well-marked  signs  of  lung 
disease  in  which  thorough  treatment  is  followed  by  complete  recovery.  4. 
Cases  with  extensive  local  disease  and  cavity  formation  in  which  arrest  takes 
place  and  the  patients  live  for  many  years.  5.  The  cases  in  which  the  infec- 
tion is  of  such  a  type  that  death  follows  no  matter  what  is  done.  The  late 
Austin  Flint,  facile  princeps  among  American  students  of  the  disease,  called 
attention  to  the  self-limitation  and  intrinsic  tendency  to  recovery  in  pulmonary 
tuberculosis.  This  natural  tendency  to  cure  is  still  more  strikingly  shown 
in  lymphatic  and  bone  tuberculosis. 

The  following  may  be  considered  favorable  circumstances  in  the  prognosis 
of  pulmonary  tuberculosis :  An  early  diagnosis,  a  good  family  history,  previous 
good  health,  a  strong  digestion,  a  suitable  environment,  and  an  insidious 
onset,  without  high  fever,  and  without  extensive  pneumonic  consolidation. 
Cases  beginning  with  pleurisy  seem  to  run  a  more  protracted  and  more  favor- 
able course.  Repeated  attacks  of  hemoptysis  are  unfavorable.  When  well 
established  the  course  of  tuberculosis  in  any  organ  is  marked  by  intervals  of 


222  SPECIFIC  I>s^FECT10US  DISEASES 

weeks  or  months  in  which  the  fever  lessens,  the  symptoms  subside,  and  there  is 
improvement  in  the  general  health. 

In  pulmonary  cases  the  duration  is  extremely  variable.  Laennec  placed 
the  average  duration  at  two  years,  and  for  the  majority  of  cases  this  is  per- 
haps a  correct  estimate.  Pollock's  large  statistics  of  over  3,500  cases  show  a 
mean  duration  of  the  disease  of  over  two  years  and  a  half.  Williams's  analysis 
of  1,000  cases  in  private  practice  shows  a  much  more  protracted  course,  as  the 
average  duration  was  over  seven  years. 

Tuberculosis  and  Marriage. — Under  the  subject  of  prognosis  comes  the 
question  of  the  marriage  of  persons  who  have  had  tuberculosis,  or  in  whose 
family  the  disease  prevails.     The  following  brief  statements  may  be  made: 

(a)  Subjects  with  healed  lymphatic  or  bone  tuberculosis  marry  with  per- 
sonal impunity  and  may  beget  healthy  children.  In  such  families  adenitis, 
caries  of  the  bone,  arthritis,  cerebral  and  pulmonary  tuberculosis  are  more 
common.    The  risks,  however,  are  such  as  may  properly  be  taken. 

(&)  The  question  of  marriage  of  a  person  who  has  arrested  or  cured  lung 
tuberculosis  is  more  difficult  to  decide.  In  a  male  the  personal  risk  is  not 
so  great;  and  when  the  health  and  strength  are  good,  the  external  environ- 
ment favorable,  and  the  family  history  not  extremely  bad,  the  experiment — 
for  it  is  such — is  often  successful,  and  many  healthy  and  happy  families  are 
begotten  under  these  circumstances.  In  women  the  question  is  complicated 
with  that  of  child-bearing,  which  increases  the  risks  enormously.  With  a 
localized  lesion,  absence  of  hereditary  taint,  good  physique,  and  favorable 
environment  marriage  might  be  permitted.  When  tuberculosis  has  existed  in 
a  girl  whose  family  history  is  bad,  and  whose  physique  is  below  the  standard, 
the  physician   should,   if  possible,  place  his  veto  upon   marriage. 

(c)  With  existing  disease,  fever,  bacilli,  etc.,  marriage  should  be  prohib- 
ited. Pregnancy  usually  hastens  the  process,  though  it  may  be  held  in  abey- 
ance. After  parturition  the  disease  advances  rapidly.  There  is  much  truth, 
indeed,  in  the  remark  of  Dubois :  "^If  a  woman  threatened  with  phthisis  mar- 
ries, she  may  bear  the  first  accouchement  well;  a  second,  with  difficulty;  a 
third,  never.''    Conception  may  occur  in  an  advanced  stage  of  the  disease. 

XII.   PROPHYLAXIS  IN  TUBERCULOSIS 

General. — Among  the  more  important  measures  may  be  mentioned  the 
following:  First,  education  of  the  public.  Much  has  been  done  in  this  direc- 
tion by  the  antituberculosis  crusade,  which  has  resulted  in  the  formation  of 
many  active  societies,  and  has  stimulated  widespread  interest  in  the  disease. 
Secondly,  the  placing  of  pulmonary  tuberculosis  on  the  list  of  reportable  dis- 
eases. This  gives  the  board  of  health  control  of  the  situation,  and,  as  the 
New  York  experience  has  demonstrated,  is  perhaps  the  most  helpful  measure 
in  the  prophylaxis.  Thirdlij,  the  improved  sanitary  condition  of  the  poor, 
particularly  with  reference  to  housing.  Fourthly,  direct  preventive  meas- 
ures, such  as  the  enactment  of  laws  against  spitting  in  public,  the  proper 
disinfection  and  cleaning  of  the  rooms  and  houses  which  have  been  occupied 
by  tuberculous  patients,  and  the  careful  inspection  of  dairies  and  abattoirs. 
Fifthly,  in  the  large  cities,  organization  of  sanatoria  and  hospitals  for  early 
curable  and  late  incurable  cases,  and  the  establishment  of  separate  dispen- 


TUBERCULOSIS  223 

saries  with  a  system  of  visiting  the  patients  at  their  homes  by  specially 
assigned  nurses.  Lastly,  the  care  of  the  sputum  of  the  tuberculous.  Thorough 
boiling  or  putting  it  into  the  fire  is  sufficient.  In  hospitals  it  is  well  to  have 
printed  directions  as  to  the  care  of  the  sputum,  and  also  printed  cards  for  out- 
patients, giving  the  most  important  rules.  It  should  be  explained  to  the 
patient  that  the  only  risk,  practically,  is  from  this  source. 

Individual. — Individual  prophylaxis  in  the  case  of  delicate  children  is 
most  important.  An  infant  born  of  tuberculous  parents,  or  of  a  family  in 
which  tuberculosis  prevails,  should  be  brought  up  with  the  greatest  care  and 
guarded  most  particularly  against  infections  of  all  kinds.  Special  attention 
should  be  given  to  the  throat  and  nose,  and  on  the  first  indication  of  mouth- 
breathing,  or  any  obstruction  of  the  naso-pharynx,  a  careful  examination 
should  be  made  for  adenoid  vegetations.  The  child  should  be  clad  in  flannel 
and  live  in  the  open  air  as  much  as  possible,  avoiding  close  rooms.  It  is  a 
good  practice  to  sponge  the  throat  and  chest  night  and  morning  with  cold 
water.  Special  attention  should  be  paid  to  diet  and  to  the  mode  of  feeding. 
The  meals  should  be  at  regular  hours  and  the  food  plain  and  substantial. 
From  the  outset  the  child  should  be  encouraged  to  drink  freely  of  milk.  Un- 
fortunately, in  these  cases  there  seems  to  be  an  aversion  to  fats  of  all  kinds. 
As  the  child  grows  older,  systematically  regulated  exercise  or  a  course  of 
pulmonary  gymnastics  may  be  taken.  In  the  choice  of  an  occupation  prefer- 
ence should  be  given  to  an  out-of-door  life.  Families  with  a  marked  pre- 
disposition to  tuberculosis  should,  if  possible,  reside  in  an  equable  climate. 

The  examination  of  children  who  have  been  in  contact  with  tuberculous 
individuals  is  important.  Four  groups  of  suspects  come  to  tuberculosis  dis- 
pensaries: (1)  The  under-fed.  ansemic,  badly  developed  child,  without  local 
lesions;  the  question  is  one  of  malnutrition.  (2)  Cases  of  thymo-lymphatism 
usually  having  adenoids  and  enlarged  tonsils.  These  children  may  not  be 
anaemic,  but  they  have  stunted,  badly  formed  chests,  and  the  superficial  lymph 
glands  may  be  enlarged.  (3)  Children  with  obviously  enlarged  lymph  glands, 
usually  cervical ;  it  may  not  be  easy  to  determine  whether  the  adenopathy  is 
due  to  throat  infection  or  bad  teeth,  or  whether  it  is  actually  tuberculosis.  (4) 
Children  with  physical  signs  in  the  chest  pointing  to  definite  local  lesion,  the 
tuberculous  nature  of  which  may  not  at  first  be  easy  to  determine. 

The  trifling  ailments  of  children  should  be  carefully  watched.  In  the 
convalescence  from  the  fevers  which  so  frequently  prove  dangerous  the  great- 
est caution  should  be  exercised  to  prevent  catching  cold.  An  open  air  life, 
a  generous  diet,  especially  in  fats,  and  iron  or  arsenic  if  there  is  anaemia,  are 
important  aids.  Care  of  the  throat  in  these  children  is  important;  enlarged 
tonsils  and  adenoids  should  be  removed. 

XIII.     TREATMENT   OF   TUBERCULOSIS  i 

The  Natural  or  Spontaneous  Cure. — The  spontaneous  healing  of  local 
tuberculosis  is  an  every-day  afl^air.  A  majority  of  those  infected  never  have 
the  disease,  i.  e.,  they  recover  without  symptoms,  without  the  slight  lesion 
having  disturbed  the  health.  Many  cases  of  adenitis  and  disease  of  the  bone 
or  of  the  joints  terminate  favorably.  The  healing  of  pulmonary  tuberculosis 
is  shown  clinically  by  the  recovery  of  patients  in  whose  sputum  elastic  tissue 


224  SPECIFIC  INFECTIOUS  DISEASES 

and  bacilli  have  been  found;  anatomically,  by  the  presence  of  lesions  in  a^l 
stages  of  repair.  In  the  granulation  products  and  associated  pneumonia  a 
scar-tissue  is  formed,  while  the  smaller  caseous  areas  become  impregnated  with 
lime  salts.  To  such  conditions  alone  should  the  term  healing  be  applied. 
When  the  fibroid  change  encapsulates  but  does  not  involve  the  entire  tubercu- 
lous tissue^  the  tubercle  may  be  termed  involuted  or  quiescent,  but  is  not 
destroyed.  When  cavities  of  any  size  have  formed,  healing,  in  the  proper 
sense  of  the  term,  does  not  occur.  We  have  yet  to  see  a  specimen  which  would 
indicate  that  a  vomica  had .  cicatrized.  Cavities  may  be  greatly  reduced  in 
size: — indeed,  an  entire  series  of  them  may  be  so  contracted  by  sclerosis  of  the 
tissue  about  them  that  an  upper  lobe,  in  which  this  process  most  frequently 
occurs,  may  be  reduced  to  a  third  of  its  ordinary  dimensions.  Laennec  under- 
stood thoroughly  this  natural  process  of  cure  in  tuberculosis,  and  recognized 
the  frequency  with  which  old  tuberculous  lesions  occurred  in  the  lungs.  He 
described  cicatrices  completes  and  cicatrices  jistuleuses,  the  latter  being  the 
shrunken  cavities  communicating  with  the  bronchi;  and  remarked  that,  as 
tubercles  growing  in  the  glands,  which  are  called  scrofula,  often  heal,  wliy 
should  not  the  same  take  place  in  the  lungs  ? 

There  is  an  old  German  axiom,  Jedermann  hat  am  Ende  ein  hischen 
Tuberculose,  a  statement  partly  borne  out  by  the  statistics  showing  the  pro- 
portions of  cases  in  persons  dying  of  all  disease  in  whom  quiescent  or  tuber- 
culous lesions  are  found  in  the  lungs.  We  find  at  the  apices  the  following 
conditions,  which  have  been  held  to  signify  healed  tuberculous  processes ; 
(a.)  Thickening  of  the  pleura,  usually  at  the  posterior  surface  of  the  ape\', 
with  subadjacent  induration  for  a  distance  of  a  few  millimetres.  This  has. 
perhaps,  no  greater  significance  than  the  milky  patch  on  the  pericardium. 
(&)  Puckered  cicatrices  at  the  apex,  depressing  the  pleura,  and  on  section 
showing  a  large  pigmented,  fibrous  scar.  The  bronchioles  in  the  neighborhood 
may  be  dilated,  but  there  are  neither  tubercles  nor  cheesy  masses.  This  may 
sometimes,  but  not  always,  indicate  a  healed  tuberculous  lesion,  (c)  Puck- 
ered cicatrices  with  cheesy  or  cretaceous  nodules,  and  with  scattered  tubercles 
in  the  vicinity,  {d)  The  cicatrices  fistuleuses  of  Laennec,  in  which  the  fibroid 
puckering  has  reduced  the  size  of  one  or  more  cavities  which  communicate 
directly  with  the  bronchi. 

General  Measures. — The  cure  of  tuberculosis  is  a  question  of  nutrition; 
digestion  and  assimilation  control  the  situation;  as  a  rule,  make  a  patient 
grow  fat  and  strong,  and  the  local  disease  may  be  left  to  tak^  care  of  itself. 
There  are  three  indications :  First,  to  place  the  patient  in  surroundings  most 
favorable  for  the  maintenance  of  a  maximum  degree  of  nutrition;  second,  to 
take  such  measures  as,  in  a  local  or  general  way,  influence  the  tuberculous 
processes;  third,  to  alleviate  symptoms.  The  importance  of  rest  must  always 
be  kept  in  mind  and  the  amount  of  exertion  allowed  carefully  ordered. 

Open-air  Treatment. — The  value  of  fresh  air  and  out-of-door  life  is  well 
illustrated  by  an  experiment  of  Trudeau.  Inoculated  rabbits  confined  in  a 
dark,  damp  place  rapidly  succumbed,  'while  others,  allowed  to  run  wild,  either 
recovered  or  show  slight  lesions.  It  is  the  same  in  human  tuberculosis.  A 
patient  confined  to  the  house — particularly  in  the  close,  overheated,  stuffy 
dwellings  of  the  poor,  or  treated  in  a  hospital  ward — is  in  a  position  analogous 
to  that  of  the  rabbit  confined  to  a  *hutch  in  the  cellar ;  whereas  a  patient  living 


TUBEECULOSIS  225 

in  the  fresh  air  or  sunshine  for  the  greater  part  of  the  day  has  chances 
comparable  to  those  of  the  ra1)bit  running  wild. 

The  open-air  treatment  of  tul:)erculosis  may  be  carried  out  at  home,  by 
change  of  residence  to  a  suitable  climate,  or  in  a  sanatorium. 

(a)  At  Home. — In  a  majority  of  all  cases  the  patient  has  to  be  cared  for 
in  his  own  home,  and,  if  in  the  city,  under  very  disadvantageous  circumstances. 
Much,  however,  may  be  done  even  in  cities  to  promote  arrest  by  insisting  upon 
systematic  treatment.  How  much  may  be  done  by  care  and  instruction  is 
shown  by  the  success  of  J.  H.  Pratt's  tuberculosis  classes.  As  not  five  per 
cent,  of  the  patients  can  be  dealt  with  in  sanatoria,  it  is  surprising  and  grati- 
fying to  see  how  successful  the  home  treatment  may  be.  Even  in  cities  the 
patients  may  be  trained  to  sleep  out  of  doors,  and  the  results  obtained  by 
Pratt,  Millett,  and  others  are  as  good  as  any  that  have  been  published.  While 
there  is  fever  the  patient  should  he  at  rest  in  bed,  and  night  and  day  the 
windows  should  be  open,  so  that  he  may  be  exposed  freely  to  the  fresh  air. 
Low  temperature  is  not  a  contra-indication.  If  there  is  a  balcony  or  a  suit- 
able yard  or  garden,  on  the  brighter  days  the  patient  may  be  wrapped  up  and 
put  in  a  reclining  chair  or  on  a  sofa.  The  important  thing  is  for  the  physician 
to  emphasize  the  fact  that  neither  the  cough,  fever,  night  sweats,  and  not 
even  ha-moptysis  contra-indicate  a  full  exposure  to  the  fresh  air.  In  country 
places  this  can  be  carried  out  much  more  effectively.  In  the  summer  the  pa- 
tient should  be  out  of  doors  for  at  least  eleven  or  twelve  hours,  and  in  winter 
six  or  eight  hours.  At  night  -the  room  should  be  cool  and  thoroughly  well 
ventilated.  It  may  require  several  months  of  this  rest  treatment  in  the  open 
air  before  the  temperature  falls  to  normal. 

(&)  Treatment  in  Sanatoria. — Perhaps  the  most  important  advance  in  the 
treatment  of  tuberculosis  has  been  in  the  establishment  of  institutions  in 
which  patients  are  made  to  live  according  to  strict  rules.  To  Brehmer,  of 
Gobersdorf,  we  owe  the  successful  execution  of  this  plan,  which  has  been  fol- 
lowed with  most  gratifying  results. ,  In  the  United  States  the  zeal,  energy, 
and  scientific  devotion  of  Edward  L.  Trudeau  demonstrated  its  feasibility,  and 
the  Saranac  institution  has  become  a  model  of  its  kind.  The  results  at  hun- 
dreds of  institutions  demonstrate  the  great  importance ,  of  system  and  rigid 
discipline  in  carrying  out  a  successful  treatment.  Much  has  been  done  to 
promote  the  sanatorium  treatment  and  the  good  results  have  quite  justified 
the  heavy  expenditure  of  money.  In  many  places  it  has  been  demonstrated 
that  with  an  inexpensive  plant  excellent  results  may  be  obtained.  A  reaction 
has  naturally  followed  the  "stuffing"  plan  of  feeding,  and  more  reasonable 
methods  are  now  employed.  The  "absolute  rest"  plan  has  been  modified  to 
meet  individual  cases.  The  all-important  matter  is  the  establishment  near  to 
the  large  cities  of  public  sanatoria  for  the  treatment  of  cases  in  the  early 
stages.  The  large  general  hospitals  should  have  special  out-patient  depart- 
ments for  tuberculous  patients,  from  which  suitable  cases  could  be  sent  to  the 
sanatoria.  Much  discussion  has  taken  place  as  to  the  result  of  sanatorium 
treatment.  There  is  no  doubt  of  its  extraordinary  benefits  in  suitable  cases. 
To  pay  a  visit  with  Dr.  Bardwell  to  the  King  Edward  Sanatorium  at  Midhurst 
and  see  nearly  every  one  of  100  patients  looking  in  good 'condition  with  fresh 
air,  judicious  rest,  proper  exercise  and  diet,  without  drugs  and  without  tu- 
berculin, impresses  one  immensely  with  the  value  of  the  method.    Statistics  are 


226  SPECIFIC  INFECTIOUS  DISEASES 

notoriously  uncertain^  but  there  is  perhaps  no  institution  of  the  English-speak- 
ing world  in  which  greater  care  has  been  taken  to  trace  the  after-history  of 
the  patients  than  at  the  Adirondack  Sanatorium.  The  total  number  of  pa- 
tients from  the  years  1885  to  1919  inclusive  was  4,97G.  It  has  been  impossible 
to  trace  263  of  these.  Of  the  remaining  4,713,  2,892  were  living  (1919)  and 
1,821  dead. 

(c)  Climatic  Treatment. — This,  after  all,  is  only  a  modification  of  the 
open-air  method.  The  first  question  to  be  decided  is  whether  the  patient  is 
fit  to  be  sent  from  home.  In  many  instances  it  is  a  positive  hardship.  A 
patient  with  M^ell-marked  cavities,  hectic  fever,  night  sweats,  and  emacia- 
tion is  much  better  at  home,  and  the  physician  should  not  be  too  much  in- 
fluenced by  the  importunities  of  the  sick  man  or  his  friends.  The  require- 
ments of  a  suitable  climate  are  a  pure  atmosphere,  an  equable  temperature 
not  subject  to  rapid  variations,  and  a  maximum  amount  of  sunsUine.  Given 
these  three  factors,  it  makes  little  difference  ichere  a  patient  goes,  so  long  as 
he  lives  an  outdoor  life.  Woodruff  believes  that  sunshine  may  be  hurtful, 
and  collected  statistics  to  show  that  tuberculosis  is  more  prevalent  and  more 
fatal  among  the  dark  races,  who  live  where  the  sun  shines  the  brightest.  The 
different  climates  may  be  grouped  into  the, high  altitudes,  the  dry,  warm  cli- 
mates, and  the  moist,  warm  climates.  Among  high  altitudes  in  the  United 
States,  the  Colorado  resorts  are  the  most  important.  Of  others,  those  in 
Arizona  and  l\ew  Mexico  have  been  growing  rapidly.  The  rarefaction  of  the 
air  in  high  altitudes  is  of  benefit  in  increasing  the  respiratory  movements,  but 
brings  about  in  time  a  condition  of  dilatation  of  the  air-vesicles  and  a  perma- 
nent increase  in  the  size  of  the  chest  which  is  a  marked  disadvantage  when  such 
persons  attempt  subsequently  to  reside  at  the  sea-level.  The  great  advantage 
of  these  western  resorts  is  that  they  are  in  progressive,  prosperous  countries,  in 
which  a  man  may  find  means  of  livelihood  and  live  in  comfort.  In  Europe 
the  chief  resorts  at  high  altitudes  are  Davos,  Les  Avants,  and  St.  Moritz.  Of 
resorts  at  a  moderate  altitude,  Asheville  and  the  Adirondacks  are  the  best 
known  in  America.  The  Adirondack  cure  has  become  quite  famous.  One 
decided  advantage  is  that  after  arrest  of  the  disease  the  patient  can  return 
to  the  sea-level  without  any  special  risk.  The  cases  most  suitable  for  high 
altitudes  are  those  in  which  the  disease  is  limited,  without  much  cavity  forma- 
tion, and  without  much  emaciation.  The  thin,  irritable  patients  with  chronic 
tuberculosis  and  a  good  deal  of  emphysema  are  better  at  the  sea-level.  The  cold 
winter  climate  seems  to  be  of  decided  advantage  in  tuberculosis,  and  in  the 
Adirondacks,  where  the  temperature  falls  sometimes  to  20°  or  even  more  below 
zero,  the  patients  are  able  to  lead  an  out-of-door  life  throughout  the  entire 
winter. 

Of  the  moist,  warm  climates,  in  America  Florida  and  the  Bermudas,  in 
Europe  the  Madeira  Islands,  and  in  Great  Britain  Eastbourne,  Bournemouth, 
Torqua}^  and  Falmouth  are  the  best  known.  Of  the  dry,  warm  climates, 
Southern  California  in  the  United  States  is  the  most  satisfactory.  Man}'  of 
the  health  resorts  in  the  Southern  States  are  delightful  winter  climates  for 
tuberculous  cases.  Egypt,  Algiers,  and '  the  Eiviera  are  the  most  satisfactory 
resorts  for  patients  from  Europe. 

Other  considerations  which  should  influence  the  choice  of  a  locality  are 
good  accommodations  and  good  food.     It  is  also  im]3ortant  to  be  under  the 


TUBEECULOSIS  227 

care  of  a  competent  physician.  Very  much  is  said  concerning  the  choice  of 
locality  in  the  different  stages  of  pulmonary  tuberculosis,  but  when  the  disease- 
is  limited  to  an  apex,  in  a  man  of  fairly  good  personal  and  family  history,  the 
chances  are  that  he  may  fight  a  winning  battle  if  he  lives  out  of  doors  in  any 
climate,  whether  high,  dry,  and  cold,  or  low,  moist,  and  warm.  With  bilateral 
disease  and  cavity  formation  there  is  but  little  hope  of  permanent  cure,  and 
the  mild  or  warm  climates  are  preferable. 

Measures  which,  by  their  Local  or  General  Action,  Influence  the  Tubercu- 
lous Process. — Under  this  heading  we  may  consider  the  specific,  the  dietetic, 
and  the  general  medicinal  treatment  of  tuberculosis. 

(a)  Specific  Teeatment. — Introduced  by  Koch  in  1890,  the  tuberculin 
treatment  soon  fell  into  disfavor,  but,  in  spite  of  the  bad  results  that  naturally 
followed  its  injudicious  use,  certain  men  (among  them,  particularly,  Trudeau) 
continued  to  use  it.  Of  late  years  there  has  been  a  reaction  in  its  favor,  and 
tuberculin  is  again  lauded  by  some  fanatics  as  the  one  and  only  means  of  cure. 
Unquestionably  in  suitable  cases  it  has  a  very  beneficial  influence;  the  dif- 
ficulty is  to  decide  which  they  are.  At  present  so  indiscriminate  is  its  use 
that  an  estimation  of  the  results  is  very  difficult.  The  preliminary  question 
arises  as  to  what  justifies  the  diagnosis  of  tuberculosis,  and  it  is  impossible  to 
compare  the  results  obtained  by  different  observers.  Anybody,  by  any  method, 
can  secure  100  per  cent,  of  cures  in  the  so-called  "closed"  pulmonary  tubercu- 
losis. As  Hamman  states  very  sensibly :  "If  in  the  case  of  every  patient  who 
presents  himself  for  examination  and  shows  some  trifling  deviation  from  the 
normal  physical  signs  a  diagnosis  of  tuberculosis  is  made,  or  if  tuberculin  is 
made  the  ultimate  test  of  a  correct  diagnosis,  similar  results  may  be  obtained 
with  any  or  with  no  method."  A  variety  of  preparations  come  under  the  name 
Tuberculin:  0.  T.  and  T.  E.,  which  are  Koch's  old  and  new  preparations; 
Denys'  tuberculin,  houillon  filtre,  known  as  B.  F.,  and  a  bacillary  emulsion  of 
Koch,  B.  E.  The  smallest  dose  which  will  bring  out  a  response  should  be  used, 
1/2000  or  1/1000  mgm.,  and  re-inoculations  are  made  at  intervals  of  from 
one  to  two  weeks.  The  amount  is  gradually  increased  when  it  is  found  that  the 
dose  previously  given  ceases  to  bring  out  a  sufficient  response.  It  is  admin- 
istered to  afebrile  patients.  It  is  not  thought  desirable — quite  the  contrary, 
in  fact — to  get  a  severe  general  reaction,  particularly  as  this  may  be  associated 
with  marked  focal  reactions.  The  aim  striven  for  is  to  get  as  high  a  grade  of 
tuberculin  tolerance  as  possible.  Trudeau,  who  had  probably  the  longest  in- 
dividual experience  of  anyone  using  tuberculin,  began  with  doses  so  small 
that  no  reaction  is  produced;  then  the  dose  is  cautiously  raised,  avoiding  the 
slightest  reaction.  On  the  other  hand,  Wilkinson  begins  with  a  very  high 
dose,  and  uses  the  tuberculin  in  a  much  wider  range  of  cases. 

(h)  Dietetic  Tkeatment. — The  outlook  in  tuberculosis  depends  much 
upon  the  digestion.  It  is  rare  to  see  recovery  in  a  patient  in  whom  there  is 
persistent  gastric  trouble,  and  the  physician  should  ever  bear  in  mind  the 
fact  that  in  this  disease  the  primce  vice,  control  the  position.  The  early  nausea 
and  loss  of  appetite  in  many  cases  are  serious  obstacles.  Many  patients  loathe 
food  of  all  kinds.  A  change  of  air  or  a  sea  voyage  may  promptly  restore  the 
appetite.  When  either  of  these  is  impossible,  and  if,  as  is  almost  always  the 
case,  fever  is  present,  the  patient  should  be  placed  at  rest,  kept  in  the  open  air 
nearly  all  day,  and  fed  at  stated  intervals  with  small  quantities  either  of  milk, 


228  SPECIFIC  INFECTIOUS  DISEASES 

buttermilk,  or  ko^^m3'ss,  alternating  if  necessary  with  meat  juice  and  egg 
albumen.  Some  patients  who  are  disturbed  by  eggs  and  milk  do  well  on 
koumyss.  It  may  be  necessary  to  resort  to  Debove's  method  of  over-alimenta- 
tion or  forced  feeding.  The  stomach  is  washed  out  with  cold  water,  and  then, 
through  the  tube,  a  mixture  is  given  containing  a  litre  of  milk,  an  egg,  and 
100  grams  of  very  finely  powdered  meat.  This  is  given  three  times  a  day. 
Sometimes  the  patients  will  take  this  mixture  without  the  necessity  of  the 
stomach-tube,  in  which  case  a  smaller  amount  may  be  given.  Eaw  eggs  are 
suitable  for  the  purpose  of  over-feeding,  and  may  be  taken  between  meals. 
Beginning  with  one  three  times  a  day,  the  number  may  be  increased  to  two, 
three,  or  even  four  at  a  time.  In  the  German  sanatoria  a  special  feature  is 
this  over-feeding,  even  when  fever  is  present.  E.  W.  Philip  advises  a  raw 
meat  diet,  half  a  pound  three  times  a  day,  either  minced  or  as  a  soup. 

In  many  cases  the  digestion  is  not  at  all  disturbed  and  the  patient  can 
take  an  ordinary  diet.  It  is  remarkable  how  rapidly  the  appetite  and  diges- 
tion improve  with  the  fresh-air  treatment,  even  inpatients  who  have  to  remain 
in  the  city.  Care  should  be  taken  that  the  medicines  do  not  disturb  the  stom- 
ach, JSTot  infrequently  the  sweet  syrups  used  in  cough  mixtures,  cod-liver  oil, 
creosote,  and  the  hypophosphites  produce  irritation,  and  by  interfering  with 
digestion  do  more  harm  than  good.  On  the  other  hand,  the  bitter  tonics,  with 
acids,  and  the  various  malt  preparations  are  often  most  satisfactory.  A  rou- 
tine administration  of  alcohol  is  not  advisable,  and  there  is  no  evidence  that 
its  persistent  use  promotes  fibroid  processes  in  the  tuberculous  areas.  In  the 
advanced  stages,  particularly  when  the  temperature  is  low  between  eight  and 
ten  in  the  morning,  whisky  and  milk,  or  whisky,  egg,  and  milk  may  be  given 
with  advantage. 

•  (c)  EsERCiSE. — The  patient  with  fever  does  best  at  absolute  rest,  and 
exercise  should  only  be  taken  after  an  afebrile  period,  and  then  ver}^  gradually. 
It  has  long  been  known  that  following  exercise  the  temperature  is  raised,  and 
Paterson,  of  Frimly,  has  adopted  a  method  of  graded  exercises  which  have 
yielded  excellent  results.  The  plan  is  based  upon  the  view  that  physical 
exercise  induces  auto-inoculation,  the  extent  of  which  may  be  controlled  by 
the  amount  of  muscular  effort.  By  a  study  of  the  fever-chart,  the  body  weight, 
the  amount  of  sputum,  and  the  appetite  the  rate  of  progress  may  be  estimated. 
The  febrile  patient  is  regarded  as  one  in  whom  auto-inoculation  is  excessive. 
To  overcome  this  the  patient  is  immobilized  in  bed  so  far  as  possible,  and  not 
allowed  to  make  any  movements  whatever.  The  effect  of  this  is  often  remark- 
able in  reducing  the  fever..  Once  afebrile,  the  principal  element  in  the  treat- 
ment is  the  induction  of  an  auto-inoculation  by  exercises,  which  Paterson  be- 
lieves has  much  the  same  effect  as  a  dose  of  tuberculin.  A  scheme  of  graded 
labor  has  been  devised,  which  has  many  advantages  in  sanatorium  life,  and  the 
results  at  Frimly  are  very  gratifying. 

(d)  Immobilizing  the  Lung  by  Induction  of  Pneumothorax. — Years 
ago  Cayley  induced  pneumothorax  in  a  case  of  haemoptysis.  The  method 
never  came  into  general  use;  but,  on  , the  principle  of  keeping  an  inflamed 
organ  at  rest,  this  method  was  advocated  in  pulmonary  tuberculosis  by  For- 
lanini  and  by  J.  B.  Murphy.  Sterile  nitrogen  is  introduced  into  the  pleural 
cavity.  It  is  best  to  use  a  special  apparatus  with  a  water-manometer,  so  that 
measured  quantities  may  be  injected.    At  first  from  200  to  300  c.  c. ;  later  as 


TUBERCULOSIS  229 

much  as  500  c.  c.  are  introduced,  at  intervals  of  a  day  or  every  other  day,  until 
the  lung  is  completely  collapsed,  and  until  there  is  a  positive  interpleural 
pressure  of  from  5  to  10  cm.  of  water.  The  method  has  been  widely  practised 
with  excellent  results  in  certain  cases;  but  there  are  dangers,  as  liEemoptysis, 
serous  effusion,  and  empyema,  and  a  serious  objection  is  the  duration  of  the 
treatment,  as  the  pleural  cavity  requires  to  be  refilled  every  month  or  two. 

(e)  General  Medical  Treatment. — No  .medicinal  agents  have  any 
special  or  peculiar  action  upon  tuberculous  processes.  The  influence  which 
tbey  exert  is  upon  the  general  nutrition,  increasing  the  physiological  resist- 
ance, and  rendering  the  tissues  less  susceptible  to  invasion.  The  following  are 
the  most  important  remedies  which  seem  to  act  in  this  manner: 

Creosote,  which  may  be  administered  in  capsules,  in  increasing  doses,  be- 
ginning with  1  minim  three  times  a  day  and,  if  well  borne,  increasing  the 
dose  to  8  or  10  minims.  It  may  also  be  given  in  solution  with  tincture  of 
cardamon  and  alcohol.  It  is  an  old  remedy,  strongly  recommended  by  Ad- 
dison, and  the  reports  of  Jaccoud,  Fraentzel,  and  many  others  show  that  it 
has  a  positive  value.  It  may  be  used  as  an  inhalation.  Guaiacol  may  be  given 
as  a  substitute,  either  internally  or  hypodermically. 

Cod-liver  Oil. — In  glandular  and  bone  tuberculosis  this  remedy  is  un- 
doubtedly beneficial  in  improving  the  nutrition.  In  pulmonary  tuberculosis 
its  action  is  less  certain,  and  it  is  scarcely  worthy  of  the  unbounded  confidence 
which  it  enjoyed  for  so  many  years.  It  should  be  given  in  small  doses,  not 
more  than  a  teaspoonf ul  three  times  a  day  after  meals.  It  seems  to  act  better 
in  children  than  in  adults.  Fever  and  gastric  irritation  are  contra-indications 
to  its  use.  Eich  cream  is  an  excellent  substitute;  the  clotted  or  Devonshire 
cream  is  preferable. 

Arsenic. — There  is  no  general  tonic  more  satisfactory  in  cases  of  tubercu- 
losis of  all  kinds  than  Fowler's  solution.  It  may  be  given  in  5-minim  doses 
three  times  a  day  and  gradually  increased,  stopping  its  use  whenever  unpleas- 
ant symptoms  arise,  and  in  any  case  intermitting  it  every  third  or  fourth 
week.  Intramuscular  injections  of  the  salts  of  cacodylic  acid  have  been  used 
to  combat  the  anaemia  so  commonly  present  in  tuberculous  infections  with, 
it  is  claimed,  unusual  success. 

Treatment  of  Special  Symptoms. —  (a)  The  Fever. — There  is  no  more 
difficult  problem  than  the  treatment  of  the  pyrexia  of  tuberculosis.  The  pa- 
tient should  be  at  absolute  rest,  and  in  the  open  air  night  and  day  for  some 
weehs.  Fever  does  not  contra-indicate  an  out-of-door  life,  but  it  is  well  for 
patients  with  a  temperature  above  100.5°  F.  to  be  at  rest.  For  the  continuous 
pyrexia  or  the  remittent  type  of  the  early  stages,  quinine  and  the  salicylates 
may  be  tried;  but  they  are  uncertain  and  rarely  reliable.  In  large  closes 
quinine  has  a  moderate  antipyretic  action,  but  it  is  just  in  these  efficient 
doses  that  it  is  so  apt  to  disturb  the  stomach.  It  is  better,  when  the  fever  rises 
above  103°  F.  to  rely  upon  cold  sponging  or  the  tepid  bath,  gradually  cooled. 
When  softening  has  taken  place  and  the  fever  assumes  the  characteristic  septic 
type,  the  problem  becomes  still  more  difficult.  As  shown  by  Chart  V  (which 
is  not  by  any  means  an  exceptional  one),  the  pyrexia,  at. this  stage,  lasts 
only  for  twelve  or  fifteen  hours.  As  a  rule  there  are  not  more  than  from 
eight  to  ten  hours  in  which  the  fever  is  high  enough  to  demand  antipyretic 
treatment.     Sometimes  phenacetine,  given  in  2-grain  (0.13  gm.)  doses  every 


230  SPECIFIC  INFECTIOUS  DISEASES 

hour  for  three  or  four  hours  before  the  rise  in  temperature  takes  place,  either 
prevents  entirely  or  limits  the  paroxysm.  It  answers  better  in  this  way  than 
given  in  the  single  doses.  Careful  sponging  of  the  extremities  for  from  half 
an  hour  to  an  hour  during  the  height  of  the  fever  is  useful. 

(&)  Sweating. — Atropine,  in  doses  of  gr.  tIo-bV  (0.0005-0.001  gm.), 
and  the  aromatic  sulphuric  acid  in  large  doses  are  the  best  remedies.  When 
there  are  cough  and  nocturnal  restlessness,  morphia  (gr.  %,  0.008  gm.)  may 
be  given  with  the  atropine.  Camphoric  acid  (gr.  x,  0.65  gm.)  at  bedtime  may 
be  tried.  The  patient  should  use  light  flannel  night-dresses,  as  the  cotton 
night-shirts,  when  soaked  with  perspiration,  have  a  very  unpleasant  cold, 
clammy  feeling. 

(c)  Cough. — The  cough  is  a  troublesome,  though  necessary,  feature  in 
pulmonary  tuberculosis.  Unless  very  worrying  and  disturbing  sleep  at  night, 
or  so  severe  as  to  produce  vomiting,  it  is  not  well  to  attempt  to  restrict  it. 
When  irritative  and  bronchial  in  character,  inhalations  are  useful,  particularly 
the  tmcture  of  benzoin  or  preparations  of  menthol,  creosote,  or  turpentine.  The 
throat  should  be  carefully  examined,  as  some  of  the  most  irritable  and  dis- 
tressing forms  of  cough  result  from  laryngeal  erosions.  The  distressing  noc- 
turnal cough,  which  begins  just  as  the  patient  gets  into  bed  and  is  preparing 
to  fall  asleep,  requires,  as  a  rule,  preparations  of  opium.  Codein  (gr.  ^-^2' 
0.016-0.03  gm.)  may  be  given.  An  excellent  combination  for  the  nocturnal 
cough  is  morphia  (gr.  ^,  0.008  gm.),  dilute  hydrocyanic  acid  (ni  iij,  0.2  c,  c), 
and  syrup  of  wild  cherry  (3  j,  4  c.  c).  The  spirit  of  chloroform,  or  a  mix- 
ture of  chloroform  and  sedatives  or  Hoffman's  anodyne,  given  in  whisky  before 
gomg  to  sleep,  is  efficacious.  Mild  counter-irritation,  or  the  application  of  a 
hot  poultice,  will  sometimes  promptly  relieve  the  cough.  The  morning  cough 
IS  often  much  relieved  by  taking  immedialtely  after  getting  up  a  glass  of  hot 
milk  or  a  cup  of  hot  water,  to  which  15  grains  of  bicarbonate  of  soda  have  been 
added.  In  the  later  stages,  when  cavities  have  formed,  the  accumulated  secre- 
tion must  be  expectorated  and  the  paroxysms  of  coughing  are  most  exhausting. 
The  sedatives,  such  as  morphia  and  hydrocyanic  acid,  should  be  given  cau- 
tiously. The  aromatic  spirit  of  ammonia  in  full  doses  helps  to  allay  the 
paroxysm.  When  the  expectoration  is  profuse,  creosote  internally,  or  in- 
halations of  turpentine  and  iodine,  or  oil  of  eucalyptus,  are  useful.  For  the 
troublesome  dysphagia  a  strong  solution  of  cocaine  (gr.  x,  0.6  gm.)  with 
boric  acid  (gr.  v,  0.3  gm.)  in  glycerine  and  water  (§  j,  30  c.  c.)  may  be  used 
locally. 

{d)  DiARRHCEA. — For  the  diarrhoea  large  doses  of  bismuth,  combined  with 
Dover's  powder,  and  small  starch  enemata,  with  or  without  opium,  may  be 
given.  The  acetate  of  lead  and  opium  pill  often  acts  promptly,  and  the  aci  1 
diarrhoea  mixture,  dilute  acetic  acid  (tlX  x-xv,  1  c.  c),  morphia  (gr.  %. 
0.008  gm.),  and  acetate  of  lead  (gr.  j-ij,  0.1  gm.),  may  be  tried. 

In  some  cases,  5  c.  c.  of  a  5  per  cent,  solution  of  calcium  chloride  injected 
intravenously  is  useful. 

(e)  The  treatment  of  the  hgemoptysis  will  be  considered  in  the  section  on 
haemorrhage  from  the  lungs.  Dyspnoea  is  rarely  a  prominent  symptom  except 
in  the  advanced  stages,  when  it  may  be  very  troublesome  and  distressing. 
Ammonia  and  morphia,  cautiously  administered,  may  be  used. 

If  the  pleuritic  pains  are  severe,  the  side  may  be  strapped,  or  painted  with 


ACTINOMYCOSIS  231 

tincture  of  iodine.  The  dyspeptic  symptoms  require  careful  treatment,  as 
the  outlook  in  individual  cases  depends  much  upon  the  condition  of  the  stom- 
ach.    Small  doses  of  calomel  and  soda  often  allay  the  distressing  nausea. 

The  treatment  of  lesions  such  as  of  the  kidney,  epididymis,  etc.,  is  surgical 
if  the  condition  is  recognized  early  enough.  Disease  elsewhere,  as  in  the 
lungs,  is  not  a  necessary  contra-indication.  The  possible  harm  resulting  from 
ether  anaesthesia  must  always  be  kept  in  mmd. 

A  last  word  on  the  subject  of  tuberculosis  to  the  general  practitioner. 
The  leadership  of  the  battle  against  this  scourge  is  in  your  hands.  Much  has 
been  done,  much  remains  to  do.  By  early  diagnosis  and  prompt,  systematic 
treatment  of  individual  cases,  by  striving  in  every  possible  way  to  improve  the 
social  condition  of  the  poor,  by  joining  actively  in  the  work  of  the  local  and 
natio7ial  antituberculosis  societies  you  can  help  in  the  most  important  and  the 
most  hopeful  campaign  ever  undertaken  by  the  profession. 


B.    NON-BACTERIAL  FUNGUS  INFECTIONS— 
THE  MYCOSES 

Much  attention  has  been  paid  to  the  local  and  general  infections  caused 
by  the  group  of  fungoid  organisms  variously  classed  as  Streptothrix,  Acti- 
nomyces, Cladothrix  and  Leptothrix.  The  French  workers  group  the  various 
diseases  caused  by  these  organisms  under  the  term  Mycoses,  which  is  a  con- 
venient and  useful  designation.  Four  or  five  of  these  diseases  are  of  suf- 
ficient importance  to  be  considered  in  a  work  of  this  scope. 


I.    ACTINOMYCOSIS 

Definition. — A  chronic  infective  disorder  produced  by  the  actinomyces  or 
ray-fungus,  Streptothrix  actinomyces. 

Etiology. — The  disease  is  widespread  among  cattle,  and  occurs  also  in  the 
pig.  It  was  first  described  by  Bollinger  in  the  ox,  in  which  it  forms  the  affec- 
tion known  in  America  as  "big-jaw/'  The  first  accurate  description  of  the 
disease  in  man  was  given  by  James  Israel,  and  subsequently  Ponfick  insisted 
upon  the  identity  of  the  disease  in  man  and  cattle. 

In  the  United  States  and  England  the  disease  is  less  common  than  in  Ger- 
many.   It  is  nearly  three  times  as  common  in  men  as  in  women. 

The  parasite  belongs  probably  to  the  Streptothrix  group.  In  both  man 
and  cattle  it  can  be  seen  in  the  pus  from  the  affected  region  as  yellowish  or 
opaque  granules  from  one-half  to  two  millimetres  in  diameter,  which  are  made 
up  of  cocci  and  radiating  threads,  presenting  bulbous,  club-like  terminations. 
The  youngest  granules  are  gray  in  color  and  semi-translucent;  in  these  the 
bulbous  extremities  are  wanting.  The  parasite  has  been  successfully  cultivated, 
and  in  a  few  instances  the  disease  has  been  inoculated  both  with  the  natural 
and  artificially  grown  organism. 

The  Mode  of  Infection. — There  is  no  evidence  of  direct  infection  with  the 
flesh  or  milk  of  diseased  animals.  The  streptothrix  has  not  been  detected  out- 
side the  body.    It  seems  highly  probable  that  it  is  taken  in  with  the  food.    The 


233  SPECIFIC  INFECTIOUS  DISEASES 

site  of  infection  in  a  majority  of  cases  in  man  and  animals  is  in  the  mouth 
or  neighboring  passages.  In  the  cow,  possibly  also  in  man,  barley,  oats,  and 
rye  have  been  carriers  of  the  germ. 

Morbid  Anatomy. — As  in  tubercle,  the  first  effect  is  the  destruction  of 
adjacent  cells  and  the  attraction  of  leucocytes — later  the  surrounding  cells 
begin  to  proliferate.  After  the  tumor  reaches  a  certain  size  there  is  great 
proliferation  of  the  surrounding  connective  tissue,  and  the  growth  may,  par- 
ticularly in  the  jaw,  look  like,  and  was  long  mistaken  for,  osteo-sarcoma. 
Finally  suppuration  occurs,  which  in  man,  according  to  Israel,  may  be  pro- 
duced directly  by  the  streptothrix  itself. 

Clinical  Forms. —  (a)  Digestive  Teact. — Israel  is  said  to  have  found 
the  fungus  in  the  cavities  of  carious  teeth.  The  jaw  has  been  affected  in  a 
number  of  cases  in  man.  The  patient  comes  under  observation  with  swelling 
of  one  side  of  the  face,  or  with  a  chronic  enlargement  of  the  jaw  which  may 
simulate  sarcoma. 

The  tongue  has  been  involved  in  several  cases,  showing  small  growths, 
either  primary  or  following  disease  of  the  jaw.  In  the  intestines  the  disease 
may  occur  either  as  a  primary  or  secondary  affection.  The  most  common 
seat  is  the  region  of  the  cscum  and  appendix.  An  actinomycotic  appendi- 
citis has  been  described;  primary  actinomycosis  of  the  large  intestine  with 
metastases  has  also  been  found.  Eansom  has  found  the  actinomyces  in  the 
stools.  Actinomycotic  peritonitis  due  to  infection  through  a  gastrostomy 
wound  has  been  described.  Actinomycosis  of  the  liver  is  rare.  Auvray  in 
1903  could  only  collect  31  cases  (Eolleston).  It  forms  a  most  characteristic 
lesion,  an  alveolar  honey-combed  abscess — like  a  sponge  soaked  in  pus.  It  is 
usually  secondary  to  an  intestinal  lesion,  but  in  a  few  cases  no  other  focus 
has  been  found. 

(&)  PuLMONAEY  ACTINOMYCOSIS. — In  September,  1878,  James  Israel  de- 
scribed a  remarkable  mycotic  disease  of  the  lungs,  which  subsequent  observa- 
tion showed  to  be  the  affection  described  the  year  before  by  Bollinger  in  cattle. 
Since  that  date  many  instances  have  been  reported  in  which  the  lungs  were 
affected.  It  is  a  chronic  infectious  pulmonary  disorder,  characterized  by 
cough,  fever,  wasting,  and  a  muco-purulent,  sometimes  fetid,  expectoration. 
The  lesions  are  unilateral  in  a  majority  of  the  cases.  Hodenpyl  classifies  them 
in  three  groups:  (1)  Lesions  of  chronic  bronchitis;  the  diagnosis  has  been 
made  by  the  presence  of  the  actinomyces  in  the  sputum.  (2)  Miliary  actino- 
mycosis, closely  resembling  miliary  tubercle,  but  the  nodules  are  seen  to  be 
made  up  of  groups  of  fungi,  surrounded  by  granulation  tissue.  This  form  of 
pulmonary  actinomycosis  is  not  infrequent  in  oxen  with  advanced  disease  of 
the  jaw  or  adjacent  structures.  (3)  The  cases  in  which  there  is  more  exten- 
sive destructive  disease  of  the  lungs,  broncho-pneumonia,  interstitial  changes, 
and  abscesses,  the  latter  forming  cavities  large  enough  to  be  diagnosed  during 
life.  Actinomycotic  lesions  of  other  organs  are  often  present  in  connection  with 
the  pulmonary  disease;  erosion  of  the  vertebrae,  necrosis  of  the  ribs  and 
sternum,  with  node-like  formations,  subcutaneous  abscesses,  and  occasionally 
metastases  in  all  parts  of  .the  body. 

Symptoms. — The  fever  is  of  an  irregular  type  and  depends  largely  on  the 
existence  of  suppuration.  The  cough  is  an  important  symptom,  and  the  diag- 
nosis in  18  of  the  cases  was  made  during  life  by  the  discovery  of  the  actino- 


SPOEOTRICHOSES  233 

myces.  Death  results  usually  with  septic  symptoms.  Occasionally  there  is  a 
condition  simulating  typhoid  feTcr.  The  average  duration  of  the  disease  was 
ten  months.  Eecovery  is  not  very  rare.  Clinically  the  disease  closely  re- 
sembles certain  forms  of  pulmonary  tuberculosis  and  of  fetid  bronchitis.  It  is 
not  to  be  forgotten  in  the  examination  of  the  sputum  that,  as  Bizzozero  men- 
tions, certain  degenerated  epithelial  cells  may  be  mistaken  for  the  organism. 
The  radiating  leptothrix  threads  about  the  epithelium  of  the  mouth  some- 
times present  a  striking  resemblance.  Streptothrix  organisms,  non-acid  fast, 
are  relatively  common  in  the  sputum  and  apparently  have  little  pathological 
significance. 

(c)  Cutaneous  Actixomycosis. — In  more  than  half  of  the  recorded  cases 
the  disease  has  involved  the  skin  of  the  head  and  neck ;  the  buccal,  lingual  and 
pharyngeal  structures  may  be  involved  also.  It  is  a  very  chronic  affection 
resembling  tuberculosis  of  the  skin,  associated  with  the  growth  of  tumors 
which  suppurate  and  leave  open  sores,  which  may  remain  for  years. 

(d)  Cerebral  Actinomycosis. — Bollinger  has  reported  an  instance  of 
primary  disease  of  the  brain  with  the  symptoms  of  tumor.  A  second  case  was 
reported  by  Gamgee  and  Delepine.  The  patient  was  admitted  to  St.  George's 
Hospital  with  left-sided  pleural  effusion.  At  the  post  mortem  three  pints  of 
purulent  fluid  were  found  in  the  left  pleura ;  there  was  an  actinomycotic 
abscess  of  the  liver,  and  in  the  brain  there  were  abscesses  in  the  frontal,  parietal, 
and  temporo-sphenoidal  lobes  which  contained  the  mycelium,  but  no  clubs. 
A  third  case,  reported  by  0.  B.  Keller,  had  empyema  necessitatis,  which  was 
opened  and  actinomycetes  were  found  in  the  pus.  Subsequently  she  had 
Jacksonian  epilepsy,  for  which  she  was  trephined  twice  and  abscesses  opened, 
Avhich  contained  actinomyces  grains.  Death  occurred  after  the  second  opera- 
tion. 

■  Diagnosis. — The  disease  is  in  reality  a  chronic  pysemia.  The  only  test  is 
the  presence  of  the  actinomyces  in  the  pus.  Metastases  may  occur  as  in  pyse- 
mia  and  in  tumors.  The  tendency,  however,  is  rather  to  the  production  of 
a  local  purulent  affection  which  erodes  the  bones  and  is  very  destructive. 

Treatment. — This  is  largely  surgical  and  is  practically  that  of  pyaemia. 
Incision  of  the  abscess,  removal  of  the  dead  tissue,  and  thorough  irrigation 
are  appropriate  measures.  Thomassen  recommended  potassium  iodide,  which, 
in  doses  of  from  40  to  60  grains  (2.5  to  4  gm.)  daily,  has  proved  curative 
in  a  number  of  cases.    The  X-rays  and  radium  have  been  successful. 


II.     THE  SPOROTRICHOSES 

Definition. — A  chronic  infection  characterized  by  cutaneous  and  internal 
lesions  due  to  the  growth  of  various  forms  of  parasitic  fungi  of  the  sporo- 
trichosis group. 

History. — In  November.  1890,  a  patient  presented  himself  at  Finney's 
outpatient  clinic  at  the  Johns  Hopkins  Hospital  with  an  infection  of  the 
right  arm,  which  had  lasted  for  several  weeks.  There  were  ulcerations  on 
the  hand  and  indurations  on  the  forearm.  The  condition  was  recognized  as 
unusual  and  Schenck,  who  undertook  its  study,  found  on  culture  a  branched 
mycelium  with  numerous  spores  or  conidia.     Its  identification  was  made  by 


234  SPECIFIC  INFECTIOUS  DISEASES 

the  well-known  expert^  Erwin  F.  Smith,  and  it  was  named  Sporotrichum 
scliencHi.  Since  then,  the  disease  has  been  widely  recognized,  owing  chiefly 
to  the  studies  of  Beurmann  and  Gougerot,  and  it  is  now  evident  that  it  is 
widely  distributed  and  one  of  the  most  clearly  defined  of  the  mycoses. 

The  Parasite. — In  the  tissues  and  in  the  pus  the  parasite  is  a  large  short 
rod  from  3  to  5  ^u,  long  and  from  2  to  3  ;u,  in  breadth.  In  cultures  it  grows 
in  filaments  of  about  2  /i  in  diameter  and  forms  characteristic  ovoid  spores. 
The  points  of  differentiation  between  the  forms  are  due  largely  to  variation 
in  the  modes  of  sporulation.  The  parasite  is  introduced  chiefly  by  accidental 
inoculation,  and  possibly  through  grains  and  fruit.  The  fungi  have  an  identi- 
cal action  with  the  pathogenic  bacteria,  producing  toxins  towards  which  there 
are  active  humoral  reactions.  Widal  and  Abrami  determined  the  agglutinat- 
ing and  fixation  properties  of  the  serum  in  individuals  affected,  and  specific 
reactions  have  been  determined.  There  are  minor  differences  between  the 
form  described  by  Schenck  and  that  described  by  Beurmann. 

Clinical  Forms. — Beurmann  and  Gougerot  recognize  three  groups :  First, 
the  disseminated  gummatous  form  in  which  in  the  subcutaneous  tissues  in 
various  parts  of  the  body  there  are  small,  firm,  solid  nodules,  which  break 
down  and  form  small  abscesses,  ulcerating  the  skin.  In  the  second,  ulcera- 
tive, type  the  lesions  are  not  unlike  those  of  cutaneous  tuberculosis,  occurring 
commonly  on  the  hands  and  arms,  though  they  may  appear  on  the  legs  or  on 
the  body.  They  may  be  single  or  in  groups  of  two  or  three,  and  in  several 
cases  seen  in  Paris  they  resembled  very  much  eroded  syphilitic  gummata.  In 
the  third  form  there  is  a  localized  lesion,  a  hard  chancroid  body,  eroded  on  the 
surface.  Dissemination  occurs  through  the  lymphatics,  the  regional  glands 
become  involved  and  there  may  be  a  group  of  open  sores  along  the  arm  or  on  the 
side  of  -the  head.  Fourthly,  there  are  certain  extra-cutaneous  forms — ulcerous 
lesions  of  the  mucous  membranes,  gummata  of  the  muscles  and  an  ulcerative 
osteo-myelitis.  The  disease  rarely  generalizes  in  the  internal  organs  but  the 
parasite  has  been  found  in  connection  with  a  pyelonephrosis. 

The  disease  is  essentially  chronic,  lasting  often  for  a  year  or  two;  some- 
times disturbing  the  health  very  slightly,  and  other  times  leading  to  anaemia. 
There  may  be  no  fever,  but  instances  of  acute  attacks  have  been  reported. 

Diagnosis. — This  has  to  be  made  from  tuberculosis,  syphilis,  and  actino- 
mycosis, which  may  be  done  by  cultures  (as  the  parasites  grow  in  a  very 
specific  way)  and  by  sporo-agglutination  and  the  fixation  reaction,  the  full 
details  of  which  are  given  in  Beurmann's  and  Gougerot's  manual. 

Treatment. — As  a  rule  this  is  surgical,  but  the  iodide  of  potassium  has 
a  most  beneficial  effect. 

III.     NOCARDIOSIS 

J.  H.  Wright  of  Boston  separated  this  group  from  the  actinomycoses 
and  the  streptothrix  infections.  On  the  one  hand  the  parasites  resemble 
bacteria,  on  the  other  hand  the  hypomy'cetes  or  moulds,  in  forming  branching, 
thread-like  filaments  and  in  the  production  of  fine  conidia.  They  represent 
a  transition  between  the  bacteria  and  the  lower  fungi.  The  majority  of 
reported  cases  have  had  the  signs  and  symptoms  of  pulmonary  tuberculosis 
or  of  multiple  abscesses.     In  the  lungs  nodules,  caseous  masses  and  lesions 


MYCETOMA  235 

not  unlike  tubercle  have  been  found.  In  three  cases  there  was  abscess  of  the 
brain.  The  parasite  may  be  recognized  by  the  typically  branched  filaments 
and  by  the  growth  in  cultures. 


IV.     OIDIOMYCOSIS 

Under  this  term  is  described  a  form  of  infective  dermatitis,  of  which  the 
majority  of  the  reported  cases  have  been  in  the  United  States.  It  has  been 
called  blastomycosis  and  saccharomycosis.  The  parasite  grows  as  a  spherical 
or  oval  budding  cell  which  is  capable  of  producing  a  mycelium  with  aerial 
hyphte. 

The  essential  lesion  is  a  granuloma,  resembling  tuberculosis  and  involving 
the  skin  of  the  face  as  a  rule,  but  sometimes  the  lesions  are  multiple  and  there 
is  extensive  ulceration  from  the  breaking  down  of  the  nodules.  In  some 
cases  the  lungs  and  other  parts  have  been  affected.  A  secondary  meningitis 
has  been  described,  and  grayish  nodular  infiltrations  have  been  found  in  the 
liver,  spleen,  lymph  glands  and  other  organs.  The  disease  is  chronic,  lasting 
for  many  years.  The  diagnosis  is  easily  made  by  the  microscopic  examination 
of  material  from  the  small  abscesses,  or  a  fragment  of  the  tissue. 

When  localized,  recovery  may  take  place,  but  when  the  lungs  or  internal 
organs  are  involved,  or  if  the  skin  lesioHS  are  very  extensive,  death  follows. 
For  treatment,  the  actual  cautery,  excision,  the  X-rays  and  the  internal  ad- 
ministration of  iodide  of  potassium  may  be  tried. 

The  coccidioidal  granuloma,  which  occurs  in  California,  is  a  separate  disease 
much  like  oidiomycosis  but  the  organism  belongs  to  the  yeast  group.  The  ini- 
tial lesion  is  on  the  skin.  The  features  of  the  lung  infection  are  much  like 
tuberculosis.     It  is  almost  always  fatal. 


V.     MYCETOMA 

(Madura  Disease) 

Vandyke  Carter  of  Bombay,  a  pioneer  in  the  study  of  tropical  diseases, 
gave  an  admirable  description  of  this  afi^ection,  which  prevails  largely  in  cer- 
tain districts  of  India,  and  sporadically  in  other  parts  of  the  world. 

The  disease,  usually  involving  the  foot,  is  characterized  by  great  swelling, 
nodular  growths  and  the  formation  of  multiple  abscesses.  There  are  remark- 
able granules  1  mm.  in  diameter,  usually  of  a  black  color,  which  occur  in 
the  discharges;  in  other  cases  the  granules  are  yellow  or  brownish  in  color. 
In  the  pale  variety  a  streptothrix  has  been  found,  which  morphologically  closely 
resembles  actinomyces.  It  is  held  by  .most  observers  that  this  streptothrix 
madura3  and  actinomyces  are  distinct  species.  From  the  black  variety  of 
granules  a  hypomycete  has  been  grown,  an  organism  closely  allied  to  as- 
pergillus. 

The  disease  begins  as  a  granuloma,  with  swelling  of  the  foot,  generally 
on  the  sole.  The  tumors  gradually  soften,  others  form,  the  foot  increases 
enormously  in  bulk,  becomes  much  deformed,  numerous  sinuses  pass  between 


236  SPECIFIC  INFECTIOUS  DISEASES 

the  bones,  the  discharges  are  muco-purulent  and  contain  the  characteristic 
granules.  Treatment  by  the  use  of  the  X-rays  and  the  intravenous  injection 
of  antimony  has  been  helpful.  Sometimes  early  excision  or,  in  later  stages, 
amputation  of  the  foot  is  necessary. 


VI.     ASPERGILLOSIS 

Bennett  in  1842  described  the  parasite  from  the  lungs,  the  Aspergillus 
furnigatus,  a  fungus  widely  distributed  as  a  harmless  parasite,  having  been 
found  in  the  auditory  canal,  nose  and  throat.  In  birds,  in  cattle,  more 
rarely  in  dogs,  the  aspergillus  may  cause  lesions  of  the  lungs  resembling 
tuberculosis,  and  there  have  of  late  years  been  a  good  many  cases  reported 
in  man,  particularly  in  pigeon  keepers  and  hair  sorters.  In  the  majority  of 
cases  the  infection  is  secondary  to  some  long-standing  affection  of  the  lungs, 
but  it  has  been  met  with  as  a  primary  disease  with  lesions  resembling  broncho- 
pneumonia, which  undergo  necrosis  and  softening  and  the  clinical  picture  is 
that  of  ordinary  tuberculosis. 

The  symptoms  are  those  of  chronic  pulmonary  disease,  cough,  fever,  and 
expectoration,  in  which  the  aspergillus  is  found.  It  is  readily  recognized  by 
the  character  of  its  spores.  In  the  case  reported  by  the  senior  author,  at  inter- 
vals of  two  or  three  months  for  twelve  years  the  patient  coughed  up,  usually 
with  a  good  deal  of  difficulty,  a  grayish-brown  n:ass  the  size  of  a  small  bean, 
which  was  made  up  entirely  of  the  mycelium  and  spores  of  the  aspergillus. 
The  interesting  point  was  that  the  patient  had  no  symptoms,  other  than  the 
cough,  and  was  in  excellent  health. 

In  the  majority  of  cases  the  outlook  is  bad,  and  the  treatment  is  that  of 
chronic  tuberculosis. 


C.   PROTOZOAN  INFECTIONS 
I.     PSOROSPERMIASIS 

Though  widely  spread  in  invertebrates,  pathogenic  psorosperms  are  not 
common  in  mammals,  and  in  man  serious  disease  is  very  rarely  caused  by 
them.  One  of  the  commonest  and  most  readily  studied  forms  of  psorosperm 
is  the  so-called  Eainey's  tube,  an  ovoid  body  found  in  the  muscle  of  the  pig. 
within  the  sarcolemma,  filled  with  small  sickle-shaped  unicellular  organisms, 
Sarcocystis  miescheri.  In  a  few  instances  similar  structures  have  been  found 
in  the  muscles  of  man.  The  only  human  parasite  of  this  group  which  has 
caused  serious  disease  belo2igs  to  the  coccidia. 

Coccidiosis. — In  a  majority  of  the  cases  of  this  group  the  psorosperms  have 
been  found  in  the  liver,  producing  a  disease  similar  to  that  which  occurs  in 
rabbits.  In  Guebler's  case  there  were  tumors  which  could  be  felt  during  life, 
and  they  were  determined  by  Leuckart  to  be  due  to  coccidia.  A  patient  of  W. 
B.  Haddon's  was  admitted  to  St.  Thomas's  Hospital  with  slight  fever  and 
drowsiness,  and  gradually  became  unconscious — death  occurring  on  the  four- 
teenth day  of  observation.     ^Yhitish  neoplasms  were  found  upon  the  perito- 


AMEBIASIS  237 

neiim,  omentum,  and  on  the  layers  of  the  pericardium;  and  a  few  were  found 
in  the  liver^,  spleen,  and  kidneys.  A  somewhat  similar  case,  though  more 
remarkable,  as  it  ran  a  very  acute  course,  is  reported  by  Silcott.  A  woman, 
aged  fifty -three,  admitted  to  St.  Mary's  Hospital,  was  thought  to  be  sutiering 
from  typhoid  fever.  She  had  had  a  chill  six  weeks  before  admission.  There 
were  fever  of  an  intermittent  type,  slight  diarrhoea,  nausea,  tenderness  over 
the  liver  and  spleen,  and  a  dry  tongue;  death  occurred  from  heart-failure. 
The  liver  was  enlarged,  weighed  83  ounces,  and  in  its  substance  there  were 
caseous  foci,  around  each  of  which  was  a  ring  of  congestion.  The  spleen 
weighed  16  ounces  and  contained  similar  bodies.  The  ileum  presented  six 
papule-like  elevations.  The  masses  resembled  tubercles,  but  on  examination 
coccidia  were  found. 

The  parasites  are  also  found  in  the  kidneys  and  ureters.  Cases  of  this 
kind  have  been  recorded  by  Bland  Sutton  and  Paul  Eve.  In  Eve's  case  the 
symptoms  were  hematuria  and  frequent  micturition,  and  death  took  place  on 
the  seventeenth  day.  The  nodules  throughout  the  pelvis  and  ureters  have 
been  regarded  as  mucous  cysts. 


II.    AMCEBIASIS 

{Amcebic  Dysentery,  Amwhic  Hepatitis) 

Definition. — A  colitis,  acute  or  chronic,  caused  by  Entamoeba  histolytica 
with  a  special  liability  to  the  formation  of  abscesses  of  the  liver. 

Distribution. — The  disease  is  widely  prevalent  in  Egypt,  in  India  and  in 
tropical  countries.  In  Europe  sporadic  cases  occur,  rarely  small  epidemics. 
It  is  uncommon  in  Great  Britain.  It  is  common  throughout  the  United  States, 
particularly  in  the  South,  where  it  is  endemic,  increasing  sometimes  to  epi- 
demic proportions.  Sporadic  cases  occur  in  all  temperate  regions.  The  rela- 
tive frequency  of  this  form  of  dysentery  in  the  tropics  is  illustrated  by  the 
Manila  statistics  given  by  Strong;  of  1,328  cases  in  the  United  States  Army, 
561  were  of  the  amoebic  variety.  The  cases  of  acute  and  chronic  dysentery  in 
the  Johns  Hopkins  Hospital  have  been  almost  exclusively  amcebic.  To  1908  of 
182  cases,  123  came  from  the  State  of  Maryland. 

Age. — It  is  not  uncommon  in  children  but  the  greatest  number  of  cases 
occur  between  the  ages  of  20  and  35. 

Sex. — Males  are  much  more  frequently  affected.  Of  182  cases  at  the 
Johns  Hopkins  Hospital  171  were  males  (Futcher). 

Eace. — The  white  race  is  more  susceptible,  1G3  whites  to  19  blacks  in  the 
Johns  Hopkins  Hospital  series.  In  the  Philippines  the  whites  are  more  often 
attacked.    In  India  the  disease  is  common  in  the  native  races. 

The  Amoeba. — The  organism  Entamcela  histolytica  was  first  described  by 
Lambl  in  1859  and  subsequently  by  Losch  in  1875.  Kartulis  in  1886  found 
them  in  the  stools  of  the  endemic  dysentery  in  Egypt  and  in  the  liver  ab- 
scesses. In  1890  the  senior  author  found  them  in  a  case  of  dysentery  with 
abscess  of  the  liver  originating  in  Panama.  Subsequently  from  his  wards  a 
series  of  cases  was  described  by  Councilman  and  Lafleur.  The  studies  of 
Quincke  and  Eoos,  of  Dock,  Harris  and  others  in  the  United  States,  of  Strong 


238  SPECIFIC  I;N"FECTI0US  DISEASES 

and  Musgrave  in  the  Philippines,  of  Kruse  and  Pasquale  in  Egypt  and  of 
Leonard  Rogers  in  India  have  put  our  knowledge  of  the  disease  on  a  firm  basis. 
To  find  the  amcebse  the  little  fiakes  of  mucus  or  pus  in  the  stools  should  be 
selected  for  examination  or  the  mucus  obtained  by  passing  a  soft  rubber  tube. 
It  is  sometimes  necessary  to  give  the  patient  a  saline  cathartic  and  then  ex- 
amine the  fiuid  portion  of  the  stool. 

Entamoeba  histolytica  is  from  15  to  20  fi  in  diameter,  has  a  clear  outer 
zone  (ectosarc)  and  a  granular  inner  zone  (endosarc).  The  nucleus  is  seen 
with  difficulty  and  contains  little  chromatin.  The  movements  are  similar 
to  those  of  the  ordinary  pond  amoeba,  consisting  of  slight  protrusions  of  the 
protoplasm.  They  vary  a  good  deal,  and  usually  may  be  intensified  by  having 
the  slide  heated.  Not  infrequently  the  amoebas  contain  red  blood  corpuscles. 
In  the  tissues  they  are  very  readily  recognized  by  suitable  stains.  They  may 
be  in  enormous  numbers,  and  sometimes  the  field  of  the  microscope  is  com- 
pletely occupied.  In  the  pus  of  a  liver  abscess  they  may  be  very  abundant, 
though  in  large,  long  standing  abscesses  they  may  not  be  found  until  after  a 
few  days,  when  the  pus  begins  to  discharge  from  the  wall.  In  the  sputum 
in  the  cases  of  pulmono-hepatic  abscess  they  are  readily  recognized. 

Amcebse  are  frequently  found  in  the  stools  of  healthy  persons,  as  Cunning- 
ham and  Lewis  pointed  out.  Schaudinn  found  them  in  from  20  to  60  per 
cent,  in  Germany,  but  they  vary  greatly  in  different  localities.  Among  300 
persons  in  Manila,  Musgrave  found  101  infected  with  amcebse;  61  of  these 
had  dysentery,  the  remaining  40  had  no  diarrhoea.  In  the  next  two  months 
8  of  the  40  cases  died  and  showed  amoebic  infection  of  the  bowel.  Within 
the  next  three  months  the  remaining  32  had  dysentery.  Schaudinn  described 
two  distinct  forms — a  non-pathogenic  Efit.  coli,  and  a  pathogenic  larger  form, 
the  Ent.  histolytica,  with  a  strongly  retractile  hyaline  ectoplasm.  The  amcebge 
can  be  cultivated,  but  with  difficulty.  The  encysted  forms  are  apparently  the 
chief  factor  in  the  spread  of  the  disease.  They  are  found  in  the  stools  of 
convalescents  and  healthy  carriers.  Infection  occurs  through  food  or  water, 
the  common  source  being  a  carrier.     Flies  may  convey  the  infection. 

Morbid  Anatomy.— Intestines. — The  lesions  consist  of  ulceration,  pro- 
duced by  preceding  infiltration,  general  or  local,  of  the  submucosa,  due  to  an 
cedematous  condition  and  to  multiplication  of  the  fixed  cells  of  the  tissue.  In 
the  earliest  stage  these  local  infiltrations  appear  as  hemispherical  elevations 
above  the  general  level  of  the  mucosa.  The  mucous  membrane  over  these 
becomes  necrotic  and  is  cast  off,  exposing  the  infiltrated  submucous  tissue  as  a 
grayish  yellow  gelatinous  mass,  which  at  first  forms  the  floor  of  the  ulcer,  but 
is  subsequently  cast  off  as  a  slough.  The  individual  ulcers  are  round,  oval, 
or  irregular,  with  infiltrated,  undermined  edges.  The  visible  aperture  is 
often  small  compared  to  the  loss  of  tissue  beneath  it,  the  ulcers  undermining 
the  mucosa,  coalescing,  and  forming  sinuous  tracts  bridged  over  by  apparently 
normal  mucous  membrane.  According  to  the  stage,  the  floor  of  the  ulcer  may 
be  formed  by  the  submucous,  the  muscular,  or  the  serous  coat  of  the  in- 
testine. The  ulceration  may  affect  the  whole  or  some  portion  only  of  the  large 
intestine,  particularly  the  caecum,  the  hepatic  and  sigmoid  flexures,  and  the ' 
rectum.  In  severe  cases  tl:-^  whole  of  the  intestine  is  much  thickened  and 
riddled  with  ulcers,  with  only  here  and  there  islands  of  intact  mucous  mem- 


AMCEBIASIS  23D 

brane.    In  100  autopsies  on  this  disease  in  Manila  the  appendix  was  involved 
in  7 ;  perforation  of  the  colon  took  place  in  19. 

The  disease  advances  by  progressive  infiltration  of  the  connective  tissue 
layers  of  the  intestine,  which  produces  necrosis  of  the  overlying  structures. 
Thus,  in  severe  cases  there  may  be  in  different  parts  of  the  bowel  sloughing 
en  masse  of  the  mucosa  or  of  the  muscularis,  and  the  same  process  is  observed, 
but  not  so  conspicuously,  in  the  less  severe  forms.  In  some  cases  a  secondary 
diphtheritic  inflammation  occurs.  Healing  takes  place  by  the  gradual  forma- 
tion of  fibrous  tissue  in  the  floor  and  at  the  edges  of  the  ulcers,  which  may 
result  in  partial  and  irregular  strictures  of  the  bowel. 

Microscopic  examination  shows  a  notable  absence  of  the  products  of  puru- 
lent inflammation.  In  the  infiltrated  tissues  polynuclear  leucocytes  are  sel- 
dom found,  and  never  constitute  purulent  collections.  On  the  other  hand, 
there  is  proliferation  of  the  fixed  connective  tissue  cells.  Amoebge  are  found 
more  or  less  abundantly  in  the  tissues  at  the  base  of  and  around  the  ulcers,  in 
the  lymphatic  spaces,  and  occasionally  in  the  blood  vessels.  The  portal  capil- 
laries occasionally  contain  them,  and  this  fact  seems  to  afford  the  best  explana- 
tion for  the  mode  of  infection  of  the  liver. 

Liver. — The  lesions  are  of  two  kinds :  first,  local  necroses  of  the  paren- 
chyma, scattered  throughout  the  organ,  and  possibly  due  to  the  action  of 
chemical  products  of  the  amoebae;  and,  secondly,  abscesses.  These  may  be 
single  or  multiple.  There  were  37  cases  of  hepatic  abscess  among  the  182 
cases  of  amoebic  dysentery  in  the  Hopkins  Hospital.  Of  these,  18  came  to 
autopsy.  In  10  the  abscess  was  single  and  in  8  multiple.  When  single  they 
are  generally  in  the  right  lobe,  either  toward  the  convex  surface  near  its 
diaphragmatic  attachment  or  on  the  concave  surface  in  proximity  to  the  bowel. 
Multiple  abscesses  are  small  and  generally  superficial.  There  may  be  innum- 
erable miliary  abscesses  containing  amoebge  scattered  throughout  the  organ.  Al- 
though the  hepatic  abscess  usually  occurs  within  the  first  two  months  from 
the  onset  of  the  dysentery,  in  one  of  our  cases  the  latter  had  lasted  one  and 
in  another  six  years.  In  5  cases  the  intestinal  symptoms  had  been  so  slight 
that  dysentery  had  never  been  complained  of.  In  2  fatal  cases  there  were  only 
scars  of  old  ulcers  and  in  2  others  the  mucosa  appeared  normal.  In  an  early 
stage  the  abscesses  are  grayish  yellow,  with  sharply  defined  contours,  and  con- 
tain a  spongy  necrotic  material,  with  more  or  less  fluid  in  its  interstices.  The 
larger  abscesses  have  ragged  necrotic  walls,  and  contain  a  more  or  less  viscid, 
greenish  yellow  or  reddish  yellow  purulent  material  mixed  with  blood  and 
shreds  of  liver  tissue.  The  older  abscesses  have  fibrous  walls  of  a  dense,  almost 
cartilaginous  toughness.  There  is  the  same  absence  of  purulent  inflammation 
as  in  the  intestine,  except  in  those  cases  in  which  a  secondary  infection  with 
pyogenic  organisms  has  taken  place. 

Lesions  in  the  lungs  are  seen  when  an  abscess  of  the  liver — as  so  fre- 
quently happens — points  toward  the  diaphragm  and  extends  by  continuity 
through  it  into  the  lower  lobe  of  the  right  lung.  This  is  the  commonest  situa- 
tion for  rupture  to  occur.  Nine  of  our  cases  ruptured  into  the  lung.  In  3 
cases  rupture  into  the  right  pleura  occurred,  causing  an  empyema.  In  one 
the  lung  abscess  ruptured  into  the  pleura,  producing  a  pyo-pneumothorax. 
Perforation  may  occur  into  adjacent  structures.  In  3  of  the  cases  perforation 
took  place  into  the  inferior  vena  cava  and  in  another  the  upper  pole  of  the 


240  SPECIFIC  INFECTIOUS  DISEASES 

right  kidney  was  invaded.  The  abscess  may  rupture  into  the  pericardium, 
peritoneum,  stomach,  intestine,  portal  and. hepatic  veins,  or  externally. 

Symptoms. — Three  groups  of  cases  may  be  recognized: 

Mild  Form. — Infection  may  be  present  for  a  month  or  two  before  the 
individual  is  aware  of  it.  There  may  be  vague  symptoms — headache,  lassi- 
tude, weakness,  slight  abdominal  pains  and  occasional  diarrhoea,  features  com- 
mon enough  in  the  tropics.  Latency  is  the  feature  in  a  large  number  of  cases. 
The  amoebae  may  be  present  without  exciting  symptoms,  or  there  may  be  slight 
transient  attacks  of  diarrhoea,  and  yet  these  are  the  very  cases  in  which  hepatic 
abscess  may  follow.  Herrick  found  in  the  Canal  zone  that  20  per  cent,  of 
his  cases  gave  no  previous  history  of  dysentery. 

Acute  Amcebic  Dysenteey. — Many  cases  have  an  acute  onset.  Pain  and 
tenesmus  are  common.  The  stools  are  bloody,  or  mucus  and  blood  occur  to- 
gether. In  very  severe  cases  there  may  be  constant  tenesmus,  with  pain  of  the 
greatest  intensity,  and  the  passage  every  few  minutes  of  a  little  blood  and 
mucus.  In  some  cases  large  sloughs  are  passed.  The  temperature  as  a  yule 
is  not  high.  The  patient  may  become  rapidly  emaciated;  the  heart's  action 
becomes  feeble,  and  death  may  occur  within  a  Aveek  of  the  onset.  Among 
other  symptoms  are  hgemorrhage  from  the  bowels,  which  occurred  in  three 
cases,  and  perforation  of  an  ulcer  with  general  peritonitis,  which  occurred  in 
three  cases.  A  majority  of  the  patients  recover;  in  others  the  disease  drags 
on  and  becomes  chronic,  the  symptoms  often  showing  a  periodicity.  In  a  few 
cases,  after  the  separation  of  the  sloughs,  there  is  extensive  ulceration  remain- 
ing, with  thickening  and  induration  of  the  colon,  and  the  patient  has  constant 
diarrhoea,  loses  weight,  and  ultimately  dies  exhausted,  usually  within  three 
months  of  the  onset.  With  the  exception  of  cancer  of  the  oesophagus  and 
anorexia  nervosa,  no  such  extreme  emaciation  is  seen.  Extensive  ulceration 
of  the  cornea  may  occur. 

Chronic  Amcebic  Dysentery. — The  disease  may  be  subacute  from  the 
onset,  and  gradually  passes  into  a  chronic  stage,  the  special  characteristic  of 
which  is  alternating  periods  of  constipation  and  of  diarrhoea.  These  may 
occur  over  a  period  of  from  six  months  to  a  year  or  more.  Some  of  our  pa- 
tients have  been  admitted  to  the  hospital  five  or  six  times  within  a  period 
of  two  years.  During  the  exacerbations  there  are  pain,  frequent  passages  of 
mucus  and  blood,  and  a  slight  rise  of  temperature.  Many  patients  do  not  feel 
very  ill,  and  retain  their  nutrition  in  a  remarkable  way ;  indeed,  in  the  United 
States  it  is  rare  to  see  the  extreme  emaciation  so  common  in. the  chronic 
cases  from  the  tropics.  Alternating  periods  of  improvement  with  attacks  of 
diarrhoea  are  the  rule.  The  appetite  is  capricious,  the  digestion  disordered,  and 
slight  errors  in  diet  are  apt  to  be  followed  at  once  by  an  increase  in  the  num- 
ber of  stools.     The  tongue  is  often  red,  glazed,  and  beefy. 

Complications  and  Sequelae. — Liver  Abscess. — A  pre-suppurative  stage 
lasting  for  several  weeks  or  months  is  recognized  by  Eogers,  characterized  by 
fever  of  an  intermittent  type,  moderate  leucocytosis,  and  an  enlarged  and 
tender  liver.  Suppuration  in  the  liver  is  the  most  serious  and  frequent  com- 
plication.   Abscess  of  the  brain  has  occurred. 

Perforation  of  the  intestine  and  peritonitis  occurred  in  three  of  our 
cases.  Intestinal  hcemorrhage  occurred  three  times.  The  infrequency  of 
this  complication  is  probably  due  to  the  thrombosis  of  the  vessels  about  the 


AMCEBIASIS  241 

areas  of  infiltration.  Occasionally  an  artln-itis,  probably  toxic  in  origin, 
may  occur.  There  was  one  case  in  our  series.  Five  cases  were  complicated 
by  malaria;  1  by  typhoid  fever;  1  by  pulmonary  tuberculosis;  and  1  by  a 
strongyloides  intestinalis  infection. 

Urinary  Amcehiasis. — Macfie  reports  a  case  and  states  that  there  are  about 
a  dozen  instances  in  the  literature.  In  the  majority  the  infection  has  been 
with  the  organism  Erit.  hisfolijfica  (feiragena).  The  infection  may  be  of  the 
kidney,  bladder,  seminal  vesicles  or  urethra.  The  process  may  be  a  primary 
infection  or  secondary  to  amoebic  dysentery. 

Diagnosis. — From  the  other  forms  of  dysentery  the  disease  is  recognized 
by  the  finding  of  amoebge  in  the  stools.  Unless  one  sees  undoubted  amoeboid 
movement  a  suspected  body  should  not  be  considered  an  amoeba.  A  non- 
motile  body  containing  one  or  more  red  cells  is  most  probably  an  amoeba,  but 
shoidd  lead  to  further  search  for  motile  organisms.  Swollen  epithelial  cells 
are  confusing,  but  the  hyaline  periphery  is  not  amceboid  in  its  action  as  is  the 
ectosarc  of  the  amoeba.  The  trichomonads  and  cercomonads  so  frequently  as- 
sociated with  amoeba  are  not  likely  to  give  trouble.  The  Ent.  histolytica  is 
distinguished  from  non-pathogenic  forms  by  its  larger  size,  distinct  refractile 
ectoplasm,  faint  nucleus,  marked  mobility,  vacuoles,  contained  red  blood  cells, 
and  scanty  chromatin  in  the  nucleus.  The  cysts  are  small  and  do  not  contain 
more  than  four  nuclei.  In  the  cysts  of  Ent.  coli  the  nuclei  are  eight  or  more. 
Various  stains  are  an  aid  in  differentiation.  The  extent  of  liver  dulness  should 
be  watched  throughout  the  course,  and  any  increase  upward  or  downward 
should  lead  to  the  suspicion  of  a  liver  abscess.  Hepatic  abscess  is  usually  ac- 
companied by  fever,  sweats,  or  chills  and  local  pain,  but  may  be  entirely  latent. 
Exploratory  puncture  is  safe  as  a  rule  but  severe  hgemorrhage  into  the  peri- 
toneum, six  cases  of  which  were  recorded  by  Hatch  in  India,  may  occur.  A 
varying  leucocytosis  occurs  in  the  abscess  cases.  The  highest  count  in  our 
series  was  53,000,  the  average  being  18,350.  The  average  leucocyte  count  in 
the  uncomplicated  dysentery  cases  was  10,600.  Hepato-pulmonary  abscess  is 
attended  by  local  lung  signs  and  the  expectoration  of  "anchovy  sauce"  sputum 
in  which  amoeba  are  almost  invariably  found. 

Prognosis.— In  many  cases  the  disease  yields  to  treatment  but  the  tendency 
to  relapse  of  the  dysenteric  symptoms  is  one  of  the  striking  characteristics. 
One  of  our  patients  was  admitted  to  the  hospital  five  times  in  nine  months. 

Treatment. — Eest  in  bed  is  very  important,  even  in  mild  attacks,  and  ma- 
terially hastens  recovery.  The  diet  should  be  governed  by  the  severity  of  the 
intestinal  manifestations.  In  the  very  acute  cases  the  patient  should  be  given 
a  liquid  diet,  consisting  of  milk,  whey,  and  broths. 

A  return  to  the  use  of  ipecacuanha  is  the  most  important  event  of  late 
years  in  the  treatment  of  this  form  of  dysentery.  It  should  always  be  tried, 
even  in  chronic  eases.  It  must  be  given  in  salol-coated  pills  or  keratin  cap- 
sules so  that  it  is  not  dissolved  in  the  stomach.  The  patient  should  be  on 
milk  diet  and  without  anything  by  mouth  for  three  hours  before  the  drug  is 
given,  the  best  time  being  at  bedtime.  One  dose  is  given  each  night;  the 
first  may  be  60  to  90  grains  (4  to  6  gm.),  which  is  reduced  by  five  grains  each 
night  until  it  is  down  to  ten  grains  (0.6  gm.).  This  course  should  be  repeated 
in  a  week  if  amoeb£e  remain  in  the  stools.  Emetine  hydrochloride  hypoder- 
mically  is  generally  preferable  to  ipecac  by  mouth.     An  average  dose  is  i^} 


242  SPECIFIC  INFECTIOUS  DISEASES 

grain  (0.03  gm.)  three  times  a  day  for  three  to  six  days,  and  this  repeated  if 
necessary.  Emetine  sometimes  causes  diarrhoea  which  may  be  mistaken  for  the 
original  dysentery.  Eogers  advises  ipecac  to  prevent  liver  abscess  when  there 
is  a  suspicion  of  hepatitis.  Doses  of  20  to  30  grains  (1.3  to  2  gm.)  are  given 
daily  and  continued  for  two  weeks  after  the  temperature  is  normal. 

Bismuth  probably  does  more  harm  than  good,  owing  to  the  fact  that  it 
coats  the  surface  of  the  ulcers.  It  is  well  in  the  chronic  forms  to  give  an 
occasional  dose  of  saline  or  castor  oil.  Large  injections  of  quinine  solution 
in  the  strength  of  1  to  5,000,  gradiially  increasing  to  1  to  500,  have  given  the 
most  satisfactory  results  of  all  the  local  remedies.  The  amcebse  are  rapidly 
destroyed  by  the  drug.  The  success  of  the  treatment  depends  largely  on  the 
care  with  which  the  injections  are  given.  The  failures  are  undoubtedly,  in 
many  instances,  due  to  the  fact  that  sufficient  care  is  not  used  to  insure  the 
solution  reaching  the  caecum  and  ascending  colon,  where  the  ulceration  is  often 
most  severe.  From  a  litre  to  two  litres  should  be  alloAved  to  flow  into  the  colon. 
The  patient's  hips  should  be  elevated  and  he  should  change  his  position  so  as 
to  allow  the  fluid  to  flow  into  all  parts  of  the  colon.  The  solution  should  be 
retained,  if  possible,  for  fifteen  minutes.  One  or  two  injections  may  be  given 
daily.  Injections  of  silver  nitrate  solution  (1  to  2,000,  increased  to  1  to  500) 
are  useful  in  chronic  cases,  given  in  the  same  wa}^  When  there  is  much 
tenesmus  a  small  injection  of  thin  starch  and  half  a  drachm  to  a  drachm  of 
laudanum  gives  great  relief.  Local  applications  to  the  abdomen,  in  the  form 
of  light  poultices,  or  turpentine  stupes,  are  very  grateful. 

When  medical  treatment  fails,  csecostomy  may  be  tried  or  irrigations  given 
through  the  appendix. 

The  treatment  of  carriers  is  a  different  problem.  The  use  of  emetine  bis- 
muth iodide  has  proved  of  value.  It  is  given  in  capsules  in  daily  doses  of 
gr.  ii-iv  (0.12-0.24  gm.)  to  a  total  amount  of  about  gr.  xxs  (2  gm.).  Others 
advise  the  oil  of  chenopodium  given  after  free  purgation.  An  ounce  of  epsom 
salts  is  given  at  6  a.  m.,  oil  of  chenopodium  in  capsules  (nx  xv,  1  c.  c.)  at  8  and 
10  A.  M.,  and  noon;  castor  oil  §i  (30  c.  c.)  with  50  minims  of  chloroform  at 
2  p.  M. 

Hepatic  abscess  should  be  drained  at  once  and  the  cavity  irrigated  by 
quinine  solution  (1  to  1,000).  Emetine  should  be  given  persistently,  as  ad- 
vised for  the  dysentery. 


HI.     MALARIAL  FEVER 

Definition. — A  protozoal  disease  with:  (a)  paroxysms  of  intermittent 
fever  of  quotidian,  tertian,  or  quartan  type;  (6)  a  continued  fever  with 
marked  remissions;  (c)  certain  pernicious,  rapidly  fatal  forms;  and  {d)  a 
chronic  cachexia,  with  anaemia  and  enlarged  spleen. 

The  haemosporidia  described  by  Laveran,  which  are  transmitted  to  man  by 
the  bite  of  the  mosquito,  are  invariably  associated  with  the  disease.  Malaria 
occurs  as  an  endemic  and  epidemic  disease,  the  latter  prevailing  in  the  tropics 
under  favoring  conditions.  No  infection  except,  perhaps,  tuberculosis  com- 
pares with  it  in  the  extent  of  its  distribution  or  its  importance  as  a  killing 
and  disabling  disease. 


MALAEIAL  FEVER  243 

Geographical  Distribution. — In  Europe,  southern  Russia  and  certain  parts 
of  Italy  are  now  the  chief  seats  of  the  disease.  It  is  rare  in  Germany,  France, 
and  England,  and  the  foci  of  epidemics  are  becoming  yearly  more  restricted. 
In  the  United  States  malaria  has  progressively  diminished  in  extent  and  se- 
verity during  the  past  fifty  years.  From  Xew  England,  where  it  once  prevailed 
extensively,  it  has  gradually  disappeared,  but  there  has  of  late  years  been  a 
slight  return  in  some  places.  In  the  city  of  jSTew  York  even  the  milder  forms 
of  the  disease  are  very  rare.  In  Philadelphia  and  along  the  valleys  of  the 
Delaware  and  Schuylkill  Rivers,  formerly  hot-beds  of  malaria,  the  disease  has 
become  much  restricted.  In  Baltimore  a  few  cases  occur  in  the  autumn,  but 
a  majority  of  the  patients  are  from  the  outlying  districts  and  some  of  the 
inlets  of  Chesapeake  Bay.  Throughout  the  Southern  States  there  are  many 
regions  in  which  malaria  prevails;  but  here,  too,  the  disease  has  diminished 
in  prevalence  and  intensity.  In  temperate  regions,  like  the  Central  Atlantic 
States,  there  are  only  a  few  cases  in  the  spring,  usually  in  the  month  of  May, 
and  a  large  number  of  cases  in  September  and  October,  and  sometimes  in 
iSTovember.  In  the  iSTorthwestern  States  malaria  is  almost  unknown.  The 
St.  Lawrence  basin  remains  free  from  the  disease. 

In  India  the  disease  is  very  prevalent,  particularly  in  the  great  river  ba- 
sins. Terrible  epidemics  occur.  In  the  Punjab  in  1908  there  were  more  than 
three  million  deaths  from  fever,  a  large  proportion  of  which  were  from  ma- 
laria. In  the  months  of  October  and  JSTovember  there  were  307,317  deaths 
from  the  disease.  In  Burma  and  Assam  severe  types  are  met  with.  In  Africa 
the  malarial  fevers  form  the  great  obstacle  to  European  settlements  on  the 
coast  and  along  the  river  basins.  The  ilacJc-ivater  or  West  African  fever  of 
the  Gold  Coast  is  a  very  fatal  type  of  malarial  haemoglobinuria.  The  Atlantic 
coast  line  of  Central  America  is  severely  infected,  and  the  Isthmus  of  Panama 
for  centuries  was  known  as  the  "white  man's  grave."  In  the  tropics  there  are 
minimal  and  maximal  periods,  the  former  corresponding  to  the  summer  and 
winter,  the  latter  to  the  spring  and  autumn  months. 

Etiology:  The  Parasite. — History. — Parasites  of  the  red  blood  corpuscles 
— hgemocytozoa — are  very  widespread  throughout  the  animal  series.  They  are 
met  with  in  the  blood  of  frogs,  fish,  birds,  and  among  mammals  in  monkeys, 
bats,  cattle,  and  man.  In  birds  and  in  frogs  the  parasites  appear  to  do  no 
harm  except  when  present  in  very  large  numbers. 

In  1880  Laveran,  a  French  army  surgeon  stationed  at  Algiers,  noted  in 
the  blood  of  patients  with  malarial  fever  pigmented  bodies,  which  he  re- 
garded as  parasites,  and  as  the  cause  of  the  disease.  Richard,  another  French 
army  surgeon,  confirmed  these  observations.  In  1885  Marchiafava  and  Celli 
described  the  parasites  with  great  accuracy,  and  in  the  same  year  Golgi  made 
the  all-important  observation  that  the  paroxysm  of  fever  invariably  coincided 
with  the  sporulation  or  segmentation  of  a  group  of  the  parasites.  In  the  fol- 
lowing year  (1886)  Laveran's  observations  were  brought  before  the  profes- 
sion of  the  United  States  by  Sternberg.  Councilman  and  Abbott  had  already, 
in  the  previous  year,  described  the  remarkable  pigmented  bodies  in  the  red 
blood  corpuscles  in  the  blood  vessels  of  the  brain  in  a  fatal  case,  and  in  1886 
Councilman  confirmed  the  observations  of  Laveran  in  clinical  cases.  Stim- 
ulated by  his  work,  the  senior  author  began  studying  the  malarial  cases  in  the 
Philadelphia  Hospital,  and  soon  became  convinced  of  the  truth  of  Laveran's 


844  SPECIFIC  INFECTIOUS  DISEASES 

discovery^  and  was  able  to  confirm  Golgi's  statement  as  to  the  coincidence  of 
the  sporulation  with  the  paroxysm.  The  work  was  taken  up  actively  in  the 
United  States  by  Walter  James,  Dock,  Koplik,  Thayer,  Hewetson,  and  others, 
and  in  a  number  of  subsequent  communications  the  extraordinary  clinical  im- 
portance of  Laveran's  discovery  was  emphasized.* 

Among  British  observers,  Vandyke  Carter  alone,  in  India,  seems  to  have 
appreciated  at  an  early  date  the  profound  significance  of  Laveran's  work. 

The  next  important  observation  was  the  discovery  by  Golgi  that  the  para- 
site of  quartan  malarial  fever  differed  from  the  tertian.  From  this  time  on 
the  Italian  observers  took  up  the  work  with  great  energy,  and  in  1889  Marchia- 
fava  and  Celli  determined  that  the  organism  of  the  severer  forms  of  malarial 
fever  differed  from  the  parasite  of  the  tertian  and  quartan  varieties. 

The  connection  of  insects  with  the  disease  is  an  old  story  suggested  in 
Eoman  times  and  revived  by  John  Crawford,  of  Baltimore  (1807),  King  of 
Washington,  and  settled  finally  by  Eoss. 

The  idea  that  fever  was  transmitted  by  the  bite  of  the  mosquito  prevailed 
widely  in  the  West  Indies  and  in  the  Southern  States.  The  important  role 
played  by  insects  as  an  intermediate  host  had  been  shown  in  the  case  of  the 
Texas  cattle  fever,  in  which  Theobald  Smith  demonstrated  that  the  hsema- 
tozoa  developed  in,  and  the  disease  was  transmitted  by,  ticks;  but  it  remained 
for  Manson  to  formulate  in  a  clear  and  scientific  way  the  theory  of  infection 
m  malaria  by  the  mosquito.  Impressed  with  the  truth  of  this,  Eoss  studied 
the  problem  in  India,  and  showed  that  the  parasites  develo^Ded  in  the  bodies 
of  the  mosquitoes,  demonstrating  conckisively  that  the  infection  in  birds  was 
transmitted  by  the  mosquito.  W.  G.  MacCallum  suggested  that  the  flagella 
were  sexual  elements,  and  observed  the  process  of  fertilization  by  them. 
Studies  by  Grassi,  Bastianelli  and  Bignami,  and  many  others,  confirmed  the 
observations  of  Eoss  and  demonstrated  the  fact  that  the  malarial  parasites  of 
human  beings  develop  only  in  mosquitoes  of  the  genus  anopheles. 

Then  came  the  practical  demonstration  by  Italian  observers,  and  by  the 
interesting  experiments  on  Manson,  Jr.,  of  the  direct  transmission  of  the 
disease  to  man  by  the  bite  of  infected  mosquitoes.  And  lastly,  as  a  practical 
conclusion  of  the  whole  matter,  the  anti-malarial  campaigns  so  energetically 
advocated  and  carried  out  by  Eoss  have  shown  tliat  by  protecting  the  individual 
from  the  bites  of  mosquitoes,  by.  exterminating  the  insects,  or  by  carefully 
treating  all  patients  so  that  no  opportunity  may  be  offered  for  the  parasite  to 
enter  the  mosquito,  malaria  may  be  eradicated  from  any  locality. 

The  Paeasite. — Belonging  to  the  sporozoa,  it  has  received  a  large  num- 
ber of  names.  The  term  Plasmodium,  inapt  though  it  may  be,  must,  accord- 
ing to  the  rules  of  zoological  nomenclature,  be  applied  to  the  human  parasite. 
There  are  three  well-marked  varieties  which  exist  in  two  separate  phases  or 

*  Tlie  following  references  to  work  on  malaria  which  has  been  done  in  connection 
with  the  Hopkins  clinic,  chiefly  under  the  supervision  of  Professor  Thayer,  may  be 
of  interest:  Phila.  Med.  Times",  1886;  British  Med.  Jour.,  March,  1887  ^Med.  News, 
1889,  vol.  i;  Johns  Hopkins  Hosp.  Bull.,  1889;  the  first  edition  of  this  Text-Book  of 
Medicine,  1892;  Thayer  and  Hewetson,  Johns  Hopkins  Hosp.  Rep.,  1895;  Thayer, 
Lectures  on  Malarial  Fever,  1897 ;  W.  G.  MacCallum,  HiBmatozoa  of  Birds,  Jour!  ol 
Exp.  Med.,  1898;  Opie,  on  the  Haeraatozoa  of  Birds,  1898;  Barker,  on  Fatal  Cases  of 
Malaria,  Johns  Hopkins  Hosp.  Rep.,  1899;  MacCallum,  on  the  Significance  of  the 
Flagella,  Lancet,  1897;  Thayer,  Trans.  Am.  Med.  Con.,  yol.  iv,  1900;  Lazear,  Struc- 
ture of  the  Malarial  Parasites,  Johns  Hopkins  Hosp.  Rep.,  1902. 


MALARIAL  FEVER  245 

stages :  (a)  the  parasite  in  man,  who  acts  as  the  intermediate  host,  and  in 
whom,  in  the  C3cle  (asexual)  of  its  development,  it  causes  symptoms  of  ma- 
laria; and  (b)  an  extracorporeal  cycle  (sexual),  in  which  it  lives  and  de- 
velops in  the  body  of  the  mosquito,  Avhich  is  its  definitive  host.  The  parasites 
have  been  grown  in  artificial  media  (Bass). 

(a)  The  Parasite  in  Man. —  (1)  The  Parasite  of  Tertian  Fever  {Plasmo- 
dium, vivax). — The  earliest  form  seen  in  the  red  blood  corpuscle  is  round  or 
irregular  in  shape,  about  2  fx  in  diameter  and  unpigmented.  It  corresponds 
very  much  in  appearance  with  the  segments  of  the  rosettes  formed  during  the 
chill.  A  few  hours  later  the  body  has  increased  in  size,  is  still  ring-shaped, 
and  there  is  pigment  in  the  form  of  fine  grains.  It  has  a  relatively  large 
nuclear  body,  consisting  of  a  Avell-defined,  clear  area,  in  part  almost  transpar- 
ent, in  part  consisting  of  a  milk-white  substance,  in  which  there  lies  a  small, 
deeply  staining  chromatin  mass.  At  this  period  it  usually  shows  active 
amoeboid  movements,  with  tongue-like  protrusions.  The  pigment  increases  in 
amount  and  the  corpuscle  becomes  larger  and  paler,  owing  to  a  progressive 
diminution  of  its  haemoglobin.  There  is  a  gradual  growth  of  the  parasite, 
whicb,  toward  the  end  of  forty-eight  hours,  occupies  almost  all  of  the  swollen 
red  corpuscle.  It  is  now  much  pigmented,  and  is  in  the  stage  of  what  is  often 
called  the  full-girown  parasite.  Between  the  fortieth  and  fort}-eiglith  hours 
many  of  the  parasites  are  seen  to  have  undergone  the  change  known  as  seg- 
mentation, in  which  the  pigment  becomes  collected  into  a  single  mass  or 
block,  and  the  protoplasm  divides  into  a  series  of  from  fifteen  to  twenty 
spores,  often  showing, a  radial  arrangement.  Certain  full-grown  tertian  para- 
sites, however,  do  not  undergo  segmentation.  These  forms,  which  are  larger 
than  the  sporulating  bodies,  and  contain  very  actively  dancing  pigment  gran- 
ules, represent  the  sexually  differentiated  form  of  the  parasite — gametocytes. 

(2)  The  Parasite  of  Quartan  Fever  {Plasmodium  malarice). — The  earliest 
form  is  very  like  the  tertian  in  appearance,  but  as  it  increases  in  size  the 
earlier  granules  are  coarser  and  darker  and  the  movement  is  not  nearly  so 
marked.  By  the  second  day  the  parasite  is  still  larger,  rounded  in  shape, 
scarcely  at  all  amoeboid,  and  the  pigment  is  more  often  arranged  at  the  per- 
iphery of  the  parasite.  The  rim  of  protoplasm  about  it  is  often  of  a  deep  yel- 
lowish-green color  or  of  a  dark  brassy  tint.  On  the  third  day  the  segmenting 
bodies  become  abundant,  the  pigment  flowing  in  toward  the  centre  of  the 
parasite  in  radial  lines  so  as  to  give  a  star-shaped  appearance.  The  parasites 
finally  break  up  into  from  six  to  twelve  segments.  Here  also,  as  in  the  case 
of  the  tertian  parasite,  some  full-grown  bodies  persist  without  sporulating, 
representing  the  gametocytes. 

(3)  The  Parasite  of  the  ^Estivo- Autumnal  Fever  {Plasmodium  falci- 
parum).— This  parasite  is  considerably  smaller  than  the  other  varieties;  at 
full  development  it  is  often  less  than  one-half  the  size  of  a  red  blood  corpuscle. 
The  pigment  is  much  scantier,  often  consisting  of  a  few  minute  granules.  At 
first  only  the  earlier  stages  of  development,  small,  hyaline  bodies,  sometimes 
with  one  or  two  pigment  granules,  are  to  be  found  in  the  peripheral  circula- 
tion; the  later  stages  are  ordinarily  to  be  seen  only  in  the  blood  of  certain 
internal  organs,  the  spleen  and  bone  marrow  particularly.  Some  workers  be- 
lieve that  there  are  two  varieties  of  this  form,  tertian  and  quotidian.  The 
corpuscles  containing  the  parasites  become  not  infrequently  shrunken,  ere- 


-/ 
246  SPECIFIC  mFECTIOUS  DISEASES 

nated,  and  brassy-colored.  After  the  process  has  existed  for  about  a  week, 
larger,  refractive,  erescentic,  ovoid,  and  round  bodies,  with  central  clumps  of 
coarse  pigment  granules,  begin  to  appear.  These  bodies  are  characteristic  of 
sestivo-autumnal  fever.  The  erescentic  and  ovoid  forms  are  incapable  of 
sporulation;  they  are  analogous  to  the  large,  full-grown,  non-sporulating 
bodies  of  the  tertian  and  quartan  parasites  which  have  been  mentioned  above, 
and  represent  sexually  differentiated  forms — gametocytes.  Within  the  human 
host  they  are  incapable  of  further  development,  but  upon  the  slide,  or  within 
the  stomach  of  the  normal  intermediate  host,  the  mosquito,  the  male  elements 
(micro-gametocytes)  give  rise  to  a  number  of  long,  actively  motile  flagella 
(micro-gametes)  which  break  loose,  penetrating  and  fecundating  the  female 
forms — macro-gametes  (W.  G.  MacCallum).  The  fecundated  female  form 
enters  into  the  stomach  wall  of  the  intermediate  host,  the  mosquito,  where  it 
undergoes  a  definite  cycle  of  existence. 

(b)  The  Parasite  within  the  Body  of  the  Mosquito. — The  brilliant  re- 
searches of  Eoss,  followed  by  the  work  of  Grassi,  Bastianelli,  Bignami, 
Stephens,  Christophers,  and  Daniels,  have  proved  that  a  certain  genus  of 
mosquito — anopheles — is  not  only  the  intermediate  host  of  the  malarial  para- 
site, but  also  the  sole  source  of  infection.  The  more  common  genera  of 
mosquito  in  temperate  climates  are  culex  and  anopheles.  The  different 
species  of  culex  form  the  great  majority  of  our  ordinary  house  mosquitoes,  and 
are  apparently  incapable  of  acting  as  hosts  of  the  malarial  parasite.  All 
malarial  regions,  however,  which  have  been  investigated  contain  anopheles. 
Although  this  is  apparently  a  positive  rule,  anopheles  may,  however,  be 
present  without  the  existence  of  malaria  under  two  circumstances:  first, 
when  the  climate  is  too  cold  for  the  development  of  the  malarial  parasite ; 
and  secondly,  in  a  region  which  has  not  yet  been  infected.  So  far  as  is 
known,  the  parasite  exists  only  in  the  mosquito  and  in  man. 

A  large  number  of  species  of  anopheles  have  been  described  in  different 
parts  of  the  world.  In  North  America,  the  commonest  variety,  and  that 
which  in  all  probability  is  most  concerned  in  the  spread  of  the  disease,  is 
A.  maculipennis,  which  is,  also,  the  most  important  agent  in  the  spread 
of  the  disease  in  Europe.  The  culex  lays  its  eggs  in  sinks,  tanks,  cisterns, 
and  any  collection  of  water  about  or  in  houses,  while  the  anopheles  lays 
its  eggs  in  small,  shallow  puddles  or  slowly  running  streams,  especially  those 
in  which  certain  forms  of  algge  exist.  The  culex  is  essentially  a  city  mosquito, 
the  anopheles  a  country  insect. 

Evolution  in  the  Body  of  the  Mosquito. — When  a  mosquito  of  the  genus 
anopheles  bites  an  individual  whose  blood  contains  sex-ripe  forms  (gameto- 
cytes) of  the  malarial  parasite,  flagellation  and  fecundation  of  the  female 
element  occur  within  the  stomach  of  the  insect.  The  fecundated  element 
then  penetrates  the  wall  of  the  mosquito's  stomach  and  begins  a  definite  cycle 
of  development  in  the  m.uscular  coat.  Two  days  after  biting  there  begin  to 
appear  small,  round,  refractive,  granular  bodies  in  the  stomach  wall  of  the 
mosquito,  which  contain  pigment  granules  clearly  identical  with  those  pre- 
viously contained  in  the  malarial  parasite.  These  develop  until  at  the  end 
of  seven  days  they  have  reached  a  diameter  of  from  60  to  70  [x.  At  this 
period  they  may  be  observed  to  show  a  delicate  radial  striation  due  to  the 
presence  of  great  numbers  of  small  sporoblasts.     The  mother  oocyst  (zygote) 


MALARIAL  FEVEE  247 

then  bursts,  setting  free  into  the  body  cavity  of  the  mosquito  an  enormous 
number  of  delicate  spindle-shaped  sporozoids.  These  accumulate  in  the  cells 
of  the  veneno-salivary  glands  of  the  mosquito,  and,  escaping  into  the  ducts, 
are  inoculated  with  subsequent  bites  of  the  insect.  These  little  spindle-shaped 
sporozoids  develop,  after  inoculation  into  the  warm-blooded  host,  into  fresh 
young  parasites.  The  sporozoid  which  has  developed  in  the  oocyst  in  the 
stomach  wall  of  the  mosquito  is  then  the  equivalent  of  the  spore  resulting 
from  the  asexual  segmentation  of  the  full-grown  parasite  in  the  circulation. 
Either  one,  on  entering  a  red  blood  corpuscle,  may  give  rise  to  the  asexual 
or  sexual  cycle.  As  a  rule  the  first  several  generations  of  parasites  in  the 
human  body  pursue  the  asexual  cycle,  the  sexual  forms  developing  later. 
These  sexual  forms,  sterile  while  in  the  human  host,  serve  as  the  means  of 
preserving  the  life  of  the  parasite  and  spreading  infection  when  the  in- 
dividual is  subjected  to  bites  of  anopheles. 

Morbid  Anatomy. — The  changes  result  from  the  disintegration  of  the 
red  blood  corpuscles,  accumulation  of  the  pigment  thereby  formed,  and  poi3- 
sibly  the  influence  of  toxic  materials  produced  by  the  parasite.  Cases  of 
simple  malarial  infection  are  rarely  fatal,  and  our  knowledge  of  the  morbid 
anatomy  is  drawn  from  the  pernicious  malaria  or  the  chronic  cachexia. 
Rupture  of  the  enlarged  spleen  may  occur  spontaneously,  but  more  com- 
monly from  trauma.  Fatal  hemorrhage  has  followed  the  exploratory  puncture 
of  an  enlarged  malarial  spleen. 

Pernicious  Malaria. — The  blood  is  hydrsemic  and  the  serum  may  even 
be  tinged  with  haemoglobin.  The  red  blood  corpuscles  present  the  endo- 
globular  forms  of  the  parasite  and  are  in  all  stages  of  destruction.  The 
capillaries  of  the  brain  may  be  filled  by  masses  of  red  cells  and  parasites,  often 
forming  thrombi.  The  spleen  is  enlarged,  often  only  moderately;  thus, 
of  two  fatal  cases  the  spleens  measured  13X8  cm.  and  1-1X8  cm.  respectively. 
In  a  fresh  infection  the  spleen  is  usually  very  soft,  and  the  pulp  lake-colored 
and  turbid.     The  liver  is  swollen  and  turbid. 

In  some  acute  pernicious  cases  with  choleraic  symptoms  the  capillaries 
of  the  gastro-intestinal  mucosa  may  be  packed  with  parasites. 

Malarial  Cachexia. — In  fatal  cases  of  chronic  paludism  death  occurs 
usually  from  anaemia  or  the  haemorrhage  associated  with  it.  The  anaemia  is 
profound,  particularly  if  the  patient  has  died  of  fever. 

The  spleen  may  weigh  from  five  to  ten  pounds.  The  liver  may  be  greatly 
enlarged,  and  presents  to  the  naked  eye  a  grayish-brown  or  slate  color,  due 
to  the  large  amount  of  pigment.  In  the  portal  canals  and  beneath  the  cap- 
side  the  connective  tissue  is  impregnated  with  melanin.  The  pigment  is 
seen  in  the  KupfEer's  cells  and  the  perivascular  tissue.  The  kidneys  may  be 
enlarged  and  present  a  grayish-red  color,  or  areas  of  pigmentation  may  be 
seen.  The  peritoneum  is  usually  of  a  deep  slate  color.  The  mucous  mem- 
brane of  the  stomach  and  intestines  may  have  the  same  hue,  due  to  the  pig- 
ment in  and  about  the  blood-vessels.  In  some  cases  this  is  confined  to  the 
lymph  nodules  of  Peyer's  patches,  causing  the  shaven-beard  appearance. 

The  Accidental  and  Late  Lesions  of  Malarial  Fever. —  (a)  The 
Liver. — Paludal  hepatitis  plays  a  very  important  role  in  the  history  of 
malaria,  as  described  by  French  writers.     Only  those  cases  ui  which  the  his- 


248  SPECIFIC  INFECTIOUS  DISEASES 

tory  of  chronic  malaria  is  definite,  and  in  wliicli  tlie  melanosis  of  both  liver 
and  spleen  coexist,  should  be  regarded  as  of  paludal  origin. 

(5)  Pneumonia  is  believed  by  many  authors  to  be  common  in  malaria, 
and  even  to  depend  directly  upon  the  malarial  parasite,  occurring  either  in' 
the  acute  or  in  the  chronic  forms  of  the  disease. 

(c)  Nephritis. — Moderate  albuminuria  is  a  frequent  occurrence,  having 
occurred  in  46.4:  per  cent,  of  the  cases  in  the  Hopkins  Hospital,  Acute 
nephritis  is  relatively  frequent  in  eestivo-autumnal  infections,  having  occurred 
in  over  4.5.  per  cent,  of  our  cases.  Chronic  nephritis  occasionally  follows 
long-continued  or  frequently  repeated  infections. 

Clinical  Forms  of  Malarial  Fever. — The  relative  frequency  of  the  differ- 
ent forms  varies  in  different  regions.  The  tertian  is  the  most  common  in 
temperatie  regions,  the  a?stivo-autumnal  in  the  tropics,  the  quartan  is  every- 
where rare  except  in  certain  parts  of  India.  In  the  Canal  Zone  the  relative 
frequency  of  the  different  forms  from  1904  to  January  1st,  1910,  was  as 
follows:  sestivo-autumnal,  22,089;  tertian,  8,013;  mixed  infections,  677,  and 
quartan,  20  cases.  The  quartan  is  relatively  much  more  frequent  in  Balti- 
more; of  1,618  cases  of  malaria,  there  were  15  instances  (Thayer). 

I.  The  Eegularly'  Intermittent  Fevees. —  (a)  Tertian  fever;  (&) 
quartan  fever.  These  forms  are  characterized  by  recurring  paroxysms,  in 
which,  as  a  rule,  chill,  fever,  and  sweat  follow  each  other  in  orderly 
sequence.  The  stage  of  incubation  is  not  definitely  known ;  it  probably  varies 
much  according  to  the  amount  of  the  infectious  material  absorbed.  Ex- 
perimentally the  period  of  incubation  varies  from  thirty-six  hours  to  fifteen 
days,  being  a  trifle  longer  in  quartan  than  in  tertian  infections.  Attacks  have 
been  reported  within  a  very  short  time  after  the  apparent  exposure.  On 
the  other  hand,  'the  infection  may  be,  as  is  said,  "in  the  system,"  and  the 
patient  -may  have  a  paroxysm  months  after  he  has  removed  from  a  malarial 
region,  though  of  course  this  can  not  be  the  case  unless  he  has  had  the 
disease  when  living  there. 

Description  of  the  Paroxysm. — The  patient  generally  knows  he  is  going 
to  have  a  chill  a  few  hours  before  its  advent  by  unpleasant  feelings  and  un- 
easy sensations,  sometimes  by  headache.  The  paroxysm  is  divided  into  three 
stages — cold,  hot,  and  sweating. 

Cold  Stage. — The  onset  is  indicated  by  a  feeling  of  lassitude  and  a  desire 
to  yawn  and  stretch,  by  headache,  uneasy  sensations  in  the  epigastrium,  some- 
times by  nausea  and  vomiting.  Even  before  the  chill  begins  the  thermometer 
indicates  a  rise  in  temperature.  Gradually  the  patient  begins  to  shiver,  the 
face  looks  cold,  and  in  the  fully  developed  rigor  the  whole  body  shakes,  the 
teeth  chatter,  and  the  movements  may  often  be  violent  -enough  to  shake  the 
bed.  Not  only  does  the  patient  look  cold  and  blue,  but  a  surface  ther- 
mometer will  indicate  a  reduction  of  the  skin  temperature.  On  the  other 
hand,  the  axillary  or  rectal  temperature  may,  during  the  chill,  be  greatly 
increased,  and,  as  shown  in  the  chart,  the  fever  may  rise  meanwhile  even  to 
105°  or,  106°.  Of  symptoms  associated  with  the  chill,  nausea  and  vomiting 
are  common.  There  may  be  intense  headache.  The  pulse  is  quick,  small, 
and  hard.  The  urine  is  increased  in  quantity.  The  chill  lasts  for  a  variable 
time,  from  ten  or  twelve  minutes  to  an  hour,  or  even  longer. 

The  hot  stage  is  ushered  in  by  transient  flushes  of.  heat;  gradually  the 


MALARIAL  FEA'ER 


249 


coldness  of  the  surface  disappears  and  the  skin  becomes  intensely  hot.  The 
contrast  in  the  patient's  appearance  is  striking:  the  face  is  flushed,  the  hands 
congested,  the  skin  reddened,  the  pulse  full  and  bounding,  the  heart's 
action  forcible,  and  the  patient  may  complain  of  a  throbbing  headache. 
There  may  be  active  delirium.     One  patient  in  this  stage  jumped  through 


Day 

Oct.  3    \                  I,                    1                  5                     \        Q 

n 

106 
105 

S.103 

^102 
a,     o 
nioi 

^100 
99 
98 

97 
96 

a; 

?':'^^j^j^  =  ^=i  =  ?^  =  ^='j  =  5j^?  ?'^N 

.[ 

s= 

s 

2 

- 

:    :    1 

;  1 

i 

1 

■ 

- 

- 

- 

_jj 

^1 

3 
o 

S"" 

ft 

' 

11 

i 

- 

- 

' 

■ 

i\ 

jl  I 

/ 

J 

1 

\ 

1 

. 

" 

~ 

/ 

V 

■ 

A  I 

1 

V 

\  i 

\ 

—'— 

rS' 

-L 

- 

- 

- 

- 

J 

— 

- 

_ 

_ 

^ 



I 

.__'_ 

_ 

-^ 

- 

-=•, 

■[*■ 

.* 

=" 

p*. 

V 

- 

^ 

- 

'  ^ 

:7 

!*> 

=^ 

^r 

^-X 

=• 

1 

' 

-^ 

j 

\z.  r 

~ 

V 

• 

'" 

_ 

_ 

j_ 

U 

_ 

u 

_ 

_ 

_ 

_ 

Chart  Via. — Double  Tertian  Infection. — Quotidian  Fe\'ee. 

a  window  and  sustained  fatal  injuries.  The  rectal  temperature  may  not 
increase  much  during  this  stage;  in  fact,  by  the  termination  of  the  chill 
the  fever  may  have  reached  its  maximum.  The  duration  of  the  hot  stage 
varies  from  half  an  hour  to  three  or  four  hours..  The  patient  is  intensely 
thirsty  and  drinks  eagerly  of  cold  water. 


July  19                    20                            21                             22                             23                            24                | 

106° 
105 

U         0 

§104^ 
fel03 
£l02 

gioi 

■-100 
99° 
98° 
97° 
96° 

i 

E 

S 

s 

s 

_-  E 

< 

s 

< 

E 

k 

MlJ^kbyi 

£ 

I 

b 

f 

s 

£ 

<  < 

i 
< 

< 

z 

£ 

£ 

■z 

s 

•2. 

■  < 

< 

£ 

< 

£ 

z 

E 

£ 

E 

S 

E 

ii 

< 

< 

s 

< 

f 

E 

E 

E 

e' 

1 

1 ,1 

[o 

- 

l— 

It' 

]- 

1- 

lo! 

< 

s 

liL 

-1 

G 

y 

in 

-J] 

1 

o 

Iti 

0-1 

r  1' 

CO 

!■ 

3 

□ 

z 

-|   ■ 

-? 

J 

' 

f 

1  '^ 

G 

V 1 

J 

i 

/ 

1 

' 

, 

f 

S: 

J 

V 

s 

- 

= 

* 

1 

.k 

S" 

— 

_ 

— 

— 

_ 

— 

_ 

r 

- 

- 

— 

- 

L 

-A 

r 

L 

- 

- 

- 

_ 

9 

1 

= 

J. 

r^ 

- 

- 

= 

= 

y 

=1: 

f 

- 

- 

— 

_,_ 

SAi^-r 

V-r 

^XvA-^^ 

r 

\- 

■- 

- 

r- 

- 

>, 

S^ 

A 

V 

A 

^ 

^ 

^ 

V 

^.. 

I 

V 

"i  1  \/ ' 

' 

1 

|V 

1 

~1 

V 

... 

L 

_ 

_ 

_ 

1 

- 

^ 

L 

_ 

^ 

_i 

Chart  Ylb. — Quartan  Fever. 

Sweating  Stage. — Beads  of  perspiration  appear  upon  the  face  and  grad- 
ually the  entire  body  is  bathed  in  a  copious  sweat.  The  uncomfortable  feel- 
ing associated  with  the  fever  disapi^ears,  the  headache  is  relieved,  and  withiji 
an  hour  or  two  the  paroxysm  is  over  and  the  patient  usually  sinks  into  a 
refreshing  sleep.  The  sweating  varies  much.  It  may  be  drenching  in  char- 
acter or  it  may  be  slight. 

Chart  Via  is  from  a  case  of  double  tertian  infection  Avith  resulting  quo- 


250 


SPECIFIC  INFECTIOUS  DISEASES 


tidian  paroxysms.     Chart  Ylb  shows  a  quartan  ague.     Charts  Vic  and  Yld 
give  temperature  curves  in  sestivo-autumnal  forms. 


October      84                                           5                                            6                           | 

109° 
10S° 
107° 
100° 
105 

HI            0 

^  104 

i  ^°^° 

1  102° 

100° 
99 

98 
97° 
90° 

s 

2 

s 

E 

F    ^ 

E 

£ 

£ 

E 

,• 

E 

S 

E 

£ 

£ 

^  s 

2 

£ 

£ 

£ 

=^1  = 

E 

£ 

£ 

? 

.■u 

E 

£ 

E 

=• 

^ 

s 

E 

E 

s 

= 

J    2 

M 

0 

J,    < 

< 

< 

* 

0 

« 

J); 

m 

0 

w  < 

< 

< 

S 

0 

S 

„ 

^ 

s 

£ 

7«'  < 

< 

S 

s  ^ 

JJ; 

Iri 

0 

:.    * 

X 

■* 

o 

l- 

(- 

> 

■z- 

0 

a 

s; 

r 

M 

> 

s 

D 

A 

m 

< 

r^ 

/\ 

'\ 

UJ 

n 

ff 

'\ 

y 

; 

\ 

«\ 

7 

\ 

s^ 

'I 

:d 

J>* 

I 

\ 

1/ 

\ 

f 

w 

- 

'^^ 

ri 

If 

\ 

N 

I 

\ 

^ 

1 

V 

1 

1 

I 

^ 

\ 

r 

V 

1 

\ 

/ 

'i 

/ 

\ 

1 

A 

/ 

\ 

/ 

\ 

^ 

1 

\ 

' 

1 

/ 

A 

\ 

^ 

\ 

/ 

\y 

/ 

^ 

\ 

/ 

V 

' 

r- 

~ 

pj" 

— 

■ 

~ 

1 

Chart  Vie. — ^^stivo-Autumnaii  Fever. — Quotidian  Paroxysms. 

The  total  duration  of  the  paroxysm  averages  from  ten  to  twelve  hours, 
but  may  be  shorter.     Variations-,  in  the  paroxysm  are  common.     Thus  the  pa- 


^  ^ 

".; 

-i 

~ 

.J 

7- 

" 

,• 

.J 

-- 

^ 

" 

1  -^^ 

- 

-] 

^ 

-:•.• 

f  <  < 

<  <  <  = 

=  a. 

^ 

dI 

a. 

.  < 

< 

< 

< 

< 

s 

0; 

d 

=  < 

< 

< 

<  < 

5     IL     C 

s^<  < 

< 

< 

< 

S 

s    < 

< 

<■  <  S 

fi   IN     Tl 

to    CO    0    f 

t  '^ 

* 

lO 

CO 

0  " 

J     CM 

■^ 

(C 

CO 

° 

- 

« 

" 

CO 

CO 

0  l: 

»     OJ 

■^ 

CD 

CO     0 

IN    CM    , 

f    CO    0:   0 

2    OJ    « 

(6 

CO 

° 

cv 

CM 

-* 

.0 

CO 

0  r 

M    CM 

^ 

c^ 

CO   0    fM 

107°|-|L 

- 

X 

" 

'    " 

<!>. 

0 

I 

- 

- 

=T-- 

s 

.^ 

t~? 

3 

K 

s 

S. 

°  r 

= 

h 

^ 

1- 

/ 

3 

^ 

/ 

\ 

i 

_L_ 

g 

\ 

3 

^ 

t 

c 

/ 

V 

?■ 

'        V 

.*, 

1 

2^""^  V 

A 

E 

/ 

\ 

3 

y 

A 

A  \ 

/ 

V 

t 

/ 

V 

^ 

A 

J  \ 

r 

N 

^ 

f 

--     -i 

N 

/ 

s 

/ 

1 

'V 

A 

/ 

\ 

<  1 

n/ 

\yi 

■n 

,    / 

\ 

J^ 

k 

^S 

-^7 

\L/ 

V 

\ 

\ 

aI 

^ 

f^ 

99° 

\. 

^  , 

\y 

■ 

' 

_ 

_ 

__ 

._ 

_ 

Chart  VI^. — ^stivo-Autumnal  Infection. — -Eemittent  Fever. 
The  case  was  treated  for  a  week  as  one  of  typhoid  fever. 

tient  may,  instead  of  a  chill,  experience  only  a  slight  feeling  of  coldness.  The 
most  common  variation  is  the  occurrence  of  a  hot  stage  alone,  or  with  very 
slight  sweating.     During  the  paroxysm  the  spleen  is  enlarged  and  the  edge 


MALAEIAL  FEVER  251 

can  usiially  be  felt  below  the  costal  margin.  In  the  interval  or  intermission 
of  the  paroxysm  the  patient  feels  very  well,,  and,  unless  the  disease  is  unusually 
severe,  he  is  able  to  be  up.  Bronchitis  is  a  common  symptom.  Herpes, 
usually  labial,  is  almost  as  frequent  in  malaria  as  in  pneumonia. 

Types  of  the  Regularly  Intermittent  Fevers. — Two  distinct  types  of  the 
regularly  intermittent  fevers  have  been  separated.  These  are  (a)  tertian  fever 
and  (b)  quartan  fever. 

(a)  Tertian  Fever. — This  type  of  fever  depends  upon  the  presence  in 
the  blood  of  the  tertian  parasite,  an  organism  which  is  usually  present  in 
sharply  defined  groups,  whose  cycle  of  development  lasts  approximately 
forty-eight  hours,  segmentation  occurring  every  third  day.  In  infections 
with  one  group  of  tertian  parasite  the  paroxysms  occur  synchronously 
with  segmentation  at  remarkably  regular  intervals  of  about  forty-eight  hours, 
every  third  day — hence  the  name  tertian.  Very  commonly,  however,  there 
may  be  two  groups  of  parasites  which  reach  maturity  on  alternate  days, 
resulting  thus  in  daily  (quotidian)  paroxysms — double  tertian  infection. 

(b)  Quartan  Fever. — The  symptoms  resemble  those  of  the  tertian  in- 
fection, but  as  a  rule  are  milder.  Paroxysms  appear  on  the  fourth  day  and 
correspond  with  the  evolution  of  a  parasitic  cycle  of  seventy-two  hours.  In 
recent  infections  the  recurrence  of  the  paroxysm  may  be  almost  precisely  the 
same  hour  every  fourth  day.  The  infection  may  be  double,  in  which  case 
there  are  two  paroxysms  followed  by  a  day  of  intermission,  or  triple,  in 
which  there  is  a  daily  paroxysm.  As  pointed  out  by  the  old  Greek  physicians, 
the  quartan  infection  is  very  difficult  to  cure.  Disappearing  for  a  time 
spontaneously,  or  yielding  promptly  to  quinine,  it  has  a  singular  proneness 
to  relapse,  even  after  the  most  energetic  treatment. 

Thus  a  quotidian  intermittent  fever  may  be  due  to  infection  with  either 
the  tertian  or  quartan  parasites. 

Course. — After  a  few  paroxysms,  or  after  the  disease  has  persisted  for 
ten  days  or  two  wgeks,  the  patient  may  get  well  without  any  special 
medication.  The  chills  may  stop  spontaneously.  Eelapses  are  common. 
The  infection  may  persist  for  years,  and  an  attack  may  follow  an  accident, 
an  acute  fever,  or  a  surgical  operation.  A  resting  stage  of  the  parasite 
has  been  suggested  in  explanation  of  these  long  intervals.  Persistence 
of  the  fever  leads  to  anaemia  and  hsematogenous  jaundice,  owing  to  the 
destruction  of  blood  cells.  Ultimately  the  condition  may  become  chronic — 
malarial  cachexia. 

II.  The  More  Irregular^  Eemittent^  or  Continued  Fevers. —  (a) 
J^stivo-auiamnal  Fever. — This  type  of  fever  occurs  in  temperate  climates, 
chiefly  in  the  later  summer  and  autumn;  hence  the  term  given  to  it  by 
Marchiafava  and  Celli,  cestivo -autumnal  fever.  The  severer  forms  of  it  pre- 
vail in  the  Southern  States  and  in  tropical  countries. 

This  type  of  fever  is  associated  with  the  presence  in  the  blood  of  the 
a'stivo-autumnal  parasite,  an  organism  the  length  of  whose  cycle  of  develop- 
ment, ordinarily  about  forty-eight  hours,  is  probably  subject  to  considerable 
variations,  while  the  existence  of  multiple  groups  of  the  parasite,  or  the 
absence  of  arrangement  into  definite  groups,  is  not  infrequent. 

The  symptoms  are  therefore,  as  might  be  expected,  often  irregular.  In 
some  instances  there  may  be  regular  intermittent  fever  occurring  at  uncer- 


252  SPECIFIC  I^NFECTIOUS  DISEASES 

tain  intervals  of  from  twenty-four  to  forty-eight  hours,  or  even  more.  In 
the  cases  with  longer  remissions  the  paroxysms  are  longer.  Some  of  the 
quotidian  intermittent  cases  may  closely  resemble  the  quotidian  fever  depend- 
ing upon  double  tertian  or  triple  quartan  infection.  Commonly,  however, 
the  paroxysms  show  material  differences;  their  length  averages  over  twenty 
hours,  instead  of  from  ten  to  twelve;  the  onset  occurs  often  without  chills 
and  even  without  chilly  sensations.  The  rise  in  temperature  is  frequently 
gradual  and  slow,  instead  of  sudden,  while  the  fall  may  occur  by  lysis  instead 
of  by  crisis.  There  may  be  a  marked  tendency  toward  anticipation  in  the 
paroxysms,  while  frequently,  from  the  anticipation  of  one  paroxysm  or  the 
retardation  of  another,  more  or  less  continuous  fever  may  result.  Some- 
times there  is  continuous  fever  without  sharp  paroxysms.  In  these  cases  of 
continuous  and  remittent  fever  the  patient,  seen  fairly  early  in  the  disease, 
has  a  flushed  face  and  looks  ill.  The  tongue  is  furred,  the  pulse  is  full  and 
bounding,  but  rarely  dicrotic.  The  temperature  may  range  from  102°  to 
103°,  or  is  in  some  instances  higher.  The  general  appearance  of  the  patient 
is  strongly  suggestive  of  typhoid  fever — a  suggestion  still  further  borne  out 
by  the  existence  of  acute  splenic  enlargement  of  moderate  grade.  As  in 
intermittent  fever,  an  initial  bronchitis  may  be  present.  The  course  of  these 
cases  is  variable.  The  fever  may  be  continuous,  with  remissions  more  or 
less  marked ;  definite  paroxysms  with  or  without  chills  may  occur,,  in  which 
the  temperature  rises  to  105°  or  106°  F.  Intestinal  symptoms  are  usually 
absent.  A  slight  haematogenous  jaundice  may  arise  early.  Delirium  of  a 
mild  type  may  occur.  The  cases  vary  very  greatly  in  severity.  In  some  the 
fever  subsides  at  the  end  of  the  week,  and  the  practitioner  is  in  doubt 
whether  he  has, had  to  do  with  a  mild  typhoid  or  a  simple  febricula.  In 
other  instances  the  fever  persists  for  from  ten  days  to  two  weeks;  there  are 
marked  remissions,  perhaps  chills,  with  a  furred  tongue  and  low  delirium. 
Jaundice  is  not  infrequent.  These  are  the  cases  to  which  the  terms  bilious 
remittent  and  typlio-malarial  fevers  are  applied.  In  other  instances  the 
symptoms  become  grave  and  assume  the  character  of  the  pernicious  type.  It 
is  in  this  form  of  malarial  fever  that  so  much  confusion  exists.  The 
similarity  of  the  cases  to  typhoid  fever  is  striking,  more  particularly  the 
appearance  of  the  facies;  the  patient  loolis  very  ill.  The  cases  occur,  too, 
in  the  autumn,  at  the  very  time  when  typhoid  fever  occurs.  The  fever  yields, 
as  a  rule,  promptly  to  quinine,  though  cases  are  met  with — rarely  indeed 
in  our  experience — -which  are  refractory.  Several  of  the  charts  in  Thayer 
and  Hewetson's  monograph  show  how  closely,  in  some  instances,  the  disease 
may  simulate  typhoid  fever. 

The  diagnosis  may  be  definitely  made  by  the  examination' of  the  blood. 
Eepeated  examinations  at  short  intervals  may  be  required  before  the  para- 
sites are  found.  The  small,  actively  motile,  hyaline  forms  of  the  ffistivo- 
autumnal  parasite  are  to  be  found,  while,  if  the  course  has  been  over  a  week, 
the  larger  crescentic  and  ovoid  bodies  are  often  seen.  In  many  cases  one  is 
unable  to  distinguish  between  typhoid. and  continued  malarial  fever  without 
a  blood  examination. 

(6)  Pernicious  Malarial  Fever. — This  is  fortunately  rare  in  temperate 
climates,  and  the  number*  of  cases  which  now  occur,  for  example,  in  Phila- 
delphia and  Baltimore,  is  very  much  less  than  it  was  thirty  or  forty  years 


MALAETAL  FEVER  253 

ago.     Pernicious  fever  is  always  associated  with  the  ffistivo-autumnal  parasite. 
The  following  are  the  most  important  types : 

(1)  Comatose  Form. — In  this  the  patient  is  struck  down  with  symptoms 
of  the  most  intense  cerehral  disturhance,  either  acute  delirium  or,  more  fre- 
quentl}^,  a  rapidly  developing  coma.  A  chill  may  or  may  not  precede  the 
attack.  The  fever  is  usually  high,  and  the  skin  hot  and  dry.  The  uncon- 
sciousness may  persist  for  from  twelve  to  twenty-four  hours,  or  the  patient 
may  sink  and  die.  After  regaining  consciousness  a  second  attack  may 
come  on  and  prove  fatal.  In  these  instances  the  special  localization  of  the 
infection  is  in  the  brain,  where  actual  thrombi  of  parasites  with  marked 
secondary  changes  in  the  surrounding  tissues  have  been  found. 

(2)  Algid  Form. — In  this  the  attack  sets  in  usually  with  gastric  symp- 
toms; there  are  vomiting,  intense  prostration,  and  feebleness  out  of  all  pro- 
portion to  the  local  disturbance.  The  patient  complains  of  feeling  cold, 
although  there  may  be  no  actual  chill.  The  temperature  may  be  normal, 
or  even  subnormal;  consciousness  may  be  retained.  The  pulse  is  feeble  and 
small,  and  the  respirations  are  increased.  There  may  be  most  severe  diar- 
rhoea, the  attack  assuming  a  choleriform  nature.  The  urine  is  often  dimin- 
ished, or  even  suppressed.  This  condition  may  persist  with  slight  exacerba- 
tions of  fever  for  several  days  and  the  patient  may  die  in  a  condition  of 
profound  asthenia.  This  is  essentially  the  same  as  described  as  the  asthenic 
or  adynamic  form  of  the  disease.  In  the  cases  with  vomiting  and  diarrhoea 
the  gastro-intestinal  mucosa  is  often  the  seat  of  a  special  invasion  by  the 
parasites,  actual  thrombosis  of  the  small  vessels  with  superficial  ulceration 
and  necrosis  occurring. 

(3)  Hasmorrhagic  Forms — Black-water  Fever — Hsemoglobinuric  Fever — 
Malarial  Hemoglobinuria. — There  are  two  types  of  hsemoglobiuuria  in  ma- 
laria, the  one  associated  with  any  severe  pernicious  malaria,  in  which  an 
enormous  number  of  red  blood  corpuscles  are  directly  destroyed  by  parasites. 
Xot  very  uncommon,  we  had  a  number  of  cases  of  this  type  at  the  Johns  Hop- 
kins Hospital.  But  in  the  true  hlack-water  fever  there  is  a  solution  of  red 
blood  corpuscles  by  an  unknown  hgemolysin,  not  directly  by  the  malarial 
parasites  themselves. 

The  figures  at  Panama,  based  on  five  years'  work  at  the  Ancon  Hospital, 
given  by  Decks  and  James,  show  230  cases  in  more  than  40,000  cases  of 
malaria.  Their  studies  strongly  favor  the  association  of  black-water  fever 
with  malaria,  holding  that  there  are  three  causes  superadded  to  the  previous 
malarial  infection:  (i)  A  renewed  malarial  attack  with  production  of  toxins 
sufficient  to  destroy  many  red  blood  corpuscles;  (ii)  a  lowering  of  the 
bodily  resistance;  (iii)  quinine,  which  appears  to  be  the  tertium  quid  nec- 
essary to  produce  the  hgemolysin.  The  general  experience  at  Panama  is 
in  favor  of  withholding  quinine  in  the  true  erytholytic  hasmoglobinuria. 

(c)  Malarial  Cachexia. — The  general  symptoms  are  those  of  secondary 
ansemia — breathlessness  on  exertion,,  oedema  of  the  ankles,  and  haemorrhages, 
particularly  into  the  retina.  Occasionally  the  bleeding  is  severe,  and  fatal 
ha?matemesis  may  occur  in  association  with  the  enlarged  spleen.  The  fever 
is  variable.  The  temperature  may  bo  low  for  days,  not  going  above  99.5°. 
In  other  instances  there  may  be  irregular  fever,  and  the  temperature  rises 
graduallv  to  102.5°  or  103°  F. 


254  SPECIFIC  I,NFECTIOUS  DISEASES 

With  careful  treatment  the  outlook  is  good,  and  a  majority  of  cases  re- 
cover. The  spleen  is  gradually  reduced  in  size,  but  it  may  take  several 
months,  or,  indeed,  years,  before  the  "ague-cake"  entirely  disappears. 

Latent  Malarial  Infection. — There  may  be  parasites  in  the  body  without  any 
clinical  manifestations  of  the  disease.  The  parasites  are  present  in  the 
spleen  in  all  the  stages  of  the  human  cycle. 

Rarer  Complications. — Paraplegia  may  be  due  to  a  peripheral  neuritis  or 
to  changes  in  the  cord,  and  hemiplegia  may  occur  in  the  pernicious  comatose 
form,  or  occasionally  at  the  very  height  of  a  paroxysm.  Acute  ataxia  has 
been  described,  and  there  are  remarkable  cases  with  the  symptoms  of  dissem- 
"inated  sclerosis  (Spiller).  Multiple  gangrene  may  occur.  Orchitis  has  been 
described  by  Charvot  in  Algiers  and  Fedeli  in  Eome. 

Eelapse. — It  is  not  easy  to  explain  thie  relapse.  Some  think  there  is  a 
resting  stage  of  the  parasite  which  remains  in  the  spleen  or  the  bone  mar- 
row. Schaudinn  believed  that  there  is  a  special  parthenogenetic  form  which 
may  remain  latent  for  an  indefinite  period.  This  seems  most  likely,  as  there 
can  be  no  question  that  months  or  even  years  may  elapse  between  the  pri- 
mary infection  and  a  relapse  occurring  under  conditions  that  preclude  the 
possibility  of  re-infection. 

Diagnosis. — The  endemic  index  of  a  country  may  be  determined  by  the 
"parasite  rate"'  or  by  the  "spleen  rate."  It  is  best  sought  for  in  children, 
in  whom,  as  is  well  known,  tbe  infection  may  occur  without  much  disturb- 
ance of  the  health.  To  determine  the  index  by  examining  the  blood  for  tho 
parasites  is  a  laborious  and  almost  impossible  task;  on  the  other  hand,  as 
the  work  of  Eoss  in  Greece  and  ]\Iauritius  has  shown,  the  index  may  be  readily 
gauged  by  an  examination  of  the  spleen.  Thus,  in  the  last-named  island,  of 
31,022  children,  34.1  per  cent,  had  enlarged  spleen.  In  Bombay,  among  50,000 
children  examined,  the  spleen  index  varied  from  5.3  per  cent,  in  the  Hindoos 
to  23.2  per  cent,  in  the  Parsees  (Bentley). 

The  individual  forms  of  malarial  infection  are  readily  recognized  by 
examination  of  the  fresh  or  stained  film,  but  it  requires  a  long  and  careful 
training  to  become  an  expert  in  blood  examination.  Great  progress  has  been 
made  and  a  diagnosis  of  malaria  is  no  longer  a  refuge  for  our  ignorance.  One 
lesson  it  is  hard  for  the  practitioner  to  learn — namely,  that  an  intermittent 
fever  which  resists  quinine  is  not  malarial. 

The  malarial  poison  is  supposed  to  influence  man}^  affections  in  a  remark- 
able way,  giving  to  them  a  paroxysmal  character.  A  whole  series  of  minor 
ailments  and  some  more  severe  ones,  such  as  neuralgia,  are  attributed  to 
certain  occult  effects  of  paludism.  The  more  closely  such  cases  are  investigated 
the  less  definite  appears  the  connection  with  malaria. 

Prophylaxis. — In  the  discovery  of  Laveran  there  lay  the  promise  of  bene- 
fits more  potent  than  any  gift  science  had  ever  offered  to  mankind — viz.,  the 
possibility  of  the  extermination  of  malaria.  By  the  persistent  missionary 
efforts  of  Eoss  this  promise  has  reached  the  stage  of  practical  fulfilment,  and 
one  of  the  greatest  scourges  of  the  race  is  now  under  our  command.  The 
story  of  the  Canal  Zone,  Panama,  under  Colonel  Gorgas  is  a  triumph  of  the 
application  of  scientific  methods.  Between  1881  and  1904  among  the  em- 
ployees of  the  French  Canal  Company  (a  maximum  in.  1887  of  17,995,  of 
whom  15,726  were  negroes)  the  monthly  mortality  ranged  from  60  to  70,  and 


MALARIAL  FEVER  255 

on  seven  occasions  was  above  100,  once  reaching-  the  enormous  figure  of  176.97 
per  1,000.  With  the  measures  given  below,  tlie  mortality  has  fallen  below  that 
of  temperate  regions.  For  the  year  1910  the  death  rate  among  50,802  em- 
ployees was,  total  deaths  558,  from  disease  381,  from  violence  177;  the  death 
rate  from  disease  was  7.5  per  1,000. 

This  most  successful  campaign  has  been  carried  out  on  the  following  lines : 
(1)  The  eradication  of  mosquito  propagation  areas  by  drainage,  and  the  fill- 
ing of  places  where  the  larvae  exist.    This  has  been  done  in  large  districts. 

(2)  The  control  of  propagation  areas  that  are  allowed  to  exist,  or  that 
cannot  be  economically  and  permanently  treated.  On  small  areas  the  larvs 
are  prevented  from  arriving  at  the  adult  stage  by  the  use  of  crude  oil  or  kero- 
sene, and  in  large  bodies  of  water  by  treating  the  edges  where  alone  the  mos- 
quito larvae  exist.  A  concentrated  larvacide  of  carbolic  acid,  resin,  and  caustic 
soda,  so  made  as  to  form  an  emulsion  with  the  water  into  which  it  is  placed, 
has  been  found  effective,  when  applied  to  the  edges  of  large  pools,  ditches,  wet 
areas  and  streams.  A  barrel  of  oil  with  an  automatic  drip  at  the  head  of  a 
stream  has  been  found  to  work  satisfactorily. 

(3)*  Protection  by  screening  of  houses.  On  the  Zone  all  the  houses  occu- 
pied by  Americans  are  protected  by  copper-bronze  screens  of  18  mesh  to  the 
inch.  Cotton  bar  treated  with  wax  is  also  recommended  as  inexpensive. 
Screened  vestibules  decrease  the  chance  of  access  of  mosquitoes.  Mosquito 
nets  over  the  beds  are  found,  as  a  rule,  to  be  a  failure,  chiefly  because  few 
persons  sleep  through  a  whole  night  without  an  arm  or  leg  coming  in  contact 
with  the  netting  on  which  the  anopheles  settle. 

(4)  The  destruction  of  adult  anopheles.  In  two  sets  of  barracks  not  far 
apart,  with  many  anopheles,  in  one  all  the  adult  mosquitoes  were  killed  daily, 
in  the  other  they  were  not;  in  the  latter  during  a  period  of  several  months 
there  was  forty-two  times  as  much  malaria.  The  mosquitoes  are  easily  caught; 
they  are  usually  in  the  corners,  and  very  often  within  a  foot  of  the  floor. 

Of  the  enormous  importance  of  these  anti-malarial  measures  there  can 
be  no  question.  It  requires  system,  organization,  energy  and  perseverance. 
But  the  story  of  Havana,  the  story  of  Ismalia,  and,  above  all,  the  story 
of  the  Panama  Canal  Zone  show  what  can  be  done.  The  following  chart, 
taken  from  an  article  of  Le  Prince,  the  chief  sanitary  inspector  of  the  Zone, 
gives  a  good  idea  of  the  results.  The  objection  offered  on  the  score  of  cost 
in  the  tropics  has  been  shown  by  Gorgas  to  be  fallacious. 

Every  patient  with  malaria  should  be  regarded  as  a  centre  of  infection  (a 
carrier),  and  in  a  systematic  warfare  reported  to  the  health  authorities.  In  the 
tropics  segregation  of  Europeans  may  do  much  to  lessen  the  chances  of 
infection.  Every  patient  should  receive  thorough  and  prolonged  treatment 
with  quinine.  There  is  far  too  much  carelessness  on  this  point  in  the  profes- 
sion. Malarial  infection  is  a  difficult  one  to  eradicate.  Quinine  is  the  only 
known  drug  which  is  an  effective  parasiticide.  Patients  should  be  told  to 
resume  the  treatment  in  the  spring  and  autumn  for  several  years  after  the 
primary  infection.  In  very  malarial  districts,  as  many  persons  harbor  the 
parasites  who  do  not  show  any  (or  at  the  most  very  few)  signs,  a  systematic 
treatment  with  quinine  should  be  instituted,  particularly  of  the  young  children. 
Patients  with  the  disease  should  be  protected  from  mosquitoes  as  far  as 
possible.    As  a  rule,  anopheles  are  more  likely  to  bite  after  sundown,  so  that 


256 


SPECIFIC  INFECTIOUS  DISEASES 


in  regions  in  which  the  disease  prevails  extensively  mosquito  netting  should 
be  used.  Persons  going  to  a  malarial  region  should  take  5  grains  (0.3  gm.) 
of  quinine  daily  and  a  double  dose  once  a  week. 

Treatment. — The  patient  should  be  in  bed  and  given  liquid  or  soft  diet. 
The  bowels  should  be  moved  freely,  for  which  a  calomel  and  saline  purge  is 
best.  In  quinine  we  possess  a  specific  remedy  against  malarial  infection. 
Experiment  has  shown  that  the  parasites  are  most  easily  destroyed  by  quinine 
at  the  stage  when  they  are  free  in  the  circulation — that  is,  during  and  just 
after  segmentation.  While  in  most  instances  the  parasites  of  the  regularly 
intermittent  fevers  may  be  destroyed,  even  in  the  intra-corpuscular  stage, 
in  sstivo-autumnal  fever  this  is  much  more  difficult.     It  should,  then,  be  our 


n 

1906 

1907 

1908 

1909 

1910             1 

\ 

951 

, 

\ 

8f< 

\ 

1 

\ 

• 

7^t 

1 

1 

\ 

/ 

6'/' 

A 

/E 

;.- 

\ 

1 

\ 

' 

^ 

_ 

P 

-- 

" 

5'} 

\ 

1 

5 

/ 

\ 

/ 

V 

A'f 

\ 

4 

\ 

v 

1 

\ 

\ 

4 

■r. 

4 

i 

y'f 

.V 

3 

To 

-' 

- 

ML 

" 

' 

L 

r 

\ 

9 

f 

3 

5' 

c^ 

\ 

\ 

^ 

\ 

^ 

r; 

3 

i 

/ 

\ 

2'1- 

2 

1 

1 

1 

Ef 

] 

P 

- 

, 

R/> 

TE 

'j 

I. 

30 

!= 

- 

36 

:? 

\ 

2 

'/' 

/ 

\ 

\ 

1^' 

1 

'/' 

\ 

/ 

\ 

1 

\ 

s 

V 

/ 

AV 

E 

1 

0 

if 

^ 

\ 

__, 

/ 

/. 

A 

E 

9C 

^) 

a 

1 

1 

r 

?^ 

TE 

F 

/ 

1 

i\ 

)= 

^ 

si'i 

of« 

z 

i 

z 

\ 

i 

< 

> 
< 

I  p 

z 

p 

I 

ii. 

z 

£ 

E 

f  S 

z 

3    = 

K 

K 

> 

z 

1 

-° 

i 

E 

> 
< 

Z 

=  ? 

H 

H 

1 

i 

5 

s 

£ 

? 

s 

i: 

E 

i 

c 

h^ 

> 

z 

1 

^   u 

^ 

5 

^ 

4 

Z 
=3 

E 

6  ^ 

3    UJ 

<  a 

K 

>  6 

Z   o 

Chart    VII. — Malaria    Cases    among    the    Employees    of    the    Isthmian    Canal. 

Commission,  1906-1910, 


object  to  have  as  much  quinine  in  circulation  at  the  time  of  the  paroxysm 
and  shortly  before  as  is  possible,  for  this  is  the  period  at  which  segmentation 
occurs.  In  the  regularly  intermittent  fevers  from  10  to  30  grains  (0.6  to  2 
gm.)  in  divided'  doses  throughout  the  day  will  in  many  instances  prevent  any 
fresh  paroxysms.  If  the  patient  comes  under  observation  shortly  before  an 
expected  paroxysm,  the  administration  of  quinine  just  before  its  onset  may  be 
advisable  to  obtain  a  maximum  effect  upon  the  group  of  parasites.  The  quinine 
will  not  prevent  the  paroxysm,  but  Mall  destroy  the  greater  part  of  the  group 
of  organisms  and  prevent  its  recurrence.  It  is  safer  to  give  at  least  20  to  30 
grains  (1.3  to  2  gm.)  daily  for  the  first  three  days,  and  then  to  continue  the 
remedy  in  smaller  doses  for  the  next  two  or  three  weeks.  In  sestivo-autumnal 
fever  larger  doses  may  be  necessary,  though  in  relatively  few  instances  is  it 
necessary  to  give  more  than  30  grains  (2  gm.)  in  the  twenty-four  hours. 
As  to  the  length  of  time  during  which  quinine  should  be  taken,  after  the 


TEYPANOSOMIASIS  257 

acute  features  are  over,  there  is  much  difference  of  opinion.  Small  doses 
(gr.  v-x,  0.3-0.6  gm.)  daily  for  six  weeks  are  usually  efficient.  It  is  wise 
to  take  a  course  of  quinine  twice  a  year  for  three  years  after.  During  the 
paroxysm  the  patient  should,  in  the  cold  stage,  be  wrapped  in  blankets  and 
given  hot  drinks.  The  reactionary  fever  is  rarely  dangerous  even  if  it 
reaches  a  high  grade.    The  body  may,  however,  be  sponged. 

The  quinine  should  be  given  in  solution  or  capsules.  Pills  and  com- 
pressed tablets  are  uncertain,  as  they  may  not  be  dissolved.  Euquinine,  in  the 
same  dosage,  or  quinine  tannate,  double  the  amount,  may  be  given  to  patients 
with  whom  quinine  disagrees. 

A  question  of  interest  is  the  efficient  dose  of  quinine  necessary  to  cure  the 
disease.  Grain  doses  three  times  a  day  will  in  many  cases  prevent  the 
paroxysm,  but  not  with  the  certainty  of  larger  doses.  In  cases  of  sestivo- 
autumnal  fever  with  pernicious  symptoms  it  is  necessary  to  get  the  system 
under  the  influence  of  quinine  as  rapidly  as  possible.  In  these  instances 
the  drug  should  be  administered  by  injection  into  the  muscles,  as  the  dihydro- 
chloride  in  ten-grain  (0.6  gm.)  doses,  in  a  freshly  prepared  solution  (1  to  3) 
in  sterile  water  and  repeated  in  two  hours.  Further  administration  must 
be  decided  by  the  condition.  The  muriate  of  quinine  and  urea  is  also  a 
good  form  in  which  to  administer  the  drug  intramuscularly;  10-grain  (0.6 
gm.)  doses  may  be  given.  In  the  most  severe  instances  some  observers  advise 
the  intravenous  administration  of  quinine,  for  which  the  very  soluble  bimuriate 
is  well  adapted.  Fifteen  grains  (1  gm.)  with  40  grains  (2.6  gm.)  of  sodium 
•chloride  may  be  injected  in  ten  ounces  (300  c.  c.)  of  freshly  distilled  wateir, 
or  the  same  amount  of  the  dihydrochloride  in  500  c.  c.  of  saline  solution. 
The  intravenous  administration  is  not  without  danger.  For  extreme  rest- 
lessness in  these  cases  opium  is  indicated,  and  cardiac  stimulants  may  be 
necessary.  If  in  the  comatose  form  the  internal  temperature  is  raised,  the 
patient  should  be  sponged  or  given  a  tub  bath.  For  malarial  anaemia  iron 
and  arsenic  are  indicated. 

An  interesting  question  is  much  discussed,  whether  quinine  does  not  cause, 
or  at  any  rate  aggravate,  hsemoglobinuria.  We  have  not  seen  a  case  in 
which  this  condition  has  occurred  as  a  result  of  the  use  of  the  drug,  and  Bas- 
tianelli  states  that  it  is  not  seen  in  the  Roman  malarial  fevers.  In  any  case 
of  haemoglobinuria  if  the  blood  shows  parasites  quinine  should  be  administered 
cautiously.  In  the  post-malarial  forms  quinine  aggravates  the  attack.  In  an 
active  malarial  infection  the  patient  runs  less  risk  with  the  quinine. 

In  malarial  cachexia  the  patient  should  have  a  change  of  climate,  be  given 
a  liberal  diet,  and  take  quinine  in  small  doses  with  iron  and  arsenic  for  some 
time. 

IV.     TRYPANOSOMIASIS 

Definition. — A  chronic  disorder  characterized  by  fever,  lassitude,  weak- 
ness, wasting,  and  often  a  protracted  lethargy — sleeping  sickness.  Trypano- 
soma gamhiense  and  T.  1-liodesiense  are  the  active  agents  in  the  disease. 

Trypanosomes  are  flagellate  infusoria,  parasitic  in  a  great  many  inverte- 
brate and  vertebrates.  The  life  history  is  in  two  stages,  a  flagellate  monadine 
phase,  in  which  they  live  in  the  blood  stream  of  vertebrates  and  in  some  of 


258  SPECIFIC  INFECTIOUS  DISEASES 

which  they  cause  serious  disease;  the  other  is  a  gregarine  non-flagellate  phase 
which,  may  also  be  parasitic  and  which  is  met  with  in  forms  of  Kala-Azar. 

History. — In  1843  Gruby  found  a  blood  parasite  in  the  frog  which  he 
called  Trypanosoma  sanguinis.  Subsequently  it  was  found  to  be  a  very  com- 
mon blood  parasite  in  fishes  and  birds.  In  1878  Lewis  found  it  in  the  rat — 
T.  lewisi — in  which  it  apparently  does  no  harm.  The  pathological  signifi- 
cance of  the  protozoa  was  first  suggested  in  1880  by  Griffith  Evans,  who  dis- 
covered trypanosomes — T.  evansi— in  the  disease  of  horses  and  cattle  in  India 
known  as  surra.  In  1895  Bruce  made  the  important  announcement  that  the 
tsetze  fly  disease  or  nagana  of  South  Africa,  which  made  whole  districts  im- 
passable for  cattle  and  horses,  was  really  due  to  a  trypanosome — T.  hrucei. 
Normally  present  in  the  blood  of  the  big-game  animals  of  the  districts,  it 
was  conveyed  by  the  tsetze  fly  to  the  non-immune  horses  and  cattle  imported 
into  what  were  called  the  fly-belts.  Other  trypanosomes  are  T.  cruzi  (Brazil), 
the  Philippine  surra,  studied  by  Musgrave,  the  mal  de  caderas — T.  equinum — 
of  South  America  and  a  harmless  infection  in  cattle  in  the  Transvaal  caused 
by  T.  tlieileri. 

Human  Trypanosomiasis. — In  1901  Button  found  a  trypanosome  in  the 
blood  of  a  West  Indian.  In  1903  Castellani  found  trypanosomes  in  the  cere- 
bro-spinal  fluid  and  in  the  blood  of  five  cases  of  African  sleeping  sick- 
ness. The  Eoyal  Society  Commission  (Bruce  and  Nabarro)  demonstrated  the 
frequency  of  the  parasites  in  the  cerebro-spinal  fluid  and  in  the  blood 
in  sleeping  sickness,  and  suggested  that  it  was  a  sort  of  human  tsetze  fly 
infection. 

Distribution. — For  many  years  it  had  been  known  that  the  West  African 
natives  were  subject  to  a  remarkable  malady  known  as  the  lethargy  or  sleep- 
ing sickness.  It  was  also  met  with  among  the  slaves  imported  into  America. 
The  demonstration  of  the  association  of  the  trypanosomes  with  the  terrible 
sleeping  sickness  has  been  the  most  important  recent  "find"  in  tropical  medi- 
cine. The  disease  prevails  in  Gambia,  Sierra  Leone,  and  Liberia,  and  is 
spreading  rapidly  in  the  Congo  basin,  Uganda,  and  Rhodesia.  The  opening 
up  of  equatorial  Africa  has  led  to  intercommunication  between  districts 
which  were  formerly  isolated,  and  the  seriousness  of  the  disease  may  be 
appreciated  from  the  fact  that  within  three  years  after  its  introduction 
100,000  negroes  died  of  it  in  Uganda.  In  the  infected  regions  a  large  number 
of  natives,  not  apparently  suffering  from  the  disease,  harbor  the  parasites 
in  the  blood  and  suffer  only  with  occasional  attacks  of  fever,  during  which 
the  trypanosomes  are  also  found  in  the  cerebro-spinal  fluid. 

The  disease  is  not  confined  to  negroes,  and  Europeans  may  be  attacked. 
Persons  particularly  prone  are  those  who  live  on  the  wooded  shores  of  the 
lakes  and  rivers,  such  as  fishermen  and  canoe  men. 

The  parasite  is  introduced  by  the  bite  of  a  fly,  the  Glossina  palpalis,  and 
where  this  insect  exists  the  disease  is  liable  to  prevail.  The  fly  lives  on  the 
bushes  on  the  lake  shores  or  river  banks,  and  feeds  on  the  blood  of  crocodiles, 
antelopes,  etc.  The  trypanosomes  undergo  changes  in  the  body  of  the  fly  and 
the  infectivity  does  not  appear  until  the  thirty-second  day,  but  continues  for 
at  least  75  days  (Bruce). 

Symptoms. — There  is  stated  to  be  a  long  latent  period.  The  Uganda  Corp- 
missioners  divide  the  course  of  the  disease  into  three  stages:  first,  of  fever 


LEISHMANIASIS  259 

with  rapid  pulse,  dulling  of  the  mind,  and  loss  of  weight;  secondly,  the  stage 
of  tremors  in  which  the  gait  becomes  shuffling,  the  speech  slow,  and  there  are 
tremors  of  the  tongue  and  of  the  hands  and  feet;  lastly,  a  stage  in  which  the 
patient  becomes  lethargic  with  low  temperature  and  presents  the  typical  pic- 
ture of  the  dreaded  sleeping  sickness.  The  parasites  are  found  in  the  cerebro- 
spinal fluid,  less  constantly  in  the  blood.  In  the  early  stages  the  glands  of  the 
neck  are  involved,  and  Todd  and  Button  recommend  puncture  of  these  glands 
for  the  purpose  of  diagnosis.  Death  is  usually  caused  by  some  intercurrent 
infection,  as  purulent  meningitis  or  suppuration  of  the  lymph  glands.  The 
duration  is  seldom  longer  than  eighteen  months.  To  stay  the  ravages  and 
prevent  the  spread  of  the  disease  will  tax  the  energies  of  the  nations  interested 
in  the  settlement  of  tropical  Africa.  The  hope  appears  to  be  in  the  extermina- 
tion of  the  animals  upon  which  the  Glossina  palpalis  feeds,  just  as  the 
killing  off  of  the  big  game  in  other  parts  of  Africa  has  saved  the  cattle 
from  the  ravages  of  the  tsetze  fly.  Though  a  colossal  task,  the  examination 
of  natives  of  infected  districts  should  be  undertaken,  isolation  villages  estab- 
lished, and  the  cases  kept  under  observation  and  treatment. 

Prognosis. — A  few  cases  in  Europeans  have  been  cured,  a,nd  some  of  these 
have  been  without  symptoms  for  a  number  of  years.  The  criteria  of  cure 
are  the  absence  of  symptoms,  failure  to  find  the  trypanosomes,  and  negative 
inoculation  of  the  blood  into  susceptible  animals.  The  outlook  is  hopeless  in 
the  stage  of  sleeping  sickness. 

Treatment. — Atoxyl  introduced  by  Wolferstan  Thom.as  and  Breinl  appears 
to  have  given  the  most  satisfactory  results.  The  parasites  seem  to  vary 
in  their  resistance  to  arsenic.  In  some  places  the  arsenophenylglycin  seems 
to  have  acted  almost  as  a  specific.  Antimony  has  been  used  a  good  deal  and 
Kerandel,  a  member  of  the  French  Commission,  cured  himself  with  it, 
injecting  intravenously  on  successive  days  a  solution  of  tartar  emetic  in 
seventeen  10-centigram  doses.  Arsphenamine  has  been  used  without  much 
benefit. 

V.    LEISHMANIASIS 

(Kala-Azar) 

Definition. — Leishmaniasis  is  an  affection  caused  by  parasites  of  the 
Leishmania  group,  of  which  thej-e  are  three  chief  forms :  the  Indian  hala-azar, 
the  infantile  I'ala-azar,  and  tropical  sore. 

Indian  Kala-Azar. — An  affection  characterized  by  enlarged  spleen,  anae- 
mia and  irregularly  remittent  fever.  Leishman  in  1900  discovered  the  para- 
site, which  was  subsequently  studied  by  Donovan  {Leishmania  donovani). 
It  is  a  protozoon  of  very  constant  form,  living  in  the  spleen  and  bone- 
marrow.  It  has  been  successfully  cultivated  by  Eogers  and  others,  and 
develops  into  a  flagellate  form. 

Distribution. — The  disease  is  widely  spread  in  Asia,  particularly  in 
Assam,  many  parts  of  India,  Burma,  Indo-China,  Ceylon  and  Syria.  Euro- 
peans contract  it  rarely. 

Etiology. — Rogers  believes  the  bedbug  of  India  is  the  chief  agent  in 
transmitting  it,  a  view  which  Fatten  shares,  as  he  found  the  ingested  parasite 


260  SPECIFIC  INFECTIOUS  DISEASES 

in  the  bedbug  underwent  development  into  flagellate  forms.  Donovan  suggests 
that  the  disease  is  transmitted  by  the  plant-feeding  bug,  the  conorrhinus, 
which  is  an  occasional  blood-sucker. 

Symptoms. — Enlargement  of  the  spleen  is  almost  constant;  there  is  irreg- 
ular fever,  which  lasts  for  months  and  is  sometimes  characterized  by  a  double 
rise  in  the  twenty-four  hours.  The  other  features  are  those  of  a  progressive 
ana?mia  of  a  secondary  type  with  marked  emaciation.  Eecovery  is  possible, 
but  the  mortality  is  above  80  per  cent. 

Infantile  Kala-Azar. — This  form,  separated  by  Nicole  and  his  associates 
at  Tunis,  is  the  infantile  splenic  anaemia  long  recognized  in  the  countries  of 
the  Mediterranean  basin.  It  differs  from  the  Indian  form  in  attacking  chil- 
dren almost  exclusively,  and  in  the  presence  of  a  parasite  known  as  the 
L.  infantum.  Another  special  feature  is  that  the  disease  may  be  reproduced 
in  dogs  and  monkeys  and  a  spontaneous  infection  of  dogs  exists  in  the  endemic 
areas  of  infantile  Kala-Azar.  Observations  strongly  suggest  that  the  disease  is 
transmitted  to  children  through  the  dog  flea,  or  through  the  human  flea 
having  bitten  an  infected  dog. 

Tropical  Sore. — Under  the  various  names  Aleppo  boil,  Delhi  boil,  Bagdad 
sore,  Nile  sore  and  many  others,  has  been  described  a  form  of  disease  charac- 
terized by  idcerating  and  non-ulcerating  lesions,  almost  always  on  the  exposed 
parts  of  the  body.  The  parasite  discovered  by  Homer  ^yright  and  known  as 
Leishmania  tropica  has  very  much  the  same  characters  as  the  other  forms,  but 
there  are  slight  differences,  morphological  and  cultural.  The  mode  of  trans- 
mission has  not  been  definitely  determined. 

Treatment. — For  Indian  kala-azar  not  much  can  be  done.  Quinine  given 
in  the  ordinary  way  seems  useless,  but  from  hypodermic  injections  into 
the  muscles  good  results  are  reported.  Atoxyl  has  been  freely  used.  Both  for 
this  and  the  infantile  form  arsphenamine  has  been  used,  but  with  doubtful 
benefit.  Tartar  emetic  (1  per  cent,  solution)  has  been  given  intravenously, 
5  c.  c.  for  the  first  dose,  and,  if  well  borne,  10  c.  c.  in  subsequent  doses.  For 
the  tropical  sore  dusting  with  potassium  permanganate,  and  a  few  days 
later  applying  a  10  per  cent,  solution  of  Prussian  blue,  has  been  found  useful. 


VI.     RELAPSING  FEVER 

(Fehris  recurrens.  Tick  Fever) 

Definition. — A  group  of  specific  infections  caused  by  spirochgetes,  charac- 
terized by  febrile  parox3^sms  which  usually  last  five  or  six  days  with  remissions 
of  about  the  same  length  of  time.  The  paroxysms  may  be  repeated  three  or 
even  four  times,  vrhence  the  name  relapsing,  or  recurring,  fever.  European, 
Indian,  American  and  African  forms  are  described  presenting  clinically  much 
the  same  features,  but  the  parasites  differ  in  certain  peculiarities. 

Etiology. — The  European  form,  which  has  also  the  name  "famine  fever" 
and  "seven-day  fever,"  has  been  known  since  the  early  part  of  the  eighteenth 
century,  and  has  from  time  to  time  extensively  prevailed,  especially  in  Ire- 
land. It  is  a  very  rare  disease  in  England.  In  the  United  States  the  disease 
appeared  in  1844,  when  cases  were  admitted  to  the  Philadelphia  Hospital, 


RELAPSING  FEVEE  261 

which  are  described  by  Meredith  Clymer  in  his  work  on  Fevers.  Flint  saw 
cases  in  1850-'51.  In  1869  it  prevailed  extensively  in  epidemic  form  in  New 
York  and  Philadelphia;  since  when-  it  has  not  reappeared.  While  clinically 
the  same  as  the  European  form,  the  organism  is  different  and  has  been  called 
S'.  novyi.  In  India,  where  the  disease  is  very  prevalent,  the  parasite  called 
after  Vandyke  Carter  differs  from  the  spirochsete  of  Obermeier.  Possibly  it 
may  be  transmitted  by  mosquitoes  as  well  as  bugs. 

The  African  relapsing  fever,  known  as  ticlc  fever,  is  a  very  serious  and 
widespread  affection,  the  parasite  of  which,  S.  dutioni,  is  distinct  from  the 
other  forms.  It  is  transmitted  by  the  tick  Ornithodoros  mouhata,  but  as 
Leishman  has  shown,  not  by  direct  inoculation  with  the  salivary  secretion,  but 
from  other  secretions  voided  in  the  act  of  gorging.  The  symptoms  are  very 
similar  to  those,  of  European  relapsing  fever,  and  as  many  as  from  five  to 
seven  relapses  may  take  place.    The  mortality  is  not  very  high. 

The  Spirilhim  or  spirochsete,  described  by  Obermeier  in  1873,  was  one  of 
the  first  micro-organisms  shown  to  be  definitely  associated  with  a  specific 
fever.  It  is  from  15  to  40  /x  in  length,  spirally  arranged  like  a  corkscrew, 
sometimes  curved  and  twisted.  The  ends  are  tapering;  whether  furnished 
with  flagella  or  not  is  doubtful.  It  is  actively  motile,  and  it  is  present  in  the 
blood  during  the  febrile  paroxysm,  disappearing  at  intervals.  Plotz  reported 
the  cultivation  of  the  spirochsetes  directly  from  the  blood. 

The  mode  of  transmission  is  probably  through  lice  and  bed  bugs.  The 
disease  has  been  reproduced  by  injecting  into  a  healthy  monkey  blood 
sucked  by  a  bug  from  an  infected  animal.  The  special  conditions  under 
which  it  occurs  are  similar  to  those  of  typhus  fever.  Neither  age,  sex,  nor 
season  seems  to  have  any  special  influence.  One  attack  does  not  confer 
immunity. 

Morbid  Anatomy. — There  are  no  characteristic  anatomical  appearances  in 
relapsing  fever.  If  death  takes  place  during  the  paroxysm  the  spleen  is  large 
and  soft,  and  the  liver,  kidneys  and  heart  show  cloudy  swelling.  There  may 
be  infarcts  in  the  kidneys  and  spleen.  The  bone-marrow  has  been  found 
in  a  condition  of  hyperplasia.     Ecchymoses  are  not  uncommon. 

Symptoms. — The  incubation  appears  to  be  short;  in  some  instances  the 
attack  occurs  within  twelve  hours  after  exposure;  more  frequently,  however, 
from  five  to  seven  days  elapse. 

The  invasion  is  abrupt,  with  chill,  fever,  and  intense  pain  in  the  back 
and  limbs.  In  young  persons  there  may  be  nausea,  vomiting,  and  convulsions. 
The  temperature  rises  rapidly  and  may  reach  104°  on  the  evening  of  the  first 
day.  Sweats  are  common.  The  pulse  is  rapid,  ranging  from  110  to  130. 
There  may  be  delirium  if  the  fever  is  high.  Swelling  of  the  spleen  can  be 
detected  early.  Jaundice  is  common  in  some  epidemics.  The  gastric  symp- 
toms may  be  severe,  but  there  are  seldom  intestinal  symptoms.  Cough  may 
be  present.  Occasionally  herpes  is  noted,  and  there  may  be  miliary  vesicles 
and  petechia.  During  the  paroxysm  the  blood  invariably  shows  the  spiro- 
chsete, and  there  is  usually  a  leucocytosis.  After  the  fever  has  persisted  with 
severity  or  even  with  an  increasing  intensity  for  five  or  six  days  the  crisis 
occurs.  In  the  course  of  a  few  hours,  accompanied  by  profuse  sweating,  some- 
times by  diarrhoea,  the  temperature  falls  to  normal  or  even  subnormal,  and 
the  period  of  apyrexia  begins. 


262  SPECIFIC  INFECTIOUS  DISEASES 

The  crisis  may  occur  as  early  as  the  third  day,  or  it  may  be  delayed  to 
the  tenth;  it  usually  comes,  however,  about  the  end  of  the  first  week.  In 
delicate  and  elderly  persons  there  may  be  collapse.  The  convalescence  is  rapid, 
and  in  a  few  days  the  patient  is  up  and  about.  Then  in  a  week,  usually  on 
the  fourteenth  day,  he  again  has  a  rigor,  or  a  series  of  chills;  the  fever  returns 
and  the  attack  is  repeated.  A  second  crisis  occurs  from  the  twentieth  to  the 
twenty-third  day,  and  again  the  patient  recovers  rapidly.  As  a  rule,  the 
relapse  is  shorter  than  the  original  attack.  A  second  and  a  third  may  occur, 
and  there  are  instances  on  record  of  even  a  fourth  and  a  fifth.  In  epidemics 
there  are  cases  which  terminate  by  crisis  on  the  seventh  or  eighth  day  without 
the  occurrence  of  relapse.  In  protracted  cases  the  convalescence  is  very  tedi- 
ous, as  the  patient  is  much  exhausted. 

Eelapsing  fever  is  not  a  very  fatal  disease.  Murchison  states  that  the  mor- 
tality is  about  4  per  cent.,  but  it  has  been  as  high  as  30  per  cent,  in  India.  In 
the  enfeebled  and  old,  death  may  occur  at  the  height  of  the  first  paroxysm. 


■  ■■^''■■■■■■■■■■■■■■■■■■■■■■BHHHHHf.yHHBHnBaBBBHHHB 

■  ■(■^■■■■■■■■■■■■■■■■■■[■■■■■■MBBVilHHBHHSBHHIHnnBaHi 

■  ■IBWillW  W  ■■■■■■■■■■■■■■!■■  ■■■»!■■■',■■■■■■■■■■  ■■—— 

■  ■l!2ij!"B"*BBBBBB*'BB***"""B**B"'*'^^<B'"^*<B**>*><*BB"SSBB 
■■■■MUBIIIBB  ■■■■■■■■■■■■■■■■  ■BWMMMMllMBBBBBBBBBBMM 

9!3!!BBIIB'IIB*l"'"B*BBB*HBHBaBBBB..flMaaBHBmBBBSBBBBBBBH 
-IIWIHHaillHIIIIMHHHBHiHHHHHBBHHHBHHHl'lHMBBHKBIBHHBBSHHBHiaM 

■■■■■■■■■■■■■■■■■■SBBSSBHBBBHaiBBaSBSSMSSBSSSBS&SSS 

naBBS!">''BIBBBBBBBBBBBBBBBBBBBIIBBBBBBiBMIIBBBBBBBBWiBB 

BIHBBBIIIIBIMBHBBBBBBBBBBBBBBBBIIBBBBBBBBHBBBBBBBBHBB 

<!BBBBB9"BB9<BBBBBBBBBBBIB^BBBBBBBBBBBBBBaBBI 

^^_^^IBBB9SB9BBBBBBBBBBBBBBiaBBBBBBBBBBBBBaBBBBI 
BHBBIBHBBBBBBBBBBBBBBBBBBB'BBBBBBBBBB^HBBBBBBBBI 

■  BBBBBiaBBBB|BBBBBBBBBBBBBBBBBBBBBBBBBBnBBBniBBBBI 

■  BBBBBBBBBBBBBBBMBBBBBBBBBBBBBBBBBBBBIIBBBBBBBBI 
■IBBgBBBBBBBBBBBBBBBBBBaKIfBBBBBBBBBBBBBIIBBBBBBBBll 
BBBBBBBBaBBBBVB:t«!knBBnBriiKB;BBBIBBBBBBBBBBUBBBaBBn«l 
BJBBBBiBBBiaBBBW,B.TiUa<U.«CBBJiaBkV^BIBBBBBBBaBBB1BBBBBVBK»& 
BBBBBBBBlBBBBMBiaHBBHnk''iBBBMBSilBBBBBBBB^Ba'BBBBViBBHI 
BBBBBnBBiaBBBMIBBBBaBBBBaBBBliSBBBaBBBBBBBBBSMBBBI 
■BBBBBBBIBBBUrBraBBBBBBBBBBBBHBBBBBBBBBBBBBBBHBBBI 
BBHHnBBllBBaBBBBBBBBBBBHBBBBBBBBBBBBBSlBnBBBBBI 
BBBBBWiBBllByiBBBBBBBBBBBBBBBBBBBBBBBBBBBWiTBBBBBBI 
BBBBBBBBBIBMBBBBBBBBBBBBBBBBBBIBBaBBB^BBIBnBBBBBBI 
BBBBBBBBBIBBBBBBBBBBBBBBBBBBBBBBaBBBBBBIirflBBSBBai 
BBBBBBBBBIKBaBBaaEaBBBBaBBaaBBraBBBBBSBaiiaBBBBB&l 
■BBBBBBBWrjBBBBBBBBBBBBBBBBBBBBBBBBBBBBIVMBBBBBBI 
BBBBBBBBBMBMBBBBBBBBBBBBBBBBBBBBBBBBBBB'MBBBBBBI 


Chart  VIII. — Eelapsing  Fever  (Murchison). 

Complications  are  not  frequent.  In  some  epidemics  hsematemesis  and 
hgematuria  have  occurred.  Pneumonia  is  not  infrequent.  The  acute  enlarge- 
ment of  the  spleen  may  end  in  rupture.  Post-febrile  paralyses  may  occur. 
Ophthalmia  has  followed  in  certain  epidemics,  and  may  prove  a  very  tedious 
and  serious  complication.  In  pregnant  women  abortion  usually  takes  place. 
Convulsions  occasionally  follow.  Button,  the  Avell-known  worker  on  tropical 
diseases,  died  in  status  epilepticus  some  weeks  after  the  attack. 

Diagnosis. — The  onset  and  general  symptoms  may  not  at  first  be  dis- 
tinctive. At  the  beginning  of  an  epidemic  the  cases  are  usiially  regarded  as 
anomalous  typhoid ;  but  once  the  typical  course  is  followed  in  a  case  the  diag- 
nosis is  clear.     The  blood  examination  is  distinctive. 

Prophylaxis. — As  overcrowding  is  an  important  element  in  the  transmis- 
sion, the  patient  should  be  isolated.  The  bedding,  clothing,  and  dwellings 
of  infected  persons  should  be  thoroughly  disinfected  and  care  taken  that  all 
cracks  and  crevices  in  woodwork  which  may  harbor  bedbugs  are  treated  with 
disinfectants.   ' 

Treatment. — The  disease  should  be  treated  like  any  other  continued  fever, 
by  careful  nursing,  a  regular   diet,   and  ordinary  hygienic  measures.      Ars- 


YELLOW  FEVEE  263 

phenamine  has  proved  very  efficient.  Pain  in  the  back,  limbs  and  joints  may 
require  sedatives.  In  enfeebled  persons  the  collapse  at  the  crisis  may  be 
serious,  and  ammonia  and  digitalis  ghould  be  given  freely. 


VII.     YELLOW  FEVER 

Definition. — A  fever  of  tropical  and  subtropical  countries,  characterized  by 
a  toxfemia  of  varying  intensity,  with  jaundice,  albuminuria,  and  a  marked 
tendency  to  liEemorrhage,  especially  from  the  stomach,  causing  the  "black 
vomit.^'  The  disease  is  transmitted  through  the  bite  of  a  mosquito,  the 
Stegomyia  calopns. 

Etiology, — The  disease  prevails  endemically  in  certain  sections  of  the 
Spanish  Main.  Until  recently  it  has  existed  in  Cuba.  From  these  regions 
it  occasionally  extended  and,  under  suitable  conditions,  prevailed  epidemically 
in  the  Southern  States.  Now  and  then  it  was  brought  to  the  large  seaports  of 
the  Atlantic  coast.  Formerly  it  occurred  extensively  in  the  United  States. 
In  the  latter  part  of  the  eighteenth  century  and  the  beginning  of  the  nine- 
teenth frightful  epidemics  prevailed  in  Philadelphia  and  other  Northern 
xiities.  The  epidemic  of  1793,  in  Philadelphia,  so  graphically  described  by 
Matthew  Carey,  was  the  most  serious  that  has  ever  visited  any  city  of  the 
Middle  States.  The  mortality,  as  given  by  Carey,  during  the  months  of 
August,  September,  October,  and  November,  was  4,041,  of  whom  3,135  died 
in  the  months  of  September  and  October.  The  population  of  the  city  at  the 
time  was  only  40,000.  Epidemics  occurred  in  the  United  States  in  1797, 
1798,  1799,  and  in  1802,  when  the  disease  prevailed  slightly  in  Boston  and 
extensively  in  Baltimore.  In  1803  and  1805  it  again  appeared;  then  for 
many  years  the  outbreaks  were  slight  and  localized.  In  1853  the  disease 
raged  throughout  the  Southern  States.  There  were  moderately  severe  epi- 
demics in  1867,  1873,  and  1878,  and  still  milder  ones  in  1897,  1898,  and  1899. 
In  July,  1899,  a  local  outbreak  occurred  in  the  Soldiers'  Home  at  Hampton, 
Va.  There  were  45  cases,  with  13  deaths.  In  September,  1903,  yellow  fever 
became  epidemic  along  the  Mexican  side  of  the  Eio  Grande.  It  crossed  into 
Texas  and  prevailed  in  several  of  the  border  towns.  In  Laredo  there  were 
1,014  cases,  with  107  deaths.  The  efficient  work  of  the  public  hearth  service 
is  shown  by  the  differences  between  New  Laredo  on  the  Mexican  border,  just 
across  the  river,  where  50  per  cent,  of  the  population  contracted  the  disease, 
and  Laredo,  Texas,  in  which  only  10  per  cent,  out  of  a  population  of  10,000 
were  attacked.  In  Europe  it  has  occasionally  gained  a  foothold,  but  there 
have  been  no  widespread  epidemics  in  the  Spanish  ports.  The  disease  has 
existed  on  the  west  coast  of  Africa,  and  the  late  Eubert  Boyce  claimed  that  it 
is  still  widely  prevalent.  It  is  sometimes  carried  to  ports  in  Great  Britain  and 
France,  but  it  has  never  extended  into  these  countries.  As  Eoss  points  out, 
yellow  fever  is  a  disease  in  which  the  parasites  live  a  very  short  time  in  the 
human  host,  unlike  malaria.  The  infective  period  in  a  case  lasts  only  about 
three  days,  so  that,  unless  the  stegomyia  index  is  high,  the  disease  has  no 
chance  to  reach  epidemic  form. 

The  epidemics  in  the  United  States  have  always  been  in  the  summer  and 
autumn  months,  disappearing  rapidly  witb  the  onset  of  cold  weather. 


264  SPECIFIC  INFECTIOUS  DISEASES 

Guiteras  recognizes  three  areas  of  infection:  (1)  The  local  zone  in  which 
the  disease  is  never  absent,  including  A'era  Cruz,  Eio,  and  other  Spanish- 
American  ports.  (2)  The  perifocal  zone  or  regions  of  periodic  epidemics, 
including  the  ports  of  the  tropical  Atlantic  in  America  and  Africa.  (3)  The 
zone  of  accidental  epidemics,  lying  between  the  35th  and  15th  parallels  of 
north  latitude. 

Mode  of  Transmission. — Xo  belief  has  been  more  strong  among  the  laity 
than  that  the  disease  is  transmitted  by  infected  clothing,  and  quarantine  ef- 
forts were  chiefly  directed  to  the  disinfection  of  fomites  of  all  sorts  shipped 
from  infected  ports.  The  remarkable  series  of  experiments  carried  out  by 
the  Yellow  Fever  Commission  of  the  United  States  Army,  consisting  of  Drs. 
Walter  Eeed,  Carroll,  Lazear,  and  Agramonte,  demonstrated  conclusively  that 
the  disease  cannot  be  conveyed  in  this  way.  At  Camp  Lazear,  Cuba,  a  frame 
house  was  so  constructed  as  to  shut  out  the  sunlight  and  fresh  air,  and  the 
vestibule  was  thoroughly  screened.  The  average  temperature  for  sixty-three 
days  was  kept  about  76°  F.  Boxes  filled  with  sheets,  pillow-slips,  blankets, 
etc.,  contaminated  by  contact  with  cases  of  yellow  fever  and  the  discharges, 
were  placed  in  the  house.  Dr.  E.  P.  Cooke  and  two  privates  of  the  hospital 
corps,  all  non-immunes,  entered  this  building  and  for  a  period  of  twenty  days 
occupied  the  room,  each  morning  packing  the  infected  articles  in  the  boxes, 
and  at  night  unpacking  them.  In  their  experiments  with  the  fomites,  seven 
non-immune  subjects  during  the  period  of  sixty-three  days  lived  in  contact 
with  the  fomites  and  remained  perfectly  well.  These  experiments,  conducted 
in  the  most  rigid  and  scientific  manner,  completely  discredit  the  belief  in  the 
transmission  of  the  disease  by  fomites. 

We  must  bear  testimony  to  the  heroism  of  the  young  soldiers  who  volun- 
tarily, without  compensation  and  purely  in  the  interests  of  humanity,  sub- 
mitted to  the  experiments,  and  also  to  the  zeal  with  which  members  of  our 
profession,  at  great  personal  risk,  attempted  to  solve  the  riddle  of  this  most 
serious  disease.  The  deaths  of  Dr.  Lazear,  of  the  American  Commission,  and 
of  Dr.  Myers,  of  the  Liverpool  Commission,  add  two  more  names  to  the  al- 
ready long  roll  of  the  martyrs  of  science. 

Carlos  Finlay,  of  Havana,  in  1881  suggested  that  the  disease  was  trans- 
mitted by  mosquitoes.  Stimulated  by  the  Avork  of  Eoss  on  malaria,  the  Ameri- 
can Commission  demonstrated  conclusively  that  yellow  fever  is  transferred 
by  a  moscjuito,  Stegomyia  calopus,  previously  fed  on  the  blood  of  infected  per- 
sons. The  Commission  showed  also  that  in  non-immunes  the  disease  could 
be  produced  by  either  the  subcutaneous  or  the  intravenous  injection  of  blood 
taken  from  patients  suffering  with  the  disease. 

An  interval  of  about  twelve  days  or  more  after  contamination  appears  to 
be  necessary  before  the  mosquito  is  capable  of  transmitting  the  disease.  The 
bite  at  an  early  period  after  contamination  does  not  confer  immunity  against 
a  subsequent  attack.  As  Eeed  pointed  out.  the  mosquito  theory  fits  in  with 
well-recognized  facts  in  connection  with  the  epidemics.  After  the  importa- 
tion of  a  case  into  an  uninfected  region,  a  definite  period  elapses,  rarely  less 
'than  two  weeks,  before  a  second  case  occurs.  The  disease  prevails  most  dur- 
ing the  mosquito  season,  and  disappears  with  the  appearance  of  frost.  Prob- 
ably, too,  as  in  very  malarious  districts,  the  disease  is  kept  up  by  its  prevalence 
in  a  very  mild  form  among  children.     As  Guiteras  remarks,  "the  foci  of  en- 


YELLOW  FEVER  265 

demicity  are  essentially  maintained  by  the  Creole  infant  population,  which  is 
subject  to  the  disease  in  a  very  mild  form."  In  all  probability  the  immunity 
which  is  acquired  by  prolonged  residence  in  a  Jocality  in  which  the  disease  is 
endemic  is  due  to  the  occurrence  of  very  slight  attacks. 

One  attack  does  not  always  confer  immunity.  Eosenau  reports  two  at- 
tacks within  eight  years,  and  Libby  two  attacks  within  a  period  of  two  years. 

Noguchi  discovered  an  organism,  which  he  termed  Leptospira  icteroides, 
belonging  to  the  general  order  of  spirochsetes.  It  was  obtained  from  the  blood 
of  patients  and  produced  characteristic  symptoms  and  lesions  in  guinea  pigs 
from  the  blood  of  which  the  organism  was  obtained  in  pure  culture.  These 
cultures  were  virulent  for  susceptible  animals.  The  organism  is  an  actively 
motile  delicate  filament,  4  to  9  />i  in  length  and  0.3  /t  in  breadth.  A  positive 
Pfeiffer  phenomenon  was  observed  in  15  of  18  convalescent  cases  studied. 

Morbid  Anatomy. — The  skin  is  more  or  less  jaundiced,  even  though  the 
patient  did  not  appear  yellow  before  death.  Cutaneous  haemorrhages  may  be 
present.  No  specific  or  distinctive  internal  lesions  have  been  found.  The 
blood-serum  may  contain  hgemoglobin,  owing  to  destruction  of  the  red  cells, 
just  as  in  pernicious  malaria.  The  heart  sometimes,  not  invariably,  shows 
fatty  change;  the  stomach  presents  more  or  less  hypersemia  of  the  mucosa 
with  catarrhal  swelling.  It  contains  the  material  which,  ejected  during  life, 
is  known  as  the  hlach  vomit.  The  essential  ingredient  in  this  is  transformed 
blood-pigment.  There  is  often  general  glandular  enlargement;  the  cervical, 
axillary  and  mesenteric  groups  are  most  involved.  The  liver  is  usually  of  a 
pale  yellow  or  brownish-yellow  color,  and  the  cells  are  in  various  stages  of  a 
fatty  degeneration.  From  the  date  of  Louis'  observations  at  Gibraltar  in 
1828,  the  appearances  of  this  organ  have  been  very  carefully  studied,  and 
some  have  thought  the  changes  in  it  to  be  characteristic.  Hgemorrhagic  and 
necrotic  areas  are  common.  The  kidneys  show  acute  parenchymatous  inflam- 
mation. The  epithelium  of  the  convoluted  tubules  is  swollen  and  very  granu- 
lar; there  may  also  be  necrotic  changes. 

Symptoms. — The  incubation  is  usually  three  or  four  days;  in  13  experi- 
mental cases  it  ranged  from  forty-one  hours  to  five  days,  seventeen  hours. 
The  onset  is  sudden,  as  a  rule,  without  premonitory  symptoms,  and  in  the 
early  hours  of  the  morning.  Chilly  feelings  are  common,  and  are  usually 
associated  with  headache  and  very  severe  pains. in  the  back  and  limbs.  The 
fever  rises  rapidly  and  the  skin  feels  very  hot  and  dry.  The  tongue  is  furred, 
but  moist ;  the  throat  sore.  Nausea  and  vomiting  are  not  constant,  and  become 
more  intense  on  the  second  or  third  day.  The  bowels  are  usually  constipated. 
The  following  in  detail,  are  the  more  important  characteristics: 

Facies. — Even  as  early  as  the  first  morning  the  patient  may  present  a 
characteristic  facies,  one  of  the  three  distinguishing  features  of  the  disease, 
which  Guiteras  describes  as  follows :  The  face  is  flushed,  more  so  than  in  any 
other  acute  infectious  disease  at  such  an  early  period.  The  eyes  are  injected, 
the  color  is  a  bright  red,  and  there  may  be  a  slight  tumefaction  of  the  eyelids 
and  of  the  lips.  Even  at  this  early  date  there  is  to  be  noticed  in  connection 
with  the  injection  of  the  superficial  capillaries  of  the  face  and  conjunctivae  a 
slight  icteroid  tint,  and  "the  early  manifestation  of  jaundice  is  undoubtedly 
the  most  characteristic  feature  of  the  facies  of  yellow  fever." 

The  Fever. — On  the  morning  of  tbe  first  day  the  temperature  may  range 


266  SPECIFIC  INFECTIOUS  DISEASES 

from  100°  to  106°  F.,  usually  it  is  between  103°  and  103°  F.  During  the 
evening  of  the  first  day  and  the  morning  of  the  second  day  the  temperature 
keeps  about  the  same.  There  is  a  slight  diurnal  variation  on  the  second  and 
third  day.  In  very  mild  cases  the  fever  may  fall  on  the  evening  of  the  second 
or  on  the  morning  of  the  third  day,  or  in  abortive  cases  even  at  the  end  of 
twenty-four  hours.  In  cases  that  are  to  terminate  favorably  the  defervescence 
takes  place  by  lysis  during  a  period  of  two  or  three  days.  The  remission  or 
stage  of  calm,  as  it  has  been  called,  is  succeeded  by  a  febrile  reaction  or  sec- 
ondary fever,  which  lasts  one,  two,  or  three  days,  and  in  favorable  cases  falls 
by  a  short  lysis.  On  the  other  hand,  in  fatal  cases  the  temperature  is  continu- 
ous, becomes  higher  than  in  the  initial  fever,  and  death  follows  shortly. 
'  The  Pulse. — On  the  first  day  the  pulse  is  rarely  more  than  100  or  110. 
On  the  second  or  third  day,  while  the  fever  still  keeps  up,  the  pulse  begins 
to  fall,  as  much  perhaps  as  20  beats,  while  the  temperature  has  risen  1.5°  or 
2°.  On  the  evening  of  the  third  day  there  may  be  a  temperature  range  of 
103°  and  a  pulse  of  only  75,  or  "a  temperature  between  103°  and  10-4°  with 
a  pulse  running  from  70  to  80."  This  important  diagnostic  feature  was  first 
described  by  Paget,  of  New  Orleans.  During  defervescence  the  pulse  may 
become  still  lower,  down  to  50,  48,  or  45,  or  even  as  low  as  30;  a  slow  pulse 
at  this  period  is  not  the  special  circulatory  feature  of  the  disease,  but  the 
sloiving  of  the  pulse  ivith  a  steady  or  even  rising  temperature. 

Albuminuria. — This,  the  third  characteristic  symptom  of  the  disease, 
occurs  as  early  as  the  evening  of  the  third  day.  G-uiteras  says  very  truly  that 
it  is  very  rare  so  early  in  other  fevers  except  those  of  an  unusually  severe 
type.  "Even  in  the  mild  cases  that  do  not  go  to  bed — cases  of  'walking  yel- 
low fever' — on  the  second,  third,  or  fourth  day  of  the  disease  albuminuria  will 
show  itself."  It  may  be  quite  transient.  In  the  severer  cases  the  amount  of 
albumin  is  very  large,  and  there  may  be  numerous  tube  casts  and  all  the  signs 
of  an  acute  nephritis;  or  complete  suppression  may  supervene,  and  death  oc- 
curs in  ursemic  convulsions  or  coma  within  twenty-four  or  thirty-six  hours. 

GrASTRic  Features. — ''Black  Vomit." — Irritability  of  the  stomach  is  pres- 
ent from  the  very  outset,  and  the  vomited  matter  consists  of  the  contents  of 
the  stomach,  and  subsequently  of  mucus  and  a  grayish  fluid.  In  the  third 
stage  of  the  disease  the  vomiting  becomes  more  pronounced  and  in  the  severe 
cases  is  characterized  by  the  presence  of  blood.  It  may  be  copious  and  forcible, 
producing  much  pain  in  the  abdomen  and  along  the  gullet.  There  is  nothing 
specific  in  this  "black  vomit,"  which  consists  of  altered  blood,  and  it  is  not 
necessarily  a  fatal  symptom,  though  occurring  only  in  the  severer  forms  of 
the  disease.  Other  hgemorrhagic  features  may  be  present — petechiaB  on  the 
skin  and  bleeding  from  the  gums  or  from  other  mucous  membranes.  The 
bowels  are  usually  constipated,  the  stools  not  clay-colored,  except  late  in  the 
disease.     They  are  sometimes  tarry  from  the  presence  of  altered  blood. 

Mental  Features. — In  very  severe  cases  the  onset  may  be  with  active 
delirium.  "As  a  rule,  in  a  majority  of  cases,  even  when  there  is  black  vomit, 
there  is  a  peculiar  alertness;  the  patient  watches  everything  going  on  abc-at 
him  with  a  peculiar  intensity  and  liveliness.  This  may  be  due  in  part  to  the 
terror  the  disease  inspires"  (Guiteras). 

Relapses  occasionally  occur.  Among  the  varieties  of  the  disease  it  is  im- 
portant to  recognize  the  mild  cases,  characterized  by  slight  fever,  continuing 


YELLOW  FEVER  267 

for  one  or  two  days,  and  succeeded  by  a  rapid  convalescence.  In  the  absence 
of  a  prevailing  epidemic  they  would  scarcely  be  recognized  as  yellow  fever. 
Cases  of  greater  severity  have  high  fever  and  the  features  of  the  disease  are 
well  marked — vomiting,  extreme  prostration,  and  hgemorrhages.  And,  lastly, 
in  the  malignant  form  the  patient  is  overwhelmed  by  the  intensity  of  the  fever, 
and  death  takes  place  in  two  or  three  days. 

In  severe  cases  convalescence  may  be  complicated  by  parotitis,  abscesses 
in  various  parts  of  the  body,  and  diarrhoea. 

Diagnosis. —  (a)  From  Dengue. — The  difficulty  in  the  differential  diag- 
nosis of  these  two  diseases  lies  in  their  frequent  coexistence,  as  during  the  epi- 
demic of  1897  in  parts  of  the  Southern  States.  During  the  autumn  of  1897 
the  profession  of  Texas  was  divided  on  the  question  of  the  existence  of  yellow 
fever  in  the  State,  some  claiming  that  the  disease  was  dengue,  others,  includ- 
ing Guiteras  and  West,  that  yellow  fever  also  existed.  In  a  majority  of  the 
cases  the  three  diagnostic  points  upon  which  Guiteras  lays  stress — the  facies, 
the  albuminuria,  and  the  slowing  of  the  pulse  with  maintenance  or  elevation 
of  the  fever — are  sufficient  for  the  diagnosis.  He  states,  too,  that  jaundice, 
which  does  sometimes  occur  in  dengue,  rarely  appears  as  early  as  the  second 
or  third  day  of  the  disease,  and  on  this  much  stress  should  be  laid.  Hemor- 
rhages are  much  less  common  in  dengue,  but  that  they  do  occur  has  been 
recognized  by  authorities  ever  since  the  time  of  Rush. 

(&)  From  Malarial  Fever. — In  the  early  stages  of  an  epidemic  cases 
are  very  apt  to  be  mistaken  for  malarial  fever.  In  the  Southern  States  the 
outbreaks  have  usually  been  in  the  late  summer  months,  the  season  in  which 
aestivo-autumnal  fever  prevails.  Among  the  points  to  be  specially  noted  is 
the  absence  of  early  jaundice.  Even  in  the  most  intense  types  of  malarial 
infection  the  color  of  the  skin  is  rarely  changed  within  four  or  five  days. 
To  the  experienced  eye  the  facies  would  be  of  considerable  help  if  the  case 
was  seen  from  the  outset.  Albumin  is  rarely  present  in  the  urine  so  early 
as  the  second  day  in  a  malarial  infection.  Other  important  points  are  the 
marked  swelling  of  the  spleen  in  malaria,  while  in  yellow  fever  it  is  not 
much  enlarged.  Hgemorrhages,  and  particularly  the  black  vomit,  epistaxis, 
and  bleeding  gums  are  very  rare  in  malarial  infection.  In  the  so-called  hse- 
morrhagic  malarial  fever  the  patient  has  usually  had  previous  attacks  of 
malaria.  Hsematuria  is  a  prominent  feature,  while  in  yellow  fever  it  is  by 
no  means  frequent.  The  point  of  greatest  importance  is  the  examination  of 
the  blood  for  malarial  parasites. 

Prognosis. — In  its  graver  forms  yellow  fever  is  one  of  the  most  fatal  of 
epidemic  diseases.  The  mortality  has  ranged,  in  various  epidemics,  from  15 
to  85  per  cent.  In  heavy  drinkers  and  those  who  have  been  exposed  to  hard- 
ships the  death-rate  is  much  higher  than  among  the  better  classes.  In  the 
epidemic  of  1878,  in  New  Orleans,  while  the  mortality  in  hospitals  was  over 
50  per  cent,  of  the  white  and  21  per  cent,  of  the  \colored  patients,  in  private 
practice  it  was  not  more  -than  10  per  cent,  among  the  white  patients.  The 
death-rate  was  very  low  in  the  epidemic  of  1897. 

Prophylaxis. — The  clearing  of  Havana  by  Gorgas  was  a  direct  outcome 
of  the  work  of  Reed  and  his  colleagues.  The  city,  with  250,000  people,  had 
been  infected  continuously  for  130  years.  Non-immunes  came  in  at  the  rate 
of  20,000  a  year,  and  there  were  6,000  children  born.     The  city  was  divided 


268  SPECIFIC  INFECTIOUS  DISEASES 

into  districts,  each  under  the  charge  of  an  inspector,  whose  work  was  arranged 
under  three  heads:  (1)  To  prevent  the  breeding  of  stegomyia  mosquitoes. 
(2)  To  destroy  those  that  had  become  infected.  (3)  To  prevent  mosquitoes 
becoming  infected  by  protecting  the  sick  so  that  they  could  not  be  bitten  by 
mosquitoes.  The  work  Avas  begun  in  February,  1901,  and  the  last  case  of 
yellow  fever  occurred  in  September  of  that  year,  since  which  date,  with  the 
exception  of  a  slight  return,  the  city  has  been  free. 

At  Panama  in  1904,  the  date  of  the  American  occupation,  the  serious 
problem  was  how  to  fight  yellow  fever.  Conditions  were  such  that  it  took 
sixteen  months  before  the  disease  disappeared.  There  has  been  no  return. 
It  is  interesting  to  note  that  in  the  yellow  fever  wards  at  Ancon  during  1905 
all  the  physicians  and  nurses  were  non-immune,  but  not  one  of  them  con- 
tracted the  disease,  as  the  wards  were  so  screened  that  no  stegomyia  mos- 
quitoes could  get  at  the  patients  to  become  infected. 

Treatment. — Careful  nursing  and  a  symptomatic  plan  of  treatment  prob- 
ably give  the  best  results.  The  patient  should  be  at  rest  in  bed  and  for  the 
first  few  days  the  diet  should  consist  of  very  simple  fluids.  Elimination  is  an 
important  part  of  treatment.  Water  should  be  given  as  freely  as  possible, 
best  in  the  form  of  cold  carbonated  alkaline  water.  The  bowels  should  be 
opened  by  a  calomel  and  saline  purge  and  enemata  used  if  necessary.  If 
there  is  vomiting,  fluid  should  be  given  by  the  bowel  or  by  infusion.  Ice  in 
small  quantities  or  cocaine  (gr.  14,  0.016  gm.)  may  be  tried.  The  fever  should 
be  treated  by  hydrotherapy,  sponges,  packs  or  baths  being  used.  The  alkaline 
treatment  is  favorably  regarded,  sodium  bicarbonate  in  full  doses  being  given 
at  short  intervals  and  as  much  alkaline  water  as  possible.  For  gastric  and 
intestinal  haemorrhage  the  perchloride  of  iron  or  oil  of  tui'pentine  may  be 
given  in  doses  of  15  minims  (1  c. 'c).  Urgemic  symptoms  are  best  treated 
by  the  hot  baths  or  packs,  the  free  administration  of  fluid  and  hot  bowel 
irrigations.  Stimulants,  especially  strychnine,  should  be  used  during  the  sec- 
ond stage  when  the  heart  becomes  feeble  and  rapid. 


VIII.     SYPHILIS 

I.    HISTORY,  ETIOLOGY  AND  MORBID  ANATOMY 

Definition. — A  specific  disease  of  slow  evolution  caused  by  Treponema 
pallidum  (spirochseta  pallida)  propagated  by  inoculation  (acquired  syphilis) 
or  transmission  through  the  mother  (congenital  syphilis). 

History. — Whether  the  disease  was  known  in  Europe  before  1493  is  still 
discussed.  Block,  in  the  System  of  Syphilis,  Vol.  I,  1908,  insists  that  there 
is  no  evidence  of  pre-Columbian  syphilis  in  the  Eastern  hemisphere  before 
the  return  of  the  Spanish  sailors  from  Hayti,  from  whom  it  spread  among 
the  inhabitants  of  Barcelona.  In  1493  it  reached  Italy  with  the  army  of 
Charles  VIII.  His  soldiers  syphilized  Naples;  the  disease  spread  throughout 
Italy,  and  in  a  few  years  Europe  was  aflame.  On  the  other  hand,  writers  who 
contend  for  the  antiquity  of  the  disease  in  Asia  and  Europe  rely  on  certain 
old  Chinese  records,  on  references  in  the  Bible  and  in  old  medical  writers  to 
diseases  resembling  syphilis  and  on  suggestive  bone  lesions  in  very  old  skele- 


SYPHILIS  '  269 

tons.  The  balance  of  evidence,  according  to  the  best  syphilographers,  is  in 
favor  of  the  American  origin.  At  first  it  v^^as  called  the  Neapolitan  disease, 
the  French  pox,  or  Morbus  Gallicus ;  and  in  1530  Fracastorius,  in  a  poem  en- 
titled "Syphilis  sive  Morbus  Gallicus,"  gave  it  the  name  by  which  it  is  now 
commonly  known.     The  etymology  of  the  name  is  uncertain. 

At  first  the  disease  was  thought  to  be  transmitted  like  any  other  epidemic, 
but  gradually  the  venereal  nature  was  recognized,  and  Fernel,  a  famous  Paris 
physician  of  the  16th  century,  insisted  on  the  necessity  of  a  primary  inocula- 
tion. Paracelsus  observed  its  congenital  character.  Throughout  the  16th  cen- 
tury the  symptoms  were  well  described.  The  disease  appears  to  have  been 
of  much  greater  severity  then  than  at  present.  Mercury  and  guaiacum  were 
introduced  as  the  important  remedies.  In  the  18th  century  Lancisi  recognized 
the  relations  existing  between  syphilis  and  aneurism,  and  Morgagni  described 
many  of  the  visceral  lesions.  Hunter,  misled  by  inoculations  made  on  his  own 
person,  decided  in  favor  of  the  unity  of  the  venereal  poisons,  gonorrhoea, 
soft  chancre  and  syphilis.  Kicord  clearly  differentiated  the  soft  and  hard 
chancre,  and  throughout  the  19th  century  the  clinical  and  pathological  lesions 
were  so  thoroughly  studied  that  scarcely  a  feature  of  the  disease  remained 
unknown.  But  all  efforts  at  discovering  the  cause  had  failed,  until  in  1905 
Schaudinn  demonstrated  the  presence  of  a  spirochsete  in  the  lesions.  Since 
then  his  work  has  been  amply  verified,  and  in  1910  Ehrlich  announced  the 
discovery  of  a  compound  which  would  destroy  the  parasite  and  not  damage 
the  individual. 

Etiology:  The  Parasite. — The  treponema  is  a  spiral,  curved  organism 
from  5  to  15  /A  in  length,  showing  active  movements  in  fresh  specimens.  It 
is  present  in  the  primary  sore,  in  the  regional  lymph  glands,  in  the  secondary 
lesions,  in  many  gummata,  and  in  special  abundance  in  the  congenital  lesions, 
particularly  in  the  liver.  It  may  live  in  the  body  as  long  as  the  host  is  alive. 
-It  is  inoculable  into  monkeys,  with  the  production  of  a  disease  resembling  in 
most  particulars  that  of  man.     The  parasite  has  been  cultivated  by  Noguchi. 

There  are  apparently  various  strains  of  the  treponema  and  this  may  explain 
some  of  the  clinical  difi'erences.  Workers  in  the  United  States  Army  Medical 
School  have  grown  spirochastes  showing  different  results  in  the  primary  and 
secondary  lesions  produced  by  them.  The  spirochgetes  from  cases  of  general 
paresis  take  60  to  80  days  for  propagation  and  60  days  for  lesions  to  be  pro- 
duced in  rabbits,  whereas  in  the  case  of  organisms  from  early  lesions  three  or 
four  weeks  is  sufficient.  The  spirochgetes  cause  the  production  of  antibodies 
in  the  tissues  and  it  seems  possible  that  with  time  a  strain  of  spirochaBtes  may 
result  with  greater  resistance  but  perhaps  less  power  of  reproduction.  The 
infection  then  does  not  cause  any  active  symptoms,  but  may  persist  indefinitely 
in  a  latent  form  to  resume  activity  after  a  long  interval  of  quiescence.  In  some 
cases  the  tissues,  so  to  speak,  become  accustomed  to  the  spirochetes,  antibodies 
are  not  produced,  and  in  the  absence  of  these  the  Wassermann  reaction  is  nega- 
tive. The  infection  must  be  active  to  cause  the  production  of  antibodies.  In 
many  cases  a  resistance  to  the  usual  remedies  is  apparently  established. 

One  of  the  most  important  results  of  the  discovery  of  the  parasite  has 
been  the  application  of  the  methods  of  serum  diagnosis.  What  is  called 
the  Wassermann  reaction  is  a  special  M^ay  of  determining  the  presence  of  im- 
iiuuie  bodies  in  the  blood  of  a  patient  suffering  from  syphilitic  infection.    An 


270  SPECIFIC  INFECTIOUS  DISEASES 

enormous  amount  of  work  has  been  done  upon  it  with  the  general  result  of  con- 
firming its  value.  A  positive  result  has  been  obtained  in  from  90  to  95  per 
cent,  of  all  cases.  It  appears  from  the  end  of  the  second  to  the  end  of  the 
fourth  week,  becomes  more  marked  and  may  continue  for  an  indefinite  period. 
During  active  treatment  it  may  be  absent,  to  reappear  again.  Its  intensity 
bears  some  relation  to  the  activity  of  the  lesions. 

Modes  of  Infection. —  (a)  In  a  majority  of  all  cases  the  disease  is  trans- 
mitted by  sexual  congress,  but  the  designation  venereal  disease  (lues  venerea) 
is  not  always  correct,  as  there  are  many  other  modes  of  inoculation.  In  the  St. 
Louis  Hospital  collection  there  are  illustrations  of  26  varieties  of  extra- 
genital chancres. 

(&)  Accidental  Infection. — In  surgical  and  in  midwifery  practice  phy- 
sicians are  not  infrequently  inoculated.  Infection  may  occur  without  a  charac- 
teristic local  sore.  Midwifery  chancres  are  usually  on  the  fingers,  but  may 
be  on  the  back  of  the  hand.  The  lip  chancre  is  the  most  common  of  these 
extra-genital  forms,  and  may  be  acquired  in  many  ways  apart  from  direct 
infection.  Mouth  and  tonsillar  sores  result  as  a  rule  from  improper  practices. 
Wet-nurses  are  sometimes  infected  on  the  nipple,  and  it  occasionally  happens 
that  relatives  of  a  syphilitic  child  are  accidentally  contaminated. 

(c)  Congenital  Transmission. — The  disease  is  not  inherited,  but  the 
fetus  is  infected  through  the  placenta.  It  is  a  question  entirely  of  intra-uterine 
infection.  The  mother  herself  may  be,  and  often  is,  apparently  quite  healthy, 
but  the  Wassermann  reaction  is  present  and  it  is  through  her  and  not  directly 
from  the  father  that  the  disease  is  transmitted.  We  can  now  understand 
what  is  known  as  Beaumes'  or  Colles'  law,  which  was  thus  stated  by  the  dis- 
tinguished Dublin  surgeon:  "That  a  child  born  of  a  mother  who  is  without 
obvious  venereal  symptoms,  and  which,  without  being  exposed  to  any  infection 
subsequent  to  its  birth,  shows  this  disease  when  a  few  weeks  old,  this  child  will 
infect  the  most  healthy  nurse,  whether  she  suckle  it,  or  merely  handle  and  dress 
it;  and  yet  this  child  is  never  known  to  infect  its  own  mother,  even  though 
she  suckle  it  while  it  has  venereal  ulcers  of  the  lips  and  tongue."  So,  too,  a 
child  showing  no  taint,  but  born  of  a  woman  suffering  with  syphilis,  may 
with  impunity  be  suckled  by  its  mother  (Profeta's  law). 

Morbid  Anatomy. — The  typical  primary  lesion,  or  chancre,  shows:  (a) 
A  diffuse  infiltration  of  the  connective  tissue  with  small,  round  cells.  (&) 
Larger  epithelioid  cells,  (c)  Giant  cells,  (d)  Changes  in  the  small  arteries 
and  veins,  chiefiy  thickening  of  the  intima,  and  alterations  in  the  nerve  fibres 
going  to  the  part.  The  sclerosis  is  due  in  part  to  this  acute  obliterative 
endarteritis.  Associated  with  the  initial  lesions  are  changes  in  the  adjacent 
lymph  glands,  which  undergo  hyperplasia,  and  finally  become  indurated. 

The  secondary  lesions  of  syphilis  are  too  varied  for  description  here.  They 
consist  of  condylomata,  skin  eruptions,  affections  of  the  eye,  etc. 

The  tertiary  lesions  consist  of  circumscribed  tumors  known  as  gummata, 
various  skin  lesions,  and  a  special  type  of  arteritis. 

Gummata. — Syphilomata  occur  in  the  bones  or  periosteum — here  they  are 
called  nodes — in  the  muscles,  skin/  brain,  lungs,  liver,  kidneys,  heart,  testes, 
and  adrenals.  They  vary  in  size  from  small,  almost  microscopic  bodies  tc 
large  solid  tumors  from  3  to  5  cm.  in  diameter.  They  are  usually  firm  and 
hard,  but  in  the  skin  and  on  the  mucous  membranes  they  tend  to  break  down 


SYPHILIS  271 

rapidly  and  ulcerate.    On  cross-section  a  medium-sized  gumma  has  a  grayish- 
white,  homogeneous  appearance,  presenting  in  the  centre  a  firm,  caseous  sub- 
stance, and  at  the  periphery  a  translucent,  fibrous  tissue.     Often  there  are 
groups  of  three  or  more  surrounded  by  dense  sclerotic  tissue. 
The  arteritis  .will  be  considered  in  a  separate  section. 

II.     ACQUIRED   SYPHILIS 

Primary  Stage. — This  extends  from  the  appearance  of  the  initial  sore  un- 
til the  onset  of  the  constitutional  symptoms,  and  has  a  variable  duration  of 
from  six  to  twelve  weeks.  The  initial  sore  appears  within  a  month  after 
inoculation,  and  it  first  shows  itself  as  a  small  red  papule,  which  gradually 
enlarges  and  breaks  in  the  centre,  leaving  a  small  ulcer.  The  tissue  about 
this  becomes  indurated  so  that  it  ultimately  has  a  gristly,  cartilaginous  con- 
sistence— hence  the  name,  hard  or  indurated  chancre.  The  size  attained  is 
variable,  and  when  small  the  sore  may  be  overlooked,  particularly  if  it  is  just 
within  the  urethra.  The  initial  lesion  has  no  invariable  characteristic  and 
may  not  be  indurated.  It  must  be  emphasized  that  infection  may  occur  with- 
out any  marked  primary  lesion.  A  negative  history  as  to  the  occurrence  of 
a  chancre  is  of  no  value  in  excluding  the  possibility  of  infection.  There  are  a 
considerable  number  of  extragenital  infections.  Syphilitic  infection  may 
occur  with  a  chancroid.  The  glands  in  the  lymph-district  of  the  chancre 
enlarge  and  become  hard.  Suppuration  both  in  the  initial  lesion  and  in  the 
glands  may  occur  as  a  secondary  change.  The  general  condition  of  the  patient 
in  this  stage  is  good.    There  may  be  no  fever  and  no  impairment  of  health. 

Secondary  Stage. — The  first  constitutional  symptoms  are  usually  mani- 
fested within  three  months  of  the  appearance  of  the  primary  sore.  They 
rarely  occur  earlier  than  the  sixth  or  later  than  the  twelfth  week : 

(a)  Fever,  slight  or  intense,  and  very  variable  in  character,  may  occur 
early  before  the  skin  rash;  more  frequently  it  is  the  "fever  of  invasion"  with 
the  secondary  symptoms,  or  the  fever  may  occur  at  any  period.  It  may  be  a 
mild  continuous  pyrexia,  or  in  other  instances  with  marked  remissions,  but  the 
most  remarkable  form  is  the  intermittent,  often  mistaken  for  malaria.  The 
fever  may  reach  105°  and  the  paroxysms  persist  for  months.  We  have  had 
several  cases  in  which  typhoid  fever  or  tuberculosis  was  suspected. 

(&)  Anmmia. — In  many  cases  the  syphilitic  poison  causes  a  pronounced 
anaemia  which  gives  to  the  face  a  muddy  pallor,  and  there  may  even  be  a 
light-yellow  tinging  of  the  conjunctivae  or  of  the  skin,  a  hematogenous  icterus. 
This  syphilitic  cachexia  may  in  some  instances  be  extreme.  The  red  blood 
corpuscles  do  not  show  any  special  alterations.  The  blood  count  may  fall  to 
three  millions  per  cubic  millimetre,  or  even  lower.  The  anaemia  may  come 
on  suddenly.  In  a  case  of  syphilitic  arthritis  in  a  young  girl,  following  three 
or  four  inunctions  of  mercury,  the  blood-count  fell  below  two  millions  per 
cubic  millimetre  in  a  few  days. 

(c)  Cutaneous  Lesions. — The  earliest  and  most  common  is  a  macular 
syphilide  or  syphUitic  roseola,  which  occurs  on  the  trunk,  and  on  the  front  of 
the  arms.  The  face  is  often  exempt.  The  spots,  which  are  reddish-brown 
and  symmetrically  arranged,  persist  for  a  week  or  two.  There  may  be  mul- 
tiple relapses  of  roseola,  sometimes  at  long  intervals,  even  eleven  years  (Four- 


272  SPECIFIC  INFECTIOUS  DISEASES 

nier).  The  pabular  sypliilide,  which  forms  acne-like  indurations  about  the 
face  and  trunk,  is  often  arranged  in  groups.  Other  forms  are  the  pustular 
rash,  which  may  closely  simulate  variola.  A  squamous  sypliilide  occurs,  not 
unlike  ordinary  psoriasis,  except  that  the  scales  are  less  abundant.  The  rash 
is  more  copper-colored  and  not  specially  confined  to  the  extensor  surfaces. 

In  the  moist  regions  of  the  skin,  such  as  the  perineum  and  groins,  and  at 
the  angles  of  the  mouth,  the  so-called  mucous  patches  occur,  which  are  flat, 
warty  outgrowths,  with  well-defined  margins  and  surfaces  covered  with  a 
grayish  secretion.    They  are  among  the  most  distinctive  lesions  of  syphilis. 

Frequently  the  hair  falls  out  (alopecia),  either  in  patches  or  by  a  general 
thinning.     Occasionally  the  nails  become  affected  (syphilitic  onychia). 

{d)  Mucous  Lesions. — With  the  fever  and  the  roseolous  rash  the  throat 
and  mouth  become  sore.  The  pharyngeal  mucosa  is  hypersemic,  the  tonsils  are 
swollen  and  often  present  small,  kidney-shaped  ulcers  with  grayish-white 
borders.  Mucous  patches  are  seen  on  the  inner  surfaces  of  the  cheeks  and  on 
the  tongue  and  lips.  Hypertrophy  of  the  papillee  in  various  portions  of  the 
mucous  membrane  produces  the  syphilitic  warts  or  condylomata  which  are 
most  frequent  about  the  vulva  and  anus. 

(e)  Adenitis. — This  is  often  general.  The  glands  are  hard,  painless  and 
not  much  enlarged.  Involvement  of  the  epitrochlear  and  posterior  cervical 
glands  is  specially  significant. 

(/)  Arthritis  and  pains  in  the  limbs  are  common  secondary  symptoms. 
Occasionally  the  joint  affection  is  severe  and  rheumatic  fever  is  suspected. 

{g)  Other  Lesions. — An  increase  of  the  cells  in  the  spinal  fluid  is  found 
in  30  to  40  per  cent,  of  cases.  Iritis  is  common,  and  usually  affects  one  eye 
before  the  other.  It  comes  on  from  three  to  six  months  after  the  chancre. 
There  may  be  only  slight  ciliary  congestion  in  mild  cases,  but  in  severer  forms 
there  is  great  pain,  and  the  condition  is  serious  and  demands  careful  manage- 
ment. Choroiditis  and  retinitis  are  rare  secondary  symptoms.  Pupillary 
changes  are  not  uncommon  in  the  early  stages.  Ear  affections  are  not  common 
in  the  secondary  stage,  but  instances  are  found  in  which  sudden  deafness 
occurs,  which  may  be  due  to  labyrinthine  disease;  more  commonly  the  im- 
paired hearing  is  due  to  the  extension  of  inflammation  from  the  throat  to  the 
middle  ear.  Epididymitis  and  parotitis  are  rare.  Jaimdice  may  occur,  the 
icterus  syphiliticus  prcecox.    The  acute  nephritis  will  be  referred  to  later. 

Tertiary  Stage. — No  hard  and  fast  line  can  be  drawn  between  the  lesions 
of  the  secondary  and  those  of  the  tertiary  period ;  and,  indeed,  in  exceptional 
cases,  manifestations  which  usually  appear  late  may  set  in  even  before  the 
primary  sore  has  properly  healed.  The  special  affections  of  this  stage  are  cer- 
tain skin  eruptions,  visceral  gummata,  and  amyloid  degenerations. 

{a)  The  late  syphilides  show  a  greater  tendency  to  ulceration  and  destruc- 
tion of  the  deeper  layers  of  the  skin,  so  that  in  healing  scars  are  left.  They 
are  also  more  scattered  and  seldom  symmetrical.  One  of  the  most  character- 
istic of  the  syphilides  is  rupia,  the  dry  stratified  crusts  of  which  cover  an  ulcer 
which  involves  the  deeper  layers  of  the-  skin  and  in  healing  leaves  a  scar. 

{h)  Giimmata. — These  may  occur  in  the  skin,  subcutaneous  tissue,  mus- 
cles, or  internal  organs.  In  the  skin  they  tend  to  break  down  and  ulcerate, 
leaving  ugly  sores  which  heal  with  difficulty.  In  the  solid  organs  they  undergo 
fibroid  transformation  and  produce  puckering  and  deformity.    On  the  mucous 


SYPHILIS  273 

membranes  these  tertiary  lesions  lead  to  ulceration,  in  the  healing  of  which 
cicatrices  are  formed ;  thus,  in  the  larynx  great  narrowing  may  result,'  and  in 
the  rectum  ulceration  with  fibroid  thickening  and  retraction  may  lead  to  stric- 
ture.    Gummatous  ulcers  may  be  infective. 

(c)  Amijloid  Degeneration. — Syphilis  plays  a  most  important  role  in  the 
production  of  this  affection.  Of  244  instances  analyzed  by  Fagge,  76  had 
sypliilis,  and  of  these  42  had  no  bone  lesions.  It  follows  the  acquired  form  and 
is  very  common  in  association  with  rectal  syphilis  in  women.  In  congenital 
lues  amyloid  degeneration  is  rare. 

{d)  Syphilis  of  the  Bones. — This  is  by  no  means  uncommon  and  should 
be  searched  for  by  radiography  in  doubtful  cases.  The  commonest  lesions  are 
periostitis  and  osteo-periostitis  which  may  exist  without  any  symptoms.  Occa- 
sionally a  gumma  is  found.  The  bone  lesions  occur  both  in  the  acquired  and 
congenital  form.  Pain  is  common,  often  nocturnal  and  relieved  by  exercise. 
It  may  occur  only  on  pressure  over  small  areas.  Involvement  of  the  spine  is 
not  unusual.  There  may  be  periostitis,  osteomyelitis  with  necrosis,  and  some- 
times the  formation  of  exostoses,  which  may  be  felt.  The  cervical  region  is 
most  often  involved  and  the  process  is  generally  limited  to  a  small  number  of 
vertebras.  The  main  features  are  pain,  tenderness,  rigidity,  and  sometimes 
deformity.  In  a  number  of  patients  neural  symptoms  are  present  and  root 
pains  may  be  marked.  The  degree  of  deformity  varies.  There  is  often  marked 
muscle  spasm  in  the  region  involved  and  hypotonicity  in  other  parts  of  the 
spine.  Involvement  of  the  cord  itself  is  comparatively  common.  The  diag- 
nosis of  involvement  of  the  spine  may  not  be  easy.  Careful  search  should  be 
made  for  luetic  lesions  elsewhere;  for  example,  ulceration  of  the  larynx  has 
been  found  in  a  certain  number  of  cases  of  involvement  of  the  cervical  region. 

Quaternary  Stage. — Long  years  it  may  be  from  the  primary  sore  and  from 
any  active  manifestations,  certain  forms  of  syphilis  may  appear,  the  chief  of 
which  are  tabes  dorsalis  and  general  paresis. 

Latent  Syphilis. — In  many  cases  there  is  a  persistence  of  the  spiro- 
chgetal  infection  without  evident  clinical  signs  of  the  disease,  proved  by  the 
presence  of  the  spirochsetes  in  certain  tissues,  especially  the  heart,  aorta  and 
testicles.  "Warthin  has  drawn  especial  attention  to  this  and  has  demonstrated 
the  organisms  in  about  one-third  of  autopsies  on  adults.  Careful  examination 
will  often  show  clinical  evidence  in  the  form  of  myocarditis,  aortitis,  or  indura- 
tion of  the  testicle.  Warthin  suggests  that  latent  syphilis  is  the  chief  factor  in 
causing  myocardial  insufficiency  and  the  cardiovascular-renal  complex.  The 
Wassermann  reaction  and  examination  of  the  spinal  fluid  are  useful  in  the 
recognition  of  these  cases'. 

III.      CONGENITAL    SYPHILIS 

With  the  exception  of  the  primary  sore,  every  feature  of  the  acquired  dis- 
ease may  be  seen  in  the  congenital  form. 

The  intra-uterine  conditions  leading  to  the  death  of  the  fetus  do  not  here 
concern  us.  The  child  may  be  born  healthy-looking  or  with  well-marked  evi- 
dences of  the  disease.  In  the  majority  of  instances  the  former  is  the  case 
and  within  the  first  month  or  two  the  signs  of  the  disease  appear. 

Symptoms. —  (a)   At  Birth.^When  the  disease  exists  at  birth  the  child 


274  SPECIFIC  INFECTIOUS  DISEASES 

is  feebly  developed  and  wasted,  and  a  skin  eruption  is  usually  present,  com- 
monly in  the  form  of  bullae  about  the  hands  and  feet  (pemphigus  neonatorum 
syphiliticus).  The  child  snuffles,  the  lips  are  ulcerated,  the  angles  of  the 
mouth  fissured,  and  there  is  enlargement  of  the  liver  and  spleen.  The  bone 
symptoms  may  be  marked,  and  the  epiphyses  may  even  be  separated.  In  such 
cases  the  children  rarely  survive  long. 

(/;)  Early  Manifestations. — When  born  healthy  the  child  thrives,  is  fat 
and  plump,  and  shows  no  abnormity  whatever;  then  from  the  fourth  to  the 
eighth  week,  rarely  later,  a  nasal  catarrh  occurs,  syphilitic  rhinitis,  which  im- 
pedes respiration,  and  produces  the  characteristic  symptom  which  has  given 
the  name  snuffles  to  the  disease.  The  discharge  may  be  sero-purulent  or 
bloody.  The  child  nurses  with  great  difficulty.  In  severe  cases  ulceration 
takes  place  with  necrosis  of  the  bone,  leading  to  a  depression  at  the  root  of  the 
nose  and  a  deformity  characteristic  of  congenital  syphilis.  This  coryza  may 
be  mistaken  at  first  for  an  ordinary  catarrh,  but  the  coexistence  of  other  mani- 
festations usually  makes  the  diagnosis  clear.  The  disease  may  extend  into 
the  Eustachian  tubes  and  middle  ears  and  lead  to  deafness. 

The  cutaneous  lesions  arise  with  or  shortly  after  the  onset  of  the  snuf- 
fles. The  skin  often  has  a  sallow,  earthy  hue.  The  eruptions  are  first  noticed 
about  the  nates.  There  may  be  an  erythema  or  an  eczematous  condition,  but 
more  commonly  there  are  irregular  reddish-brown  patches  with  well-defined 
edges.  A  papular  syphilide  in  this  region  is  by  no  means  uncommon.  A  des- 
quamative dermatitis  of  the  palms  of  the  hands  and  soles  of  the  feet  may 
occur.  Fissures  occur  about  the  lips,  either  at  the  angles  of  the  mouth  or  in  the 
median  line.  These  rhagades,  as  they  are  called,  are  very  characteristic. 
There  may  be  marked  ulceration  of  the  muco-cutaneous  surfaces.  The  secre- 
tions from  these  mouth  lesions  are  very  virulent,  and  it  is  from  this  source  that 
the  wet-nurse  is  usually  infected.  Not  only  the  nurse,  but  members  of  the 
family,  may  be  contaminated.  There  are  instances  in  which  other  children 
have  been  accidentally  inoculated  from  a  syphilitic  infant.  The  hair  of  the 
head  or  of  the  eyebrows  may  fall  out.  The  syphilitic  onychia  is  not  uncom- 
mon. Enlargement  of  the  glands  is  not  so  frequent*  in  the  congenital  as  in 
the  acquired  disease.  When  the  cutaneous  lesions  are  marked  the  contiguous 
glands  can  usually  be  felt.  As  pointed  out  by  Gee,  the  spleen  is  enlarged  in 
many  cases.  The  condition  may  persist  for  a  long  time.  Enlargement  of  the 
liver,  though  often  present,  is  less  significant,  since  in  infants  it  may  be  due 
to  various  causes.  These  are  among  the  most  constant  symptoms  of  congenital 
syphilis,  and  usually  arise  between  the  third  and  twelfth  weeks.  Frequently 
they  are  preceded  by  a  period  of  restlessness  and  wakefulness,  particularly  at 
night.  Some  authors  have  described  a  peculiar  syphilitic  cry,  high-pitched 
and  harsh.  Among  rarer  manifestations  are  haemorrhages — the  syphilis  he- 
morrhagica neonatorum.  The  bleeding  may  be  subcutaneous,  from  the  mucous 
surfaces,  or,  when  early,  from  the  umbilicus.  All  of  such  cases,  however, 
are  not  syphilitic,  and  the  disease  must  not  be  confounded  with  the  acute 
hsemoglobinuria  of  new-born  infants.  E.  Fournier  described  a  remarkable  en- 
largement of  the  subcutaneous  veins. 

(c)  Laie  Manifestations. — Children  with  congenital  syphilis  rarely  thrive. 
Usually  they  present  a  wizened,  wasted  appearance,  and  a  prematurely  aged 
face.     In  the  patients  who  recover  the  general  nutrition  may  remain  good 


SYPHILIS  275 

and  the  cliild  may  show  no  further  manifestations;  commonly,  however,  at 
the  period  of  second  dentition  or  at  puberty  the  disease  reappears.  Although 
the  child  may  have  recovered  from  the  early  lesions,  it  does  not  develop  like 
other  children.  Growth  is  sIoav,  development  tardy,  and  there  are  facial  and 
cranial  characteristics  which  often  render  the  disease  recognizable  at  a  glance. 
A  young  man  of  nineteen  or  twenty  may  neither  look  older  nor  be  more 
developed  than  a  boy  of  ten  or  twelve — infantilism.  The  forehead  is  promi- 
nent, the  frontal  eminences  are  marked,  and  the  skull  may  be  very  asym- 
metrical. The  bridge  of  the  rose  is  depressed,  the  tip  retrousse.  The  lips  are 
often  prominent,  and  there  are  striated  lines  running  from  the  corners  of  the 
mouth.  The  teeth  are  deformed  and  may  present  appearances  which  Jonathan 
Hutchinson  claimed  are  specific  and  peculiar.  The  upper  central  incisors  of 
the  permanent  set  are  peg-shaped,  stunted  in  length  and  breadth,  and  narrower 
at  the  cutting  edge  than  at  the  root.  On  the  anterior  surface  the  enamel  is 
well  formed,  and  not  eroded  or  honeycombed.  At  the  cutting  edge  there  is  a 
single  notch, 'usually  shallow,  sometimes  deep,  in  which  the  dentine  is  exposed. 
The  upper  first  large  molar  may  have  a  supernumerary  cusp  on  the  inner  side 
which  forms  a  protuberance. 

Among  late  manifestations,  particularly  apt  to  appear  about  puberty,  is 
the  interstitial  l-eratitis,  which  usually  begins  as  a  slight  steaminess  of  the 
corner,  which  present  a  ground-glass  appearance.  It  afi^ects  both  eyes,  though 
one  is  attacked  before  the  other.  It  may  persist  for  months,  and  usually  clears 
completely,  though  it  may  leave  opacities,  which  prevent  clear  vision.  Iritis 
and  choroiditis  may  occur.  Of  ear  affections,  apart  from  those  which  follow  the 
pharyngeal  disease,  a  form  occurs,  about  the  time  of  puberty  or  earlier,  in 
which  deafness  comes  on  rapidly  and  persists  in  spite  of  treatment.  It  is  un- 
associated  with  obvious  lesions,  and  is  probably  labyrinthine  in  character.  Bone 
lesions,  occurring  oftenest  after  the  sixth  year,  are  not  rare  among  the  late 
manifestations  of  congenital  syphilis.  The  tibia  are  most  frequently  attacked. 
It  is  really  a  chronic  gummatous  periostitis,  which  gradually  leads  to  great 
thickening  of  the  bone.  The  nodes  of  congenital  syphilis,  which  are  often 
mistaken  for  rickets,  are  more  commonly  diffuse  and  affect  the  bones  of  the 
upper  and  lower  extremities.  They  are  generally  symmetrical  and  rarely  pain- 
ful.   They  may  occur  late,  even  after  the  twenty-first  year. 

Joint  lesions  are  rare.  Glutton  has  described  a  symmetrical  synovitis  of 
the  knee  in  hereditary  syphilis.  Enlargement  of  the  spleen,  sometimes  with 
the  lymph-glands,  may  be  one  of  the  late  manifestations,  and  may  occur  either 
alone  or  in 'connection  with  disease  of  the  liver. 

The  central  nervous  system  is  often  affected.  This  may  show  itself  in 
various  degrees  of  lack  of  mental  development  or  general  paresis  may  result. 
Certain  patients  show  symptoms  much  like  the  ordinary  chorea.  It  is  a  safe 
rule  to  consider  syphilis  in  any  abnormality  in  a  child. 

Gummata  of  the  liver,  brain,  and  kidneys  have  been  found  in  late  congenital 
syphilis. 

7s  syphilis  transmitted  to  the  third  generation?  The  discovery  of  the 
treponema  answers  this  question.  The  disease  can  be  carried  through  as  many 
generations  as  are  able  to  reproduce.  This  makes  a  thorough  study  of  the 
family  for  several  generations  an  important  aid  in  the  diagnosis  of  con- 
genital syphilis. 


276  SPECIFIC  IXFFCTIOrS  DISEASES 

IV.      VISCEEAL    SYPHILIS 

1.     Cerehro-spinal  SypJiilis 

The  nervous  system  is  frequently  involved  in  the  primary  and  secondary 
stages  as  shown  by  changes  in  the  cerehro-spinal  fluid.  In  the  great  majority 
there  are  no  lat^r  manifestations.  Mattauschek  and  Pilcz  follovred  4,1-13  cases 
of  syphilis  for  from  twenty  to  thirtv  years  with  special  reference  to  this  point : 
4.7  per  cent,  developed  paresis,  3.2  per  cent,  had  cerehro-spinal  syphilis  and 
2.7  per  cent,  tabes  dorsalis.  The  figures  were  highest  in  those  who  had  little  or 
no  treatment. 

Pathology. — The  process  may  involve  (a)  the  meninges.  (&)  the  arteries 
and  {c)  the  parenchyma.  In  the  majority'  of  cases  the  lesions  are  not  limited 
to  one  of  these  structures.  Involvement  of  one  alone  is  probably  most  common 
in  the  arteries — endarteritis.  TVitli  this  the  cerehro-spinal  fluid  shows  little  if 
any  change  and  the  symptoms  are  due  to  the  vascular  disease.  In  all  forms 
marked  perivascular  changes  are  common.  The  exudate  due  to  these  interferes 
with  the  lymphatic  circulation.  This  with  the  endarteritis  often  results  in 
marked  interference  with  the  blood  supply.  In  general  the  lesions  may  be 
classified  as  (1)  parenchymatous,  which  includes  tabes  and  paresis,  and  (2) 
interstitial,  which  comprises  the  forms  usually  termed  cerehro-spinal  syphilis. 

The  parenchymatous  lesions  appear  much  later  than  the  interstitial,  but 
there  is  often  a  history  of  earlier  nervous  symptoms  which  responded  quickly 
to  treatment.  These  are  usually  due  to  a  basilar  meningitis.  The  interval 
suggests  that  there  has  been  a  slow  process  gradually  advancing  which  gives 
time  for  degenerative  processes  to  develop.  The  majority'  of  the  cases  of  the 
interstitial  type  appear  within  five  years  of  infection. 

(a)  Meninges. — ]\Ieningitis  is  a  common  manifestation  and  occurs  particu- 
larly at  the  base,  about  the  chiasm  and  along  the  Sylvian  fissures.  Gummata 
form,  attached  to  the  pia  mater,  sometimes  to  the  dura ;  they  are  most  common 
in  the  cerebrum.  They  form  definite  tumors  varying  in  size  from  a  pea  to  a 
walnut  and  are  usually  multiple.  They  are  rarely  found  imassociated  with  the 
meninges.  "^Tien  small  they  have  a  uniform,  translucent  appearance,  but 
when  large  the  centre  undergoes  a  fibrocaseous  change  with  a  firm  grayish 
tissue  at  the  periphery.  They  may  resemble  tuberculous  tumors.  Occasionally 
they  midergo  cystic  degeneration.  Large  growths  are  not  so  common  in  the 
cord.  Intense  encephalitis  or  myelitis  may  occur  in  the  neighborhood  of  a 
gumma. 

In  the  brain,  gummatous  arteritis  is  a  common  cause  of  softening,  which 
may  be  extensive,  as  when  the  middle  cerebral  artery  is  involved,  or  when  there 
is  a  large  patch  of  meningitis.  In  such  cases  the  process  is  really  a  meningo- 
encephalitis and  the  symptoms  are  due  to  the  secondary  changes. 

(6)  Arieries. — A  common  lesion  is  the  typical  progressive  endarteritis. 
Perivascular  changes  are  common.  There  may  be  a  marked  inflammatory 
reaction  with  oedema  and  resulting  interference  with  the  lymphatics,  or  small 
nodular  tumors  on  the  vessels  which  may  break  down  or  lead  to  rupture. 
Arterial  disease  is  often  combined  with  lesions  in  the  meninges. 

(c)  Parenchyma. — The  changes  here  are  largely  degenerative  and  are  due 
partly  to  interference  with  nutrition  by  the  vascular  lesions  and  partly  to  the 


SYPHILIS  277 

direct  action  of  toxins  from  spirochsetes  in  the  tissues  (especially  in  paresis). 
It  is  evident  that  lesions  of  the  meninges  and  vessels  offer  much  more  hope  of 
benefit  from  treatment  than  those  of  the  parenchyma. 

Cerebro-spinal  Fluid. — The  examination  of  this  is  of  great  value  in  diagno- 
sis and  in  estimating  the  effect  of  treatment.  The  special  points  in  cerebro- 
spinal syphilis  are : 

(a)  Cell  Content. — A  lymphocytosis  occurs  in  85-90  per  cent,  of  cases. 
The  cells  are  often  over  100  and  may  reach  1,000  per  c.mm.,  the  number  being 
some  guide  to  the  intensity  of  the  meningitis.  With  endarteritis  alone  the  cells 
may  be  normal. 

(6)  Glohulin. — An  increase  is  present  in  90-95  per  cent,  of  cases.  It  prob- 
ably represents  abnormal  transudation  from  damaged  vessels  and  may  occur 
in  a  great  variety  of  conditions.  An  increase  in  globulin  may  be  the  only 
change  in  the  fluid  in  the  early  secondary  periods. 

(c)  Wassermann  Reaction. — This  is  positive  in  85-90  per  cent.,  and  indi- 
cates some  active  process  in  the  cerebro-spinal  tissues.  In  the  early  secondary 
period  it  may  be  absent  even  with  increase  in  cells  and  globulin. 

(d)  Colloidal  Gold  Reaction. — This  is  present  in  75-80  per  cent,  of  cases. 
The  type  of  curve  is  useful  in  distinguishing  paresis  from  tabes  and  cerebro- 
spinal syphilis. 

Symptoms. — The  chief  features  are  as  follows: 

(a)  Psychical  features.  A  sudden  and  violent  onset  of  delirium  may  be 
the  first  symptom.  In  other  instances  prior  to  the  occurrence  of  delirium  there 
may  have  been  headache,  alteration  of  character,  and  loss  of  memory.  The 
condition  may  be  accompanied  by  convulsions.  There  may  be  no  neuritis,  no 
palsy,  and  no  localizing  symptoms. 

(&)  More  commonly  following  headache,  giddiness,  or  an  excited  state 
Avhich  may  amount  to  delirium,  the  patient  has  an  epileptic  seizure  or  a  hemi- 
plegic  attack,  or  there  is  involvement  of  the  nerves  of  the  base.  Some  of  these 
cases  display  a  prolonged  torpor,  a'  special  feature  of  brain  syphilis  to  which 
both  Buzzard  and  Huebner  have  referred,  which  may  persist  for  a  month. 

(c)  In  some  cases  the  clinical  picture  is  that  of  general  paresis. 

(d)  Many  cases  of  cerebral  syphilis  display  the  symptoms  of  brain  tumor 
— headache,  optic  neuritis,  vomiting,  and  convulsions.  Of  these  symptoms 
convulsions  are  the  most  important,  and  both  Fournier  and  "Wood  have  laid 
great  stress  on  the  value  of  this  symptom  in  persons  over  thirty.  The  first 
symptoms  may,  however,  rather  resemble  those  of  embolism  or  thrombosis; 
thus  there  may  be  sudden  hemiplegia,  with  or  without  loss  of  consciousness. 

The  symptoms  of  spinal  sypliilis  are  extremely  varied  and  may  be  caused 
by  large  gummatous  growths  attached  to  the  meninges,  in  which  case  the 
features  are  those  of  tumor,  by  gummatous  arteritis  with  secondary  softening, 
by  meningitis  with  secondary  cord  changes,  or  by  late  scleroses.  Syphilitic 
myelitis  will  be  considered  under  affections  of  the  spinal  cord. 

Dia^osis. — The  history  is  of  the  first  importance,  but  it  may  be  extremely 
difficult  to  get  a  trustworthy  account.  Careful  examination  should  be  made 
for  traces  of  the  primary  sore,  for  the  cicatrices  of  bubo,  for  scars  of  the  skin 
eruption  or  throat  ulcers,  and  for  bone  lesions.  The  oculo-cardiac  reflex  may 
Ije  absent.  The  character  of  the  symptoms  is  often  of  great  assistance.  They 
are  multiform,  variable,  and  often  such  as  could  not  be  explained  by  a  single 


278  SPECIFIC  INFECTIOUS  DISEASES 

lesion;  thus  there  may  be  anomalous  spinal  symptoms  or  involvomi-nt  of  the 
nerves  of  the  brain  on  both  sides.  The  study  of  the  spinal  tiuid  and  the 
Wassermann  reaction  in  it  and  in  the  blood  are  of  the  greatest  aid.  The 
result  of  treatment  has  a  bearing  on  the  diagnosis,  as  the  symptoms  may 
disappear  with  the  use  of  anti-syphilitic  remedies. 

2.     Syphilis  of  the  Respiratory  Organs 

Syphilis  of  the  Trachea  and  Bronchi. — L.  A,  Conner  has  analyzed  128 
recorded  cases  of  syphilis  of  the  trachea  and  bronchi.  In  53  per  cent,  of  the 
cases  the  trachea  was  alone  involved.  In  only  10  per  cent,  were  characteristic 
lesions  of  syphilis  found  in  the  lungs.  Bronchial  dilatation  below  the  lesion 
was  found  in  15  per  cent,  of  the  cases.  In  ten  of  the  cases  the  lesion  occurred 
in  congenital  syphilis. 

Syphilis  of  the  Lung. — This  is  a  rare  disease.  In  2,800  post  mortems 
at  the  Johns  Hopkins  Hospital  there  were  12  cases  with  syphilitic  disease  in 
the  lungs;  in  8  of  these  the  lesions  were  in  congenital  syphilis.  In  11  cases 
there  were  definite  gummata.  Clinically  the  presence  of  syphilis  of  the  lung 
was  suspected  in  three  cases.  Fowler  visited  the  museums  of  the  London  hos- 
pitals and  the  Boyal  College  of  Surgeons,  and  could  find  only  twelve  speci- 
mens illustrating  syphilitic  lesions  of  the  lungs,  two  of  which  are  doubtful. 
For  a  consideration  of  pulmonary  syphilis,  the  reader  is  referred  to  chapter 
xxxvii  of  Fowler  and  Godlee's  work  on  Diseases  of  the  Lungs. 

It  occurs  under  the  following  forms: 

(a)  The  ivhite  pneumonia  of  the  fettis. — This  may  affect  large  areas  or 
an  entire  lung,  which  then  is  firm,  heavy,  and  airless,  even  though  the  child 
may  have  been  alive.  On  section  it  has  a  grayish-white  appearance — the  so- 
called  white  hepatization  of  Yirchow.  The  chief  change  is  in  the  alveolar 
walls,  which  are  greatly  thickened  and  infiltrated,  and  the  section  is  like  one 
of  the  pancreas — "pancreatization"  of  the  lung.  In  the  early  stages,  for  exam- 
ple, in  a  seven  or  eight  months'  fetus,  there  may  be  scattered  miliary  foci  of 
this  induration  chiefly  about  the  arteries.  The  air-cells  are  filled  with  des- 
quamated and  swollen  epithelium. 

(&)  In  the  form  of  definite  gummata,  which  vary  in  size  from  a  pea  to 
a  goose-egg.  They  occur  irregularly  scattered  through  the  lung,  but,  as  a 
rule,  are  more  numerous  toward  the  root.  They  present  a  grayish-yellow 
caseous  appearance,  are  dry  and  usually  imbedded  in  a  translucent,  more  or 
less  firm,  connective  tissue.  In  a  case  described  by  Councilman  there  was  ex- 
tensive involvement  of  the  root  of  the  hmgs.  Bands  of  connective  tissue  passed 
inward  from  the  thickened  pleura,  and  between  these  strands  and  surrounding 
the  gummata  there  was  in  places  a  mottled  red  pneumonic  consolidation.  In 
the  caseous  nodules  there  is  typical  hyaline  degeneration.  In  a  few  rare  in- 
stances there  are  most  extensive  caseous  gummata  with  softening  and  forma- 
tion of  hronchiectatic  cavities,  and  clinically  a  picture  of  pulmonary  tuber- 
culosis without  the  presence  of  tubercle  bacilli.  Bronchiectasis  in  children  may 
be  due  to  syphilis. 

(c)  A  fo7-m  suggesting  tuberculosis. — Areas  may  be  involved  either  at  the 
root,  or  at  the  apex  or  base  of  the  lung.  The  physical  signs  are  much  as  in 
tuberculosis.    There  may  be  cough,  possibly  with  a  good  deal  of  sputum,  some- 


SYPHILIS  279 

times  blood-streaked,  loss  of  weight  and  fever,  with  signs  at  one  apex  or  base. 
The  picture  may  suggest  tuberculosis  but  tubercle  bacilli  are  not  found.  The 
condition  may  persist  for  a  considerable  time  without  very  marked  change. 
The  differential  diagnosis  is  difficult.  It  is  important  to  look  for  lesions  else- 
where, particularly  in  the  larynx,  and  to  try  the  Wassermann  test.  In  some 
cases  the  results  of  treatment  are  very  suggestive.  The  signs  may  suggest 
advanced  tuberculosis.  In  one  case,  a  man  aged  twenty-seven  had  cough  and 
bloody  expectoration  for  a  year  and  died  of  severe  haemoptysis.  Bacilli  were 
never  found  in  the  sputum.  There  were  extensive  caseous  gummata  through- 
out both  lungs,  with  much  fibrous  thickening,  and  in  the  lower  lobe  of  the 
right  lung  a  cavity  3  by  5  cm.  in  diameter,  on  the  wall  of  which  a  branch  of 
the  pulmonary  artery  was  eroded.  This  is  the  only  instance  among  our  cases 
in  which  there  was  an  extensive  destruction  of  the  lung  tissue  with  the  clinical 
picture  simulating  pulmonary  tuberculosis. 

(d)  A  majority  of  authors  follow  Virchow  in  recognizing  the  fibrous  in- 
terstitial pneumonia  at  the  root  of  the  lung  and  passing  along  the  bronchi  and 
vessels  as  probably  syphilitic.  This  much  may  be  said,  that  in  certain  cases 
gummata  are  associated  with  these  fibroid  changes.  Again,  this  condition 
alone  is  found  in  persons  with  well-marked  syphilitic  history  or  with  other 
visceral  lesions.  It  seems  in  many  instances  to  be  a  purely  sclerotic  process, 
advancing  sometimes  from  the  pleura,  more  commonly  from  the  root  of  the 
lung,  and  invading  the  interlobular  tissue,  gradually  producing  a  more  or  less 
extensive  fibtoid  change.  It  rarely  involves  more  than  a  portion  of  a  lobe  or 
portions  of  the  lobes  at  the  root  of  the  lung.    The  brmichi*  are  often  dilated. 

Diagnosis. — It  is  to  be  borne  in  mind,  in  the  first  place,  that  hospital  physi- 
cians and  pathologists  the  world  over  bear  witness  to  the  extreme  rarity  of 
lung  syphilis.  In  the  second  place,  the  therapeutic  test  upon  which  so  much 
reliance  is  placed  is  by  no  means  conclusive.  With  pulmonary  tuberculosis 
there  should  be  no  confusion,  owing  to  the  readiness  with  which  the  presence 
of  bacilli  is  determined.  Bronchiectasis  in  the  lower  lobe  of  a  lung,  dependent 
upon  an  interstitial  pneumonia  of  syphilitic  origin,  could  not  be  distinguished 
from  any  other  form  of  the  disease.  So  far  as  our  experience  goes,  tuberculosis 
in  a  syphilitic  subject  has  no  special  peculiarities.  The  lesions  of  syphilis  and 
tuberculosis  can  coexist  m  a  lung.  The  Wassermann  reaction  is  helpful  in 
a  doubtful  case. 

3.     Syphilis  of  the  Liver 

Varieties. —  (a)  Congenital. — Gubler  in  1853  described  the  diffuse  hepatitis 
which  occurs  in  a  large  percentage  of  all  deaths  in  congenital  lues.  While 
there  may  be  little  or  no  macroscopic  change,  the  liver  preserves  its  form  and 
is  usually  enlarged,  hard  and  resistant,  and  has  a  yellowish  color,  compared 
by  Trousseau  to  sole-leather.  Small  grayish  nodules  may  be  seen  on  the  section. 
In  other  cases  there  are  definite  gummata  with  extensive  sclerosis.  The  spiro- 
chaetes  are  present  in'  extraordinary  numbers. 

The  child  may  be  still-born,  die  shortly  after  birth,  or  may  be  healthy 
when  born  and  the  liver  enlarges  within  a  few  weeks.  The  organ  is  firm;  the 
edge  may  be  readily  felt,  usually  far  below  the  navel.  The  spleen  is  also 
enlarged.  The  features  are  those  of  cirrhosis,  but  jaundice  and  ascites  are  not 
common.    Hochsinger  states  that  of  45  cases  recovery  took  place  in  30. 


280  SPECIFIC  INFECTIOUS  DISEASES 

(h)  Delayed  Congenital  Syphilis. — The  condition  is  by  no  means  rare. 
Of  133  cases  of  syphilis  hereditaria  tarda  collected  by  Forbes^  in  34  the  liver 
was  involved.  The  children  are  nearly  always  ill-developed,  sometimes  with 
marked  clubbing  of  the  fingers  and  showing  signs  of  infantilism.  Jaundice 
is  rare.    The  liver  is  usually  enlarged,  or  it  may  show  nodular  masses. 

Acquired  Syphilis. —  (a)  In  the  secondary  stage  the  liver  is  not  often 
involved,  but  may  be  slightly  enlarged.  Jaundice  may  occur  coincident  with 
the  rash  and  Avith  the  enlargement  of  the  superficial  glands,  Eolleston  thinks 
it  is  probably  due  to  a  catarrhal  condition  of  the  smaller  ducts,  part  of  a 
general  syphilitic  hepatitis.  There  are  cases  in  Avhich  it  has  passed  on  to  a 
state  of  acute  yellow  atrophy.    The  prognosis  is  generally  good. 

(h)  Tertiary  Lesions. — The  frequency  with  which  the  liver  is  involved  in 
syphilis  in  adults  is  very  variously  estimated.  J.  L.  Allen,  quoted  by  Eolles- 
ton, found  37  cases  of  hepatic  gummata  among  11,629  autopsies  at  St.  George's 
Hospital;  in  27  eases  cicatrices  alone  were  present.  Flexner  at  the  Philadel- 
phia Hospital  found  88  cases  of  hepatic  syphilis  among  5,088  autopsies. 
Among  2,300  autopsies  at  the  Johns  Hopkins  Hospital  there  were  47  cases  of 
syphilis  of  the  liver,  gummata  in  19,  scars  in  16,  cirrhosis  in  21  cases;  6  of 
the  cases  were  congenital.  In  our  experience  the  disease  is  by  no  means  un- 
common in  the  United  States. 

Anatomically  the  lesions  may  be  either  gummata  or  scars  or  a  syphilitic 
sclerosis.  The  gummata  range  in  size  from  a  pea  to  an  orange.  When  small 
they  are  pale  and  gray ;  the  larger  ones  present  yellowish  centres ;  but  later 
there  is  a  "pale,  yellowish,  cheese-like  nodule  of  irregular  outline,  surrounded 
by  a  fibrous  zone,  the  outer  edge  of  which  loses  itself  in  the  lobular  tissue,  the 
lobules  dwindling  gradually  in  its  grasp.  This  fibrous  zone  is  never  very 
broad;, the  cheesy  centre  varies  in  consistence  from  a  gristle-like  toughness  to 
a  pulpy  softness;  it  is  sometimes  mortar-like,  from  cretaceous  change" 
(Wilks).  They  may  form  enormous  tumors,  as  in  the  remarkable  one 
figured  in  Eolleston's  work  on  Diseases  of  the  Liver.  They  may  be  felt  as 
large  as  an  orange  beneath  the  skin  in  the  epigastrium  and  they  may  dis- 
appear with  the  same  extraordinary  rapidity  as  the  subcutaneous  or  periosteal 
gumma.  Macroscopically  they  may  at  first  look  like  a  massive  cancer.  Ex- 
tensive caseation,  softening  and  calcification  may  occur.  The  syphilitic  scars 
are  usually  linear  or  star-shaped.  They  may  be  very  numerous  and  divide 
the  liver  into  small  sections — the  so-called  botyroid  organ,  of  which  a  remark- 
able example  is  figured  in  the  Lectures  on  Abdominal  Tumors. 

Symptoms. — In  the  first  place,  the  clinical  picture  may  be  tliat  of  cirrhosis 
— slight  jaundice,  fever,  portal  obstruction,  ascites.  There  may  not  be  the 
slightest  suspicion  of  the  syphilitic  nature  of  the  case.  One  of  our  patients 
had  been  tapped  thirteen  times  before  admission  to  the  hospital.  The  diag- 
nosis was  made  by  finding  gummata  on  the  shins.    She  recovered  promptly. 

In  a  second  group  of  cases  the  patient  is  ansemic,  passes  large  quantities 
of  pale  urine  containing  albumin  and  tube-casts;  the  liver  is  enlarged,  perhaps 
irregular,  and  the  spleen  also  is  enlarged.  Dropsical  symptoms  may  super- 
vene, or  the  patient  may  be  carried  off  by  some  intercurrent  disease.  Exten- 
sive amyloid  degeneration  of  the  spleen,  the  intestinal  mucosa,  and  of  the 
liver,  with  gummata,  is  found. 

Thirdly,  in  a  very  important  group  the  symptoms  are  those  of  tumor  of 


SYPHILIS  -281 

the  liver,  causing  pain  and  distress,  and  on  examination  an  irregular  or 
nodular  mass  is  discovered.  The  tumor  may  be  large,  causing  a  prominent 
bulging  in  the  epigastrium.  Naturally  carcinoma  is  thought  of,  as  there  may 
be  nothing  to  suggest  syphilis.  In  other  cases  the  history  or  the  presence  of 
gummata  elsewhere  should  aid  in  the  diagnosis.  In  other  instances  the  rapid 
disappearance  under  treatment  even  of  a  large  visible  tumor  makes  the  syphi- 
litic nature  quite  positive.  Lastly,  in  a  few  cases  the  irregular  fever  with  en- 
largement and  irregularity  of  the  liver  may  suggest  suppuration,  or  the  uni- 
form great  enlargement  of  the  organ  hypertrophic  biliary  cirrhosis,  while 
there  are  some  cases  in  which  the  spleen  is  so  greatly  enlarged,  the  angemia 
so  pronounced,  and  the  liver  so  small  and  contracted  that  the  diagnosis  of 
splenic  anaemia  is  made, 

4.     Syphilis  of  the  Digestive  Tract 

The  base  of  the  tongue  may  show  obliteration  of  the  usual  surface  mark- 
ings with  smoothness  of  the  surface  and  induration  of  the  tissues  due  to 
fibroid  change.  The  oesophagus  is  very  rarely  affected.  Stenosis  is  the  usual 
result.  The  frequency  of  syphilis  of  the  stomach  is  difficult  to  estimate  but  it 
is  not  rare.  There  is  no  definite  clinical  picture,  the  symptoms  depending  on 
the  site  and  extent  of  the  lesion.  There  may  be  the  usual  features  of  dyspepsia 
or  ulcer,  or  the  findings  may  suggest  carcinoma.  A  positive  Wassermann  test 
and  rapid  improvement  under  specific  treatment  are  suggestive,  but  gastric 
disease  and  ulcer  in  patients  with  syphilis  are  not  necessarily  due  to  it.  Syphi- 
litic ulceration  has  been  found  in  the  small  intestine  and  in  the  caecum. 

Syphilis  of  the  rectum  is  found  most  commonly  in  women,  and  results  from 
the  growth  of  gummata  in  the  submucosa  above  the  internal  sphincter.  The 
process  is  slow  and  tedious,  and  may  last  for  years  before  it  finally  induces 
stricture.  The  symptoms  are  usually  those  of  narrowing  of  the  lower  bowel. 
The  condition  is  readily  recognized  by  rectal  examination.  The  history  of 
graduaL  on-coming  stricture,  the  state  of  the  patient,  and  the  fact  that  there 
is  a  hard,  fibrous  narrowing,  not  an  elevated  crater-like  ulcer,  usually  render 
easy  the  diagnosis  from  malignant  disease.  In  medical  practice  these  cases 
come  under  observation  for  other  symptoms,  particularly  amyloid  degenera- 
tion; and  the  rectal  disease  may  be  entirely  overlooked,  and  only  discovered 
post  mortem. 

5.     Circulatory  System 

Syphilis  of  the  Heart. — A  fresh,  warty  endocarditis  due  to  syphilis  is  not 
recognized,  though  occasionally  in  persons  dead  of  the  disease  this  form  is 
present,  as  is  not  uncommon  in  conditions  of  debility. 

The  frequency  of  the  association  of  syphilis  with  myocarditis,  angemic 
necrosis,  and  coronary  artery  disease  has  long  been  known.  It  is  only  since 
the  introduction  of  newer  methods  that  we  have  been  able  to  determine  how 
frequently  this  organ  is  the  seat  of  syphilitic  infection.  Warthin  made  a  study 
of  200  hearts,  50  from  congenital  and  150  from  acquired  syphilis,  from  which 
he  groups  the  primary  lesions  of  cardiac  syphilis  as  follows:  Large  colonies 
of  spirochetes  may  be  found  in  the  myocardium  in  congenital  and  in  the 
active  stages  of  acquired  syphilis  without  definite  changes  in  the  heart  muscle. 


282  SPECIFIC  INFECTIOUS  DISEASES 

An  oedema  with  loss  of  striation  is  not  imcommon.  A  focal  fatty  degenera- 
tion may  be  the  only  lesion,  or  there  may  be  areas  of  necrosis  5  mm.  in 
diameter;  a  very  striking  feature  is  the  presence  of  myxoma-like  translucent 
areas  which  contain  the  spirochastes  in  large  numbers.  Interstitial  changes 
are  common,  oedema  associated  with  the  presence  of  numerous  spirochaetes  and 
leukocytes.  Interstitial  proliferation,  usually  perivascular,  may  be  the  earliest 
recognizable  lesion.  A  transition  is  found  between  focal  oedema  and  small, 
sharply  localized  non-ca  seating  gummata.  It  is  interesting  to  note  that 
spirochaetes  may  be  found  in  great  numbers  in  the  myocardium  when  no 
others  can  be  found  elsewhere  in  the  body. 

Involvement  of  the  7nyocardium  may  occur  in  the  secondary  stage  but  is 
usually  more  marked  later.  There  may  be  fatty  degeneration,  sometimes  sec- 
ondary to  coronary  artery  disease,  or  fibroid  changes.  Epicardial  changes, 
with  peri-arteritis,  are  common.  The  symptoms  are  those  of  slight  cardiac 
insufficiency  with  a  varying  amount  of  precordial  pain,  sometimes  vague, 
sometimes  severe  and  localized.  There  may  be  increase  in  rate  and  some 
irregularity  with  a  soft  apex  systolic  murmur,  not  transmitted,  and  increased 
by  exercise.  Later  the  signs  are  those  of  myocarditis  with  pain  and  pre- 
cordial tenderness;  the  pain  may  suggest  angina  pectoris.  The  association  of 
pain  with  signs  of  myocarditis  in  a  young  adult  should  suggest  the  possibility 
of  syphilis.  The  pain  diifers  in  position  from  that  of  acute  aortitis  which  may 
be  associated  with  it.  Dyspnoea  is  often  marked.  The  giving  of  mercury 
often  results  in  rapid  improvement.  Eupture  or  sudden  death  may  take  place ; 
indeed,  sudden  death  is  frequent,  occurring  in  21  of  63  cases  (Mracek). 

Syphilis  of  the  Arteries. — Syphilis  plays  an  important  role  in  arterio- 
sclerosis and  aneurism.  Its  connection  with  these  processes  will  be  considered 
later;  here  we  shall  refer  only  to  the  syphilitic  affection  of  the  smaller  vessels, 
which  occurs  in  two  forms: 

{a)  An  ohliterating  endarteritis,  characterized  by  a  proliferation  of  the 
subendothelial  tissue.  The  new  growth  lies  within  the  elastic  lamina,  and 
may  gradually  fill  the  entire  lumen;  hence  the  term  obliterating.  The  media 
and  adventitia  are  also  infiltrated  with  small  cells.  This  form  of  endarteritis 
is  not  characteristic  of  syphilis,  and  its  presence  alone  in  an  artery  could  not 
be  considered  pathognomonic.  If,  however,  there  are  gummata  in  other  parts, 
or  if  the  condition  about  to  be  described  exists  in  adjacent  arteries,  the  proc- 
ess may  be  regarded  as  syphilitic. 

(b)  Gummatous  Periarteritis. — With  or  without  involvement  of  the  in- 
tima,  nodular  gummata  may  develop  in  the  adventitia  of  the  artery,  producing 
globular  or  ovoid  swellings,  which  may  attain  considerable  size.  They  are 
not  infrequent  in  the  cerebral  arteries,  which  seem  to  be  specially  prone  to 
this  affection.  This  form  is  specific  and  distinctive  of  syphilis.  Many  ob- 
servers have  found  Treponema  pallidum  in  the  syphilitic  aortitis,  and  also  in 
gummatous  arteritis  of  the  cerebral  vessels. 

6.     Syphilis  of  the  Urinary  Tract 

Acute  Syphilitic  Nephritis. — This  condition  has  been  carefully  studied 
by  the  French  writers  and  by  Lafleur  of  Montreal.  It  is  estimated  to 
occur  in  the  secondary  stage  in  about  3.8  per  cent.,  and  may  occur  in  from 


SYPHILIS  283 

three  to  six  months,  sometimes  later,  from  the  initial  lesion.  The  outlook  is 
good,  though  often  the  albuminuria  may  persist  for  months;  more  rarely 
chronic  nephritis  follows.  In  a  few  instances  syphilitic  nephritis  has  proved 
rapidly  fatal  in  a  fortnight  or  three  weeks.  The  lesions  are  not  specific,  but 
are  similar  to  those  in  other  acute  infections. 

Grummata. — Gummata  occasionally  are  found  in  the  kidneys,  particularly 
in  cases  in  which  there  is  extensive  gummatous  hepatitis.  They  are  rarely 
numerous,  and  occasionally  lead  to  scattered  cicatrices.  Clinically  the  affection 
is  not  recognizable. 

Bladder. — This  is  not  common,  but  should  be  considered  in  cases  of  un- 
explained frequency  of  urination  with  hsematuria.  Papilloma  may  be  simu- 
lated and  a  gumma  may  suggest  carcinoma. 

7.     Syphilitic  Orchitis 

This  affection  is  of  special  significance^,  as  its  detection  may  clinch  the 
diagnosis  in  obscure  disorders.     Syphilis  occurs  in  the  testes  in  two  forms: 

(a)  The  gummatous  growth^  forming  an  indurated  mass  or  group  of 
masses  in  the  substance  of  the  organ,  and  sometimes  difficult  to  distinguish 
from  tuberculous  disease.  The  area  of  induration  is  harder  and  it  affects 
the  body  of  the  testes,  while  tubercle  more  commonly  involves  the  epididymis. 
It  rarely  tends  to  invade  the  skin,  or  to  break  down,  soften,  and  suppurate, 
and  is  usually  painless. 

(&)  An  interstitial  orchitis  which  leads  to  fibroid  induration.  It  is  a  slow, 
progressive  change,  coming  on  without  pain,  and  usually  involving  one  organ 
more  than  the  other. 

V.     DIAGNOSIS,  TREATMENT,   ETC. 

Diagnosis. — General  Diagnosis. — There  is  seldom  any  doubt  concerning 
the  recognition  of  syphilitic  lesions;  but  the  number  of  persons,  without  any 
evident  sign  of  the  disease,  in  whom  a  positive  Wassermann  reaction  is  found 
proves  that  a  negative  diagnosis  cannot  be  based  on  the  absence  of  history 
and  clinical  manifestations.  Syphilis  is  common  in  the  community,  and  is 
no  respecter  of  age,  sex,  or  station  in  life.  The  primary  sore  may  have  been 
of  trifling  extent,  or  urethral  and  masked  by  a  gonorrhoea,  and  the  patient 
may  not  haye  had  severe  secondary  symptoms,  or  the  infection  may  occur 
without  any  chancre  and  the  secondary  lesions  may  be  so  slight  that  they  are 
not  noticed.  Inquiries  should  be  made  into  the  history  to  ascertain  if  the 
patient  has  had  skin  rashes,  sore  throat,  or  if  the  hair  has  fallen  out.  Careful 
inspection  should  be  made  of  the  throat  and  skin  for  signs  of  old  lesions. 
Skin  lesions  with  induration  or  scarring  and  a  crescentic  shape  should  excite 
suspicion.  Scars  in  the  groins,  the  result  of  buboes,  are  uncertain  evidences 
of  syphilitic  infection.  The  cicatrices  on  the  legs  are  often  copper-colored, 
though  this  cannot  be  regarded  as  peculiar  to  syphilis.  The  bones  should  be 
examined  for  nodes.  In  doubtful  cases  the  scar  of  the  primary  sore  may  be 
found,  or  there  may  be  signs  of  atrophy  or  of  hardening  of  the  testes.  In 
women  the  occurrence  of  miscarriages  and  the  bearing  of  stillborn  children  are 
always  suggestive.    In  doubtful  cases  the  study  of  the  spinal  fluid  is  important. 


284  SPECIFIC  INFECTIOUS  DISEASES 

In  the  congenital  disease,  the  occurrence  within  the  first  three  months  of 
snuffles  and  skin  rash  is  conclusive.  Later,  the  characters  of  the  syphilitic 
facies  often  give  a  clew  to  the  nature  of  some  obscure  visceral  lesion.  Other 
distinctive  features  are  the  symmetrical  development  of  nodes  on  the  bones 
and  the  interstitial  keratitis. 

The  Treponema;  'pallidum  may  be  found  in  the  fresh  lesion.  After  clean- 
ing carefully,  serum  is  sucked  out  and  the  living  spirochgetes  may  be  seen  in  the 
special  "dark  field'"  apparatus. 

Serum  Diagnosis. — The  complement  fixation  test  in  good  hands  may  be 
accepted  as  a  most  valuable  aid  in  diagnosis.  It  is  obtained  in  from  80  to  90 
per  cent,  of  all  cases  of  syphilis  with  manifestations.  The  results  in  tabes  and 
general  paresis  are  very  constant,  ■ 

Cutaneous  Eeaction. — An  emulsion  or  extract  of  pure  cultures  of  Tre- 
ponema pallidum — termed  luetin — has  been  employed  by  Noguchi  to  obtain 
a  skin  reaction.  The  skin  is  sterilized  and  0.05  c.  c.  injected  intradermically. 
The  local  reaction  is  usually  papular,  and  surrounded  by  a  zone  of  redness, 
but  may  become  pustular.  There  is  very  slight  constitutional  effect.  The 
reaction  is  most  constant  and  marked  in  tertiary  and  congenital  cases;  it  is 
infrequent,  and,  if  present,  mild  in  the  primary  and  secondary  stages,  in 
which  the  complement  fixation  test  is  more  constant.  Treatment  affects  the 
latter  more  than  the  cutaneous  reaction  which  may  be  given  by  non-syphilitics 
who  have  been  taking  iodide  recently. 

Theeapeutic  Test. — In  a  doubtful  case,  as,  for  example,  an  obstinate 
skin  rash  or  an  obscure  tumor  in  the  abdomen,  antisyphilitic  treatment  may 
prove  successful,  but  this  cannot  always  be  relied  upon. 

Prophylaxis. — Irregular  intercourse  has  existed  from  the  beginning  of 
recorded .  history,  and  unless  man's  nature  wholly  changes — and  of  this  we 
can  have  no  hope — will  continue.  Eesisting  all  attempts  at  solution,  the 
social  evil  remains  the  great  blot  upon  our  civilization,  and  inextricably 
blended  with  it  is  the  question  of  the  prevention  of  syphilis.  Two  measures 
are  available — the  one  personal,  the  other  administrative. 

Personal  purity  is  the  prophylaxis  which  we,  as  physicians,  are  especially 
bound  to  advocate.  Continence  may  be  a  hard  condition  (to  some  harder  than 
to  others),  but  it  can  be  borne,  and  it  is  our  duty  to  urge  this  lesson  upon 
young  and  old  who  seek  our  advice  in  matters  sexual.  Certainly  it  is  better, 
as  St.  Paul  says,  to  marry  than  to  burn,  but  if  the  former  is  not  feasible  there 
are  other  altars  than  those  of  Venus  upon  which  a  young  man  may  light-  fires. 
He  may  p:^actise  at  least  two  of  the  five  means  by  which,  as  the  physician 
Eondibilis  counseled  Panurge,  carnal  concupiscence  may  be  cooled  and  quelled 
— hard  work  of  body  and  hard  work  of  mind.  Idleness  is  the  mother  of 
lechery;  and  a  young  man  wiU  find  that  absorption  in  any  pursuit  will  do 
much  to  cool  passions  which,  though  natural  and  proper,  cannot  in  the  exig- 
encies of  our  civilization  always  obtain  natural  and  proper  gratification. 

To  carry  out  successfully  any  administrative  measures  seems  hopeless,  at 
any  rate  in  our  Anglo-Saxon  civilization;  The  state  accepts  the  responsibility 
of  guarding  citizens  against  small-pox  or  cholera,  but  in  dealing  with  syphilis 
the  problem  has  been  too  complex  and  has  hitherto  baffled  solution.  Inspec- 
tion, segregation,  and  regulation  are  difficult,  if  not  impossible,  to  carry  out, 
and  public  sentiment  is  bitterly  opposed  to  this  plan.    The  compulsory  regis- 


SYPHILIS  285 

tration  of  every  case  of  gonorrhoea  and  syphilis,  with  greatly  increased  facili- 
ties for  thorough  treatment,  offers  a  more  acceptable  alternative. 

The  patient  should  be  warned  of  the  various  ways  in  which  he  may  spread 
the  disease  and  given  directions  regarding  this.  Measures  for  the  prevention 
of  infection  after  exposure  can  be  carried  out  in  the  military  and  naval  services 
more  readily  than  in  civil  life.  The  most  successful  is  the  application  of  mer- 
curial ointment  mixed  with  lanolin  soon  after  exposure. 

Treatment. — That  the  later  stages  which  come  under  the  charge  of  the 
physician  are  so  common  results,  in  great  part,  from  the  carelessness  of  the 
patient,  who,  wearied  with  treatment,  cannot  understand  why  he  should  con- 
tinue to  take  medicine  after  all  the  symptoms  have  disappeared ;  but,  in  part, 
the  profession  also  is  to  blame  for  not  insisting  more  urgently  that  acquired 
syphilis  is  not  cured  in  a  few  months,  but  takes  at  least  three  years,  during 
which  time  the  patient  should  be  under  careful  supervision. 

The  patient  should  lead  a  regular  life,  avoiding  excess  of  all  kinds.  If 
there  is  fever  rest  in  bed  is  advisable.  The  usual  diet  can  be  taken  and  the 
patient  should  drink  large  quantities  of  water.  The  use  of  alcohol  and  to- 
bacco should  be  forbidden  during  active  treatment.  When  mercury  is  being 
taken  special  care  must  be  given  to  the  mouth.  A  mouth  wash  and  a  potas- 
sium chlorate  tooth  paste  should  be  used  frequently.  Treatment  to  rid  the 
body  of  spirochaetes  consists  in  the  use  of  two  remedies,  mercury  and  arsenic; 
iodide  of  potassium  influences  certain  of  the  tissue  changes  resulting  from  the 
infection. 

Energetic  treatment  in  the  acute  stages  should  be  started  as  soon  as  the 
diagnosis  is  made.  The  object  is  to  kill  the  spirochgetes  as  rapidly  as  possible 
and  the  treatment  should  be  intensive  in  the  hope  of  completely  ridding  the 
body  of  the  infection.  Mild  treatment  may  result  in  the  production  of  a 
resistant  strain  of  spirochetes  and  mercury  by  mouth  alone  is  not  a  proper 
method.  There  is  no  agreement  as  to  the  best  method  and  many  variations 
are  employed;  it  is  advisable  to  use  both  arsenic  and  mercury.  Some  give 
them  alternately;  others  use  the  arsenic  preparations  at  short  intervals  for  a 
time  and  then  a  full  course  of  mercury.  The  main  thing  is  to  carry  on  active 
treatment. 

Ajrsenic. — The  arsenic  preparation  (dioxydiamido-arsenobenzol)  is  given 
various  names  and  the  terms  arsphenamine  and  neo-arsphenamine  are  em- 
ployed here.  If  treatment  is  begun  with  arsphenamine  an  initial  full  dose  is 
0.5  or  0.6  gm.  intravenously.  It  should  be  given  well  diluted  (50  c.  c.  for  each 
0.1  gm.  of  the  drug)  and  always  in  a  freshly  prepared  solution.  It  is  usually 
injected  into  one  of  the  veins  at  the  elbow,  care  being  taken  to  be  sure  that  the 
needle  is  in  the  vein  and  some  salt  solution  being  run  in  first.  It  is  well  to 
keep  the  patient  in  bed  until  the  following  morning.  The  frequency  of  repe- 
tition varies.  A  second  similar  dose  may  be  given  in  five  to  ten  days  and 
then  the  same  or  smaller  doses  (0.2-0.3  gm.)  at  the  same  or  shorter  intervals 
until  six  or  eight  doses  are  given.  After  this  a  complete  course  of  mercury 
is  given  by  inunction  or  injection.  Another  method  is  to  give  a  full  dose  of 
arsphenamine,  then  a  vigorous  course  of  mercury  for  two  or  three  weeks,  then 
another  full  dose  of  arsphenamine,  and  mercury  again,  this  being  carried  on 
for  a  period  of  three  or  four  months.  Whichever  method  is  chosen,  after  a 
period  of  vigorous  treatment  an  interval  of  four  weeks  may  pass  without  any 


286  SPECIFIC  INFECTIOUS  DISEASES 

treatment  and  then  the  complement  fixation  test  is  tried.  If  this  is  negative 
it  should  be  taken  every  three  months  for  a  year,  and  if  all  are  negative,  the 
infection  is  probably  cured.  If  the  reaction  is  positive,  the  treatment  should 
be  resumed  until  it  is  negative.  The  complement  fixation  test  should  be  used 
as  a  guide  to  treatment  throughout. 

Many  things  influence  the  dose  of  arsphenamine.  In  general  the  weight 
of  the  patient  is  a  good  guide.  For  young  children  doses  of  0.1  to  0.15  gm. 
are  used  and  for  infants  0.02  to  0.1  gm.  Changes  in  the  eye  grounds  and 
severe  circulatory  and  renal  lesions  always  suggest  caution  and  may  be  contra- 
indications. In  such  cases  doses  of  0.2  gm.  are  the  usual  maximum.  In 
general  the  dose  of  neo-arsphenamine  may  be  considered  as  slightly  less  than 
double  that  of  arsphenamine.  Many  prefer  to  use  the  neo-arsphenamine 
throughout. 

The  conditions  in  which  arsphenamine  is  especially  useful  are:  (1)  at  the 
onset  when  an  early  diagnosis  is  made,  (2)  in  patients  with  severe  skin  or 
mucous  membrane  lesions,  (3)  in  intractable  cases  in  those  resistent  to  or 
unable  to  take  mercury,  (4)  in  malignant  cases,  (5)  in  congenital  syphilis, 
and  (6)  in  latent  eases,  in  which  without  any  signs  of  syphilis  a  Wassermann 
reaction  is  present.  In  visceral  syphilis  the  drug  is  less  useful.  Its  value  in 
tabes  dorsalis  and  paresis  is  not  settled,  but  some  patients  are  undoubtedly 
benefited.  The  earlier  in  the  course  of  syphilis  the  drug  is  given  the  better 
the  effect.  Mercury  should  always  be  given  after  arsphenamine  which,  except 
in  a  few  cases  given  early,  can  not  be  regarded  as  a  complete  remedy  in  itself. 

Mercury. — It  is  well  to  push  its  administration  so  that  the  patient  is 
brought  under  its  influence  as  rapidly  as  possible;  salivation  is  to  be  avoided. 
Inunction  is  the  most  effective  means  of  administration.  One-half  to  a  dram 
(2-4  gm.)  of  mercurial  ointment  or  oleate  of  mercury  is  thoroughly  rubbed 
into  the  skin,  on  areas  free  from  hair,  daily  for  six  days;  on  the  seventh  a 
warm  bath  is  taken.  It  is  well  to  apply  the  ointment  to  different  places  on 
successive  days.  The  sides  of  the  chest  and  abdomen  and  the  inner  surfaces 
of  the  arms  and  thighs  are  the  best  positions.  Thirty  inunctions  is  an 
average  number  for  each  course.  Intramuscular  injection  is  also  satisfactory, 
care  being  taken  to  avoid  infection  and  to  give  the  injections  deeply.  Mercury 
salicylate  (gr.  i-ii,  0.06-0.12  gm.)  in  a  10  per  cent,  solution  is  probably 
the  best,  an  injection  being  given  every  five  to  seven  days.  Bichloride  of 
mercury  (gr.  1/20-1/10,  0.003-0.006  gm.)  in  olive  oil,  biniodide  of 
mercury  (gr.  1/6,  0.01  gm.),  the  "gray  oil,"  calomel  (gr.  i,  0.065  gm.)  in 
equal  parts  of  glycerine  and  water  (1  of  calomel  to  10  of  this  mixture)  are 
also  used.  A  course  of  twenty  to  thirty  injections  should  be  given.  Intravenous 
injections  are  sometimes  given,  usually  of  the  bichloride  {^\  xv,  1  c.  c.  of  a  0.1 
to  0.2  per  cent,  solution  in  sterile  salt  solution).  By  mouth  the  gray  powder, 
hydrargyrum  cum  creta  in  one  grain  (0.065  gm.)  doses  with  a  grain  of 
Dover's  powder,  may  be  given.  The  bichloride  (gr.  1/16-1/8,  0.004-0.008  gm.), 
the  biniodide  (gr.  1/16,  0.004  gm.)  and  the  protoiodide  (gr.  1/4,  0.016  gm.) 
may  also  be  used.  It  is  well  for  the  profession  not  to  forget  that  mercury 
is  still  in  existence;  some  men  seem  to  have  forgotten  it. 

The  Wassermann  reaction  should  be  tried  twice  a  year  for  three  years  and 
active  treatment  resumed  if  it  is  positive.  ISTo  one  can  be  regarded  as  free 
of  the  disease  from  a  negative  blood  test  alone;  the  spinal  fluid  should  be 


SYPHILIS  287 

studied  also.  In  the  later  stages  it  is  well  to  follow  much  the  same  general 
course,  as  a  rule  giving  treatment  intensively  for  certain  periods,  with  a  rest 
between.  While  the  Wassermann  reaction  is  a  helpful  guide  in  treatment  it  is 
not  always  possible  to  secure  a  negative  reaction.  If  mercury  by  mouth  and 
the  "mixed"  treatment  are  used,  it  should  be  only  after  a  thorough  adminis- 
tration by  inunction  or  injection. 

In  CONGENITAL  SYPHILIS  the  treatment  of  patients  born  with  bullae  and 
other  signs  of  the  disease  is  not  satisfactory,  and  the  infants  usually  die 
within  a  few  days  or  weeks.  The  child  should  be  nursed  by  the  mother  alone, 
or,  if  this  is  not  feasible,  should  be  hand-fed,  but  under  no  circumstances 
should  a  wet-nurse  be  employed.  Arsphenamine  is  generally  useful.  The 
child  is  most  rapidly  and  thoroughly  brought  under  the  influence  of  mercury 
by  inunction.  The  mercurial  ointment  may  be  smeared  on  the  flannel  binder. 
This  is  not  a  very  cleanly  method,  and  sometimes  rouses  the  suspicion  of  the 
mother.  The  drug  may  be  given  by  mouth,  in  the  form  of  gray  powder,  half 
a  grain  (0.03  gm.)  three  times  a  day.  In  the  late  manifestations  associated 
with  bone  lesions  the  combination  of  mercury  and  iodide  of  potassium  is 
most  suitable  and  is  well  given  in  the  form  of  Gilbert's  syrup,  which  consists 
of  the  biniodide  of  mercury  (gr.  j,  0.065  gm.),  of  potassium  iodide  (§ss,  15 
gm.),  and  water  (gij,  60  c.  c).  Of  this  the  dose  for  a  child  under  three  is 
from  five  to  ten  drops  three  times  a  day,  gradually  increased.  Under  these 
measures  the  cases  of  congenital  syphilis  usually  improve  with  great  rapidity. 
The  medication  should  be  continued  at  intervals  for  many  months,  and  it  is 
well  to  watch  these  patients  carefully  during  the  period  of  second  dentition 
and  at  puberty,  and  if  necessary  to  place  them  on  specific  treatment. 

In  the  treatment  of  the  visceeal  lesions^  iodide  of  potassium  is  of  equal 
or  even  greater  value  than  mercury.  The  iodide  saturates  the  unsaturated  fatty 
acid  radicals  which  inhibit  autolysis.  The  ferments  then  become  active, 
autolysis  follows  and  the  necrotic  tissue  is  absorbed.  Under  its  use  ulcers 
rapidly  heal,  gummatous  tumors  melt  away,  and  we  have  an  illustration  of  a 
specific  action  only  equaled  by  that  of  mercury  or  arsenic  in  the  secondary 
stages,  by  iron  in  certain  forms  of  angemia,  and  by  quinine  in  malaria.  It  is 
as  a  rule  well  borne  in  an  initial  dose  of  10  grains  (0,6  gm.)  ;  given  in  milk 
the  patient  does  not  notice  the  taste.  It  should  be  gradually  increased  to  30 
or  more  grains  three  times  a  day.  In  syphilis  of  the  nervous  system  it  may  be 
used  in  still  larger  doses.    Arsphenamine  or  mercury  should  also  be  given. 

For  syphilitic  hepatitis  the  combination  of  mercury  and  iodide  of  potas- 
sium is  most  satisfactory.  If  there  is  ascites,  Addison's  or  Guy's  pill  (as  it  is 
often  called)  of  mercury,  digitalis,  and  squill  will  be  found  very  useful.  Oc- 
casionally the  iodide  of  sodium  is  more  satisfactory  than  the  potassium  salt. 
It  is  less  depressing  and  agrees  better  with  the  stomach. 

Syphilis  and  Marriag-e. — Upon  this  question  the  family  physician  is  often 
called  to  decide.  He  should  insist  upon  the  necessity  of  two  full  years 
elapsing  between  the  date  of  infection  and  the  contracting  of  marriage. 
This,  it  should  be  borne  in  mind,  is  the  earliest  possible  limit,  and  marriage 
should  be  allowed  only  if  the  treatment  has  been  thorough,  at  least  a  year  has 
passed  without  any  manifestation  of  the  disease,  and  the  Wassermann  test  is 
negative. 

Syphilis  and  Life  Insurance. — An  individual  with  syphilis  can  not  be  re- 


^88  SPECIFIC  INFECTIOUS  DISEASES 

garded  as  a  first-class  risk  unless  he  can  furnish  evidence  of  prolonged  and 
thorough  treatment  and  of  immunity  for  two  or  three  years  from  all  mani- 
festations. Even  then,  when  we  consider  the  extraordinary  frequency  of  the 
cerebral  and  other  complications  in  persons  who  have  had  this  disease  and 
who  may  even  have  undergone  thorough  treatment,  the  risk  to  the  company 
is  certainly  increased  (see  Bramwell,  Clinical  Studies,  vol.  i). 

Yaws. —  {Framhcesia) . — This  is  a  disease  much  like  syphilis,  prevalent  in 
Africa,  parts  of  x4sia,  the  ^Yest  Indies  and  tropical  America,  caused  by 
SpirochcEta  pertenuis  (v.  paUiduIa).  Wood  brings  up  the  possibility  that  the 
disease  has  been  present  unrecognized  in  the  Southern  States.  It  is  particu- 
larly a  disease  of  children  and  is  readily  communicated  from  one  to  another. 
The  primary  lesion  is  a  papule  which  later  shows  a  fungoid  appearance;  in 
the  secondary  stage  similar  lesions  develop  generally.  The  skin  lesions  con- 
sist of  raspberry-like  growths  from  which  a  sero-purulent  fluid  exudes,  or  they 
are  covered  by  a  yellow  crust.  The  secondary  general  eruption  has  the  same 
character  and  is  widespread.  The  mucous  membranes  are  not  involved. 
There  may  be  fever,  headache  and  general  malaise.  The  course  is  from  a  few 
months  to  three  years.  The  mortality  is  low.  Arsphenamine  is  specific  and 
its  use  results  in  a  rapid  cure. 


IX.     DISEASES  DUE  TO  PARASITIC  INFUSORIA 

Several  flagellates  are  parasitic  in  man.  Tricliomonas  vaginalis,  which 
measures  15  /*  to  25  /*  in  length  and  has  four  flagella,  as  long  as  or  longer  than 
the  body,- is  by  no  means  uncommon  in  the  acid  vaginal  mucus. 

Triclwmonas  or  Cercomonas  Jiominis  lives  in  the  intestines,  and  is  met 
with  in  the  stools  under  all  sorts  of  conditions.  Freund  from  Dock's  clinic 
reported  a  series  of  cases  which  show  that  the  parasite  may  cause  acute  and 
chronic  diarrhoea  with  severe  abdominal  pain,  and  anatomically  an  acute 
enteritis.  In  one  of  Dock's  cases  the  parasites  were  associated  with  a  hsemor- 
rhagic  cystitis  without  bacteria. 

Lamblia  intestinalis  was  a  frequent  cause  of  enteritis  during  the  recent 
war.  The  onset  was  often  insidious  and  the  condition  tended  to  become  chronic. 
The  general  condition  of  the  patient  was  markedly  affected.  Flagellates  have 
been  found  in  the  expectoration  in  cases  of  gangrene  of  the  lung  and  of 
bronchiectasis,  and  in  the  exudate  of  pleurisy. 

BaUntidium  coli,  oval  in  form,  70  ^i  to  100  /x  long  and  50  /*  to  70  fi 
broad,  may  be  pathogenic.  It  is  common  in  pigs,  and  has  been  known  to 
produce  an  epidemic  dysentery  in  apes  (Harlow  Brooks).  The  pathological 
significance  of  this  parasite  has  been  demonstrated  by  Strong  and  Musgrave 
in  the  Philippines,  where  it  is  a  cause  of  dysentery.  It  has  not  only  been 
foimd  in  the  stools  and  on  the  mucous  membrane  of  the  intestine,  but  the 
parasites  have  occurred  in  the  mucosa  itself  and  in  the  submucosa.  Appar- 
ently they  do  not  extend  beyond  the  wall  of  the  bowel. 


,      DISEASES  DUE  TO  FLUKES— DISTOMIASIS  289 

D.    DISEASES  DUE  TO  METAZOAN  PARASITES 
I.     DISEASES  DUE  TO  FLUKES— DISTOMIASIS 

The  Trematoda  or  flukes  are  parasitic  platyhelminths,  usually  with  flat- 
tened or  leaf-shaped  bodies.  The  term  Distomiasis  is  based  upon  Distoma,  the 
term  being  used  to  designate  the  trematodes. 

The  following  are  the  important  clinical  forms : 

1.  Pulmonary  Distomiasis;  Parasitic  Haemoptysis. — Paragonimus  (Disto- 
ma) ivestermanii,  the  Asiatic  lung  or  bronchial  fluke,  is  from  8  to  16  mm. 
in  length  by  4  to  8  mm.  broad,  and  of  a  pinkish  or  reddish-brown  color. 

It  is  found  extensively  in  China  and  Japan,  Formosa,  and  the  Philippines, 
and  eases  are  occasionally  imported  into  Europe  and  America,  and  have  beeii 
met  with  in  the  oriental  population  of  the  Pacific  coast.  It  has  been  found 
in  the  United  States  in  the  cat,  in  the  dog,  and  in  the  hog.  One  instance 
of  pulmonary  distomiasis  has  been  reported  caused  by  the  giant  liver  fluke. 

Clinically  the  disease,  as  described  by  Manson  and  Ringer,  is  characterized 
by  a  chronic  cough,  with  rusty-brown  sputum,  and  occasional  attacks  of 
haemoptysis,  usually  trifling,  but  sometimes  very  severe.  The  disease  is  very 
apt  to  be  mistaken  for  tuberculosis,  but  the  diagnosis  is  easily  made  by 
microscopic  examination  of  the  sputum.  The  ova,  which  are  abundant  in 
the  sputum,  are  oval,  smooth,  and  measure  from  80  //,  to  100  /a  in  length  by 
40  /A  to  60  /A  in  breadth.  The  parasites  may  affect  other  organs — the  liver, 
the  brain,  and  eyelid. 

2.  Hepatic  Distomiasis.— Six  species  of  liver  flukes  are  known  to  occur  in 
man.  More  specifically  these  are:  (1)  The  common  liver  fluke — Fasdola 
hepatica — which  is  a  very  common  parasite  in  the  ruminants.  It  is  a  rare 
and  accidental  parasite  in  man,  but  in  Syria  a  strange  disease  called  Halzoun 
is  caused  by  eating  raw  goat-liver  infected  with  the  parasite.  (2)  The  lancet 
fluke — Dicrocoelium  lanceaium.  (3)  Opisthorchis  felineus,  which  is  found 
in  Prussia  and  Siberia,  and  by  Ward  in  cats  in  Nebraska.  (4)  Opisthorchis 
noverca — the  Indian  liver  fluke  described  in  man  by  McConnell.  (5)  Clon- 
orchis  sinensis  and  C.  endemicus,  the  mo'st  important  of  the  liver  flukes  which 
occur  extensively  in  Japan,  China,  and  India.  The  eggs  are  oval,  27  /a  to  30  /x 
by  15  /x  to  17  IX,  dark  brown,  with  sharply  defined  operculum.  Imported  cases 
have  been  found  in  Canada  and  the  United  States.  White  found  18  cases  in 
San  Francisco. 

The  symptoms  of  hepatic  distomiasis  are  best  described  in  connection  with 
the  last  form.  The  following  account  is  abstracted  from  Wallace  Taylor. 
Young  children  are  the  chief  sufferers.  Many  members  of  a  family  are  usu- 
ally affected.  In  some  villages  a  large  proportion  of  the  inhabitants  are 
attacked.  Among  important  symptoms  is  an  irregular,  intermittent  diar- 
rhoea ;  at  first  there  may  or  may  not  be  blood.  The  liver  enlarges  and  a  con- 
dition of  cirrhosis  gradually  comes  on.  There  may  be  pain  and  an  intermittent 
jaundice.  There  is  not  much  fever.  After  lasting  for  two  or  three  years 
dropsy  comes  on,  with  anasarca  and  ascites.  Even  then  transient  recovery  may 
take  place,  but  as  a  rule  there  is  a  recurrence,  and  the  patient  dies  after  many 
years  of  illness.     The  ova  of  the  parasite  are  readily  found  in  the  stools. 


290  SPECIFIC  INFECTIOUS  DISEASES 

3.  Intestinal  Distomiasis. — In  India  the  Pasciolopsis  husJcii  has  been 
found  in  a  number  of  cases  in  the  small  intestines. 

The  Asiatic  AmpMstome — Gastrodiscus  (Amphistoma)  hominis — a  not 
uncommon  parasite  in  India — is  easily  recognized  by  its  large  posterior  sucker. 

4.  Haemic  Distomiasis ;  Bilharziasis. — One  of  the  most  important  of  para- 
sitic diseases,  caused  by  the  blood  fluke.  Schistosoma  hwmatobium  (Bilharzia 
hmmatohia) .  Endemic  hsematuria  has  been  known  for  many  years,  particu- 
larly in  Egypt,  where  in  1851  Bilharz  discovered  the  parasite  of  the  disease. 
It  prevails  in  South  and  North  Africa,  particularly  the  latter,  in  Arabia, 
Persia,  and  the  west  coast  of  India.  Imported  cases  are  not  very  uncommon 
in  Europe,  and  an  occasional  instance  is  met  with  in  the  United  States. 
In  Egypt,  among  11,698  patients  admitted  to  the  Cairo  Hospital,  1,270  were 
infected,  practically  10  per  cent.  (Madden).  Of  500  autopsies  at  the  same 
hospital,  in  8  per  cent,  death  was  due  to  the  effects  of  Bilharzial  disease.  The 
seriousness  of  the  condition  in  Egypt  is  well  illustrated  by  the  fact  that  in  7.5 
per  cent,  of  army  recruits  the  ova  are  found  in  the  urine. 

A  lateral  spined  form — 8.  mansoni — is  found  only  in  the  faeces.  This 
enters  a  snail  and  ultimately  the  human  host.  It  occurs  in  the  West  Indies 
and  Brazil. 

The  parasite  is  singular  among  flukes  in  having  the  sexes  separate,  and 
the  male  usually  carries  the  female  in  a  gynaecophorous  canal.  The  eggs  are 
characteristic,  oval  in  shape,  0.16  mm.  by  0.06  mm.,  and  one  end  has  a  terminal 
spine.  The  eggs  hatch  in  water,  and  emerging  from  the  terminal  spined  egg 
the  miracidium  enters  the  liver  of  a  fresh  water  mollusc,  common  in  the 
canals  of  Egypt,  and  becomes  transformed  into  sporocysts  and  daughter 
sporocysts,  in  which  numbers  of  cercarise  develop.  These  escape  into  the 
water,  penetrate  the  skin  of  man,  travel  to  the  portal  veins  and  liver,  where 
in  six  to  ten  weeks  they  mature  to  adult  trematodes.  They  travel  to  various 
parts  of  the  body,  particularly  to  the  veins  of  the  bladder  and  rectum,  and 
produce  the  terminal  spined  eggs  which  escape  with  the  urine.  A  majority 
of  the  parasites  remain  in  the  tissues  and  cause  irritation,  fibroid  changes, 
and  papillomata  in  the  bladder  and  rectum.  Collecting  in  the  bladder  as 
foreign  bodies  they  form  the  nuclei  of  calculi. 

Symptoms. — As  is  so  often  the*  case  with  animal  parasites,  they  may 
cause  no  inconvenience.  Irritability  of  the  bladder,  dull  pain  in  the  peri- 
neum, and  haematuria  are  the  most  frequent  symptoms.  A  chronic  cystitis 
follows  when  the  walls  of  the  bladder  are  much  thickened  by  the  irritation 
caused  by  the  ova.  The  anaemia  caused  by  the  haemorrhage  is  slight  in  com- 
parison with  that  of  uncinariasis.  When  the  rectum  is  involved  there  are 
straining  and  tenesmus,  with  the  passage  of  mucus  and  blood ;  in  severe 
cases  large  papillomata  form  and  a  chronic  ulcerative  proctitis.  There  may 
be  a  chronic  vaginitis.  Of  the  complications,  calculi  in  kidney  and  bladder  are 
the  most  important.  Milton,  Madden,  and  others  of  the  Cairo  School  of  Med- 
icine have  studied  carefully  the  surgical  aspects.  Periurethral  abscess  and 
perineal  fistulae  are  common  in  the  chronic  cases. 

Few  symptoms  are  caused  by  the  presence  of  the  parasites  in  the  portal 
veins,  but  there  may  be  an  advanced  cirrhosis  of  a  Glissonian  type  due  to  an 
enormous  thickening  of  the  periportal  tissues  (Symmers).  This  author  hap 
also  reported  an  instance  of  the  Bilharzia  in  the  pulmonary  blood  in  a  case 


DISEASES  CAUSED  BY  CESTODES— T^NIASIS  291 

of  Bilharzial  colitis,  and  the  worms  were  found  living  in  the  pulmonary 
circulation.  The  diagnosis  is  readily  made  by  finding  the  characteristic  ova  in 
the  bloody  urine  or  in  the  blood  and  mucus  from  the  rectum.  The  Bilharzia 
may  be  present  in  the  body  for  years  without  producing  serious  damage,  and  in 
slight  infections  the  symptoms  may  disappear  (Sandwith),  particularly  in 
children. 

Schistosoma  japo/iiciim. — In  China,  Japan  and  the  Philippines  there  is  a 
disease  characterized  by  cirrhosis  of  the  liver,  splenomegaly,  ascites,  dysentery, 
progressive  ansemia,  and  sometimes  by  focalized  epilepsy.  Dermatitis  and 
angio-neurotic  oedema  may  occur.  It  occurs  extensively  in  one  district  of 
Japan,  and  is  known  as  the  "Katayama"  disease.  Woolley  met  with  it  in  the 
Philippines,  and  Catto  in  China.  It  seems  that  the  so-called  urticarial  fever, 
which  is  not  very  uncommon  in  China  and  Japan,  is  associated  with  the 
presence  of  this  parasite,  and  an  eosinophilia  with  fever  and  urticaria  should 
lead  to  a  careful  examination  of  the  stools  for  its  eggs.  The  parasite  lives 
in  the  vessels  of  the  alimentary  canal;  the  ova  are  smaller  than  those  of 
*S'.  hcematohium_,  and  have  not  the  characteristic  spine.  The  parasite  develops 
in  a  snail  and  the  disease  is  acquired  by  working  in  wet  rice  fields. 

Treatment. — We  know  of  nothing  which  can  kill  the  parasites  in  the  blood. 
Extract  of  male  fern  is  recommended  for  the  hematuria.  Tartar  emetic  has 
been  used  with  good  results. 


II.     DISEASES  CAUSED  BY  CESTODES— TiENIASIS 

Man  harbors  the  adult  parasites  in  'the  small  intestine,  the  larval  forms 
in  the  muscles  and  solid  organs. 

1.     INTESTINAL   CESTODES;    TAPEWORMS 

Taenia  solium  (Pork  Tapeworm). — This  is  not  a  common  form  in  the 
United  States  and  is  more  frequent  in  parts  of  Europe  and  Asia.  When 
mature  it  is  from  6  to  12  feet  in  length.  The  head  is  small,  round,  not  so 
large  as  the  head  of  a  pin,  and  provided  with  four  sucking  disks  and  a  double 
row  of  hooklets;  hence  it  is  called,  in  contradistinction  to  the  other  form  in 
man,  the  armed  tapeworm.  To  the  head  succeeds  a  narrow,  thread-like  neck, 
then  the  segments,  or  proglottides,  as  they  are  called.  The  segments  possess 
both  male  and  female  generative  organs,  and  at  about  the  four-hundred-and- 
fiftieth  they  become  mature  and  contain  ripe  ova.  The  worm  attains  its  full 
growth  in  from  three  to  three  and  a  half  months,  after  which  time  the  seg- 
ments are  continuously  shed  and  appear  in  the  stools.  The  segments  are 
about  1  cm.  in  length  and  from  7  to  8  mm.  in  breadth.  Pressed  between  glass 
plates  the  uterus  is  seen  as  a  median  stem  with  about  eight  to  fourteen  lateral 
branches.  There  are  many  thousands  of  ova  in  each  ripe  segment,  and  each 
ovum  consists  of  a  firm  shell,  inside  of  which  is  a  little  embryo,  provided  with 
six  hooklets.  The  segments  are  continuously  passed,  and  if  the  ova  are  to 
attain  further  development  they  must  be  taken  into  the  stomach,  either  of  a 
pig,  or  of  man  himself.  The  egg-shells  are  digested,  the  six-hooked  embryos 
become  free,  and  passing  from  the  stomach  reach  various  parts  of  the  body  (the 


292  SPECIFIC  mFECTIOUS  DISEASES 

liver,  muscles,  brain,  or  eye),  where  they  develop  into  the  larvae  or  cysticerci. 
A  hog  under  these  circumstances  is  said  to  be  measled,  and  the  cysticerci  are 
spoken  of  as  measles  or  bladder  worms. 

Tcenia  solium  received  its  name  because  it  was  thought  to  exist  as  a  soli- 
tary parasite  in  the  bowel,  but  two  or  three  or  even  more  worms  may  occur. 

Taenia  saginata  or  Mediocanellata  (Unarmed,  Fat,  or  Beef  Tapeworm). — 
This  is  a  longer  and  larger  parasite  than  TcBnia  solium.  It  is  certainly  the 
common  tapeworm  of  Xorth  America.  According  to  Berenger-Feraud  it  has 
spread  rapidly  in  western  Europe,  owing  probably  to  the  importation  of  beef 
and  live-stock  from  the  Mediterranean  basin.  It  may  attain  a  length  of  15  or 
30  feet,  or  more.  The  head  is  large  in  comparison  with  that  of  Tcenia  solium, 
and  measures  over  2  mm.  in  breadth.  It  is  square-shaped  and  provided  with 
four  large  sucking  disks,  but  there  are  no  booklets.  The  ripe  segments  are 
from  17  to  18  mm.  in  length  and  from  8  to  10  mm.  in  breadth.  The  uterus 
consists  of  a  median  stem  with  from  fifteen  to  thirty-five  lateral  branches, 
which  are  given  off  more  dichotomously  than  in  Tcenia  solium.  The  ova  are 
somewhat  larger,  and  the  shell  is  thicker,  but  the  two  forms  can  scarcely  be 
distinguished  by  their  ova.  The  ripe  segments  are  passed  as  in  Tcenia  solium, 
and  are  ingested  by  cattle,  in  the  flesh  or  organs  of  which  the  eggs  develop 
into  the  bladder  worms  or  cysticerci. 

Of  other  forms  of  tapeworm  may  be  mentioned: 

Dipylidinm  caninum. — A  small  parasite  common  in  the  dog  and  occa- 
sionally found  in  man;  the  larvae  develop  in  the  lice  and  fleas  of  the  dog. 

Hymenolepis  diminuta. — This  small  cestode  was  found  in  the  intestine 
of  a  child  in  Boston,  and  has  since  been  met  with  in  twelve  cases  (Ransom). 
It  is  common  in  rats.     The  larvae  develop  in  moths  and  beetles. 

Hymenolepis  nana  occurs  not  infrequently  in  Italy.  It  is  not  very  un- 
common in  the  United  States  (Stiles).  The  Davainea  madagascariensis  is  a 
rare  form. 

Taenia  confnsa,  a  new  species  described  by  Ward. 

Dibothriocephalus  latus. — A  cestode  worm  found  in  certain  districts 
bordering  on  the  Baltic  Sea,  in  parts  of  Switzerland,  and  in  Japan.  Nicker- 
son  has  shown  that  it  is  common  in  the  ^N'orthwestern  States,  especially  among 
the  Finns,  and  it  seems  probable  that  the  fish  in  the  Great  Lakes  have  become 
infected,  as  cases  have  increased  of  late  years.  The  parasite  is  large  and  long, 
measuring  from  25  to  30  feet  or  more,  tts  head  is  different  from  that  of  the 
taenia,  as  it  possesses  two  lateral  grooves  or  pits  and  has  no  booklets.  The 
larvae  develop  in  the  peritoneum  and  muscles  of  the  pike  and  other  fish,  and 
grow  into  the  adult  worm  when  eaten  by  man. 

Symptoms  of  Tapeworm  Infection. — These  parasites  are  found  at  all  ages. 
They  are  not  uncommon  in  children  and  are  occasionally  found  in  sucklings. 
■W.  T.  Plant  refers  to  a  number  of  cases  in  children  under  two  years,  and  there 
is  one  in  the  literature  in  which  it  is  stated  that  the  tapeworm  was  found  in 
an  infant  five  days  old ! 

The  parasites  may  cause  no  disturbance  and  are  rarely  dangerous.  A 
knowledge  of  the  existence  of  the  worm  is  generally  a  source  of  worry  and 
anxiety;  the  patient  may  have  considerable  distress  and  cornplain  of  abdominal 
pains,  nausea,  diarrhoea,  and  sometimes  anaemia.  Occasionally  the  appetite 
is  ravenous.     In  women  and  in  nervous  patients  the  constitutional  disturb- 


DISEASES  CAUSED  BY  CESTODES— T^NIASIS  293 

ance  may  be  considerable,  and  we  not  infrequently  see  great  mental  depres- 
sion and  even  hypochondria.  Various  nervous  phenomena,  such  as  chorea, 
convulsions,  or  epilepsy,  are  believed  to  be  caused  by  the  parasites.  Such 
effects,  however,  are  very  rare.  The  DihotJiriocepJialiLs  may  cause  a  severe 
and  even  fatal  form  of  anaemia,  which  has  been  described  fully  in  the  mono- 
graph of  Schaumann,  of  Helsingfors.  It  has  been  suggested  that  the  metabolic 
products  of  the  worm  may  have  in  some  cases  a  hsemolytic  action.  Eosinophilia 
may  occur. 

Diagnosis. — The  diagnosis  is  never  doubtful.  The  presence  of  the  seg- 
ments is  distinctive  and  the  ova  may  be  recognized  in  the  stools.  As  regards 
the  variety  the  ripe  segments  of  Tcenia  saginata  are  larger  and  broader,  and 
show  differences  in  the  generative  system  as  already  mentioned. 

Prophylaxis. — This  is  most  important  and  careful  attention  should  be 
given  to  three  points.  First,  all  tapeworm  segments  should  be  burned;  they 
should  never  be  thrown  into  the  water-closet  or  outside;  secondly,  careful  in- 
spection of  meat  at  the  abattoirs;  and,  thirdly,  cooking  the  meat  sufficiently 
to  kill  the  parasites. 

In  the  case  of  the  beef  measles,  the  distribution  of  the  parasites,  as  given 
by  Ostertag,  shows  that  the  muscles  of  the  jaw  are  much  more  frequently 
affected  than  other  parts — 360  times — while  other  organs  were  infected  but 
55  times.  Sometimes  there  are  instances  of  general  infection.  Cold  storage 
kills  the  cysticercus  usually  within  three  weeks.  The  measles  are  more  readily 
overlooked  in  beef  than  in  pork,  as  they  do  not  present  such  an  opaque  white 
color. 

In  the  examination  of  hogs  for  cysticerci  "particular  stress  should  be 
laid  upon  the  tongue,  the  muscles  of  mastication,  and  the  muscles  of  the 
shoulder,  neck,  and  diaphragm"  (Stiles).  They  may  be  seen  very  easily 
on  the  under  surface  of  the  tongue.  American  hogs  are  comparatively 
free.  In  Prussia  one  hog  is  infected  in  about  every  637.  Specimens  have 
been  found  alive  twenty-nine  days  after  slaughtering.  In  the  examination 
of  1,000  hogs  in  Montreal,  76  instances  of  cysticerci  were  found. 

Treatment. — Three  days  should  be  given  to  preparation  for  treatment, 
whatever  drug  is  employed.  For  two  days  the  patient  should  take  soft  food 
and  the  third  day  liquids  only.  The  bowels  should  be  well  moved  by  castor 
oil  taken  each  evening  and  a  saline  in  the  morning  if  necessary.  Unless  the 
bowels  have  moved  freely  an  enema  should  be  given.  On  the  third  night  a 
laxative,  such  as  cascara,  should  be  taken.  There  are  many  drugs,  but  male 
fern  is  usually  the  most  reliable,  given  in  the  form  of  the  oleoresin.  This  is 
taken  early  in  the  morning  of  the  fourth  day  before  any  food  is  taken.  The 
usual  dose  is  31  (4  c.  c),  which  is  repeated  in  an  hour.  It  may  be  given  in 
capsules  or  in  glycerine  (o  ss,  15  c.  c).  If  there  is  fear  of  nausea  a  cup 
of  coffee  may  be  taken  before  the  drug.  The  drug  may  be  given  by  the 
duodenal  tube.  After  taking  the  male  fern  the  patient  should  remain  quiet 
and  resist  any  desire  to  vomit.  One  hour  after  the  second  dose  of  male  fern 
a  full  dose  of  saline  is  taken  (magnesium  or  sodium  sulphate,  or  magnesium 
citrate),  and  an  hour  later  a  second  dose  if  the  bowels  have  not  moved.  Great 
care  should  be  taken  during  the  expulsion  of  the  worm,  which  should  be  passed 
into  a  chamber  containing  water  at  about  the  body  temperature,  a  practice 
recommended  by  Celsus. 


294  SPECIFIC  INFECTIOUS  DISEASES 

The  pomegranate  root  is  a  very  efficient  remedy,  and  may  be  given  as  an 
infusion  of  the  bark,  3  ounces  of  which  may  be  macerated  in  10  ounces  of 
water  and  reduced  to  one-half  by  evaporation.  The  entire  quantity  is  taken 
in  divided  doses.  It  occasionally  produces  colic,  but  is  very  effective.  The 
active  principle,  pelletierine,  is  employed  as  the  tannate,  given  in  doses  of 
6  to  8  or  even  10  grains  (0.4  to  0.6  gm.),  and  followed  in  an  hour  by  a  purge. 

Pumpkin  seeds  are  sometimes  efficient.  Three  or  four  ounces  should  be 
carefully  bruised,  macerated  for  twelve  or  fourteen  hours,  the  entire  quantity 
taken  and  followed  in  an  hour  by  a  purge.  Of  other  remedies,  cusso,  naph- 
thalein  (gr.  v,  0.3  gm.),  and  thymol  (gr.  v,  0.3  gm.  daily  for  a  week)  may  be 
mentioned.  Sometimes  a  combination  of  remedies  is  effectual  when  one  fails. 
In  children  the  use  of  pumpkin  seeds  or  pelletierine  is  generally  best.  One 
cause  of  failure  is  the  use  of  drugs  which  are  old  and  inert. 

Unless  the  head  is  brought  away,  the  parasite  continues  to  grow,  and 
within  a  few  months  the  segments  again  appear.  Some  cases  are  extraordi- 
narily obstinate.  Doubtless  almost  everything  depends  upon  the  exposure  of 
the  worm.  The  head  and  neck  may  be  thoroughly  protected  beneath  the 
valvulse  conniventes,  in  which  case  the  remedies  may  not  act.  Owing  to  its 
armature  Tcenia  solium  is  more  difficult  to  expel.  It  is  probable  that  no 
degree  of  peristalsis  can  dislodge  the  head,  and  unless  the  worm  is  killed  it 
does  not  let  go  its  firm  hold.  Owing  to  the  danger  of  cysticercosis,  treatment 
should  not  be  delayed  in  case  of  infection  with  Tcenia  solium. 

2.      SOMATIC    T^NIASIS 

Whereas  adult  taenia  may  give  rise  to  little  or  no  disturbance,  and  rarely, 
if  ever,  prove  directly  fatal,  the  affections  caused  by  the  larvae  or  immature 
forms  in  the  solid  organs  are  serious.  There  are  two  chief  cestode  larvae 
known  to  frequent  man:  (a)  the  Cysticercus  cellulosce,  the  larva  of  Tcenia 
solium,  and  (6)  the  E  china  coccus,  the  larva  of  Tcenia  echinococcus.  The 
Cysticercus  tcenioe  saginatce  has  been  found  very  rarely  in  man. 

Cysticercus  cellulosaa. — When  man  accidentally  takes  into  his  stomach 
the  ripe  ova  of  Tcenia  solium  he  is  liable  to  become  the  intermediate  host, 
a  part  usually  played  for  this  tapeworm  by  the  pig.  This  may  occur  in  an 
individual  the  subject  of  Tcenia  solium,  in  which  case  the  mature  proglottides 
either  themselves  wander  into  the  stomach  or  are  forced  into  the  organ  in 
attacks  of  prolonged  vomiting.  The  accidental  ingestion  from  the  outside 
of  a  few  ova  is  quite  possible,  and  the  liability  of  infection  should  always  be 
borne  in  mind  in  handling  the  segments  of  the  worm. 

The  symptoms  depend  entirely  upon  the  number  of  ova  ingested  and  the 
localities  reached.  In  the  hog  the  cysticerci  produce  very  little  disturbance. 
The  muscles,  the  connective  tissue,  and  the  brain  may  be  swarming  with  the 
"measles,"  as  they  are  called,  and  yet  the  nutrition  is  maintained  and  the 
animal  does  not  appear  to  be  seriously  incommoded.  In  the  invasion  period, 
if  large  numbers  of  the  parasites  are  taken,  there  is,  in  all  probability,  con- 
stitutional disturbance;  certainly  this  is  seen  in  the  calf,  when  fed  with  the 
ripe  segments  of  Taenia  saginata. 

In  man  a  few  cysticerci  lodged  beneath  the  skin  or  in  'the  muscles  give 
no  trouble,  and  in  time  the  larv^  die  and  become  calcified.     They  are  occa- 


DISEASES  CAUSED  BY  CESTODES— T^NIASIS  295 

sionally  found  in  dissection  subjects  or  in  post  mortems  as  ovoid  white  bodies 
in  the  muscles  or  subcutaneous  tissue.  In  America  they  are  very  rare.  We 
have  seen  but  two  instances  in  post  mortem  experience.  Depending  on  the 
number  and  the  locality  specially  affected,  the  symptoms  may  be  grouped  into 
general,  cerebro-spinal,  and  ocular.  In  155  cases  compiled  by  Stiles,  the 
parasite  in  117  was  found  in  the  brain,  in  33  in  the  muscles,  in  9  in  the  heart, 
in  3  in  the  lungs,  subcutaneously  in  5,  in  the  liver  in  2. 

1.  General. — As  a  rule  the  invasion  of  the  larvge  in  man,  unless  in  very 
large  numbers,  does  not  cause  very  definite  symptoms.  It  occasionally  hap- 
pens, however,  that  a  striking  picture  is  produced.  A  patient  was  admitted 
very  stiff  and  helpless,  so  much  so  that  he  had  to  be  assisted  upstairs  and 
into  bed.  He  complained  of  numbness  and  tingling  in  the  extremities  and 
general  weakness,  so  that  at  first  he  was  thought  to  have  a  peripheral  neuritis. 
At  the  examination,  however,  a  number  of  painful  subcutaneous  nodules  were 
discovered,  which  proved  on  excision  to  be  the  cysticerci.  Altogether  75  could 
be  felt  subcutaneously,  and  from  the  soreness  and  stiffness  they  probably  ex- 
isted in  large  numbers  in  the  muscles.  There  were  none  in  his  eyes,  and  he 
had  no  brain  symptoms. 

2.  Cerebro-spinal. — Remarkable  symptoms  may  result  from  the  pres- 
ence of  the  cysticerci  in  the  brain  and  cord.  In  the  silent  region  they  may 
be  abundant  without  producing  any  symptoms.  In  the  ventricles  of  the  brain 
the  cysticerci  may  attain  a  considerable  size,  owing  to  the  fact  that  in  regions 
in  which  they  are  unrestrained  in  their  growth,  as  in  the  peritoneum,  the 
bladder-like  body  grows  freely.  When  in  the  fourth  ventricle  remarkable  irri- 
tative symptoms  may  be  produced.  In  1884  the  senior  author  saw  with 
Friedlander  in  Berlin  a  case  from  Eiess's  wards  in  which  during  life  there 
had  been  symptoms  of  diabetes  and  anomalous  nervous  symptoms.  Post 
mortem,  the  cysticercus  was  found  beneath  the  valve  of  Vieussens,  pressing 
upon  the  floor  of  the  fourth  ventricle. 

3.  Ocular.- — Since  von  Graefe  demonstrated  the  presence  of  the  cysticer- 
cus in  the  vitreous  humor  many  cases  have  been  placed  on  record,  as  it  is  a 
condition  easily  recognized. 

Except  in  the  eye,  the  diagnosis  can  rarely  be  made;  when  the  cysticerci 
are  subcutaneous  one  may  be  excised.  It  is  possible  that  when  numerous 
throughout  the  muscles  they  may  be  seen  under  the  tongue,  in  which  situa- 
tion they  may  exist  in  the  pig  in  numbers. 

Echinococcus  or  Hydatid  Disease. — The  hydatid  worms  or  echinococci  are 
the  larvge  of  Tcenia  exhijto coccus  of  the  dog.  This  is  a  tiny  cestode  not  more 
than  4  or  5  mm.  in  length,  consisting  of  only  three  or  four  segments,  of  which 
the  terminal  one  alone  is  mature,  and  has  a  length  of  about  2  mm.  and  a 
breadth  of  O.G  mm.  The  head  is  small  and  provided  with  four  sucking  disks 
and  a  rostellum  with  a  double  row  of  booklets.  This  is  an  exceedingly  rare 
parasite  in  the  dog.  .  Cobbold  states  that  he  has  never  met  with  a  natural  speci- 
men in  England.  Leidy  had  not  one  in  his  large  collection;  Curtice,  of 
Washington,  found  it  once  in  an  American  dog.  The  worms  are  so  small 
that  they  may  be  readily  overlooked,  since  they  form  small,  white,  thread-like 
bodies  closely  adherent  among  the  villi  of  the  small  intestines.  The  ripe  seg- 
ment contains  about  5,000  eggs,  which  attain  their  development  in  the  solid 
organs  of  various  animals,  particularly  the  hog  and  ox,  more  rarely  the  horse 


296  SPECIFIC  INFECTIOUS  DISEASES 

and  the  sheep.     In  some  countries  man  is  an  intermediate  host,  owing  to 
accidental  ingestion  of  the  ova. 

Development. — The  little  six-hooked  embryo,  freed  from  the  egg-shell  by 
digestion,  burrows  through  the  intestinal  wall  and  reaches  the  peritoneal  cav- 
ity or  the  muscles ;  it  may  enter  the  portal  vessels  and  be  carried  to  the  liver. 
It  may  enter  the  systemic  vessels,  and,  passing  the  pulmonary  capillaries,  as  it 
is  protoplasmic  and  elastic,  may  reach  the  brain  or  other  parts.  Once  having 
reached  its  destination,  it  undergoes  the  following  changes :  The  hooklets 
disappear  and  the  little  embryo  is  gradually  converted  into  a  small  cyst  which 
presents  two  distinct  layers — an  external,  laminated,  cuticular  membrane  or 
capsule,  and  an  internal,  granular,  parenchymatous  layer,  the  endocyst.  The 
little  cyst  or  vesicle  contains  a  clear  fluid.  There  is  more  or  less  reaction  in 
the  neighboring  tissues,  and  the  cyst  in  time  has  a  fibrous  investment.  When 
this  primary  cyst  or  vesicle  has  attained  a  certain  size,  buds  develop  from  the 
parenchymatous  layer,  which  are  gradually  converted  into  cysts,  presenting 
a  structure  identical  with  that  of  the  original  cyst,  namely,  an  elastic 
chitinous  membrane  lined  with  a  granular  parenchymatous  layer.  These  sec- 
ondary or  daughter  cysts  are  at  first  connected  with  the  lining  membrane  of 
the  primary  cyst,  but  are  soon  set  free.  In  this  way  the  parent  cyst  as  it 
grows  may  contain  a  dozen  or  more  daughter  cysts.  Inside  these  daughter 
cysts  a  similar  process  may  occur,  and  from  buds  in  the  walls  granddaughter 
cysts  are  developed.  From  the  granular  layer  of  the  parent  and  daughter 
cysts  buds  arise  which  develop  into  brood  capsules.  From  the  lining  mem- 
brane the  little  outgrowths  arise  and  gradually  develop  into  bodies  known  as 
scolices,  which  represent  in  reality  the  head  of  the  T.  echinococcus  and  present 
four  sucking  disks  and  a  circle  of  hooklets.  Each  scolex  is  capable  when 
transferred  to  the  intestines  of  a  dog  of  developing  into  an  adult  tape- 
worm. The  difference  between  the  ovum  of  an  ordinary  tapeworm,  such 
as  T.  solium,  and  T.  ediinococcus  is  in  this  way  very  striking.  In  the  former 
case  the  ovum  develops  into  a  single  larva — Cysticercus  cullulosce — whereas  the 
egg  of  T.  echinococcus  develops  into  a  cyst  which  is  capable  of  multiplying 
enormously  and  from  the  lining  membrane  of  which  millions  of  larval  tape- 
worms develop.  Ordinarily  in  man  the  development  of  the  echinococcus  takes 
place  as  above  mentioned  and  by  an  endogenous  form  in  which  the  secondary 
and  tertiary  cysts  are  contained  within  the  primary ;  but  in  animals  the  forma- 
tion may  be  different,  as  the  buds  from  the  primary  cyst  penetrate  between  the 
layers  and  develop  externally,  forming  the  exogenous  variety.  A  third  form 
is  the  multilocular  echinococcus,  in  which  form  the  primary  cyst  buds  develop 
which  are  cut  off  completely  and  are  surrounded  by  thick  capsules  of  a  connec- 
tive tissue,  which  join  together  and  ultimately  form  a  hard  mass  represented 
by  strands  of  connective  tissue  inclosing  alveolar  spaces  about  the  size  of  peas 
or  a  little  larger.  In  these  spaces  are  found  the  remnants  of  the  echinococcus 
cyst,  occasionally  the  scolices  or  hooklets,  but  they  are  often  sterile. 

The  fluid  is  limpid,  non-albuminous;  specific  gravity  1.005  to  1.009,  occa- 
sionally higher.  It  may  contain  sugar  and  succinic  acid,  and,  after  repeated 
tapping  of  the  cyst,  albumin.  When  not  degenerated  the  hydatid  heads  or 
the  characteristic  hooklets  are  found  in  the  contents  of  the  cyst. 

Changes  in  the  Cyst. — It  is  not  known  definitely  how  long  the  echino- 
coccus remains  alive,  probably  many  years,  possibly  as  long  as  twenty  years. 


DISEASES  CAUSED  BY  CESTODES— T^ENIASIS  297 

The  most  common  change  is  death  and  the  gradual  inspissation  of  the  contents 
and  conversion  of  the  cyst  into  a  mass  containing  putty-like  granular  mate- 
rial which  may  be  partially  calcified.  Remnants  of  the  chitinous  cyst  wall 
or  hooklets  may  be  found.  These  obsolete  hydatid  cysts  are  not  infrequently 
found  in  the  liver.  A  more  serious  termination  is  rupture,  which  may  take 
place^into  a  serous  sac,  or  perforation  may  take  place  externally  when  the 
cysts  are  discharged,  as  into  the  bronchi  or  alimentary  canal  or  urinary 
passages.  More  unfavorable  are  the  instances  in  which  rupture  occurs  into 
the  bile-passages  or  into  the  inferior  cava.  Recovery  may  follow  the  rupture 
and  discharge  of  the  hydatids  externally.  Sudden  death  has  been  known  to 
follow  the  rupture.  A  third  and  very  serious  mode  of  termination  is  sup- 
puration, which  may  occur  spontaneously  or  follow  rupture  and  is  found 
most  frequently  in  the  liver. 

Geographical  Distribution. — The  disease  prevails  most  extensively  in 
those  countries  in  which  man  is  brought  into  close  contact  with  the  dog,  par- 
ticularly when,  as  in  Australia,  the  dogs  are  used  for  herding  sheep,  the 
animal  in  which  the  larval  form  of  T.  echinococcus  is  most  often  found.  In 
Iceland  the  cases  are  numerous.  In  Europe  the  disease  is  not  uncommon. 
In  Great  Britain  and  in  Xorth  America  it  is  rare,  and  a  majority  of  the  cases 
are  in  foreigners.  Statistics  of  the  prevalence  of  the  disease  in  America  have 
been  published  by  Osier  (1883),  Sommer  (1895-'96),  and  Lyon  (1902),  who 
collected  241  cases.  Of  these,  136  cases  were  in  foreigners;  in  92  the  nation- 
ality was  not  stated;  10  were  negroes;  2  Canadians,  and  only  1  a  native  Amer- 
ican. Fifty-six  cases  occurred  in  Manitoba,  where  there  is  a  settlement  of  Ice- 
landers, who  brought  the  disease  with  them.  Only  one  instance  is  known 
in  a  Canadian-born  offspring  of  an  Icelandic  emigrant. 

Distribution  in  the  Body. — Of  1,634  cases  in  the  statistics  of  Davaine, 
Bocker,  Finsen,  and  Neisser,  the  parasite , existed  in  the  liver  in  820;  in  the 
lung  or  pleura  in  137;  in  the  abdoniinal  organs,  including  the  kidneys,  bladder, 
and  genitalia,  in  334;  in  the  nervous  system  in  122;  in  the  circulatory  system 
in  42;  in  other  organs  179.  Of  the  241  cases  in  Lyon's  series  in  America 
the  liver  was  the  seat  in  177,  and  the  omentum,  peritoneal  cavity,  and  mesen- 
tery in  26.  In  11  cases  cysts  were  passed  per  rectum,  in  7  cases  cysts  or 
hooklets  were  expectorated,  and  in  2  cases  passed  per  urethram. 

Symptoms. — 1.  Hydatids  of  the  Liver. — Small  cysts  may  cause  no  dis- 
turbance; large  and  growing  cysts  produce  signs  of  tumor  of  the  liver  with 
great  increase  in  the  size  of  the  organ.  Naturally  the  physical  signs  depend 
much  upon  the  situation  of  the  growth.  Near  the  anterior  surface  in  the 
epigastric  region  the  tumor  may  form  a  distinct  prominence  and  have  a  tense, 
firm  feeling,  sometimes  with  fluctuation.  A  not  infrequent  situation  is  to 
the  left  of  the  suspensory  ligament,  the  resulting  tumor  pushing  up  the  heart 
and  causing  an  extensive  area  of  dulness  in  the  lower  sternal  and  left  hypo- 
chondriac regions.  In  the  right  lobe,  if  the  tumor  is  on  the  posterior  sur- 
face, the  enlargement  of  the  organ  is  chiefly  upward  into  the  pleura  and  the 
vertical  area  of  Jlilness  in  the  posterior  axillary  line  is  increased.  Super- 
ficial cysts  may  give  what  is  known  as  the  hydatid  fremitus.  If  the  tumor 
is  palpated  lightly  with  the  fingers  of  the  left  hand  and  percussed  at  the  same 
time  with  those  of  the  right,  there  is  felt  a  vibration  or  trembling  movement 
which  persists  for  a  certain  time.     It  is  not  always  present,  and  it  is  doubtful 


298  SPECIFIC  INFECTIOUS  DISEASES 

whether  it  is  iDeculiar  to  the  hydatid  tumors  or  due  to  the  collision  of  the 
daughter  cysts.  Very  large  cysts  are  accompanied  by  feelings  of  pressure  or 
dragging  in  the  hepatic  region,  sometimes  actual  pain.  The  general  condi- 
tion of  the  patient  is  at  first  good  and  the  nutrition  little,  if  at  all,  interfered 
with.  Unless  some  of  the  accidents  already  referred  to  occur,  the  symptoms 
may  be  trifling  and  due  only  to  the  pressure  or  weight  of  the  tumor. 

Historically,  one  of  the  most  interesting  cases  is  that  of  the  first  Lord 
Shaftesbury  (Achitopel),  who  had  a  tumor  below  the  costal  border  for  many 
years.  It  suppurated  and  was  opened  by  the  philosopher  John  Locke,  his 
ph5^sician,  who  describes  with  great  detail  the  escape  of  the  bladder-like  bodies. 
Among  the  Shaftesbury  papers  in  the  Eecord  Office  are  several  other  cases 
collected  by  Locke;  the  disease  may  have  been  more  common  in  England  at 
that  period. 

Suppuration  of  the  cyst  changes  the  picture  into  one  of  pyaemia.  There 
are  rigors,  sweats,  more  or  less  jaundice,  and  rapid  loss  of  weight.  Perfora- 
tion may  occur  into  the  stomach,  colon,  pleura,  bronchi,  or  externally,  and  in 
some  instances  recovery  has  taken  place.  Perforation  has  occurred  into  the 
pericardium  and  inferior  vena  cava;  in  the  latter  case  the  daughter  cysts  have 
been  found  in  the  heart,  plugging  the  tricuspid  orifice  and  pulmonary  artery. 
Perforation  of  the  bile-passages  causes  intense  jaundice,  and  may  lead  to  sup- 
purative cholangitis. 

An  interesting  symptom  connected  with  the  rupture  of  hydatid  cysts  is 
the  occurrence  of  urticaria,  which  may  also  follow  aspiration  of  the  cysts. 
Brieger  separated  a  highly  toxic  material  from  the  fluid,  and  to  it  the  symp- 
toms of  poisoning  may  be  due. 

Diagnosis. — Cysts  of  moderate  size  may  exist  mthout  producing  symp- 
toms. Large  multiple  echinococci  may  cause  great  enlargement  with  irregu- 
larity of  the  outline,  and  such  a  condition  persisting  for  any  time  with  re- 
tention of  the  health  and  strength  suggests  hydatid  disease.  An  irregular, 
painless  enlargement,  particularly  in  the  left  lobe,  or  the  presence  of  a  large, 
smooth,  fluctuating  tumor  in  the  epigastric  region  is  suggestive,  and  in  this 
situation,  when  accessible  to  palpation,  it  gives  a  sensation  of  a  smooth  elastic 
growth  and  possibly  also  the  hydatid  tremor.  When  suppuration  occurs  the 
clinical  picture  is  really  that  of  abscess,  and  only  the  existence  of  previous 
enlargement  of  the  liver  with  good  health  would  point  to  the  fact  that  the 
suppuration  was  associated  with  hydatids.  Syphilis  may  produce  irregular 
enlargement  without  much  disturbance  in  the  health,  sometimes  also  a  very 
definite  tumor  in  the  epigastric  region,  but  this  is  usually  firm  and  not  fluctu- 
ating. The  clinical  features  may  simulate  cancer  very  closely.  In  one  case 
the  liver  was  greatly  enlarged  and  there  were  many  nodular  tumors  in  the 
abdomen.  The  post  mortem  showed  enormous  suppurating  hydatid  cysts  in 
the  left  lobe  of  the  liver  which  had  perforated  the  stomach  in  two  places  and 
also  the  duodenum.  The  omentum,  mesentery,  and  pelvis  also  contained  nu- 
merous cysts.  As  a  rule,  the  clinical  course  suffices  to  separate  it  clearly  from 
cancer.  Dilatation  of  the  gall-bladder  and  hydronephrosis  have  been  mis- 
taken for  hydatid  disease.  In  the  former  the  mobility  of  the  tumor,  its  shape, 
and  the  mucoid  character  of  the  contents  suffice  for  the  .diagnosis.  In  some 
instances  of  hydronephrosis  only  the  exploratory  puncture  could  distinguish 
between   the    conditions.     More   frequent   is   the    mistake   of   confounding   a 


DISEASES  CAUSED  BY  CESTODES— T.EXIASIS  299 

hydatid  cyst  of  the  right  lobe  pitching  up  the  pleura  with  pleural  effusion  of 
the  right  side.  Tlie  heart  may  be  dislocated,  the  liver  depressed,  and  dui- 
ness,  feeble  breathing,  and  diminished  fremitus  are  present  in  both  condi- 
tions. Frerichs  lays  stress  upon  the  different  character  of  the  line  of  dul- 
ness;  in  the  echinococcus  cyst  the  upper  limit  presents  a  curved  line,  the 
maximum  of  which  is  usually  in  the  scapular  region.  Suppurative  pleurisy 
may  be  caused  by  the  perforation  of  the  cyst.  If  adhesions  result,  the  per- 
foration takes  place  into  the  lung,  and  fragments  of  the  cysts  or  small  daugh- 
ter cysts  may  be  coughed  up.  For  diagnostic  purposes  the  exploratory  punc- 
ture should  be  used.  The  fluid  is  usually  perfectly  clear  or  slightly  opalescent, 
the  reaction  is  neutral,  and  the  specific  gravity  varies  from  1.005  to  1.009. 
It  is  non-albuminous,  but  contains  chlorides  and  sometimes  traces  of  sugar, 
Hooklets  may  be  found  in  the  clear  fluid  or  in  the  suppurating  cysts.  They 
are  sometimes  absent,  however,  as  the  cyst  may  be  sterile. 

2.  Echinococcus  of  the  Eespiratory  System. — Of  809  cases  of  single  hy- 
datid cyst  collected  by  Thomas  in  Australia,  the  lung  was  affected  in  134 
cases.  Of  241  American  cases,  in  16  the  pleura  or  lung  was  affected.  The 
larvae  may  develop  primarily  in  the  pleura  and  attain  a  large  size.  The 
symptoms  are  at  first  those  of  compression  of  the  lung  and  dislocation  of  the 
heart.  The  physical  signs  are  those  of  fluid  in  the  pleura.  The  line  of  dul- 
ness  may  be  quite  irregular.  As  in  the  echinococcus  of  the  liver,  the  general 
condition  of  the  patient  may  be  excellent  in  spite  of  the  existence  of  extensive 
disease.  Pleurisy  is  rarely  excited.  The  cysts  may  become  inflamed  and 
perforate  the  chest  wall.  Cary  and  Lyon  analyzed  40  cases  of  primary 
echinococcus  cyst  of  the  pleura ;  death  results  in  a  majority  of  the  cases  from 
the  toxaemia  following  the  rupture  and  the  absorption  of  the  fluid  or  from 
the  sepsis  following  suppuration. 

Echinococci  occur  more  frequently  in  the  lung  than  in  the  pleura.  If 
small,  they  may  exist  for  some  tii^e  without  causing  serious  symptoms.  In 
their  growth  they  compress  the  lung  and  sooner  or  later  lead  to  inflamma- 
tory processes,  often  to  gangrene,  and  the  formation  of  cavities  which  connect 
with  the  bronchi.  Fragments  of  membrane  or  small  cysts  may  be  expectorated. 
Haemorrhage  is  not  infrequent.  Perforation  into  the  pleura  with  empyema 
is  common.  A  majority  of  the  cases  are  regarded  during  life  as  tuberculosis 
or  gangrene,  and  it  is  only  the  detection  of  the  characteristic  membranes  or 
the  hooklets  which  leads  to  the  diagnosis.  Of  a  series  of  21  cases,  17  recov- 
ered; 5  of  the  cases  suppurated  (C.  H.  Fleming,  Victoria). 

3.  Echinococcus  of  the  Kidneys. — In  the  collected  statistics  referred  to 
above  the  genito-urinary  system  comes  second  as  the  seat  of  hydatid  disease, 
though  here  the  affection  is  rare  in  comparison  with  that  of  the  liver.  Of 
the  241  American  cases,  there  were  17  in  which  the  kidneys  or  bladder  were 
involved.  The  kidney  may  be  converted  into  an  enormous  cyst  resembling  a 
hydronephrosis.  The  diagnosis  is  only  possible  by  puncture  and  examination 
of  the  fluid.  The  cyst  may  perforate  into  the  pelvis  of  the  kidney,  and  por- 
tions of  the  membrane  or  cysts  may  be  discharged  with  the  urine,  sometimes 
producing  renal  colic.  In  one  case  for  many  months  the  patient  passed  at 
intervals  numbers  of  small  cysts  with  the  urine.  The  general  health  was 
little  if  at  all  disturbed,  except  by  the  attacks  of  colic  during  the  passage  of 
the  parasites. 


300  SPECIFIC  INFECTIOUS  DISEASES 

4.  Echinococcus  of  the  Kervous  System. — The  common  cystic  disease  of 
the  choroidal  plexuses  has  been  mistaken  for  hydatids.  Davies  Thomas,  of 
Australia,  tabulated  97  cases,  including  some  of  the  Cysticercus  celluJosce. 
According  to  his  statistics,  the  cyst  is  more  common  on  the  right  than  on 
the  left  side,  and  is  more  frequent  in  the  cerebrum. 

The  symptoms,  very  indefinite,  as  a  rule  are  those  of  tumor.  Persistent 
headache,  convulsions,  either  limited  or  general,  and  gradually  developing 
blindness  have  been  prominent  features  in  many  cases. 

Multilocular  Echinococcus. — This  form  merits  a  brief  description,  as  it 
differs  so  remarkably  from  the  usual  type.  It  has  been  met  with  only  in 
Bavaria,  Wiirttemberg,  the  adjacent  districts  of  Switzerland,  and  in  the 
TyroL  Possett  reported  13  cases  from  von  Eokitansky's  clinic  at  Innsbruck. 
In  the  United  States  a  few  cases  have  been  described,  chiefiy  in  Germans. 
Delafield  and  Prudden's  patient  had  lived  there  five  years,  and  for  a  year 
before  his  death  had  been  jaundiced.  A  fluctuating  tumor  was  found  in  the 
right  flank,  apparently  connected  with  the  liver.  This  was  opened,  and  death 
followed  from  haemorrhage.  In  OerteFs  case  the  patient  had  lived  there  ten 
years.  He  was  deeply  jaundiced,  and  had  a  tumor  mass  at  the  right  border 
of  the  liver,  which  was  enlarged.  Bacon  resected  a  cyst  from  the  left  lobe  of 
the  liver.  The  primary  tumor  presents  irregularly  formed  cavities  separated 
from  each  other  by  strands  of  connective  tissue,  and  lined  with  the  echinococcus 
membrane.  The  cavities  are  filled  with  a  gelatinous  material,  so  that  the  tumor 
has  very  much  the  appearance  of  an  alveolar  colloid  cancer.  It  is  possible 
that  a  special  form  of  taenia  echinococcus  represents  the  adult  type  of  this 
peculiar  parasite.  This  form  is  almost  exclusively  confined  to  the  liver,  and 
the  symptoms  resemble  more  those  of  tumor  or  cirrhosis.  The  liver  is,  as  a 
rule,  enlarged  and  smooth,  not  irregular  as  in  the  ordinary  echinococcus. 
Jaundice  is  common  and  the  spleen  is  usually  enlarged;  there  is  progressive 
emaciation  and  toward  the  close  hgemorrhages  are  common. 

Treatment  of  Echinococcus  Disease. — Medicines  are  of  no  avail.  Post 
mortem  reports  show  that  in  a  considerable  number  of  cases  the  parasite 
dies  and  the  cyst  becomes  harmless.  Operative  measures  should  be  resorted 
to  when  the  cyst  is  large  or  troublesome.  The  simple  aspiration  of  the  con- 
tents has  been  successful  in  a  number  of  cases,  and  may  be  tried  before  the 
more  radical  procedure  of  incision  and  evacuation  of  the  cysts.  Suppuration 
has  occasionally  followed  the  puncture.  Injections  into  the  sac  should  not 
be  practised.  Surgeons  open  and  evacuate  the  echinococcus  cysts  with  great 
boldness,  and  the  Australian  records,  which  are  the  most  numerous  and  impor- 
tant on  this  subject,  show  that  recovery  is  the  rule  in  a  large  proportion  of  the 
cases.  Suppurative  cysts  in  the  liver  should  be  treated  as  abscess.  The  treat- 
ment of  hydatid  disease  has  been  greatly  advanced  by  Australian  surgeons. 
The  works  of  the  Australian  physicians,  James  Graham  and  Thomas,  may  be 
consulted  for  details  in  diagnosis  and  treatment. 

Spargannm  mansoni  is  a  larval  bothriocephalus  met  with  in  Japan  and 
China,  usually  in  the  subcutaneous  tissues,  the  adult  form  of  which  is  not 
known. 


DISEASES  CAUSED  BY  NEMATODES  301 

m.     DISEASES  CAUSED  BY  NEMATODES 

1.     ASCARIASIS 

Ascaris  lumbricoides,  the  most  common  human  parasite,  is  found  chiefly 
in  children.  The  female  is  from  7  to  12  inches  in  length,  the  male  from  4 
to  8  inches.  In  form  it  is  cylindrical,  pointed  at  both  ends,  with  a  yel- 
lowish-brown, sometimes  a  slightly  reddish  color.  Four  longitudinal  bands 
can  be  seen,  and  it  is  striated  transversely.  The  ova,  which  are  sometimes 
found  in  large  numbers  in  the  faeces,  are  small,  brownish-red  in  color,  ellip- 
tical, and  have  a  very  thick  covering.  They  measure  0.075  mm.  in  length  and 
0.058  mm.  in  \^ddth.  The  life  history  has  been  demonstrated  to  be  "direct" — 
i.  e.,  without  intermediate  host.  The  larvae  enter  the  tissues,  migrate  through 
the  lungs  and  return  to  the  alimentary  tract.  The  parasite  occupies  the  upper 
portion  of  the  small  intestine.  Usually  not  more  than  one  or  two  are  present, 
but  occasionally  they  occur  in  enormous  numbers.  The  migrations  are 
peculiar.  They  may  pass  into  the  stomach,  whence  they  may  be  ejected  by 
vomiting,  or  they  may  crawl  up  the  oesophagus  and  enter  the  pharynx,  from 
which  they  may  be  withdrawn.  A  child  in  the  smallpox  department  of  the 
Montreal  General  Hospital,  during  convalescence,  withdrew  in  this  way  more 
than  thirty  round  worms  within  a  few  weeks.  In  other  instances  the  worm 
reaches  the  larynx,  and  has  been  known  to  produce  fatal  asphyxia,  or,  passing 
into  the  trachea,  to  cause  gangrene  of  the  lung.  They  may  go  through  the 
Eustachian  tube  and  appear  at  the  external  meatus.  The 'worms  have  been 
found  in  extraordinary  numbers  in  the  bile-ducts.  Eemarkable  specimens 
exist  in  the  Dupuytren,  the  Wistar-Horner  (Philadelphia),  and  the  Netley 
Museums.  Chalmers  (Ceylon)  and  Leys  (U.  S.  N.)  have  called  attention 
to  their  importance  in  causing  abscess  of  the  liver.  Ebstein  reported  certain 
markings,  strangulations,  on  the  round  worms,  as  if  they  had  been  nipped  in 
the  bile-ducts !  The  bowel  may  be  blocked,  or  in  rare  instances  an  ulcer  may 
be  perforated.     Even  the  healthy  bowel  wall  may  be  penetrated. 

A  peculiarly  irritating  substance,  often  evident  to  the  sense  of  smell  in 
handling  specimens,  is  formed  by  the  round  worms.  Peiper  and  others  sug- 
gest that  the  nervous  symptoms,  sometimes  resembling  those  of  meningitis, 
are  due  to  this  poison.  Chauffard,  Marie,  and  Tauchon  report  a  remarkable 
condition  of  fever,  intestinal  symptoms,  foul  breath,  and  intermittent  diarrhea 
in  connection  with  the  presence  of  lumbricoides.  They  call  it  typho-lum- 
bricosis.  The  febrile  condition  may  continue  for  a  month  or  more.  There 
may  be  eosinophilia  to  25  to  30  per  cent.,  and  in  some  cases  a  marked  anemia. 
The  question  of  the  toxins  produced  by  these  parasites  is  an  open  one. 

A  few  parasites  may  cause  no  disturbance.  In  children  irritative  symp- 
toms of  many  kinds  are  attributed  to  worms,  such  as  restlessness,  irritability, 
picking  at  the  nose,  grinding  of  the  teeth,  twitchings,  or  convulsions.  The 
diagnosis  is  made  by  finding  the  worms  or  eggs  in  the  stools. 

Treatment.— Csive  should  be  taken  to  avoid  auto-infection  by  thorough 
washing  after  defecation,  and  those  infected  should  not  be  allowed  to  prepare 
food  or  serve  it  to  others.  It  is  well  to  give  soft  diet  on  the  day  previous 
and  a  dose  of  castor  oil  the  night  before  treatment.     Santonin  is  usually 


303  SPECIFIC  WFECTIOUS  DISEASES 

efficient  given  in  the  morning  in  doses  of  one  grain  (0.065  gm.)  for  a  small 
child,  and  three  to  five  grains  (0.2  to  0.3  gm.)  for  an  adult.  One  to  two 
grains  of  calomel  should  be  given  with  it.  Three  hours  later  a  good  dose 
of  saline  should  be  given.  This  should  be  done  two  mornings  in  succes- 
sion and  repeated  in  a  week  if  worms  or  eggs  are  again  passed.  The  occa- 
sional effects  of  santonin  (yellow  vision,  vertigo)  should  be  explained  before- 
hand. Oil  of  chenopodium  is  useful  in  doses  of  10  to  15  drops  in  an  ounce 
of  castor  oil,  followed  in  an  hour  by  a  second  dose  of  castor  oil.  If  these  are 
not  effectual  male  fern  or  thymol  may  be  given. 

Oxyuris  vermicularis  (Thread-worm;  Pin- worm). — This  common  parasite 
occupies  the  rectum  and  colon.  The  male  measures  about  4  mm.  in  length, 
the  female  about  10  mm.  They  produce  great  irritation  and  itching,  par- 
ticularly at  night,  symptoms  which  become  intensely  aggravated  by  the  noc- 
turnal migration  of  the  parasites.  The  oxyuris  may  traverse  the  intestinal 
wall,  and  has  been  found  in  the  peritoneal  cavity,  where  they  may  form  ver- 
minous tubercles  in  Douglas's  fossa  or  peri-rectal  abscesses. 

The  patients  become  extremely  restless  and  irritable,  the  sleep  is  often 
disturbed,  and  there  may  be  loss  of  appetite  and  angemia.  Though  most 
common  in  children,  the  parasite  occurs  at  all  ages. 

The  worm  is  readily  detected  in  the  fgeces.  Infection  probably  takes  place 
through  the  water,  or  possibly  through  salads,  such  as  lettuce  and  cresses.  A 
person  the  subject  of  the  worms  passes  ova  in  large  numbers  in  the  faeces,  and 
the  possibility  of  re-infection  must  be  scrupulously  guarded  against. 

Treatment. — Every  care  should  be  taken  to  avoid  auto-infection  or  the 
infection  of  others,  by  care  in  cleansing  the  anus  and  perineum,  and  thorough 
washing  .of  the  hands  after  defecation.  Auto-infection  is  often  responsible 
for  the  persistence  of  the  disease.  Treatment  must  be  directed  to  the  removal 
of  the  worms  both  from  the  small  intestine  and  rectum.  Santonin  and  calo- 
mel are  useful,  given  as  in  ascaris  infection  for  several  days.  Thymol  and 
naphthalein  are  also  used.  To  remove  the  worms  from  the  rectum  injections 
are  required  which  should  be  retained  as  long  as  possible;  it  is  well  to  wash 
out  the  bowel  before  giving  them  and  the  injection  need  not  be  over  six 
ounces.  Cold  solutions  of  salt  and  water,  ice  water,  glycerine,  infusion  of 
quassia  (one  ounce  of  quassia  chips  to  a  pint  of  water),  or  lime  water  may 
be  employed  and  should  be  used  daily  for  two  weeks.  For  the  itching,  car- 
bolated  vaseline,  gall  and  opium  ointment,  or  menthol  (5  per  cent.)  in  vaseline 
may  be  employed. 

2.      TEICHINIASIS 

The  Trichina  or  Trichinella  spiralis  in  its  adult  condition  lives  in  the 
small  intestine.  The  disease  is  produced  by  the  embryos,  which  pass  from 
the  intestines  and  reach  the  voluntary  muscles,  where  they  finally  become 
encapsulated  larvae — muscle  trichinge.  It  is  in  the  migration  of  the  embryos 
(possibly  from  poisons  produced  by  them)  that  the  group  of  symptoms  known 
as  trichiniasis  is  produced. 

The  ovoid  cysts  were  described  in  human  muscle  by  Tiedemann  in  1832, 
and  by  Hilton  in  1832 ;  the  parasite  was  figured  and  named  by  Richard  Owen. 
Leidy  in  1845  described  it  in  the  pig.  For  a  long  time  the  trichina  was 
looked  upon  as  a  pathological  curiosity;  but  in  1860  Zenker  discovered  in  a 


DISEASES  CAUSED  BY  NEMATODES  303 

girl  in  the  Dresden  Hospital,  who  had  symptoms  of  typhoid  fever,  both  the 
intestinal  and  muscle  forms,  and  established  their  connection  with  a  serious 
and  often  fatal  disease. 

Description  of  the  Parasites. — (a)  Adult  or  intestinal  form.  The  female 
measures  from  3  to  4  mm.;  the  male,  1.5  mm.,  and  has  two  little  projections 
from  the  hinder  end.  (&)  The  larva  or  muscle  trichina  is  from  0.6  to  1  mm. 
in  length  and  lies  coiled  in  an  ovoid  capsule,  which  is  at  first  translucent,  but 
subsequently  opaque  and  infiltrated  with  lime  salts.  The  worm  presents  a 
pointed  head  and  a  somewhat  rounded  tail. 

When  flesh  containing  the  trichinae  is  eaten  by  man  or  by  any  animal  in 
which  the  development  can  take  place,  the  capsules  are  digested  and  the 
trichinge  set  free.  They  pass  into  the  small  intestine,  and  about  the  third 
day  attain  their  full  growth  and  become  sexually  mature.  On  the  sixth  or 
seventh  day  the  embryos  are  fully  developed.  The  young  produced  by  each 
female  trichina  have  been  estimated  at  several  hundred.  Leuckart  thought 
that  various  broods  are  developed  in  succession,  and  that  as  many  as  a  thou- 
sand embryos  may  be  produced  by  a  single  worm.  The  time  from  the  inges- 
tion of  the  flesh  containing  the  muscle  trichinae  to  the  development  of  the 
brood  of  embryos  in  the  intestines  is  from  seven  to  nine  days.  The  female 
worm  penetrates  the  intestinal  wall  and  the  embryos  are  probably  discharged 
directly  into  the  lymph  spaces,  thence  into  the  venous  system,  and  by  the 
blood  stream  to  the  muscles,  which  constitute  their  seat  of  election.  J.  Y. 
Graham  gives  strong  arguments  in  favor  of  the  transmission  through  the 
blood  stream.  They  have  been  found  in  the  blood  early  in  the  infection  and 
since  the  demonstration  of  their  presence  by  Herrick  and  Janeway  have  been 
seen  by  a  number  of  observers.  They  are  found  also  in  the  spinal  fluid  in  some 
cases.  They  have  been  reported  as  occurring  in  the  fluid  of  a  pleural  exudate, 
in  the  milk  of  a  nursing  woman  and  in  the  pus  from  a  furuncle.  After  a  pre- 
liminary migration  in  the  inter-muscular  connective  tissue  they  penetrate  the 
primitive  muscle-fibres,  and  in  about  two  weeks  develop  into  the  full-grown 
muscle  form.  In  this  process  an  interstitial  myositis  is  excited  and  gradu- 
ally an  ovoid  capsule  develops  about  the  parasite.  Two,  occasionally  three 
or  four,  worms  may  be  seen  within  a  single  capsule.  This  process  of  encapsu- 
lation has  been  estimated  to  take  about  six  weeks.  Within  the  muscles  the 
parasites  do  not  undergo  further  change.  Gradually  the  capsule  becomes 
thicker,  and  ultimately  lime  salts  are  deposited  within  it.  This  change  may 
take  place  in  man  within  four  or  five  months.  In  the  hog  it  may  be  deferred 
for  many  years.  The  calcification  renders  the  cyst  visible,  and  these  small, 
opaque,  oat-shaped  bodies  are  familiar  objects  to  demonstrators  of  normal 
and  morbid  anatomy.  The  trichinae  may  live  within  the  muscles  for  an  in- 
definite period.  They  have  been  found  alive  and  capable  of  developing  as  late 
as  twenty  or  even  twenty-five  years  after  their  entrance  into  the  system.  In 
many  instances,  however,  the  worms  are  completely  calcified.  The  trichina 
has  been  found  or  "raised"  in  twenty-six  different  species  of  animals  (Stiles). 
Medical  literature  abounds  in  references  to  its  presence  in  fish,  earthworms, 
etc.,  but  these  parasites  belong  to  other  genera.  In  faecal  examinations  for 
the  parasite  it  is  well  to  remember  that  the  "cell  body"  of  the  anterior  portion 
of  the  intestine  is  a  diagnostic  criterion  of  the  T.  spiralis.  Experimentally, 
guinea-pigs  and  rabbits  are  readily  infected  by  feeding  them  with  muscle  con- 


304  SPECIFIC  WFECTIOUS  DISEASES 

taining  the  larval  form.  Dogs  are  infected  with  difficulty;  cats  more  readily. 
Experimentally,  animals  sometimes  die  of  the  disease  if  large  numbers  of  the 
parasites  have  been  eaten.  In  the  hog  the  trichinae,  like  the  cysticerci,  cause 
few  if  any  symptoms.  An  important  point  is  the  fact  that  in  the  hog  the 
capsule  does  not  readily  become  calcified,  so  that  the  parasites  are  not  visible 
as  in  the  human  muscles. 

The  anatomical  changes  are  chiefly  in  the  voluntary  muscles.  The  trich- 
inae enter  the  primitive  muscle  bundles,  which  undergo  granular  degenera- 
tion with  marked  nuclear  proliferation.  There  is  a  local  myositis,  and 
gradually  about  the  parasite  a  cyst  wall  is  formed.  These  changes,  as  well 
as  the  remarkable  alterations  in  the  blood,  have  been  described  by  Brown. 
Cohnheim  described  a  fatty  degeneration  of  the  liver  and  enlargement  of  the 
mesenteric  glands.  At  the  time  of  death,  in  the  fourth  or  fifth  week  or  later, 
the  adult  trichinae  are  still  found  in  the  intestines. 

Incidence. — Man  is  infected  by  eating  the  flesh  of  trichinous  hogs.  In 
Germany,  where  a  systematic  microscopic  examination  of  all  swine  flesh  is 
made,  the  proportion  of  trichinous  hogs  is  about  1  in  1,852,  Statistics  are 
not  available  in  England,  In  America  inspections  have  been  made  since  1892, 
The  percentage  of  animals  found  infected  has  ranged  from  1.04  to  1.95,  In 
1883,  with  A,  W.  Clement,  the  senior  author  examined  1,000  hogs  at  the 
Montreal  abattoir,  and  found  only  4  infected. 

Modes  of  Infection, — The  danger  of  infection  depends  entirely  upon  the 
mode  of  preparation  of  the  flesh.  Thorough  cooking,  so  that  all  parts  of 
the  meat  reach  the  boiling  point,  destroys  the  parasites;  but  in  large  joints 
the  central  portions  are  often  not  raised  to  this  temperature.  The  frequency 
of  the  disease  in  different  countries  depends  largely  upon  the  habits  of  the 
people  in  the  preparation  of  pork.  In  North  Germany,  where  raw  ham  and 
Wwst  are  freely  eaten,  the  greatest  number  of  instances  have  occurred.  In 
South  Germany,  France,  and  England  cases  are  rare.  In  the  United  States 
the  greatest  number  of  persons  attacked  have  been  Germans,  Salting  and 
smoking  the  flesh  are  not  always  sufficient,  and  the  Havre  experiments 
showed  that  animals  are  readily  infected  when  fed  with  portions  of  the 
pickled  or  the  smoked  meat  as  prepared  in  America.  Carl  Fraenkel,  how- 
ever, states  that  the  experiments  on  this  point  have  been  negative,  and  that 
it  is  very  doubtful  if  any  cases  of  trichiniasis  in  Germany  have  been  caused 
by  American  pork.  Germany  has  yet  to  show  a  single  case  of  trichiniasis  due 
to  pork  of  unquestioned  American  origin. 

Frequency  of  Infection. — H.  U.  Williams,  of  Buffalo,  made  a  thorough 
study  of  the  muscle  from  505  unselected  autopsies,  and  found  27  cases  of 
trichiniasis,  5.3  per  cent.  The  subjects  had  all  died  of  causes  other  than 
trichiniasis.  This  important  study  shows  how  widespread  is  the  disease, 
and  that  in  reality  we  frequently  overlook  the  sporadic  form. 

The  disease  occurs  in  groups  or  outbreaks  in  which  from  a  dozen  to 
several  hundred  individuals  are  attacked,  and  in  sporadic  cases  which  have 
been  shown  of  late  years  to  be  not  infrequent.  In  the  epidemics  a  large 
number  of  persons  are  infected  from  one  source ;  in  the  two  famous  out- 
breaks of  Hedersleben  and  Emersleben  337  and  250  individuals  were  attacked. 
In  the  United  States  Stiles  estimates  that  there  have  been  more  than  1,000 
■small  outbreaks.    The  discovery  in  the  wards  at  the  Johns  Hopkins  Hospital 


DISEASES  CAUSED  BY  NEMATODES  305 

by  T.  R.  Brown  of  the  eosinophilia  in  the  disease  has  led  to  the  much  more 
frequent  detection  of  the  sporadic  caseS;,  and  this  form  of  the  disease  is  not 
at  all  uncommon  in  the  United  States. 

Symptoms. — The  ingestion  of  trichinous  flesh  is  not  necessarily  followed 
by  the  disease.  When  a  limited  number  are  eaten  only  a  few  embryos  pass 
to  the  muscles  and  may  cause  no  symptoms.  Well-characterized  cases  pre- 
sent a  gastro-intestinal  period  and  a  period  of  general  infection. 

In  the  course  of  a  few  days  after  eating  the  infected  meat  there  are  signs 
of  gastro-intestinal  disturbance — pain  in  the  abdomen,  loss  of  appetite,  vom- 
iting, and  sometimes  diarrhoea.  The  preliminary  symptoms,  however,  are  by 
no  means  constant,  and  in  some  of  the  large  epidemics  cases  have  been  ob- 
served in  which  they  have  been  absent.  In  other  instances  the  gastro-intes- 
tinal features  have  been  marked  from  the  outset,  and  the  attack  has  resembled 
cholera  nostras.  Pain  in  different  parts  of  the  body,  general  debility,  and 
weakness  have  been  noted  in  some  of  the  epidemics. 

The  invasion  symptoms  occur  between  the  seventh  and  the  tenth  day, 
sometimes  not  until  the  end  of  the  second  week.  There  is  fever,  except  in 
very  mild  cases.  Chills  are  not  common.  The  thermometer  may  register 
103°  or  104°  F.,  and  the  fever  is  usually  remittent  or  intermittent.  The  mi- 
gration of  the  parasites  into  the  muscles  excites  a  more  or  less  intense  myositis, 
which  is  characterized  by  pain  on  pressure  and  movement,  and  by  swelling 
and  tension  of  the  muscles,  over  which  the  skin  may  be  cedematous.  The 
limbs  are  placed  in  the  positions  in  which  the  muscles  are  in  least  tension. 
The  involvement  of  the  muscles  of  mastication  and  of  the  larynx  may  cause 
difficulty  in  chewing  and  swallowing.  In  severe  cases  the  involvement  of 
the  diaphragm  and  intercostal  muscles  may  lead  to  intense  dyspnoea,  which 
sometimes  proves  fatal.  Qlldema,  a  feature  of  great  importance,  may  be  early 
in  the  face,  particularly  about  the  eyes.  Later  it  occurs  in  the  extremities 
when  the  swelling  and  stiffness  of  the  muscles  are  at  their  height.  Profuse 
sweats,  tingling  and  itching  of  tile  skin,  and  in  some  instances  urticaria, 
have  been  described.  Kernig's  sign  is  usually  present  and  the  leg  reflexes  may 
be  absent. 

Blood. — A  marked  leucocytosis,  which  may  reach  above  30,000,  is  usually 
present.  A  special  feature  is  the  extraordinary  increase  in  the  number  of 
eosinophilic  cells,  which  may  comprise  more  than  50  per  cent,  of  all  the 
leucocytes.  There  were  in  four  years,  in  the  Johns  Hopkins  Hospital,  ?' 
cases  in  which  the  eosinophilia  was  most  pronounced.  In  4  of  them  the 
diagnosis  was  actually  sugge.sted  by  the  great  increase  in  the  eosinophiles ; 
in  1  ease  they  reached  68  per  cent,  of  the  total  number  of  leucocytes. 

The  general  nutrition  is  much  disturbed  and  the  patient  becomes  emaci- 
ated and  often  anaemic,  particularly  in  the  protracted  cases.  The  patients 
are  usually  conscious,  except  in  cases  of  very  intense  infection,  in  which  the 
toxEemia,  dry  tongue,  and  tremor  give  a  picture  suggesting  typhoid  fever. 
In  addition  to  the  dyspnoea  present  in  the  severer  infections,  there  may  be 
bronchitis,  and  in  the  fatal  cases  pneumonia  or  pleurisy.  In  some  epidemics 
polyuria  has  been  a  common  symptom.     Albuminuria  is  frequent. 

The  intensity  and  duration  of  the  symptoms  depend  entirely  upon  the 
grade  of  infection.  In  the  mild  cases  recovery  is  complete  in  from  ten  to 
fourteen  days.     In  the  severe  forms  convalescence  is  not  established  for  six 


306  SPECIFIC  INFECTIOUS  DISEASES 

or  eight  weeks,  and  it  may  be  months  before  the  patient  recovers  the  mus- 
cular strength.  One  patient  in  the  Hedersleben  epidemic  was  weak  eight 
years  after  the  attack. 

Of  72  fatal  cases  in  the  Hedersleben  epidemic,  the  greatest  mortality  oc- 
curred in  the  fourth  and  fifth  and  sixth  weeks;  namely,  52  cases.  Two  died 
in  the  second  week  with  severe  choleraic  symptoms.  The  mortality  has 
ranged  in  different  outbreaks  from  1  or  2  per  cent,  to  30  per  cent.  Among 
456  cases  reported  in  the  United  States  there  were  122  deaths. 

The  prognosis  depends  much  upon  the  quantity  of  infected  meat  eaten 
and  the  number  of  trichinse  which  mature  in  the  intestines.  In  children  the 
outlook  is  more  favorable.  Early  diarrhoea  and  moderately  intense  gastro- 
intestinal symptoms  are,  as  a  rule,  more  favorable  than  constipation. 

Diagpiosis. — The  disease  should  always  be  suspected  when  a  large  party 
among  Germans  is  followed  by  cases  of  apparent  typhoid  fever.  The  parasites 
may  be  found  in  the  remnants  of  the  ham  or  sausages  used  on  the  occasion. 
The  worms  may  be  discovered  in  the  stools  or  found  in  the  duodenal  con- 
tents. The  stools  should  be  spread  on  a  glass  plate  or  black  background  and 
examined  with  a  low-power  lens,  when  the  trichinas  are  seen  as  small,  glisten- 
ing, silvery  threads.  In  doubtful  cases  the  diagnosis  may  be  made  by  the 
removal  of  a  piece  of  muscle.  The  disease  may  be  mistaken  for  rheumatic 
fever,  particularly  as  the  pains  are  so  severe  on  movement,  but  there  is  no 
special  swelling  of  the  joints.  The  great  increase  of  the  eosinophiles  in  the 
blood  is  a  most  suggestive  point  in  diagnosis.  The  tenderness  is  in  the 
muscles  both  on  pressure  and  on  movement.  The  intensity  of  the  gastro- 
intestinal symptoms  has  led  to  the  diagnosis  of  cholera.  Many  of  the  former 
epidemics  were  described  as  typhoid  fever,  which  the  severer  cases,  owing  to 
the  prolonged  fever,  the  sweats,  the  delirium,  dry  tongue,  and  gastro-intestinal 
symptoms,  somewhat  resemble.  The  pains  in  the  muscles,  with  tension  and 
swelling,  oedema,  particularly  about  the  eyes,  and  shortness  of  breath,  are  the 
most  important  diagnostic  points. 

Prophylaxis. — It  is  not  definitely  known  how  swine  become  diseased.  It 
has  been  thought  that  they  are  infected  from  rats  about  slaughter-houses, 
but  it  is  just  as  reasonable  to  believe  that  the  rats  are  infected  by  eating 
the  trichinous  flesh  of  swine.  The  swine  should,  so  far  as  possible,  be  grain- 
fed,  and  not  allowed  to  eat  offal.  The  most  satisfactory  prophylaxis  is  the 
complete  cooking  of  pork  and  sausages,  and  to  this  custom  in  England, 
France,  South  Germany,  and  the  United  States  immunity  is  largely  due. 

Treatment. — If  it  has  been  discovered  within  twenty-four  or  thirty-six 
hours  that  a  large  number  of  persons  have  eaten  infected  meat,  the  indica- 
tions are  to  thoroughly  evacuate  the  gastro-intestinal  canal.  Calomel  (gr. 
ii,  0.13  gm.)  should  be  given  at  once  and  repeated  in  two  hours.  Four 
hours  after  the  second  dose  half  an  ounce  of  castor  oil  or  magnesium  sulphate 
should  be  given  and  repeated  if  necessary.  An  enema  should  be  given  unless 
the  bowels  move  freely.  Glycerine  has  been  recommended  in  large  doses,  in 
order  that  by  passing  into  the  intestines  it  may  by  its  hygroscopic  properties 
destroy  the  worm.  Male  fern,  kamala,  santonin,  and  thymol  have  all  been 
recommended  in  this  stage.  Turpentine  may  be  tried  in  full  doses.  There 
is  no  doubt  that  diarrhoea  in  the  first  week  or  ten  days  of  the  infection  is 
distinctly  favorable.     The  indications  in  the  stage  of  invasion  are  to  relieve 


DISEASES  CAUSED  BY  NEMATODES  307 

the  pains,  to  ser-ure  sleep,  and  to  snpport  the  patient's  strength.  There  are 
no  medicines  which  have  any  iniinence  upon  the  embryos  in  their  migration 
throngh  tlie  muscles.  The  use  of  arsphenamine  has  been  advised  but  proof 
of  its  value  is  lacking. 

3.      UNCINAKIASIS  ^     . 

(Hool:worm  Disease,  Anhylostomiasis) 

Synonyms. — One  of  the  most  important,  widespread  of  all  metazoan  in- 
fections, variously  known  as  anemia  of  miners,  bricklayers,  tunnel- workers ; 
tropical  and  Egyptian  chlorosis. 

History. — For  three  centuries  the  disease,  but  not  its  nature,  was  recog- 
nized in  the  tropics  under  various  names.  Dubini,  in  1838,  first  described 
the  worms,  and  gave  the  name  from  the  curved  or  bent  appearance  of  the 
mouth.  In  1853  and  185rt  Bilhartz  and  Griesinger  recognized  the  relation 
of  the  parasites  to  the  ansmia  and  dropsy.  In  South  America  in  1866 
Wucherer  called  attention  to  the  frequency  of  the  disease  in  negro  slaves. 
In  the  "seventies"  and  "eighties"  of  the  last  century  the  anemia  of  brick- 
workers  in  Italy  and  of  miners  and  tunnel  diggers  was  shown  to  be  due 
to  this  parasite.  Occasional  statements  were  made  as  to  the  occurrence  of 
the  disease  in  the  United  States,  but  it  was  not  until  the  extensive  investiga- 
tions of  Stiles  in  1901,  and  later,  that  it  was  shown  that  the  hookworm  was 
widely  prevalent,  that  it  was  responsible  for  an  enormous  amount  of  ill  health 
and  anaemia,  and  that  it  was  directly  connected  v/ith  the  old  and  long-ago 
described  practice  of  dirt-eating.  It  was  gradually  realised  how  widespread 
the  disease  was  in  the  Southern  States.  Ashford  and  King  studied  the  dis- 
ease in  Porto  Eico,  and  carried  out  one  of  the  most  successful  of  modern 
sanitary  campaigns.  In  1898  Looss  discovered  the  cardinal  fact  of  the  pene- 
tration of  the  skin  by  the  larvae,  apd  of  the  route  by  which  they  reach  the 
intestine.  Special  monographs  have  been  published  by  Dock  and  Bass,  by 
Ashford  and  Igaravidez,  and  by  Boycott  (all  in  1911). 

Distribution. — The  parasite  exists  in  most  parts  of  the  world,  and  there 
is  scarcely  a  tropical  country  in  which  it  does  not  prevail.  In  India  the  in- 
fection is  from  60  to  80  per  cent.,  in  Porto  Eico  90  per  cent.,  in  the  Philip- 
pines about  15  per  cent.  In  Europe  it  is  chiefly  an  affection  of  miners  in 
Germany,  Hungary,  France,  and  Belgium.  In  England  there  was  a  small 
outbreak  in  Cornwall,  but  the  disease  has  not  extended.  Stiles  showed  that 
more  than  12  per  cent,  of  cotton-mill  employees  in  the  Southern  United 
States  were  infected,  and  the  examination  of  recruits,  college  students,  and 
school  children  in  different  parts  of  the  country  gave  a  percentage  of  infec- 
tion of  from  20  to  70  or  even  80.  Among  18,390  white  troops  examined, 
hook-worm  was  found  in  13.7  per  cent.  In  the  West  Indies  the  Eockefeller 
Commission  found  97,632  infected  among  165,866  examined. 

Parasites. — There  are  two  chief  forms,  the  Ancylostoma  duodenale,  the 
old  world  species,  and  the  Necator  americanus,  the  new  world  species.  The 
Ancylostoma  is  a  small  cylindrical  nematode,  the  male  about  10  mm.  and 
the  female  from  8  to  18  mm.  in  length.  The  mouth  has  chitinous  plates, 
and  is  provided  with  two  pairs  of  sharp,  hook-shaped  teeth,  with  which  they 
pierce  the  mucosa  of  the  bowel.     The  male  has  a  prominent,  umbrella-like 


308  SrECIFIC  INFECTIOUS  DISEASES 

caudal  expansion.  The  new  world  worm  has  much  the  same  characters, 
only  it  is  more  slender,  the  mouth  globular,  and  the  arrangement  of  the 
teeth  quite  different.  The  eggs  are  from  52  /*  to  60  /x  by  about  34  /*  in 
width  in  the  European  form,  and  from  64  ju,  to  76  /x.  by  about  36  fx  in 
breadth  in  the  American  form.  They  are  very  characteristic  bodies  in  the 
fseces  of  infected  individuals.  When  laid  they  are  already  in  process  of 
segmentation.  Complete  desiccation,  and  direct  sunlight,  or  much  water  in 
the  fasces  kills  the  eggs;  but  ihej  are  sometimes  very  resistant,  and  may  sur- 
vive freezing  followed  by  a  gentle  thawing.  The  rapidity  of  development 
depends  upon  favoring  conditions  and  temperature,  and  the  larvse  after 
escaping  from  the  eggs  may  live  for  months  in  the  mud  or  water  of  the 
mines,  and  they  pass  through  a  series  of  moults  before  ■  they  reach  what  is 
called  the  ripe  stage.  They  then  show  a  remarkable  tenacity  of  life,  and 
may  live  in  water  or  slime  for  many  months;  and  in  this,  which  is  the  infec- 
tive stage,  they  have  a  great  tendency  to  wander. 

Modes  of  Infection.^ — An  extraordinary  number  of  eggs  are  passed  with 
each  stool  of  a  badly  infected  person,  as  many  it  has  been  estimated  as  four 
millions.  They  develop  most  readily  in  fseces  mixed  with  sand  or  earth 
at  a  temperature  of  from  70°  to  90°.  The  larvas  become  infective  when 
about  4  or  5  days  old.  Infection  takes  place  either  by  the  mouth  directly, 
which  is  rare,  or  by  the  skin.  Looss  showed  experimentally  that  the  larvae 
entering  the  skin  are  carried  by  the  veins  to  the  heart,  and  thence  to  the 
kmgs,  in  which  they  escape  from  the  pulmonary  vessels,  pass  up  the  bronchi 
arid  trachea,  and  so  to  the  gullet,  stomach  and  intestines.  These  remark- 
able observations  of  Looss  have  been  abundantly  confirmed.  As  C.  A.  Smith's 
work  has  shown,  it  takes  about  seven  weeks  before  the  ova  appear  in  the 
stools,  and  in  the  process  of  infection  there  may  be  sore  throat  and  fever.  It 
would  appear  that  the  skin  is  the  common  channel  of  entrance,  and  usually 
shows  signs  of  irritation— ^rO'^ntZ  itch.  Larvae  accidentally  swallowed  may 
pass  through  the  stomach,  and  develop  in  the  intestines. 

The  careless  disposition  of  fasces  permits  the  pollution  of  the  soil,  and 
in  tropical  and  sub-tropical  districts,  and  in  mines,  it  is  easy  to  understand 
how  children  and  others  are  infected  through  the  skin.  Ashford  and  King 
give  a  history  of  ground-itch  in  more  than  90  per  cent,  of  their  cases. 

Morbid  Anatomy  and  Pathology.- — The  worms  are  chiefly  in  the  Jeju- 
num; Saudwith  found  1,353  out  of  1,524  worms  in  the  first  six  feet  of  the 
bowel.  They  are  also  occasionally  found  in  the  stomach.  A  variable  num- 
ber of  worms  are  found  attached  to  the  mucosa.  Very  characteristic  lesions 
are  the  ecchymoses  and  small  erosions  of  the  mucosa,  in  the  centre  of  which 
may  be  a  pale  area,  slightly  raised,  to  which  the  worm  is  attached;  it  may 
be  almost  buried  in  the  mucosa.  There  are  usually  more  bites  or  holes  than 
worms.  Blood  cysts  occur  in  the  sub-mucosa,  in  which,  occasionally,  worms 
are  found  (Whipple).  The  contents  of  the  bowel  are  often  blood-stained. 
In  long-standing  cases  the  mucosa  may  show  many  areas  of  pigmentation. 
Other  lesions  are  those  of  chronic  anaemia  with  fatty  degeneration.  Much 
discussion  has  taken  place  as  to  whether  the  worms  live  on  blood  or  not. 
They  are  certainly  built  for  blood-sucking,  and,  as  Whipple  states,  when  ' 
the  mucosa  is  normal  the  worms  feed  chiefly  on  blood,  when  it  is  thickened 
and  infiltrated  they  have  to  be  content  with  the  epithelium  and  mucosa.     The 


DISEASES  CAUSED  BY  NEMATODES  309 

loss  of  blood  is  largely  direct,  but  it  has  been  shown  by  Loeb  and  A.  J. 
Smith  that  the  head-glands  of  the  worm  secrete  a  substance  which  retards 
coagulation,  probably  a  hsemolytic  poison,  the  presence  of  which  Whipple 
has  demonstrated.  Another  feature  of  importance  is  the  liability  to  infec- 
tion through  the  bites;  and  the  anaemia  may  in  part,  at  any  rate,  be  due  to 
poisonous  products  absorbed  through  the  bowel  lesions. 

Symptoms. — Hookworm  disease  presents  a  very  variable  picture,  nor  does 
the  severity  of  the  symptoms  seem  to  depend  always  upon  the  number  of 
worms.  There  have  been  fatal  cases  in  which  only  ten  or  twelve  worms  were 
found,  while  recovery  has  followed  after  more  than  4,000  worms  have  been 
expelled  (Dock).  In  infected  districts,  as  in  the  Southern  States,  the  hook- 
worm disease  causes  a  widespread  degeneration  in  the  community,  the 
children  and  young  adults  showing  a  pallor,  under-development,  and  failure 
of  nutrition.  With  the  infection,  too,  are  associated  apathy  and  lack  of 
energy,  so  that  the  common  opipion  in  the  South  ■  is  that  the  hookworm  is 
the  cause  of  laziness.  There  is  no  question  that,  as  Stiles  and  others  have 
shown,  the  widespread  infection  is  responsible  for  a  great  deal  of  ill  health 
and  physical  incapacity,  often  without  any  actual  illness.  In  more  severe 
cases  the  anaemia  is  pronounced,  the  hsemoglobin  being  from  40  to  50  per 
cent. ;  the  child  is  stunted  and  puberty  is  long  delayed,  and  the  patient  may 
belong  to  the  group  of  dirt-eaters.  The  retardation  of  growth  is  remark- 
able, and  the  individual  may  continue  to  grow  until  he  is  25  or  26  years 
of  age.  In  the  severest  type  of  all  the  anaemia  is  still  more  pronounced;  the 
haemoglobin  below  25  or  20  per  cent. ;  oedema  occurs,  the  patient  is  bedridden, 
and  death  occurs  from  exhaustion,  diarrhoea,  or  some  intercurrent  affection. 
The  ancemia  is.  of  a  secondary  type,  averaging  from  50  to  60  per  cent,  of 
the  corpuscles,  with,  as  a  rule,  a  low  color  index.  Leucocytosis  is  not  often 
present,  and  the  differential  count  shows  nothing  unusual  except  the  great 
increase  in  the  eosinophiles,  ranging  from  15  to  26  or  even  30  per  cent.  The 
eosinophilia  bears  no  relation  to  the  severity  of  the  infection. 

"Ground-itdi"  the  local  lesion  through  which  the  parasites  enter  the  sys- 
tem, is  most  commonly  on  the  feet  and  legs  in  children,  or  on  the  arms  and 
hands  in  gardeners  and  miners.  The  most  common  region  is  between  and 
beneath  the  toes.  The  eruption  is  vesicular  at  first,  and  then  pustules  form 
with  a  sticky  exudate,  and  sometimes  with  much  swelling  of  the  skin.  The 
vesicles  and  pustules  gradually  dry,  and  in  about  eight  or  ten  days  heal 
with  exfoliation. 

Other  general  features  are  the  well  known  circulatory  and  respiratory 
features  of  anaemia.  The  digestive  symptoms  are  remarkable.  In  the  mild 
cases  there  are  slight  epigastric  pain  and  discomfort ;  in  the  severer  ones  there 
are  anorexia  and  remarkable  perversion  of  appetite;  the  patients  eat  earth, 
paper,  chalk,  starch,  hair  and  clay.  The  dirt-eaters  of  the  Southern  States 
are  all  subject  to  hookworm  disease.  With  the  apathetic,  listless  expression 
there  is  dilatation  of  the  pupils,  and  Stiles  has  remarked  upon  the  "dull, 
blank,  almost  fish-like  or  cadaveric  stare,"  which  gives  a  very  characteristic 
appearance  to  the  expression. 

Diagnosis. — In  tropical  and  sub-tropical  regions  slight  anaemia  and  ill 
health  should  lead  to  the  examination  of  the  stools,  from  which  a  certain 
iliao-nosis  mav  ])e  made  l)v   finding  the  eggs.     "The  combination  of  amemia 


310  SPECIFIC  INFECTIOUS  DISEASES 

with  under-development,  weakness,  dilated  heart,  and  the  history  of  ground- 
itch  is  not  likely  to  be  confused  with  anything  else''  (Stiles).  In  badly  in- 
fected regions  a  fairly  accurate  diagnosis  may  be  made  on  inspection  alone, 
and  this  may  be  confirmed  by  the  examination  of  the  feeces  and  by 
the  rapid  improvement  after  the  administration  of  thymol.  Two  or  three 
drachms  of  faces  suffice;  they  should  be  collected  in  a  wide-mouthed  bottle. 
A  little  practice  may  be  required  at  first,  but  the  necessary  technique  is 
easily  acquired.  The  eggs  are  characteristic  structures,  usually  containing 
4  or  8  segments,  sometimes  the  complete  embryo  nearly  ready  to  burst  its 
shell.  Various  estimates  have  been  made  of  the  number  of  worms  based 
on  the  number  of  eggs  found.  It  is  to  be  remembered  that  the  eggs  vary 
greatly  in  number,  and  the  stools  may  be  negative  one  day  and  contain  many 
a  few  days  later.  Grassi  states  that  150  eggs  per  centigram  of  fseces  rep- 
resent about  1,000  worms.  For  special  methods  of  examining  the  stools 
the  student  is  referred  to  the  monograph  of  Dock  and  Bass.  The  presence 
of  eosinophilia  is  an  important  diagnostic  aid.  Boycott  and  Haldane  found 
that  94  per  cent,  of  infected  persons  had  over  8  per  cent,  of  eosinophiles. 

Prophylaxis. — Destruction  of  the  adult  worms,  removing  conditions  suit- 
able to  the  growth  of  the  embryos,  and  a  campaign  of  sanitary  education  are 
the  three  essentials.  The  proper  disposal  of  fseces,  obtaining  a  pure  water 
supply,  and  decreasing  the  chance  of  infection  by  wearing  shoes  and  stock- 
ings are  important  points.  The  work  of  the  Porto  Eico  commission  shows  what 
can  be  done  in  the  tropics,  even  in  the  most  unfavorable  surroundings.  More 
than  300,000  persons  have  received  specific  treatment  for  the  disease  since  the 
commission  began  its  work.  That  the  mortality  in  the  island  has  fallen  from 
42  per  1,000  in  1899-1900  to  20.9  in  1910  is  in  great  part  due  to  the  devoted 
work  of' the  medical  staff  and  the  nurses  in  dealing  with  hookworm  cases. 

The  International  Health  Board  of  the  Eockefeller  Foundation  is  con- 
tinuing its  active  campaign,  and  has  introduced  what  is  called  the  intensive 
method,  which  is  an  attempt  as  nearly  as  possible  to  relieve  and  control  hook- 
worm disease  within  a  given  area  by  sanitary  and  therapeutic  measures.  A 
census  of  the  population  is  taken,  a  microscopic  examination  made  of  the 
stools,  all  infected  persons  are  treated,  and  the  treatment  continued  until 
microscopic  examination  shows  that  a  cure  has  resulted.  The  people  are 
educated  both  as  to  the  method  of  cure  and  the  dangers  of  soil  pollution. 

In  mines  care  should  be  taken  to  prevent  local  conditions  favoring  the 
growth  of  the  embryos.  Oliver  has  found  that  cinder  and  slag  are  destruc- 
tive of  the  larvEe.  New  workers  should  be  examined  and  proved  not  to  have 
the  disease  before  being  admitted. 

Treatment. — The  following  directions  are  given  by  the  Porto  Eican  com- 
mission : 

Take  one  of  the  two  purgatives  to-night  in  water. 

Take  at  6  o'clock  to-morrow  morning  half  of  the  capsules   (thymol). 

Take  the  other  half  at  8  o'clock  the  same  morning. 

Take  the  other  purgative  at  10  o'clock. 

You  should  neither  drink  wine  nor  any  alcoholic  liquor  during  the  time  you  are 
taking  these  medicines. 

Have  a  privy  in  your  house.  Do  not  defecate  on  the  surface  of  the  ground,  but 
in  the  privy. 

Do  not  walk  barefooted,  so  that  you  may  avoid  contracting  the  disease  in  your 
feet.     Wear  shoes  and  you  will  never  suffer  from  anaemia. 


DISEASES  CAUSED  BY  NEMATODES  311 

The  purgative  preferred  is  an  ordinary  saline,  and  the  dose  of  the  thymol 
is  graduated  according  to  the  age  of  the  patient,  seven  grains  (0.5  gm.)  for 
children  under  five,  and  increasing  the  dose  according  to  age  and  strength 
to  sixty  grains  (4  gm.)  for  adults.  Very  few  ill  effects  follow  its  use,  but 
it  sometimes  is  irritating  to  the  bowels,  and  occasionally  it  has  been  toxic. 
This  treatment  should  be  carried  out  on  one  day  of  each  week  until  the 
patient  is  cured.  No  alcohol  or  oil  should  be  given  at  the  time  of  admin- 
istration of  thymol. 

Oil  of  chenopodium  (wormseed  oil)  is  often  efficient,  given  in  doses  of  15 
drops  in  castor  oil  every  two  hours  for  two  or  three  doses.  Two  hours  later  a 
full  dose  of  castor  oil  is  given.  The  angemia  should  receive  the  usual  treat- 
ment. 

4.      FILARIASIS 

For  a  full  discussioii  of  the  zoological  relations  of  this  important  group 
see  Stiles'  article  in  our  "System  of  Medicine,"  Second  Edition,  A'ol.  II. 

The  important  species  are : 

Filaria  bancrofti  (Cobbold,  1877). — This  is  the  ordinary  blood  filaria.  The 
embryos  are  found  in  the  peripheral  circulation  only  during  sleep  or  at  night. 
The  mosquito  is  the  intermediate  host.  The  embryos  measure  270  to  340  n 
long  by  7  to  11  /u,  broad;  tail  pointed.  The  adult  male  measures  83  mm. 
long  by  0.407  mm.  broad;  the  tail  forms  two  turns  of  a  spiral.  The  adult 
female  measures  155  mm.  long  by  0.715  mm.  broad;  vulva  2.56  mm.  from 
anterior  extremity;  eggs  38  /a  by  14  fx.  This  is  the  species  to  which  the 
hsematochyluria  and  elephantiasis  are  attributed. 

Filaria  loa  (Cobbold,  1864). — This  is  the  eye-worm  of  tropical  West 
Africa  which  causes  "Calabar  swellings."  It  occurs  in  the  peripheral  circu- 
lation during  the  day.    The  adults  move  about  in  the  subcutaneous  tissues. 

Filaria  perstans  (Manson,  1891). — The  adult  is  found  in  the  retroperito- 
neal tissues  and  the  embryo  is  present  in  the  blood  both  by  day  and  night. 

The  most  important  of  these  is  the  Filaria  bancrofti,  which  produces  the 
hfematochyluria  and  the  lymph-scrotum. 

The  female  produces  an  extraordinary  number  of  embryos,  which  enter 
the  blood  current  through  the  lymphatics.  Each  embryo  is  within  its  shell, 
which  is  elongated,  scarcely  perceptible,  and  in  no  way  impedes  the  move- 
ments. They  are  about  the  ninetieth  part  of  an  inch  in  length  and  the 
diameter  of  a  red  blood-corpuscle  in  thickness,  so  that  they  readily  pass 
through  the  capillaries.  They  move  with  the  greatest  activity,  and  form 
very  striking  and  readily  recognized  objects  in  a  blood-drop  under  the  micro- 
scope. A  remarkable  feature  is  the  periodicity  in  the  occurrence  of  the  embryos 
in  the  blood.  In  the  daytime  they  are  almost  or  entirely  absent,  whereas  at 
night,  in  typical  cases,  they  are  present  in  large  numbers.  This  does  not 
occur  in  the  Pacific  islands,  one  reason  given  being  that  there  a  day-feeding 
stegomyia  mosquito  is  the  common  intermediary.  The  night-feeding  Culex 
fatigans  is  not  the  usual  carrier  in  these  islands  as  it  is  in  Asia,  Africa  and 
America.  If,  however,  as  Stephen  j\Iackenzie  has  shown,  the  patient,  reversing 
his  habits,  sleeps  during  the  day,  the  periodicity  is  reversed.  Lynch  sug- 
gests that  the  periodicity  is  largely  dependent  on  the  difficulty  of  passage 
through  the  peripheral  capillaries  during  periodic  tonicity.     In  the  case  re- 


312  SPECIFIC  INFECTIOUS  DISEASES 

ported  by  Lothrop  and  Pratt  the  number  of  embryos  per  cubic  centimetre  of 
blood  was  calculated  hourly  during  the  night;  it  rose  steadily  from  four 
o'clock  in  the  afternoon  till  midnight,  when  2,100  per  c.  c.  were  present,  then 
fell,  none  being  found  at  ten  o'clock  the  following  morning.  The  further 
development  of  the  embryos  is  associated  with  the  mosquito,  which  sucks  the 
blood  and  in  this  way  frees  them  from  the  body.  They  develop  in  the  mos- 
quito and  reach  the  proboscis  from  which  they  pass  to  the  human  host.  The 
filarise  may  be  present  in  the  body  without  causing  any  symptoms.  In  the 
blood  of  animals  filarise  are  very  common  and  rarely  cause  inconvenience. 
It  is  only  when  the  adult  worms  or  the  ova  block  the  lymph  channels  that 
certain  definite  symptoms  occur.  Manson  suggests  that  it  is  the  ova  (pre- 
maturely discharged),  which  are  considerably  shorter  and  thicker  than  the 
full-grown  embryos,  which  block  the  lymph  channels  and  produce  the  condi- 
tions of  hsematochyluria,  elephantiasis,  and  lymph-scrotum. 

The  parasite  is  widely  distributed,  particularly  in  tropical  and  sub-tropical 
countries.  Guiteras  has  shown  that  the  disease  prevails  extensively  in  the 
Southern  States,  and,  since  his  paper,  contributions  have  been  made  by 
Matas,  of  New  Orleans,  Mastin,  of  Mobile,  De  Saussure,  of  Charleston,  and 
Opie. 

The  effects  produced  may  be  described  under  the  following  conditions : 

1.  H^MATOCHYLURiA. — Without  any  external  manifestations,  and  in 
many  cases  without  special  disturbance  of  health,  the  subject  from  time  to 
time  passes  urine  of  an  opaque  white,  milky  appearance,  or  bloody,  or  a 
chylous  fluid  which  on  settling  shows  a  slightly  reddish  clot.  The  condition 
indicates  dilatation  and  rupture  of  dilated  lymphatics  in  some  part  of  the 
urinary  tract  and  obstruction  of  the  thoracic  duct.  The  urine  may  be  nor- 
mal in  quantity  or  increased.  The  condition  is  usually  intermittent,  and  the 
patient  may  pass  normal  urine  for  weeks  or  months  at  a  time.  Micro- 
scopically, the  chylous  urine  contains  minute  molecular  fat  granules,  and 
usually  red  blood  cells  in  various  amounts.  The  embryos  were  first  discov- 
ered by  Demarquay  at  Paris  (1863),  and  in  the  urine  by  Wucherer,  at  Bahia, 
in  1866.  It  is  remarkable  for  how  long  the  condition  may  persist  without 
serious  impairment  of  the  health.  A  patient,  sent  by  Dawson,  of  Charleston, 
had  hgematochyluria  intermittently  for  eighteen  years.  The  only  incon- 
venience had  been  in  the  passage  of  blood-clots  which  collected  in  the  bladder. 
At  times  he  had  uneasy  sensations  in  the  lumbar  region.  The  embryos  were 
present  in  his  blood  at  night  in  large  numbers.  Chyluria  is  not  always  due 
to  filaria.     There  is  a  non-parasitic  form  of  the  disease. 

Opportunities  for  studying  the  anatomical  condition  of  these  cases  rarely 
occur.  In  the  case  described  by  Stephen  Mackenzie  the  renal  and  peritoneal 
lymph  plexuses  were  enormously  enlarged,  extending  from  the  diaphragm  to 
the  pelvis.     The  thoracic  duct  above  the  diaphragm  was  impervious. 

2.  Elephantiasis  is  common  in  all  countries  in  which  the  filarise  pre- 
vail. The  parasites  are  not  always  found  in  the  blood.  The  condition  is 
more  common  in  the  legs,  one  or  both,  beginning  below  the  knee,  but  grad- 
ually involving  the  entire  limb.  Next  in  frequency  is  lympli-scroUim  and 
other  forms  involving  the  genitalia.  The  scrotal  tumor  may  reach  an  enor- 
mous size,  and  40  to  50  pounds  in  weight.  The  onset  may  be  painless  and 
slow,  or  it  may  be  sudden,  with  fever  and  rapid  swelling  and  redness  of  the 


DISEASES  CAUSED  BY  NEMATODES  313 

part.  There  may  be  a  series  of  such  attacks,  each  one  leaving  the  part  more 
swollen.  The  so-called  "^elephantoid  fever"  may  occur  in  all  forms  of  the 
infection. 

Sporadic  Elephantiasis. — A  non-parasitic  type  may  be  mentioned  here, 
which  is  not  very  uncommon  in  temperate  regions,  characterized  by  progres- 
sive enlargement  of  a  limb  or  portion  of  the  body,  wdth  a  hyperplasia  of  the 
skin  and  subcutaneous  tissues,  due  apparently  to  an  obstructive  inflamma- 
tion of  the  lymph-vessels.  It  may  arise  spontaneously  without  any  obvious 
cause,  or  follow  an  inflammation  of  the  skin  of  the  part,  occasionally  removal 
of  the  lymph-glands.  The  legs  are  most  frequently  involved,  beginning  usu- 
ally in  one  leg,  about  the  foot  or  ankle,  and  gradually  extending  until  the 
whole  leg  is  greatly  enlarged.  The  skin  is  usually  smooth,  but  it  may  be 
hard  and  indurated  or  warty  and  nodular.  Most  of  the  cases  are  in  young 
women,  in  whom  the  affection  has  come  on  without  any  obvious  cause  and 
progressed  slowly  until  the  leg  was  greatly  enlarged.  In  one  case  eight  years 
elapsed  before  the  other  leg  became  involved,  and  in  another  case  more  than 
ten  years  passed  with  the  disease  still  confined  to  one  leg. 

Diagnosis. — The  filaria  larva  may  be  found  in  the  blood,  urine  or  chylous 
fluid.  A  negative  finding  does  not  exclude  filarial  infection.  Adult  worms 
may  be  found  in  lymph  glands  or  in  abscesses.     Eosinophilia  is  present. 

Treatment. — So  far  as  known,  no  drug  destroys  the  embryos  in  the  blood 
with  certainty.  In  infected  districts  the  drinking-water  should  be  boiled  or 
filtered.  In  cases  of  chyluria  the  patients  should  use  a  dry  diet  and  avoid 
all  excess  of  fat.  The  chyle  may  disappear  quite  rapidly  from  the  urine 
under  these  measures,  but  it  does  not  necessarily  indicate  that  the  case  is  cured. 
So  long  as  clots  and  albumin  are  present  the  leak  in  the  lymphoid  varix  is  not 
healed,  although  the  fat,  not  being  supplied  to  the  chyle,  may  not  be  present. 
A  single  tumblerful  of  milk  will  at  once  give  ocular  proof  of  the  patency  or 
otherwise  of  the  rupture  in  the  varix  (Manson). 

Elephantoid  fever  demands  rest,  liquid  diet,  free  purgation  and  sedative 
applications  to  painful  areas.  In  elephantiasis  during  periods  with  acute 
symptoms  the  patient  should  be  at  rest  and  the  legs  firmly  bandaged.  Good 
results  are  reported  from  the  use  of  fibrolysin. 

The  surgical  treatment  of  some  of  these  cases  is  most  successful,  partic- 
ularly in  the  removal  of  the  adult  filarige  from  the  enlarged  lymph-glands, 
especially  in  the  groin.     Surgical  measures  may  be  advisable  in  elephantiasis. 

Infected  individuals  should  be  protected  from  mosquitoes. 

5.      DEACONTIASIS 
{Guinea-worm  Disease) 

Dracunculus  medinensis  is  a  widely  spread  parasite  in  parts  of  Africa 
and  the  East  Indies.  In  the  United  States  instances  occasionally  occur. 
Jarvis  reported  a  case  in  a  post  chaplain  who  had  lived  at  Fortress  Monroe, 
Va.,  for  thirty  years.  Van  Harlingen's  patient,  a  man  aged  forty-seven, 
had  never  lived  out  of  Philadelphia,  so  that  the  worm  must  be  included 
among  the  parasites  of  the  United  States.  A  majority  of  the  cases  reported 
in  American  journals  have  been  imported. 


314  SPECIFIC  mFECTIOUS  DISEASES 

The  female  develops  in  the  subcutaneous  and  intermuscular  connective 
tissues  and  produces  vesicles  and  abscesses.  In  the  large  majority  of  the  cases 
the  parasite  is  found  in  the  leg.  Of  181  cases,  in  124  the  worm  was  found 
in  the  feet,  33  times  in  the  leg,  and  11  times  in  the  thigh.  It  is  usually  soli- 
tary, though  there  are  cases  on  record  in  which  six  or  more  have  been  present. 
It  is  cylindrical  in  form,  about  2  mm.  in  diameter,  and  from  50  to  80  cm. 
in  length.  The  male  has  been  found  by  Leiper  in  a  monkey,  a  very  small 
worm  only  22  mm.  in  length. 

In  water  the  embryos  develop  in  a  cyclops — a  small  crustacean — and  it 
seems  likely  that  man  is  infected  by  drinking  the  water  containing  these 
developed  larvae.  It  is  probable  that  both  male  and  female  are  ingested;  but 
the  former  dies  and  is  discharged,  while  the  latter  after  impregnation  pene- 
trates the  intestine  and  attains  its  full  development  in  the  subcutaneous 
tissues,  where  it  may  remain  quiescent  for  a  long  time  and  can  be  felt  beneath 
the  skin  like  a  bundle  of  string.  The  worm  contains  an  enormous  number  of 
living  embryos,  and  to  enable  them  to  escape  she  travels  slowly  downward 
head  first,  and  usually  reaches  the  foot  or  ankle.  The  head  then  penetrates 
the  skin  and  the  epidermis,  forms  a  little  vesicle,  which  ruptures,  and  a  small 
ulcer  is  left,  at  the  bottom  of  which  the  head  often  protrudes.  The  distended 
uterus  ruptures  and  the  embryos  are  discharged  in  a  whitish  fluid.  After 
getting  rid  of  them  the  worm  will  spontaneously  leave  her  host. 

When  the  worm  first  appears  it  should  not  be  disturbed,  as  after  par- 
turition it  may  leave  spontaneously.  When  the  worm  begins  to  come  out 
a  common  procedure  is  to  roll  it  round  a  portion  of  smooth  wood  and  in  this 
way  prevent  the  retraction,  and  each  day  wind  a  little  more  until  the  entire 
worm  is  withdrawn.  It  is  stated  that  special  care  must  be  taken  to  prevent 
tearing  of  the  worm,  as  disastrous  consequences  sometimes  follow,  probably 
from  the  irritation  caused  by  the  migration  of  the  embryos. 

The  parasite  may  be  excised  entire,  or  killed  by  injections  of  bichloride 
of  mercury  (1  to  1,000).  It  is  stated  that  the  leaves  of  the  plant  called 
amarpattee  are  almost  a  specific  in  the  disease.  Asafetida  in  full  doses  is 
said  to  kill  the  worm. 

6.      OTHER   NEMATODES 

Filariae. — Among  less  important  filarian  worms  parasitic  in  man  the  fol- 
lowing may  be  mentioned :  Filaria  volvulus  occurs  on  the  West  Coast  of  Africa. 
It  causes  masses  in  the  axillae  which  are  easily  removed.  F.  immitis — ^the 
common  F.  sanguinis  of  the  dog — of  which  Bowlby  described  two  cases  in 
man.  In  one  case  with  haematuria  female  worms  were  found  in  the  portal 
vein,  and  the  ova  were  present  in  the  thickened  bladder  wall  and  in  the  ureters. 
F.  equina  has  rarely  infected  man. 

Trichocephaliasis. — Tricliuris  tricliiura  (whipworm)  is  not  infrequently 
found  in  the  caecum  and  large  intestine  of  man.  It  measures  from  4  to  5 
cm.  in  length,  the  male  being  somewhat  shorter  than  the  female.  The  worm 
is  readily  recognized  by  the  remarkable  difference  between  the  anterior  and 
posterior  portions.  The  former,  which  forms  at  least  three-fifths  of  the 
body,  is  extremely  thin  and  hair-like  in  contrast  to  the  thick  hinder  por- 
tion of  the  body,  which  in  the  female  is  conical  and  pointed,  and  in  the  male 


PARASITIC  AEACH^IDA  AND  TICKS  315 

more  obtuse  and  usually  rolled  like  a  spring.  The  eggs  are  oval,  lemon- 
shaped,  0.05  mm.  in  length,  and  provided  with  a  button-like  projection. 

The  number  of  the  worms  found  is  variable,  as  many  as  a  thousand  having 
been  counted.  It  is  a  widely  spread  parasite.  In  parts  of  Europe  it  occurs 
in  from  10  to  30  per  cent,  of  all  bodies  examined,  but  in  tlie  United  States  it 
is  not  so  common.  In  285  West  Indian  workers  at  Panama  Darling  found 
46  per  cent,  infected.  It  is  possible,  he  thinks,  that  these  parasites  play  a 
role  in  amoebic  dysentery,  the  lesions  of  which  begin  at  the  exact  location  of 
the  points  of  their  attachment.  The  whipworm  rarely  causes  symptoms. 
French  and  Boycott  found  ova  in  40  of  500  Guy's  Hospital  patients.  They 
found  no  etiological  relationship  of  the  parasite  to  appendicitis.  Several 
cases  have  been  reported  in  which  profound  ansemia  has  occurred  in  connection 
with  this  parasite,  usually  with  diarrhoea.  Enormous  numbers  may  be  pres- 
ent, as  in  Eudolph's  case,  without  producing  any  symptoms. 

The  diagnosis  is  readily  made  by  the  examination  of  the  faeces,  which 
contain  the  characteristic  lemon-shaped,  hard,  dark-brown  eggs. 

Bioctophyme  renale  (Eustrongylus  gigas)  .—This  enormous  nematode,  the 
male  of  which  measures  about  a  foot  in  length  and  the  female  about  three 
feet,  occurs  in  many  animals  and  has  occasionally  been  found  in  man.  It  is 
usually  found  in  the  renal  region  and  may  entirely  destroy  the  kidney. 

Anguillula  aceti. — The  Anguillula  aceti,  or  vinegar  eel,  is  sometimes  pres- 
ent in  urine  (in  one  case  it  is  said  from  the  bladder).  It  is  probably  a  con- 
tamination from  a  dirty  bottle  in  which  the  urine  is  collected. 

Strongyloides  stercoralis. — The  parasite  was  discovered  in  1876  by  JSTor- 
mand,  and  was  formerly  described  as  Anguillula  intestinalis.  It  is  a  common 
parasite  in  tropical  diarrhoea,  particularly  in  Cochin  China.  It  is  found  in 
about  3  per  cent,  of  the  medical  patients  in  the  Isthmus  of  Panama,  and  in 
from  20  to  30  per  cent,  of  the  patients  in  the  insane  division.  When  in  large 
numbers  they  cause  diarrhoea,  but  Darling  concludes  that  they  are  not  the 
cause  of  severe  diarrhoea,  though  they  may  produce  moderate  anaemia.  The 
mother  worm  burrows  in  the  mucous  membrane  and  deposits  ova.  The  para- 
site is  found  in  the  upper  parts  of  the  small  intestines.  They  are  met  with 
occasionally  in  the  temperate  regions.  Three  cases  were  reported  from  the 
Hopkins  clinic  by  Thayer.     Thymol  and  sulphur  are  useful  in  treatment. 

Acanthocephali  {Thorn-headed  ^Yorms). — The  Gigantorhynchus  or  Echi- 
norhynchus  gigas  is  a  common  parasite  in  the  intestine  of  the  hog  and  attains 
a  large  size.  The  larvae  develop  in  cockchafer  grubs.  The  American  inter- 
mediate host  is  the  June  bug  (Stiles).  A  case  of  E ciiinorhynchus  monili- 
formis has  been  described  in  Italy  by  Grassi  and  Calandruccio. 


IV.     PARASITIC  ARACHNIDA  AND  TICKS 

Pentastomes. — 1.  Lingdatdla  rhinaria  (Pentasioma  tanioides)  has  a 
somewhat  lancet-shaped  body,  the  female  being  from  3  to  4  inches  in  length, 
the  male  about  an  inch  in  length.  The  body  is  tapering  and  marked  by 
numerous  rings.  The  adult  worm  infests  the  frontal  sinuses  and  nostrils 
of  the  dog,  more  rarely  of  the  horse.  The  larval  form,  known  as  Linguatula 
serrata   (Pentastomum   denticMlatum) ,  is  seen  in  the  internal  organs,  par- 


316  SPECIFIC  INFECTIOUS  DISEASES 

ticularly  the  liver,  but  lias  also  been  found  in  the  kidney.  The  adult  worm 
has  been  found  in  the  nostril  of  man,  but  is  very  rare  and  seldom  occasions 
any  inconvenience.  The  larvae  are  by  no  means  uncommon,  particularly  in 
parts  of  Germany.  The  parasite  is  very  rare.  Flint  refers  to  a  Missouri 
case  in  which  from  75  to  100  of  the  parasites  were  expectorated.  The  liver 
was  enlarged  and  the  parasites  probably  occupied  this  region. 

2.  The  PoROCEPHALUS  ARMiLLATUS  (Peiitastoinum  constrictum)  has  the 
length  of  half  an  inch,  with  twenty-three  rings  on  the  abdomen.  It  is  found 
in  the  Congo  district  and  in  parts  of  Asia.  The  larvae,  found  in  cysts  in  the 
lungs  and  liver,  cause  disease  as  they  wander.  The  adult  form  lives  in  the 
nasal  cavities  and  lungs  of  pythons  and  other  snakes  and  man  is  infected 
probably  through  the  drinking  water. 

Demodex  ( Acarus)  f olliculorum  (var.  hominis) . — A  minute  parasite,  from 
0.3  mm.  to  0.4  nun.  in  length,  which  lives  in  the  sebaceous  follicles,  par- 
ticularly of  the  face.  It  is  doubtful  whether  it  produces  any  symptoms.  Pos- 
sibly when  in  large  numbers  they  may  excite  inflammation  of  the  follicles, 
leading  to  acne. 

Sarcoptes  (Acarus)  scabiei  (ItcJi  Insect). — This  is  the  most  important 
of  the  arachnid  parasites.  The  male  is  0.23  mm.  in  length  and  0.19  mm.  in 
breadth;  the  female  is  0.45  mm.  in  length  and  0.35  mm.  in  width.  The  female 
can  be  seen  readily  with  the  naked  eye  and  has  a  pearly-white  color.  It  is  not 
so  common  in  the  United  States  and  Canada  as  in  Europe. 

The  insect  lives  in  a  small  burrow,  about  1  cm.  in  length,  which  it  makes 
for  itself  in  the  epidermis.  At  the  end  of  this  burrow  the  female  lives. 
The  male  is  seldom  found.  The  chief  seat  of  the  parasite  is  in  the  folds 
where  the  skin  is  most  delicate,  as  in  the  web  between  the  fingers  and  toes, 
the  backs  of  the  hands,  the  axilla,  and  the  front  of  the  abdomen.  The  head 
and  face  are  rarely  involved.  The  lesions  which  result  from  the  presence 
of  the  itch  insect  are  very  numerous  and  result  largely  from  the  irritation 
of  the  scratching.  The  commonest  is  a  papular  and  vesicular  rash,  or,  in 
children,  an  ecthymatous  eruption.  The  irritation  and  pustulation  which 
follow  the  scratching  may  completely  destroy  the  burrows,  but  in  typical 
cases  there  is  rarely  doubt  as  to  the  diagnosis. 

The  treatment  is  sim|)le.  It  should  consist  of  warm  baths  with  a  thor- 
ough use  of  a  soft  soap,  after  which  the  skin  should  be  anointed  with  sulphur 
ointment,  which  in  the  case  of  children  should  be  diluted.  An  ointment  of 
naphthol  (drachm  to  the  ounce)  is  very  efficacious. 

Leptus  autumnalis  {Harvest  Bug). — This  reddish-colored  parasite,  about 
half  a  millimetre  in  size,  is  often  found  in  large  numbers  in  fields  and  in 
gardens.  They  attach  themselves  to  animals  and  man  with  their  sharp 
proboscides,  and  the  booklets  of  their  legs  produce  a  great  deal  of  irritation. 
They  are  most  frequently  found  on  the  legs.  They  are  readily  destroyed  by 
sulphur  ointment  or  corrosive-sublimate  lotions. 

Ixodiasis  {Ticl:-fever). — In  South  Africa,  particularly  in  the  western 
provinces  of  the  Uganda  Protectorate,  the  western  districts  of  German  East 
Africa  and  the  eastern  regions  of  the  Congo  Free  State,  there  is  a  disease 
known  by  this  name,  believed  to  be  transmitted  by  a  tick— the  Ornifhodorus 
or  Argas  moubata.    The  ticks  live  in  old  houses,  and  their  habits  are  very  much 


PAEASITIC  INSECTS  317 

like  those  of  the  common  bedbug.  This  tick  transmits  the  Spirochwia  duttoni, 
the  cause  of  the  African  form  of  relapsing  fever. 

The  Dermacentor  occidenialis  is  present  in  the  Northwestern  States  from 
California  to  Montana.  The  bites  may  cause  severe  lymphangitis.  It  appears 
to  be  the  medium  of  transmission  of  the  Rocky  Mountain  spotted  fever. 

In  Arizona  and  other  parts  of  the  Southwestern  States  a  tick — Ormtho- 
dorus  megnini — is  occasionally  found  in  the  ear  and  in  the  nose,  causing 
suppuration  and  intense  suffering.  Several  other  varieties  of  ticks  are  occa- 
sionally found  on  man — rthe  Ixodes  ricinus  and  the  Dermacentor  americanus, 
which  are  met  with  in  horses  and  oxen. 

Tich  paralysis. — In  connection  with  the  bites  of  ticks  of  the  genus  Ixodes 
and  the  genus  Dermacentor  a  flaccid  paralysis  of  the  legs  has  been  described, 
particularly  in  British  Columbia,  Wyoming,  Montana,  and  possibly  in  Aus- 
tralia. Children  are  usually  affected,  and,  curiously  enough,  if  the  tick  is 
found  and  removed  promptly,  the  child  gets  well  within  twenty-four  hours, 
but  if  not,  the  paralysis  may  spread  to  the  arms,  stupor  may  come  on,  and 
the  child  may  die  of  a  widespread  paralysis.  In  adults  sometimes  there  are 
pain,  an  erythematous  rash,  and  vertigo.  It  appears  to  be  a  toxic  effect  of 
the  parasite  and  not  an  infection.  , 


V.     PARASITIC  INSECTS 

Pediculi  (Plithiriasis ;  Pediculosis). — There  are  three  varieties: 

Pediculus  humanus  {Head  Louse). — The  male  is  from  1  to  1.5  mm.  in 
length  and  the  female  nearly  2  mm.  The  color  varies  somewhat  with  the  dif- 
ferent races  of  men.  It  is  light  gray  with  a  black  margin  in  the  European,  and 
very  much  darker  in  the  negro  and  Chinese.  They  are  oviparous,  and  the  fe- 
male lays  about  sixty  eggs,  which  mature  in  a  week.  The  ova  are  attached  to  the 
hairs,  and  are  known  popularly  as  nits.  The  symptoms  are  irritation  and 
itching  of  the  scalp.  When  numerous,  the  insects  may  excite  an  eczema  or  a 
pustular  dermatitis,  which  causes  crusts  and  scabs,  particularly  at  the  back 
of  the  head.  In  extreme  cases  the  hair  becomes  tangled  in  these  crusts  and 
matted  together,  forming  a  firm  mass  which  is  known  as  plica  polonica,  as  it 
was  not  infrequent  among  the  Jewish  inhabitants  of  Poland. 

Pediculus  corporis  (vestimentorum) . — This  is  considerably  larger  than 
the  head  louse.  It  lives  on  the  clothing,  and  in  sucking  the  blood  causes 
minute  hsemorrhagic  specks,  which  are  very  common  about  the  neck,  back, 
and  abdomen.  The  irritation  of  the  bites  may  cause  urticaria,  and  the 
scratching  is  usually  in  linear  lines.  In  long-standing  cases,  particularly 
in  old  dissipated  characters,  the  skin  becomes  rough  and  greatly  pigmented, 
a  condition  which  has  been  termed  the  vagabond's  disease — morbus  eirorum 
— which  may  be  mistaken  for  the  bronzing  of  Addison's  disease.  The  pig- 
mentation may  be  extreme  and  extend  to  the  face  and  buccal  mucosa. 

Phthirius  pubis  {crah  louse)  differs  somewhat  from  the  other  forms,  and 
is  found  in  the  parts  of  the  body  covered  with  short  hairs,  as  the  pubes ;  more 
rarely  the  axilla  and  eyebrows. 

The  iaclies  hleuatres,  maculce  cerulecB,  or  peliomata,  excited  by  the  irrita- 
tion of  pediculi,  are  peculiar  subcuticular  bluish  or  slate-colored  spots  from 


318  SPECIFIC  INFECTIOUS  DISEASES 

5  to  10  mm,  in  diameter  seen  about  the  abdomen  and  thighs,  particularly  in 
febrile  cases.  The  spots  are  more  marked  on  white  thin  skins.  They  are 
stains  caused  by  a  pigment  in  the  secretion  of  the  salivary  glands  of  the  louse. 

Treatment. — For  the  Pediculus  humanus,  when  the  condition  is  very  bad, 
the  hair  should  be  cut  short,  as  it  is  very  difficult  to  destroy  all  the  nits. 
Repeated  saturations  of  the  hair  in  coal-oil  or  in  turpentine  are  usually  effica- 
cious, or  with  lotions  of  carbolic  acid,  1  to  50.  The  application  of  a  mixture 
of  equal- parts  of  xylene,  alcohol  and  ether  is  useful.  Scrupulous  cleanliness 
and  Care  are  sufficient  to  prevent  recurrence.  In  the  case  of  the  Pediculus 
corporis,  the  clothing  should  be  placed  for  hours  in  a  disinfecting  oven.  To 
allay  the  itching  a  warm  bath  containing  4  or  5  ounces  of  bicarbonate  of  soda 
is  useful.  For  the  Plithiriu^  pubis  white  precipitate  or  ordinary  mercurial 
ointment  should  be  used,  and  the  parts  should  be  thorou.ghly  washed  two  or 
three  times  a  day  with  soft  soap  and  water. 

Cimex  lectularius  (Commo7i  Bedbugs). — The  tropical  and  sub-tropical 
variety  is  Cimex  rotundalius  (W.  S.  Patton).  It  lives  in  the  crevices  of  the 
bedstead  and  in  the  cracks  in  the  floor  and  in  the  walls.  It  is  nocturnal  in 
its  habits.  The  peculiar  odor  of  the  insect  is  caused  by  the  secretion  of  a 
special  gland.  The  parasite  possesses  a  long  proboscis,  with  which  it  sucks 
the  blood.  Individuals  differ  remarkably  in  the  reaction  to  the  bite  of  this 
insect;  some  are  not  disturbed  in  the  slightest  by  them,  in  others  the  irrita- 
tion causes  hypersemia  and  often  intense  urticaria.  Fumigation  with  sulphur 
or  scouring  with  corrosive-sublimate  solution  or  kerosene  destroys  them.  Iron 
bedsteads  should  be  used. 

Pulex  irritans  {Common  Flea). — The  male  is  from  2  to  2.5  mm.  in 
length,  the  female  from  3  to  4  mm.  The  flea  is  a  transient  parasite  on  man. 
The  bite  causes  a  circular  red  spot  of  hyperemia  in  the  centre  of  which  is  a 
little  speck  where  the  boring  apparatus  has  entered.  The  amount  of  irritation 
caused  by  the  bite  is  variable.  Many  persons  suffer  intensely  and  a  diffuse 
erythema  or  an  irritable  urticaria  develops;  others  suffer  no  inconvenience 
whatever. 

The  Pulex  penetrans  {sand-flea,  jigger)  is  found  in  tropical  countries, 
particularly  in  the  West  Indies  and  South  America.  It  is  much  smaller 
than  the  common  flea,  and  not  only  penetrates  the  skin,  but  burrows  and 
produces  an  inflammation  with  pustular  or  vesicular  swelling.  It  most  fre- 
quently attacks  the  feet.  It  is  readily  removed  with  a  needle.  Where  they 
exist  in  large  numbers  the  essential  oils  are  used  on  the  feet  as  a  preventive. 


VI.     PARASITIC  FLIES 

{Myiasis,  Myiasis) 

The  accidental  invasion  of  the  body  cavities  and  of  the  skin  by  the  larvae 
of  the  diptera  is  known  as  myiasis. 

The  larvae  of  the  Compsomyia  macellaria,  the  so-called  screw-worm,  have 
been  found  in  the  nose,  in  wounds,  and  in  the  vagina  after  delivery.  They  can 
be  removed  readily  with  forceps;  if  there  is  any  difficulty,  thorough  cleansing 
and  the  application  of  an  antiseptic  bandage  are  sufficient  to  kill  them.     The 


PARASITIC  FLIES  319 

ova  of  tlie  blue-bottle  fly  may  be  deposited  iu  the  nostrils,  the  ears,  or  the  con- 
junctiva— the  myiasis  narium,  aurium,  conjunctivge.  This  invasion  rarely 
takes  place  unless  these  regions  are  the  seat  of  disease.  In  the  nose  and 
in  the  ear  the  larva  may  cause  serious  inflammation.  Even  the  urethra  has 
not  been  spared  in  these  dipterous  invasions. 

Gastro-intestinal  myiasis  may  result  from  the  swallowing  of  the  larvae  of 
the  common  house-fly  or  of  species  of  the  genus  A^ithomyia.  There  are  many 
cases  on  record  in  which  the  larvae  of  the  Musca  domestica  have  been  dis- 
charged by  vomiting.  Instances  in  which  dipterous  larvas  have  been  passed 
in  the  faeces  are  less  common.  Finlayson,  of  Glasgow,  has  reported  an  inter- 
esting case  in  a  physician,  who,  after  protracted  constipation  and  pain  in 
the  back  and  sides,  passed  large  numbers  of  the  larvae  of  the  flower-fly — • 
Antliomyia  canicularis.  Among  other  forms  of  larvae  or  gentles,  as  they  are 
sometimes  called,  which  have  been  found  in  the  faeces  are  those  of  the  com- 
mon house-fly,  the  blue-bottle  fly,  and  the  Tecliomyza  fusca.  The  larvae  of 
other  insects  are  extremely  rare.  It  is  stated  that  the  caterpillar  of  the  taby 
moth  has  been  found  in  the  faeces. 

A  specimen  of  the  Ilomalomyia  scalaris,  one  of  the  privy  flies,  was  sent 
by  Dr.  Hartin,  of  Kaslo  City,  British  Columbia,  the  larvae  of  which  were 
passed  in  large  numbers  in  the  stools  of  a  man  aged  twenty-four,  a  native  of 
Louisiana.  They  were  present  in  the  stools  from  May  1  to  July  15,  1897. 
There  are  cases  in  which  the  larvae  have  been  passed  for  years. 

Although  no  grave  results  necessarily  follow  the  invasion  of  the  alimen- 
tary tract  by  these  larvae,  yet  they  may  be  the  cause  of  serious  intestinal  ulcer- 
ation manifesting  itself  by  a  dysenteric  disease  with  fatal  result.  Cockayne, 
who  studied  the  question,  states  that  there  are  four  deaths  on  record. 

Cutaneous  Myiasis. — The  most  common  form  is  that  in  which  an  external 
wound  becomes  "living,"  as  it  is  called.  This  is  caused  by  the  larvae  of  either 
the  blue-bottle  or  the  common  flesh-fly.  The  skin  may  also  be  infected  by 
the  larvae  of  the  Musca  vomitoria',  but  more  commonly  by  the  bot-flies  of  the 
ox  and  sheep  which  occasionally  attack  man.  This  is  rare  in  temperate  cli- 
mates. Matas  described  a  case  in  which  oestrus  larvae  were  found  in  the  gluteal* 
region.  In  parts  of  Central  America  the  eggs  of  another  bot-fly,  the  Derma- 
iohia,  are  not  infrequently  deposited  in  the  skin  and  produce  a  swelling  very 
like  the  ordinary  boil. 

Dermamyiasis  linearis  migrans  cestrosa  is  a  remarkable  cutaneous  condi- 
tion, observed  particularly  in  Russia  and  occasionally  in  other  countries,  in 
which  the  larva  of  Gastropliilus  equi  (Samson),  the  horse  bot-fly,  makes  a 
slightly  raised  pale  red  "line"  which  travels  over  the  body  surface,  sometimes 
with  great  rapidity.  It  has  been  referred  to  as  Larva  migrans  and  as  Creep- 
ing Eruption.     (See  Hamburger,  Journal  of  Cutaneous  Diseases,  1904.) 

In  Africa  the  larvae  of  the  Cayor  fly  are  not  uncommonly  found  beneath 
the  skin  in  little  boils.  In  the  Congo  region  Dutton,  Todd,  and  Christy 
found  a  troublesome  blood-sucking  dipterous  larva,  known  as  the  floor  mag- 
got, the  fly  of  which  is  the  Anc]im,eromyia  luteola. 

Phlebotomous  Fever. — In  Herzegovina,  Malta  and  Crete  and  other  parts 
of  the  Mediterranean  there  is  a  fever  of  two  or  three  days'  duration,  caused 
by  the  bite  of  the  sand-fly,  Phlehotomus  papatasii.  The  manifestations  are 
those  of  fever  alone,  and  may  be  mistaken  for  abortive  typhoid,  febricula 


320  SPECIFIC  I^^FECTIOUS  DISEASES 

or  mild  Malta  fever.  The  disease  is  known  as  pappataci  fever  and  sand  fly 
fever.  The  experiments  of  Doerr  and  of  Birt  show  that  the  disease  is  readily 
caused  by  the  bite  of  infected  sand-flies. 

Caterpillar  Rash. — In  some  districts  in  Europe  the  hairs  of  the  proces- 
sion caterpillar,  particularly  of  the  species  Cnethocampa,  cause  an  intense 
urticaria,  the  so-called  TJ.  ep  ids  mica:  There  are  districts  in  Switzerland 
which  have  been  rendered  uninhabitable  in  consequence  of  the  skin  rashes 
caused  by  the  caterpillars.  Of  late  years  in  Xew  England  and  some  other 
parts  of  the  United  States  the  caterpillar  of  the  brown-tailed  moth  has  caused 
much  discomfort.  The  hairs  are  widely  distributed  by  the  wind,  and  the 
barbs  are  so  arranged  that  they  readily  work  into  the  skin.  "Wliole  families 
have  been  affected  by  an  intense  eruption  which  has  been  mistaken  for  that  of 
small-pox.  In  England,  Thresh  called  attention  to  the  frequency  of  these 
caterpillar  rashes  due  to  the  yellow-tailed  moth,  Portliesia  similis. 

Harvest  Rash  (Erythemu  Autumnale). — In  parts  of  England  during  the 
autumn  many  people  are  attacked  by  the  harvest  bug  or  harvesters,  which 
may  cause  a  very  obstinate  and  distressing  malady.  Usually  attributed  to 
the  harvest  spider,  it  is  in  reality  caused  by  a  mite,  parasitic  upon  it,  the 
hexapod  larva  of  the  silky  trombidian.  It  is  so  small  as  to  be  scarcely  visible 
and  is  brick-red  in  color.  They  chiefly  attack  persons  with  delicate  skins 
on  the  ankles  and  legs,  but  they  may  also  attack  the  arms  and  the  neck.  The 
mite  attaches  itself  to  the  skin  by  its  claws,  sucks  the  blood,  and  the  swollen 
red  abdomen  may  sometimes  be  seen  as  a  bright-red  dot.  A  papulo-vesicular, 
sometimes  a  pustular,  eruption  with  an  intolerable  itching  is  caused  by  it. 
So  intense  may  the  eruption  be,  with  perhaps  an  entire  family  attacked  at 
once,  that  suspicion  of  poisoning  may  be  aroused.  The  parasite  is  readily 
killed  by  benzine. 


E    INFECTIOUS  DISEASES  OF  DOUBTFUL  OE  UNKNOWN 

ETIOLOGY 

I.     SMALL-POX  (Variola) 

Definition. — An  acute  infectious  disease  characterized  by  a  cutaneous  erup- 
tion which  passes  through  the  stages  of  papule,  vesicle,  pustule,  and  crust. 

History. — The  existence  of  the  disease  in  ancient  Egypt  is  suggested  by 
the  eruption  on  the  skin  of  a  mummy  of  the  20th  dynasty — 1,200  to  1,100 
B.  C.  (Riiifer  and  Ferguson).  The  disease  existed  in  China  many  centuries 
before  Christ.  The  pesta  magna  described  by  Galen  (of  which  Marcus  kwre- 
lius  died)  is  believed  to  have  been  small-pox.  In  the  sixth  century  it  pre- 
vailed, and  subsequently,  at  the  time  of  the  Crusades,  became  widespread. 
It  was  brought  to  America  by  the  Spaniards  early  in  the  sixteenth  century. 
The  first  accurate  account  was  given  by  Ehazes,  an  Arabian  physician  who 
lived  in  the  ninth  century,  and  whose  admirable  description  is  available  in 
Greenhill's  translation  for  the  Svdenham  Society.  In  the  seventeenth  cen- 
tury the  illustrious  Sydenham  differentiated  measles  from'  small-pox.  Special 
events  in  the  history  of  the  disease  are  the  introduction  of  inoculation  into 


SMALL-POX  331 

Europe,  by  Lady  Mary  Wortley  Montagu,  in  1718,  and  the  discovery  of  vacci- 
nation by  Jenner,  in  1796. 

Etiology. — Small-pox  is  one  of  the  most  virulent  of  contagious  diseases, 
and  persons  exposed,  if  unprotected  by  vaccination,  are  almost  invariably 
attacked.  Instances  of  natural  immunity  are  rare.  It  is  said  that  Diemer- 
broeck,  a  celeln-ated  Utrecht  professor  in  the  seventeenth  century,  vas  not 
only  himself  exempt,  but  likewise  many  members  of  his  family.  An  attack 
may  not  protect  for  life.  There  are  undoubted  cases  of  a  second,  reputed 
instances,  indeed,  of  a  third  attack.  Louis  XV  of  France  died  of  a  second 
attack  of  small-pox. 

Age. — Small-pox  is  common  at  all  ages,  but  is  particularly  fatal  to  young 
children.  Of  3,164  deaths  in  the  Montreal  epidemic  of  1885-'86,  2,717  were 
of  children  under  ten  years  of  age.  The  fetus  in  utero  may  be  attacked,  but 
only  if  the  mother  herself  is  the  subject  of  the  disease.  The  child  may  be 
born  with  the  rash  out  or  with  the  scars.  In  the  case  of  twins,  only  one  may 
be  attacked;  Kaltenbach  records  an  instance  of  triplets,  only  two  of  which 
were  affected  (Comby).  Children  born  in  a  small-pox  hospital,  if  vaccinated 
immediately,  may  escape  the  disease;  usually,  however,  they  die  early. 

Sex. — Males  and  females  are  equally  affected. 

Eace. — Among  aboriginal  races  small-pox  is  terribly  fatal.  When  the 
disease  was  first  introduced  into  America  the  Mexicans  died  by  thousands, 
and  the  ISTorth  American  Indians  have  also  been  frequently  decimated  by 
this  plague.  It  is  stated  that  the  negro  is  especially  susceptible,  and  the 
mortality  is  greater — about  42  per  cent,  in  the  black,  against  29  per  cent,  in 
the  white  (W.  M.  Welch). 

It  is  claimed  that  isolation  hospitals  increase  the  incidence  of  the  disease 
in  a  locality.  J.  Glaister,  who  considered  the  question  very  carefully,  con- 
cludes that  as  a  centre  of  traffic  such  an  institution,  through  the  channels  of 
human  intercourse,  naturally  favors  the  spread  of  the  disease  locally,  but 
decides  against  its  aerial  conveyance,  in  spite  of  the  strong  evidence. 

The  disease  smoulders  here  and  there  and  when  conditions  are  favorable 
becomes  epidemic.  This  was  well  illustrated  by  the  Montreal  outbreak  of 
1885.  For  several  years  there  had  been  no  small-pox  in  the  city,  and  a  large 
unprotected  population  grew  up  among  the  French-Canadians,  many  of  whom 
were  opposed  to  vaccination.  On  February  28  a  Pullman-car  conductor,  who 
had  traveled  from  Chicago,  was  admitted  into  the  Hotel-Dieu,  the  civic  small- 
pox hospital  being  closed  at  the  time.  Isolation  was  not  carried  out,  and  on 
the  1st  of  April  a  servant  in  the  hospital  died  of  small-pox.  Following  her 
decease,  the  authorities  of  the  hospital  dismissed  all  patients  presenting  no 
symptoms  of  contagion  who  could  go  home.  The  disease  spread  like  fire  in 
dry  grass,  and  in  nine  months  3,164  persons  died  in  the  city  of  small-pox. 

Variations  in  the  Virulence  of  Epidemics. — Sydenham  states  that 
"small-pox  also  has  its  peculiar  kinds,  which  take  one  form  during  one  series 
of  years,  and  another  during  another'^;  and  not  only  does  what  he  called  the 
epidemic  constitution  vary  greatly,  but  one  sometimes  sees  the  most  extra- 
ordinary variations  in  the  intensity  of  the  disease  in  members  of  a  family 
all  exposed  to  the  same  infection.  A  striking  illustration  of  this  variability 
has  been  given  in  recent  epidemics,  which  have  been  of  so  mild  a  character 
that  in  many  localities  it  has  been  mistaken  for  chicken-pox ;  in  others,  par- 


322  SPECIFIC  INFECTIOUS  DISEASES 

ticularly  in  the  United  States,  the  belief  prevailed  that  a  new  disease  had 
arisen,  to  which  the  name  "Cuban  itch"  or  "Philippine  itch"  was  given. 
Very  often  a  correct  diagnosis  is  not  reached  until  a  fatal  case  has  occurred. 
A  small  outbreak  occurred  in  one  of  the  Hopkins  wards  for  colored  patients, 
which  we  mistook  at  first  for  chicken-pox.  The  same  peculiarities  have  been 
observed. in  the  Leicester,  Nottingham,  and  Cambridge  outbreaks.  Even  in 
unvaccinated  children  the  disease  has  been  exceedingly  mild.  Some  of  the 
Leicester  cases  had  only  a  few  pocks  (Allan  Warner) ;  but  this  is  an  old  story 
in  the  history  of  the  disease.  John  Mason  Good,  in  commenting  on  this  very 
point,  refers  to  the  great  variability  in  the  epidemics,  and  states  that  he  him- 
self as  a  child  of  six  (1770)  passed  through  small-pox  with  "scarcely  any 
disturbance  and  not  more  than  twenty  scattered  pustules" ! 

The  disease  described  in  some  Brazilian  states  as  Alastrin  amas,  or  varioloid 
varicella,  seen  also  in  the  West  Indies,  is  probably  mild  small-pox. 

Recent  Prevalence. — In  the  United  States  in  1917  there  were  204  deaths  in 
the  registration  area.  The  mild  type  of  the  disease  continues,  but  in  places 
there  have  been  virulent  outbreaks.  In  England  and  Wales  there  were  18 
deaths  from  the  disease  in  1916. 

ISTatuke  of  CoNTAGioisr.— Protozoon-like  bodies  were  described  in  the  skin 
lesions  by  Guarnieri — the  cytoryctes  va/riolce.  Councilman  and  his  colleagues 
describe  a  protozoon  with  a  double  cycle  and  cytoplasmic  stage,  with  small 
structureless  bodies  in  the  lower  layer  of  the  epithelial  cells.  Infection  occurs 
probably  by  the  nasal  secretion  and  sputum.  The  dried  scales  are  also  an 
important  element,  and  as  a  dust-like  powder  are  distributed  everywhere  in 
the  room  during  convalescence,  becoming  attached  to  clothing  and  various 
articles  of  furniture.  The  disease  is  probably  infectious  from  a  very  early 
stage,  though  it  has  not  been  determined  whether  the  contagion  is  active  be- 
fore the  eruption  develops.  The  poison  is  of  unusual  tenacity  and  clings  to 
infected  localities.  It  is  conveyed  by  persons  who  have  been  in  contact  with 
the  sick  and  by  fomites.  During  epidemics  it  is  no  doubt  widely  spread  in 
street-cars  and  public  conveyances.  An  unprotected  person  may  contract  a 
very  virulent  form  of  the  disease  from  a  patient  with  a  mild  attack. 

Morbid  Anatomy. — The  pustules  may  be  seen  upon  the  tongue  and  the 
buccal  mucosa,  and  on  the  palate ;  sometimes  also  in  the  pharynx  and  the 
upper  part  of  the  oesophagus.  In  exceptionally  rare  cases  the  rash  extends 
down  the  oesophagus  and  even  into  the  stomach.  Swelling  of  the  Peyer's 
follicles  is  not  uncommon;  the  pustules  have  been  seen  in  the  rectum. 

In  the  larynx  the  eruption  may  be  associated  with  a  fibrinous  exudate  and 
sometimes  with  oedema.  Occasionally  the  inflammation  penetrates  deeply 
and  involves  the  cartilages.'  In  the  trachea  and  bronchi  there  may  be  ulcera- 
tive erosions,  but  true  piock's,  such  as  are  seen  on  the  skin,  do  not  occur. 

The  heart   occasionally   shows   myocardial   changes,   parenchymatous   and 
fatty;  endocarditis   and  pericarditis  are  uncommon.     French  writers   have 
described  an  endarteritis  of  the  coronary  vessels.     The  spleen  is  markedly  en- 
larged.    Apart  from  the  cloudy  swelling  and  areas  of  coagulation-necroais^  • 
lesions  of  the  kidneys  are  not  common.     iSTephritis  may  occur.  ■.■  :; 

In  the  hasmorrhagic   form   extravasations   are  found   on  the  serous- ;S(,nd' 
mucous  surfaces,  in  the  parenchyma  of   organs,  in  the  connective  tissiitesiK(" 
about  the  nerve-sheaths  and  in  the  muscles.    In  one  instance  the  entire  retrO**''-' 


SMALL-POX 


333 


peritoneal  tissue  was  infiltrated  with  a  large  coagulum,  and  there  were  also 
extensive  extravasations  in  the  course  of  the  thoracic  aorta.  Hsemorrhages  in 
the  bone-marrow  have  been  described.  The  spleen  is  firm  and  hard  in  hsemor- 
rhagic  small-pox.  In  these  rapidly  fatal  forms  the  liver  has  been  described 
as  fatty,  but  in  5  of  7  cases  it  was  of  normal  size,  dense,  and  firm. 

Symptoms. — Three  forms  of  small-pox  are  described,  but  they  only  repre- 
sent various  degrees  of  severity. 

(a)   Variola  vera;  (1)  Discrete,  (2)  Confluent. 

(&)  Variola  h(Bmorrhagica ;  (1)  Purpura  variolosa  or  black  small-pox; 
(2)  Hsemorrhagic  pustular  form,  variola  hsemorrhagica  pustulosa. 

(c)    Varioloid,  or  small-pox  modified  by  vaccination. 

(a)  Variola  Vera. — The  affection  may  be  conveniently  described  under 
various  stages:  Incubation. — "From  nine  to  fifteen  days;  oftenest  twelve." 
The  senior  author  saw  it  as  early  as  the  eighth  day  after  exposure,  and  there 


2         3         4         5 


7         8         9        10        11      12        13        14        15        16        17        18 


40.0' 


39.0 


38.0" 


37.0 


InitiB-l  Fever 

Eruption. 


Suppurative  Fever. 

Chart  IX. — True  Small-pox  (Striimpell). 


are  authenticated  instances  in  which  this  stage  has  been  prolonged  to  twenty 
days.    It  is  unusual  for  patients  to  complain  of  any  symptoms. 

Invasion. — In  adults  a  chill  and  in  children  a  convulsion  are  common 
initial  symptoms.  There  may  be  repeated  chills  within  the  first  twenty-four 
hours.  Intense  frontal  headache,  severe  lumbar  pains,  and  vomiting  are  very 
constant  features.  The  pains  in  the  back  and  in  the  limbs  are  more  severe 
in  the  initial  stage  of  this  than  of  any  other  eruptive  fever,  and  their  combi- 
nation with  headache  and  vomiting  is  so  suggestive  that  precautionary  meas- 
ures may  often  be  taken  several  days  before  the  eruption  appears.  The  tem- 
perature rises  quickly,  and  may  on  the  first  day  be  103°  or  104°.  The  pulse 
is  rapid  and  full,  not  often  dicrotic.  In  severe  cases  there  may  be  marked 
delirium,  particularly  if  the  fever  is  high.  The  patient  is  restless  and  dis- 
tressed, the  face  flushed,  and  the  eyes  bright  and  clear.  The  skin  is  usually 
dry,  though  occasionally  there  are  profuse  sweats.  One  cannot  judge  from 
the  initial  symptoms  whether  a  case  is  likely  to  be  discrete  or  confluent,  as 
convulsions,  severe  headache,  and  high  fever  may  precede  a  mild  attack. 

Initial  Rashes. — Two  forms  can  be  distinguished:  the  diffuse,  scarlatinal, 
and  the  macular  or  measly  form;  either  of  which  may  be  associated  with 
petechise  and  occupy  a  variable  extent  of  surface.    In  some  instances  they  are^ 


324  SPECIFIC  lA^FECTIOUS  DISEASES 

general,  but  as  a  rule  are  limited  either  to  the  lower  abdominal  areas,  to  the 
inner  surfaces  of  the  thighs,  and  to  the  lateral  thoracic  region,  or  to  the 
axillffi.  Occasionally  they  are  found  over  the  extensor  surfaces,  particularly 
in  the  neighborhood  of  the  knees  and  elbows.  These  rashes,  usually  purpuric, 
are  often  associated  with  an  erj-thematous  or  erysipelatous  blush.  The  scarla- 
tinal rash  may  come  out  as  early  as  the  second  day,  and  be  as  diffuse  and 
vivid  as  in  a  true  scarlatina.  The  measly  rash  may  also  be  diffuse  and  resemble 
closely  that  of  measles.  Urticaria  is  seen  only  occasionally.  It  was  present 
once  in  the  Montreal  cases.  The  initial  rashes  are  more  abundant  in  some 
epidemics  than  in  others.    They  occur  in  from  10  to  16  per  cent,  of  cases. 

Eruption. —  (1)  In  the  discrete  form,  usually  on  the  fourth  day.  macules 
appear  on  the  forehead,  preceded  sometimes  by  an  erythematous  flush,  and  on 
the  anterior  surfaces  of  the  wrists.  Within  the  first  twenty-four  hours  from 
their  appearance  they  occur  on  other  parts  of  the  face  and  on  the  extremities, 
and  a  few  are  seen  on  the  trunk.  The  spots  are  from  2-3  millimetres  m 
diameter,  of  a  bright  red  color,  and  disappear  completely  on  pressure.  As  the 
rash  comes  out  the  temperature  falls,  the  general  symptoms  subside,  and  the 
patient  feels  comfortable.  On  the  fifth  or  sixth  day  the  papules  change  into 
vesicles  ynih  clear  summits.  Each  one  is  elevated,  circular,  and  presents  a 
little  depression  or  umbilication  in  the  centre.  About  the  eighth  day  the 
vesicles  change  into  pustules,  the  umbilication  disappears,  the  flat  top  assumes 
a  globular  form  and  becomes  grayish-yellow  in  color,  owing  to  the  contained 
pus.  There  is  an  areola  of  injection  about  the  pustules  and  the  skin  between 
them  is  swollen.  This  maturation  first  takes  place  on  the  face,  and  follows 
the  order  of  the  appearance  of  the  eruption.  The  temperature  now  rises — 
secondary  fever — and  the  general  symptoms  r'eturn.  The  swelling  about  the 
pustules "^is  attended  with  a  good  deal  of  tension  and  pain  in  the  face;  the 
eyelids  become  swollen  and  closed.  In  the  discrete  form  the  temperature  of 
maturation  does  not  usually  remain  high  for  more  than  twenty-four  or  twenty- 
six  hours,  so  that  on  the  tenth  or  eleventh  day  the  fever  disappears  and  the 
stao-e  of  convalescence  begins.  The  pustules  rapidly  dry,  first  on  the  face 
and  then  on  the  other  parts,  and  by  the  fourteenth  or  fifteenth  day  desquama- 
tion mav  be  far  advanced  on  the  face.  The  march  and  distribution  of  the 
rash  are  often  most  characteristic.  The  abdomen  and  groins  and  the  legs 
are  the  parts  least  affected.  The  rash  is  often  copious  on  the  upper  part  of 
the  back,  scanty  on  the  lower.  A'esicles  in  the  mouth,  pharynx,  and  larynx 
cause  soreness  and  swelling  in  these  parts,  with  loss  of  voice.  "Wliether  pitting 
takes  place  depends  a  good  deal  upon  the  severity  of  the  disease.  In  a  majority 
of  cases  Sydenham's  statement  holds  good,  that  '*'it  is  very  rarely  the  case 
that  the  distinct  small-pox  leaves  its  mark."  The  odor  of  a  small-pox  patient 
is  very  distinctive  even  in  the  early  stages,  and  has  been  a  help  in  the  diagnosis 
of  a  doubtful  case. 

(2)  The  Confluent  Form. — AVith  the  same  initial  symptoms,  though  usu- 
allv  of  .gi-eater  severity,  the  rash  appears  .on  the  fourth,  or,  according  to  Syden- 
ham, on  the  third  day.  The  more  the  eruption  shows  itself  before  the  fourth 
day  the  more  sure  it  is  to  become  confluent  (Sydenham).  The  papules  at 
first  may  be  isolated,  and  it  is  only  later  in  the  stage  of  maturation  that  the 
eruption  is  confluent.  But  in  severer  cases  the  skin  is  swollen  and  hypera?raic 
and  the  papules  are  very  close  together.     On   the  feet  and  hands,   too,  the 


SMALL-POX  325 

papules  are  thickly  set;  more  scattered  on  the  limbs;  and  quite  discrete  on 
the  trunk.  With  the  appearance  of  the  eruption  the  symptoms  subside  and 
the  fever  remits,  but  not  to  the  same  extent  as  in  the  discrete  form.  Oc- 
casionally the  temperature  falls  to  normal  and  the  patient  may  be  very  com- 
fortable. Then,  usually  on  the  eighth  day,  the  fever  again  rises,  the  vesicles 
change  to  pustules,  the  hypergemia  becomes  intense,  the  swelling  of  the  face 
and  hands  increases,  and  by  the  tenth  day  the  pustules  have  fully  maturated, 
many  of  them  have  coalesced,  and  the  entire  skin  of  the  head  and  extremities 
is  a  superficial  abscess.  The  fever  rises  to  103°  or  105°,  the  pulse  is  from  110 
to  120,  and  there  is  often  delirium.  As  pointed  out  by  Sydenham,  salivation 
in  adults  and  diarrhoea  in  children  are  common  symptoms  of  this  stage. 
There  is  usually  much  thirst.  The  eruption  may  also  be  present  in  the  mouth, 
and  usually  the  pharynx  and  larynx  are  involved  and  the  voice  is  husky.  Great 
swelling  of  the  cervical  lymphatic  glands  occurs.  At  this  stage  the  patient 
presents  a  terrible  picture,  unequaled  in  any  other  disease  and  one  which 
fully  justifies  the  horror  and  fright  with  which  small-pox  is  associated  in  the 
public  mind.  Even  when  the  rash  is  confluent  on  the  face,  hands,  and  feet, 
the  pustules  remain  discrete  on  the  trunk.  The  danger,  as  pointed  out  by 
Sydenham,  is  in  proportion  to  the  number  upon  the  face.  "If  upon  the  face 
they  are  as  thick  as  sand,  it  is  no  advantage  to  have  them  few  and  far  between 
on  the  rest  of  the  body."  In  fatal  cases  by  the  tenth  or  eleventh  day  the 
pulse  gets  feebler  and  more  rapid,  the  delirium  is  marked,  there  is  subsultus, 
sometimes  diarrhoea,  and  with  these  symptoms  the  patient  dies.  In  other 
instances  between  the  eighth  and  eleventh  day  hsemorrhagic  features  occur. 
"WHien  recovery  takes  place,  the  patient  enters  on  the  eleventh  or  twelfth  day  the 
period  of  desiccation. 

Desiccation. — The  pustules  break  and  the  pus  exudes  or  they  dry  and 
form  crusts.  Throughout  the  third  week  the  desiccation  proceeds  and  in 
cases  of  moderate  severity  the  secondary  fever  subsides;  but  in  others  it  may 
persist  until  the  fourth  week.  The  crusts  in  confluent  small-pox  adhere  for 
a  long  time  and  the  process  of  scarring  may  take  three  or  four  weeks.  On 
the  face  they  fall  off  singly,  but  the  tough  epidermis  of  the  hands  and  feet 
may  be  shed  entire. 

(h)  H.EMORRHAGIC  SMALL-POX  occurs  in  two  forms.  In  one,  the  pe- 
techial or  black  small-pox — purpura  variolosa — the  special  symptoms  appear 
early  and  death  follows  in  from  two  to  six  days.  In  the  other  form  the  case 
progresses  as  one  of  ordinary  variola,  and  in  the  vesicular  or  pustular  stage 
hemorrhages  take  place  into  the  pocks  or  from  the  mucous  membranes — 
variola  luemorrhagica  pustulosa. 

Purpura  variolosa  is  more  common  in  some  epidemics  than  in  others. 
It  is  less  frequent  in  children  than  in  adults.  Young  and  vigorous  persons  seem 
more  liable  to  this  form.  Men  are  more  frequently  affected  than  women; 
thus  in  one  series  there  were  21  males  and  only  6  females.  The  influence  of 
vaccination  is  shown  in  the  fact  that  of  the  cases  14  were  unvaccinated,  while 
not  one  of  the  13  who  had  scars  had  been  revaccinated.  The  illness  starts 
with  the  usual  symptoms,  but  with  more  intense  constitutional  disturbance. 
On  the  second  or  the  third  day  there  is  a  diffuse  hypergemic  rash,  particularly 
in  the  groins,  with  small  punctiform  hagmorrhages.  The  rash  extends,  licoomes 
more  distinctly  hsemorrhagic,  and  the  spots  increase  in  size.     Ecchymoses  ap- 


326  SPECIFIC  INFECTIOUS  DISEASES 

pear  on  the  conjunctivse,  and  as  early  as  the  third  day  there  may  be  haemor- 
rhages from  the  mucous  membranes.  Death  may  take  place  before  the  papules 
appear.  In  this  truly  terrible  affection  the  patient  may  present  a  frightful 
appearance.  The  skin  may  have  a  uniformly  purplish  hue  and  the  unfortu- 
nate victim  may  even  look  plum-colored.  The  face  is  swollen  and  large  con- 
junctival haemorrhages  with  the  deeply  sunken  cornese  give  a  ghastly  appear- 
ance. The  mind  may  remain  clear  to  the  end.  Death  occurs  from  the  third 
to  the  sixth  day;  thus  in  thirteen  of  the  series  it  took  place  between  these 
dates.  The  earliest  death  was  on  the  third  day  and  there  were  no  traces  of 
papules.  There  may  be  no  mucous  haemorrhages;  thus  in  one  case  of  a  most 
virulent  character  death  occurred  without  bleeding  early  on  the  fourth  day. 
Hsematuria  is  perhaps  most  common,  next  hgematemesis,  and  melsna  was 
noticed  in  a  third  of  the  cases.  Metrorrhagia  was  present  in  only  one  of  the 
six  females.  The  pulse  in  this  form  is  rapid  and  often  hard  and  small. 
The  respirations  are  greatly  increased  in  frequency  and  out  of  all  proportion 
to  the  intensity  of  the  fever. 

In  variola  fjustulosa  licemorrliagica  the  disease  progresses  as  a  severe  case, 
and  the  haemorrhages  do  not  occur  until  the  vesicular  or  pustular  stage.  The 
first  indication  is  haemorrhage  into  the  areolae  of  the  pocks,  and  later  the  matu- 
rated pustules  fill  with  blood.  The  earlier  the  hemorrhage  the  greater  is  the 
danger.  Bleeding  from  the  mucous  membranes  is  also  common  in  this  form, 
and  the  great  majority  of  the  cases  prove  fatal,  usually  on  the  seventh,  eighth, 
or  ninth  day,  but  a  few  cases  recover.  In  patients  with  the  discrete  form,  if 
allowed  to  get  up  early,  haemorrhage  may  take  place  into  the  pocks  on  the  legs. 

Leucocytes. — In  variola  vera  there  is  a  marked  leucocytosis,  12-16  thou- 
sand, about  the  eighth  day,  then  a  slight  decline  and  a  rise  again  about  the 
twelfth  or  fourteenth  day,  sometimes  to  18,000  or  20,000.  There  is  an  in- 
crease in  the  mononuclear  elements,  which  may  be  the  only  marked  feature  of 
the  mild  cases  (Magrath,  Brinckerhotf,  and  Bancroft). 

(c)  Varioloid. — This  term  is  applied  to  the  modified  form  which  affects 
persons  who  have  been  vaccinated.  It  may  set  in  with  abruptness  and  severity, 
the  temperature  reaching  103°.  More  commonly  it  is  in  every  respect  milder 
in  its  initial  symptoms,  though  the  headache  and  backache  may  be  very  dis- 
tressing. The  papules  appear  on  the  evening  of  the  third  or  on  the  fourth 
day.  They  are  few  in  number  and  may  be  confined  to  the  face  and  hands. 
The  fever  drops  at  once  and  the  patient  feels  perfectly  comfortable.  The 
vesiculation  and  maturation  of  the  pocks  take  place  rapidly,  and  there  is  no 
secocdary  fever.  There  is  rarely  any  scarring.  As  a  rule,  when  small-pox 
attacks  a  person  who  has  been  vaccinated  within  five  or  six  years  the  disease 
is  mild,  but  it  may  prove  severe^  even  fatal. 

Abortive  Types. — Eecent  epidemics  have  been  characterized  by  the  large 
number  of  mild  cases.  Even  in  unvaccinated  children  only  a  few  pustules 
may  appear,  and  the  disease  is  over  in  a  few  days.  Even  with  a  thickly  set 
eruption  the  vesicles  at  the  fifth  or  sixth  .day,  instead  of  filling,  dry  and  abort, 
forming  the  so-called  horn-,  crystalline-,  or  wart-pox.  Variola  sine  eruptione 
is  described.  It  seems  to  have  been  not  uncommon  in  the  recent  epidemics. 
Bancroft  observed  twelve  cases  in  the  Boston  outbreak,  all  among  physicians 
and  attendants.  The  symptoms  are  headache,  pain  in  the  back,  fever,  and 
vomiting.     As  already  mentioned,  the  pocks  may  be  very  scanty  and  easily 


SMALL-POX  337 

overlooked,  even  in  nnvaccinated  persons.  One  of  Bancroft's  cases  was  of 
special  interest — a  pregnant  woman  who  had  slight  symptoms  after  exposure, 
but  no  rash.     Her  child  showed  a  tj^pical  eruption  when  two  days  old. 

Complications. — Considering  the  severity  of  many  of  the  cases  and  the 
character  of  the  disease,  associated  with  multiple  foci  of  suppuration,  the 
complications  in  small-pox  are  remarkably  few. 

Laryngitis  is  serious  in  three  ways :  it  may  produce  a  fatal  oedema  of  the 
glottis;  it  is  liable  to  extend  and  involve  the  cartilages,  producing  necrosis; 
and  by  diminishing  the  sensibility  of  the  larynx  it  may  allow  irritating  par- 
ticles to  reach  the  lower  air-passages,  where  they  excite  bronchitis  or  broncho- 
pneumonia. Broncho-pneumonia  is  almost  invariably  present  in  fatal  cases. 
Lobar  pneumonia  is  rare.    Pleurisy  is  common  in  some  epidemics. 

The  cardiac  complications  are  also  rare.  In  the  height  of  the  fever  a 
systolic  murmur  at  the  apex  is  not  uncommon ;  but  endocarditis,  either  simple 
or  malignant,  is  rarely  met  with.  Pericarditis,  too,  is  very  uncommon.  Myo- 
carditis seems  to  be  more. frequent,  and  may  be  associated  with  endarteritis  of 
the  coronary  vessels. 

Of  complications  in  the  digestive  system,  parotitis  is  rare.  In  severe  cases 
there  is  extensive  pseudo-diphtheritic  angina.  Vomiting,  which  is  so  marked 
a  symptom  in  the  early  stage,  is  rarely  persistent.  Diarrhoea  is  not  uncom- 
mon, as  noted  by  Sydenham,  and  particularly  in  children. 

Albuminuria  is  frequent,  but  true  nephritis  is  rare.  Inflammation  of  the 
testes  and  of  the  ovaries  may  occur. 

Among  the  most  interesting  and  serious  complications  are  those  pertaining 
to  the  nervous  system.  In  children  convulsions  are  common.  In  adults  the 
delirium  of  the  early  stage  may  persist  and  become  violent,  and  finally  sub- 
side into  a  fatal  coma.  Post-febrile  insanity  is  occasionally  met  with  during 
convalescence,  and  very  rarely  epilepsy.  Many  of  the  old  writers  spoke  of 
paraplegia  in  connection  with  the  intense  backache  of  the  early  stage,  but  it  is 
probably  associated  with  the  severe  agonizing  lumbar  and  crural  pains  and  is 
not  a  true  paraplegia.  It  must  be  distinguished  from  the  form  occurring  in 
convalescence,  which  may  be  due  to  peripheral  neuritis  or  to  a  diffuse  myelitis 
(Westphal).  The  neuritis  may,  as  in  diphtheria,  involve  the  pharynx  alone, 
or  it  may  be  multiple.  Of  this  nature,  in  all  probability,  is  the  so-called 
pseudo-tabes,  or  ataxie  variolique.  Hemiplegia  and  aphasia  have  been  met 
with  in  a  few  instances,  the  result  of  encephalitis. 

Among  the  most  constant  and  troublesome  complications  are  those  in- 
volving the  skin.  During  convalescence  boils  are  very  frequent  and  may  be 
severe.  Acne  and  ecthyma  are  also  met  with.  Local  gangrene  in  various 
parts  may  occur.  A  remarkable  secondary  eruption  (recurrent  small-pox) 
occasionally  occurs  after  desquamation. 

Arthritis  may  occur,  usually  in  the  period  of  desquamation,  and  may  pass 
on  to  suppuration.     Acute  necrosis  of  the  bone  is  sometimes  met  with. 

Special  Senses. — The  eye  affections  which  were  formerly  so  common  and 
serious  are  not  now  so  frequent,  owing  to  the  care  which  is  given  to  keeping 
the  conjunctivae  clean.  A  cat_irrhal  and  purulent  conjunctivitis  is  common  in 
severe  cases.  The  secretions  cause  adhesions  of  the  eyelids,  and  unless  great 
care  is  taken  a  diffuse  keratitis  is  excited,  which  may  go  on  to  ulceration  and 


328  SPECIFIC  INFECTIOUS  DISEASES 

perforation.     Iritis  is  not  very  uncommon.     Otitis  media  may  result  from  an 
extension  of  the  disease  through  the  Eustachian  tubes. 

Prog-nosis. — In  unprotected  persons  small-pox  is  a  very  fatal  disease,  the 
death-rate  ranging  from  25  to  35  per  cent.  In  Japan  the  mortality  among 
unprotected  persons  has  been  even  higher.  In  the  recent  mild  epidemics  in 
the  United  States  the  mortality  has  been  very  slight,  often  less  than  1  per  cent. 
At  the  Municipal  Hospital,  Philadelphia,  of  2,831  cases  of  variola,  1,534 — 
i.  e.,  54.18  per  cent. — died,  while  of  2,169  cases  of  varioloid  only  28 — i.  e., 
1.29  per  cent. — died  (W.  M.  Welch).  Purpura  variolosa  is  invariably  fatal, 
and  a  majority  of  those  attacked  with  the  severer  confluent  forms  die.  The 
intemperate  and  debilitated  succumb  more  readily  to  the  disease.  As  Syden- 
ham observed,  the  danger  is  directly  proportionate  to  the  intensity  of  the 
disease  on  the  face  and  hands.  "When  the  fever  increases  after  the  appearance 
of  the  pustules,  it  is  a  bad  sign ;  but  if  it  is  lessened  on  their  appearance,  that 
is  a  good  sign"  (Ehazes).  A^ery  high  fever,  delirium  and  subsultus  are  symp- 
toms of  ill  omen.  The  disease  is  particularly  fatal  in  pregnant  women  and 
abortion  usually  takes  place.  It  is  not,  however,  uniformly  so,  and  severe 
cases  may  recover  after  miscarriage.  Moreover,  abortion  is  not  inevitable. 
Very  severe  pharyngitis  and  laryngitis  are  fatal  complications. 

Death  results  in  the  early  stage  from  the  action  of  the  poison  upon  the 
nervous  system.  In  the  later  stages  it  usually  occurs  about  the  eleventh  or 
twelfth  day,  at  the  height  of  the  eruption.  In  children,  and  occasionally  in 
adults,  the  laryngeal  and  pulmonary  complications  prove  fatal. 

Diagnosis. — During  an  epidemic  the  initial  chill,  the  headache  and  back- 
ache, and  the  vomiting  at  once  put  the  physician  on  his  guard. 

The  initial  rashes  may  lead  to  error.  The  scarlatinal  rash  ha.s  rarely  the 
extent  and  never  the  persistence  of  the  rash  in  true  scarlet  fever.  The  rash 
of  measles  has  been  mistaken  for  the  initial  rash  of  small-pox.  The  general 
condition  of  the  patient,  the  presence  of  coryza,  conjunctivitis  and  Koplik's 
sign,  may  be  better  guides  than  the  rash  itself. 

Malignant  hsemorrhagic  small-pox  may  prove  fatal  before  the  character- 
istic rash  appears.  Of  27  cases  of  purpura  variolosa,  in  only  one,  in  which 
death  occurred  on  the  third  day,  did  inspection  fail  to  show  the  papules.  In  3 
cases  dying  on  the  fourth  day  the  characteristic  papular  rash  was  noticed.  It 
may  be  difficult  or  impossible  to  recognize  this  form  of  haemorrhagic  small- 
pox from  luemorrhagic  scarlet  fever  or  lueniorrkagic  measles,  though  in  the 
latter  there  is  rarely  so  constant  involvement  of  the  mucous  membranes. 

Naturally  enough,  as  they  are  allied  affections,  varicella  is  the  disease 
which  most  frequently  leads  to  error.  Particularly  has  this  been  the  case  in 
the  mild  epidemics  which  have  prevailed  during  the  ^past  few  years.  The 
following  points  are  to  be  borne  in  mind:  first,  very  mild  epidemics  of  true 
small-pox  may  occur;  secondly,  any  large  number  of  cases  of  a  contagious 
disease  with  a  pustular  eruption  occurring  in  adults  is  strongly  in  favor  of 
small-pox.  The  characters  of  the  rash  are  of  less  value.  Its  abundance  on 
the  trunk  in  varicella  is  important.  At  the  outset  the  papules  have  rarely 
the  shotty,  hard  feel  of  small-pox.  The  vesicles  are  more  superficial,  the  in- 
filtrated areola  is  not  so  intense  nor  so  constant,  and  as  a. rule  the  pocks  may 
be  seen  in  the  same  patient  in  all  stages  of  development.  The  longer  period 
of  invasion,  the  prodromal  rashes,  the  great  intensity  of  the  onset  are  also 


SMALL-POX  329 

important  points  in  small-pox.  But  there  are  mild  epidemics  in  which  it 
must  be  confessed  that  the  diagnosis  is  only  confirmed  by  the  appearance  of  a 
severe  case  of  the  confluent  or  hsemorrhagic  form. 

The  disease  may  be  mistaken  for  cerebrospinal  fever,  in  which  purpuric 
symptoms  are  not  uncommon.  A  four-year-old  child  was  taken  suddenly  ill 
with  fever,  pains  in  the  back  and  head,  and  on  the  second  or  third  day  petechias 
appeared.  There  were  retraction  of  the  head  and  marked  rigidity  of  the 
limbs.  The  haemorrhages  became  more  abundant;  and  finally  hsematemesis 
occurred  and  the  child  died  on  the  sixth  day.  At  the  post  mortem  there  were 
no  lesions  of  cerebro-spinal  fever,  and  in  the  deeply  hsemorrhagic  skin  the 
papules  could  be  readily  seen.  The  post  mortem  diagnosis  of  small-pox  was 
confirmed  By  the  mother  taking  the  disease  and  dying  of  it. 

Pustular  Sypliilides. — A  copious  pustular  rash  may  resemble  variola,  par- 
ticularly if  accompanied  by  fever,  but  the  history  and  distribution,  particularly 
the  slight  amount  on  the  face,  leave  no  question  as  to  the  diagnosis. 

Pustular  glanders  has  been  mistaken  for  small-pox.  In  an  instance  in 
Montreal  there  was  a  widespread  pustular  eruption,  which  we  thought  at  first 
was  small-pox,  but  the  course  and  the  fact  that  there  was  glanders  among 
the  horses  in  the  stable  led  to  the  correct  diagnosis.  The  eruption  resembled 
exactly  that  described  in  Eayer's  monograph  (De  la  Morve,  1837). 

Impetigo  contagiosa  is  stated  to  have  been  mistaken  for  variola. 

Specific  Test. — Eabbits  sensitized  to  vaccine  virus  give  a  marked  reaction 
in  2-1  to  48^  hours  after  the  intradermic  injection  of  small-pox  vesicle  contents. 
The  result  of  inoculation  of  material  from  the  pocks  in  the  cornea  of  the 
rabbit  is  helpful  when  positive. 

Prophylaxis. — Thorough  vaccination  and  re-vaccination  are  the  most  im- 
portant preventive  measures.  All  those  exposed  to  infection  should  be  vacci- 
nated at  once,  as  four  days  after  exposure  a  successful  vaccination  may  pro- 
tect from  the  disease.  During  epidemics  general  vaccination  of  the  com- 
munity should  be  done  and  special  care  taken  to  recognize  mild  cases.  Those 
who  have  been  exposed  should  be  isolated  for  sixteen  days.  Isolation  of  those 
with  the  disease  should  be  rigid  and,  if  possible,  they  should  be  placed  in  a 
special  hospital.  The  attendants  should  wear  gowns  and  caps;  rubber  gloves 
are  an  advantage.  The  linen  should  be  placed  in  phenol  solution  (2  per  cent.) 
and  boiled  afterwards.  Dressings  should  be  burned.  The  patient  should  not 
be  discharged  until  all  the  crusts  are  removed;  a  thorough  sponging  with 
phenol  solution    (2  per  cent.)    is  advisable. 

Treatment. — General  Considerations. — Segregation  in  special  hospitals 
is  imperative.  In  the  case  of  local  outbreaks  temporary  barracks  or  tents 
may  be  constructed. 

We  have  no  specific  treatment.  There  should  be  abundance  of  fresh  air; 
the  diet  should  be  liquid  and  large  amounts  of  water  and  cold  drinks  given. 
A  calomel  and  saline  purge  is  advisable  at  the  onset  and  later  the  bowels 
should  be  kept  open  by  salines.  In  the  early  stages  two  symptoms  call  for 
treatment:  the  pain  in  the  back,  which,  if  not  relieved  by  phenacetine  (gr. 
v,  0.3  gm.),  requires  opium  in  some  form,  as  advised  by  Sydenliam;  and  the 
vomiting,  which  is  very  difficult  to  check  and  may  be  uncontrollable.  Nothing 
should  be  given  except  a  little  ice,  and  it  usually  stops  with  the  appearance  of 
the  eruption. 


330  SPECIFIC  INFECTIOtJS  DISEASES 

For  the  fever,  cold  sponging  or  the  tub  bath  may  be  used;  when  there  is 
much  delirium  with  high  fever  the  latter  or  the  cold  pack  is  preferable.  In 
some  cases,  particularly  with  severe  toxsemia  and  marked  eruption,  the  con- 
tinuous warm  bath  is  advisable. 

The  treatment  of  the  eruption  is  important.  After  trying  all  sorts  of 
remedies,  such  as  puncturing  the  pustules  with  nitrate  of  silver,  or  treating 
them  with  iodine  and  various  ointments,  Sydenham's  conclusion  that  in  guard- 
ing the  face  against  being  disfigured  "the  only  effect  of  oils,  liniments,  and 
the  like  was  to  make  the  white  scurfs  slower  in  coming  off  seems  correct.'^ 
The  constant  application  on  the  face  and  hands  of  lint  soaked  in  cold  water, 
to  which  antiseptics  such  as  phenol  (3  per  cent.)  or  bichloride  of  mercury 
(1  to  5,000)  may  be  added,  is  perhaps  the  most  suitable  local  treatment.  It  is 
pleasant  to  the  patient,  and  for  the  face  it  is  well  to  make  a  mask  of  lint, 
which  can  be  covered  with  oiled  silk.  When  the  crusts  begin  to  form,  the 
chief  point  is  to  keep  them  thoroughly  moist  with  oil  or  glycerine.  This  pre- 
vents the  desiccation  and  diffusion  of  the  flakes  of  epidermis.  Vaseline  is 
particularly  useful,  and  at  this  stage  may  be  freely  used  upon  the  face.  Phenol 
(3  to  5  per  cent.)  in  oil  or  vaseline  may  be  used.  It  also  relieves  the  itching. 
For  the  odor,  which  is  sometimes  so  disagreeable,  the  dilute  phenol  solutions 
are  best.  If  the  eruption  is  abundant  on  the  scalp,  the  hair  should  be  cut 
short  to  prevent  matting  and  decomposition  of  the  crusts.  When  suppuration 
is  marked  the  continuous  warm  bath  (95°)  is  useful.  Boric  acid,  alum  or 
potassium  permanganate  may  be  added  to  the  water. 

The  papules  do  not  maturate  so  well  when  protected  from  th*e  light,  and 
for  centuries  attempts  have  been  made  to  modify  the  course  of  the  pustules  by 
either  excluding  the  light  or  by  changing  its  character.  In  the  Middle  Ages 
John  of  Gaddesden  recommended  wrapping  the  patient  in  red  flannel,  and 
treated  in  this  way  the  son  of  Edward  I.  It  was  an  old  practice  of  the 
Egyptians  and  Arabians  to  cover  the  exposed  parts  of  small-pox  patients 
with  gold-leaf.  Lutzenberg,  a  distinguished  New  Orleans  physician,  in  1832 
treated  patients  by  exclusion  of  the  sunlight.  The  red-light  treatment  of  the 
disease  has  been  advocated  by  Finsen,  but  the  statements  do  not  agree  as  to  its 
value.  Nash  states  that  the  course  of  the  rash  may  be  modified  by  the  treat- 
ment, but  Eicketts  and  Byles  could  see  no  influence  whatever,  even  in  cases 
taken  at  the  earliest  possible  date. 

Complications. — If  the  diarrhoea  is  severe,  paregoric  may  be  given. 
When  the  pulse  becomes  feeble  and  rapid,  stimulants  may  be  freely  given.  The 
maniacal  delirium  may  require  chloroform  or  morphia,  but  for  less  intense 
nervous  symptoms  the  bath  or  cold  pack  is  the  best.  For  the  severe  hgemor- 
rhages  of  the  malignant  cases  nothing  can  be  done,  and  it  is  only  cruel  to 
drench  the  patient  with  iron,  ergot,  and  other  drugs.  Symptoms  of  obstruc- 
tion in  the  larynx,  usually  from  oedema,  may  call  for  tracheotomy.  In  the 
late  stages,  if  the  patient  is  debilitated  and  the  subject  of  abscesses  and  bed- 
sores, he  may  be  placed  on  a  water-bed  or  treated  in  the  continuous  bath. 

The  care  of  the  eyes  is  most  important.  The  lids  should  be  thoroughly 
cleansed  and  the  conjunctivas  washed  with  a  warm  solution  of  salt  or  boracic 
acid.  In  the  confluent  cases  the  eyelids  are  swollen  and  glued  together,  and 
only  constant  watchfulness  prevents  keratitis.  The  edges  of  the  lids  should 
be  smeared  with  vaseline.     The  mouth  and  throat  should  be  kept  clean,  a 


VACCINIA  S31 

potassium  permangaDate  mouth  wash  and  gargle  used,  and  the  treatment  of 
the  nose  with  glycerin  or  oil  should  be  begun  early,  as  it  prevents  the  forma- 
tion of  hard  crusts.  Douching  the  nose  with  a  warm  alkaline  solution  is 
helpful. 

The  treatment  in  the  stage  of  convalescence  is  important.  Frequent  bath- 
ing helps  to  soften  the  crusts^,  and  the  skin  may  be  oiled  daily.  Convalescence 
should  not  be  considered  established  until  the  skin  is  perfectly  smooth  and 
clean  and  free  from  any  trace  of  scabs. 


II.     VACCINIA  (Cow-pox)— VACCINATION 

Definition.- — An  eruptive  disease  of  the  cow,  the  virus  of  which,  inoculated 
into  man  (vaccination),  produces  a  local  pock  with  constitutional  disturbance, 
which  afEords  protection,  more  or  less  permanent,  against  small-pox. 

History. — For  centuries  it  had  been  a  popular  belief  among  farmer  folk 
that  cow-pox  protected  against  small-pox.  The  notorious  Duchess  of  Cleve- 
land, replying  to  some  joker  who  suggested  that  she  would  lose  her  occupation 
if  she  was  disfigured  with  small-pox,  said  that  she  was  not  afraid  of  the  dis- 
ease, as  she  had  had  a  disease  that  protected  her  against  small-pox.  Jesty,  a 
Dorsetshire  farmer,  had  had  cow-pox,  and  in  1774  vaccinated  successfully  his 
wife  and  two  sons.  Plett,  in  Holstein,  in  1791,  also  successfully  vaccinated 
three  children.  When  Jenner  was  a  student  at  Sodbury,  a  young  girl,  who 
came  for  advice,  when  small-pox  was  mentioned,  exclaimed,  "I  cannot  take 
that  disease,  for  I  have  had  cow-pox."  Jenner  subsequently  mentioned  the 
subject  to  Hunter,  who  in  reply  gave  the  famous  advice:  "Do  not  think,  but 
try;  be  patient,  be  accurate."  As  early  as  1780  the  idea  of  the  protective 
power  of  vaccination  was  firmly  impressed  on  Jenner's  mind.  The  problem 
which  occupied  his  attention  for  many  years  was  brought  to  a  practical  issue 
when,  on  May  14,  1796,  he  took  matter  from  the  hand  of  a  dairy-maid,  Sarah 
Nelmes,  who  had  cow-pox,  and  inoculated  a  boy  names  James  Phipps,  aged 
eight  years.  On  July  1st,  matter  was  taken  from  a  small-pox  pustule  and 
inserted  into  the  boy,  but  no  disease  followed.  In  1798  appeared  An  Inquiry 
into  the  Causes  and  Effects  of  the  Variola  Vaccinge,  a  Disease  discovered  in 
some  of  the  Western  Counties  of  England,  particularly  Gloucestershire,  and 
known  by  the  Name  of  Cow  pox  (pp.  iv,  75,  four  plates,  4to.  London,  1798). 

In  the  United  States  cow-pox  was  introduced  by  Benjamin  Waterhouse, 
Professor  of  Physic  at  Harvard,  who  on  July  8,  1800,  vaccinated  seven  of  his 
children.  In  Boston  on  August  16,  1802,  nineteen  boys  were  inoculated  with 
the  cow-pox.  On  November  9th  twelve  of  them  were  inoculated  with  small- 
pox; nothing  followed.  A  control  experiment  was  made  by  inoculating  two 
unvaccinated  boys  with  the  same  small-pox  virus ;  both  took  the  disease.  Thd 
nineteen  children  of  August  16th  were  again  unsuccessfully  inoculated  with 
fresh  virus  from  these  two  boys.  This  is  one  of  the  most  crucial  experiments 
in  the  history  of  vaccination,  and  fully  justified  the  conclusion  of  the  Board 
of  Health — cow-pox  is  a  complete  security  against  the  small-pox. 

Practitioners  should  familiarize  themselves  with  the  literature  on  vaccina- 
tion. The  centenary  number  of  the  British  Medical  Journal  is  particularly 
valuable  (1896).    The  report  of  the  Eoyal  Commission  on  vaccination  (1897), 


332  SPECIFIC  INFECTIOUS  DISEASES 

the  exhaustive  articles  in  Allbutt  and  Eolleston's  System  by  T.  D.  Acland, 
Copeman  and  McVail,  and  Cory's  monograph  on  the  subject  afford  a  large 
body  of  material.  To  public  health  officials  who  wish  for  distribution  in 
handy  shape  Facts  about  Small-pox  and  Vaccination  leaflets  issued  by  the 
British  Medical  Association  will  be  of  the  greatest  value.  The  Yacchwiion 
Law  of  the  German  Empire,  printed  in  English  (Berlin,  B.  Paul,  1904),  eon- 
tains  important  information  and  statistics. 

Nature  of  Vaccinia. — Is  cow-pox  a  separate  independent  disease,  or  is  it 
only  small-pox  modified  by  passing  through  the  cow?  In  spite  of  a  host  of 
observations,  this  is  not  yet  settled.  The  experiments  may  be  divided  into  two 
groups.  First,. those  in  which  the  inoculation  of  the  small-pox  matter  in  the 
heifer  produced  p'ocks  corresponding  in  all  respects  to  the  vaccine  vesicles. 
Lymph  from  the  first  calf  inoculated  into  a  second  or  third  produced  the 
characteristic  lesions  of  cow-pox,  and  from  the  first,  second,  or  third  animal 
lymph  used  to  vaccinate  a  child  produced  a  typical  localized  vaccine  vesicle 
without  any  of  the  generalized  features  of  small-pox.  The  experiments  of 
Ceely,  of  Babeock,  and  many  other  workers  seem  to  leave  no  question  whatever 
that  typical  vaccinia  may  be  produced  in  the  calf  by  the  inoculation  of  variol- 
ous matter.  A  great  deal  of  the  vaccine  material  at  one  time  in  use  in 
England  was  obtained  in  this  way.  Secondly,  against  this  are  urged  Chau- 
veau's  Lyons  experiments.  Seventeen  young  animals  were  inoculated  with 
the  virus  of  small-pox.  Small  reddish  papules  occurred  which  disappeared 
rapidly,  but  the  animals  did  not  acquire  cow-pox.  Fifteen  of  the  seventeen 
animals  were  also  vaccinated.  Of  these  only  one  showed  a  typical  cow-pox 
eruption.  To  determine  the  nature  of  the  original  papules  one  was  excised 
and  inoculated  into  a  non-vaccinated  child,  which  developed  as  a  result 
generalized  confluent  small-pox.  A  second  child  inoculated  from  the  primary 
pustule  of  the  first  child  developed  discrete  small-pox.  The  French  hold  to 
the  Lyons  experiments  as  demonstrating  the  duality  of  the  diseases. 

The  weight  of  evidence  favors  the  view  that  cow-pox  and  horse-pox  are 
variola  modified  by  transmission ;  or  "small-pox  and  vaccinia  are  both  of  them 
descended  from  a  common  stock — from  an  ancestor,  for  instance — ^which  re- 
sembled vaccinia  far  more  than  it  resembled  small-pox"  (Copeman). 

The  bodies  described  by  Guarnieri  have  been  very  thoroughly  studied  by 
Councilman  and  his  colleagues,  who  regard  them  as  forms  of  a  protozoon — 
Cytoryctes  vaccinice — with  a  well-characterized  development  cycle,  increasing 
in  size  until  they  undergo  segmentation. 

Normal  Vaccination. — Period  of  Incubation. — At  first  there  may  be  a 
little  irritation  at  the  site  of  inoculation,  which  subsides. 

Period  of  Eruption. — On  the  third  day,  as  a  rule,  a  papule  is  seen  sur- 
rounded by  a  reddish  zone.  This  gradually  increases,  and  on  the  fifth  or 
sixth  day  shows  a  definite  vesicle,  the  margins  of  which  are  raised  while  the 
centre  is  depressed.  By  the  eighth  day  the  vesicle  has  attained  its  maximum 
size.  It  is  round  and  distended  with  a  limpid  fluid,  the  margin  hard  and 
prominent,  and  the  umbilication  is  more  distinct.  By  the  tenth  day  the  vesicle 
is  still  large  and  is  surrounded  by  an  extensive  areola.  The  contents  have 
now  become  purulent.  The  skin  is  also  swollen,  indurated,  and  often  pain- 
ful. On  the  eleventh  or  twelfth  day  the  hypertemia  diminishes,  the  lymph 
becomes  more  opaque  and  begins  to  dry.    By  the  end  of  the  second  week  the 


VACCINIA  333 

vesicle  is  converted  into  a  brownish  scab,  which  gradually  becomes  dry  and 
hard,  and  in  about  a  week  (that  is,  about  the  twenty-first  or  twenty-fifth 
day  from  the  vaccination)  separates  and  leaves  a  circular  pitted  scar.  If 
the  points  of  inoculation  have  been  close  together,  the  vesicles  fuse  and  may 
form  a  large  combined  vesicle.  Constitutional  symptoms  of  a  more  or  less 
marked  degree  follow  the  vaccination.  Usually  on  the  third  or  fourth  day 
the  temperature  rises,  and  may  persist,  increasing  until  the  eighth  or  ninth 
day.  There  is  a  marked  leucocytosis.  In  children  it  is  common  to  have  with 
the  fever  restlessness,  particularly  at  night,  and  irritability;  but  as  a  rule 
these  symptoms  are  trivial.  If  the  inoculation  is  made  on  the  arm,  the  axillary 
glands  become  large  and  sore;  if  on  the  leg,  the  inguinal  glands.  Immunity 
is  not  necessarily  complete  at  once  after  vaccination ;  it  may  take  as  long  as 
three  weeks;  on  the  other  hand,  a  person  exposed  to  small-pox  and  success- 
fully vaccinated  at  once  may  escape  entirely,  or  the  two  diseases  may  run 
concurrently,  with  the  small-pox  much  modified.  The  duration  of  the  im- 
munity is  extremely  variable,  difi^ering  in  different  individuals.  In  some 
instances  it  is  permanent,  but  a  majority  of  persons  within  ten  or  twelve  years 
again  become  susceptible. 

E evaccination  should  be  performed  about  the  ninth  or  tenth  year,  and 
whenever  small-pox  is  epidemic.  The  susceptibility  to  revaccination  is  very 
general.  In  1891-^92  vaccination  pustules  developed  in  88.7  per  cent,  of  the 
newly  enrolled  troops  of  the  German  army,  most  of  whom  had  been  vaccinated 
twice  in  their  lives  before.  The  vesicle  in  revaccination  is  usually  smaller, 
has  less  induration  and  hyperemia,  and  the  resulting  scar  is  less  perfect. 
Particular  care  should  be  taken  to  watch  the  vesicle  of  revaccination,  as  it 
not  infrequently  happens  that  a  spurious  pock  is  formed,  Avhich  reaches  its 
height  early  and  dries  to  a  scab  hy  the  eighth  or  ninth  day. 

Irregular  Vaccination.^ (a)  Local  Variations. — We  occasionally  meet 
with  instances  in  which  tbe  vesicle  develops  rapidly  with  much  itching,  has 
not  the  characteristic  flattened  appearance,  the  lymph  early  becomes  opaque, 
and  the  crust  forms  by  the  seventh  or  eighth  day.  The  evolution  of  the  pocks 
may  be  abnormally  slow.  In  such  cases  the  operation  should  again  be  per- 
formed with  fresh  lymph.  The  contents  of  the  vesicles  may  be  watery  and 
bloody.  In  the  involution  the  bruising  or  irritation  of  the  pocks  may  lead  to 
ulceration  and  inflammation.  A  very  rare  event  is  the  recurrence  of  the  pock 
in  the  same  place.     Sutton  reports  four  such  recurrences  within  six  months. 

(&)  Generalized  Vaccinia. — It  is  not  uncommon  to  see  vesicles  in  the 
vicinity  of  the  primary  sore.  Less  common  is  a  true  generalized  pustular  rash, 
developing  in  different  parts  of  the  body,  often  beginning  about  the  wrists  and 
on  the  back.  The  secondary  pocks  may  continue  to  make  their  appearance  for 
five  or  six  weeks  after  vaccination.  In  cbildren  the  disease  may  prove  fatal. 
They  may  be  most  abundant  on  the  vaccinated  limb,  and  occur  usually  about 
the  eighth  to  the  tenth  day. 

(c)  Complications. — In  unhealthy  subjects,  or  as  a  result  of  uncleanli- 
ness,  or  sometimes  injury,  the  vesicles  infiame  and  deep  excavated  ulcers  re- 
sult. Sloughing  and  deep  cellulitis  may  follow.  In  debilitated  children  there 
may  be  a  purpuric  rash  with  this.  Acland  thus  arranges  the  dates  at  which 
the  possible  eruptions  and  complications  may  1)C  looked  for: 


334  SPECIFIC  I^^FECTIOUS  DISEASES 

1.  During  the  first  three  days:  Erythema;  urticaria;  vesicular  and  bul- 
lous eruptions;  invaccinated  erysipelas. 

2.  After  the  third  day  and  until  the  pock  reaches  maturity:  Urticaria; 
lichen  urticatus,  erythema  multiforme;  accidental  erysipelas. 

3.  About  the  end  of  the  first  week:  Generalized  vaccinia;  impetigo;  vac- 
cinal ulceration;  glandular  abscess;  septic  infections;  gangrene. 

(d)  Teaxsmissiox  of  Diseases  by  A'accixattox. — Syphilis  has  undoubt- 
edly been  transmitted  by  vaccination,  but  such  instances  are  very  rare,  and  a 
large  number  of  the  cases  of  alleged  vaccino-syphilis  muLJ  be  thrown  out. 
The  question  is  now  of  no  importance  since  the  general  use  of  animal  lymph. 
Dr.  Cory's  sad  experiment  may  be  referred  to.  He  vaccinated  himself  four 
times  from  syphilitic  children.  With  the  first  vaccination  followed,  but  no 
syphilis.  Two  other  attempts  (negative)  were  made.  The  fourth  time  he  was 
vaccinated  from  a  child  the  subject  of  congenital  syphilis.  The  lymph  was 
taken  from  the  child's  arm  with  care,  avoiding  any  contamination  with  blood. 
At  two  of  the  points  of  insertion  red  papules  appeared  on  the  twenty-first  day. 
On  the  thirty-eighth  day  a  little  ulcer  was  found,  which  Sir  Jonathan  Hutchin- 
son decided  was  syphilitic.  The  diseased  parts  were  then  removed.  By  the 
fiftieth  day  the  constitutional  symptoms  were  well  marked. 

Tuberculosis. — "Xo  undoubted  case  of  invaccinated  tubercle  was  broughl, 
before  the  Eoyal  Commission  on  Vaccination"  (Acland).  The  risk  of  trans- 
mitting tuberculosis  from  the  calf  is  so  slight  that  it  need  not  be  considered. 
The  transmission  of  leprosy  by  vaccination  is  doubtful. 

The  observations  on  the  presence  of  actinomyces  in  vaccine  virus  have  been 
confirmed  by  W.  T.  Howard,  Jr.,  who  found  it  24  times  in  95  cultures  from 
the  virus  of  five  producers  in  the  United  States. 

Tetanus. — McFarland  collected  95  cases,  practically  all  American.  Sixty- 
three  occurred  in  1901,  a  majority  of  which  could  be  traced  to  one  source 
of  supply,  in  which  R.  W.  Wilson  demonstrated  the  tetanus  bacillus.  Most  of 
the  cases  occurred  about  Philadelphia.  Since  that  date  very  few  cases  have 
been  reported.  The  occurrence  of  this  complication  emphasizes  the  necessity 
of  the  most  scrupulous  care  in  the  preparation  of  the  virus,  as  the  tetanus 
bacillus  is  almost  constantly  present  in  the  intestines  of  cattle. 

(e)  Influence  of  Vaccination  upon  Other  Diseases. — A  quiescent 
malady  may  be  lighted  into  activity  by  vaccination.  This  has  happened  with 
congenital  syphilis,  occasionally  with  tuberculosis.  An  old  idea  was  prevalent 
that  vaccination  had  a  beneficial  infiuence  upon  existing  diseases.  Thomas 
Archer,  the  first  niedical  graduate  in  the  United  States,  recommended  it  in 
whooping-cough,  and  said  that  it  had  cured  six  or  eight  cases  in  his  hands. 

Technique. — That  part  of  the' arm  about  the  insertion  of  the  deltoid  is 
usually  selected  for  the  operation.  Mothers  "in  society"  prefer  to  have  girl 
babies  vaccinated  on  the  leg.  The  skin  should  be  cleansed  and  put  upon  the 
stretch.  Then,  with  a  scalpel,  needle,  or  the  ivory  point,  superficial  incisions 
should  be  made  in  one  or  more  places.  Four  points  of  insertion,  an  inch  apart, 
or  two  incisions,  each  about  half  an  inch  long  and  a  little  less  than  an  inch 
apart,  may  be  made.  The  incision  should  not  be  deep  enough  to  draw  blood 
in  large  drops.  The  virus  is  rubbed  gently  into  the  incisions  and  allowed  to 
dry.  When  glycerin  lymph  is  used  the  drops  may  be  placed  on  the  skin  first 
gnd  the  incisions  then  made.     When  the  lymph  has  dried  on  the  points  it  is 


VACCINIA  335 

best  to  moisten  it  in  sterile  water.  The  clothing  should  not  be  adjusted  until 
the  spot  has  dried,  and  it  should  be  protected  for  a  day  or  two  with  lint  or  a 
soft  handkerchief.  Another  method  is  by  acupuncture.  In  doing  this  the 
vaccine  is  deposited  on  the  cleaned  skin,  which  is  then  drawn  tight.  An 
ordinary  needle  is  used  with  the  point  slanting  and  nearly  parallel  with  the 
skin.  It  is  pressed  against  the  skin  through  the  drop  of  vaccine  and  a  very 
slight  puncture  made.  Six  of  these  are  made  in  a  small  space.  When  the 
vesicle  forms  it  can  be  protected  by  sterile  gauze  held  in  place  by  strapping. 
Vaccination  is  usually  performed  between  the  fourth  and  sixth  month.  If 
unsuccessful,  it  should  be  repeated  from  time  to  time.  It  should  be  postponed 
if  the  child  has  any  ailment  or  suffers  from  syphilis  or  a  skin  disease.  Re- 
vaccination  should  be  done  at  the  age  of  nine  years.  A  person  exposed  to  the 
contagion  of  small-pox  should  always  be  revaccinated.  This,  if  successful, 
will  usually  protect;  but  not  always.  The  cases  in  which  small-pox  is  taken 
within  a  few  years  after  vaccination  are  probably  instances  of  spurious 
vaccination. 

The  Value  of  Vaccination. — Sanitation  cannot  account  for  the  diminution, 
in  small-pox  and  for  the  low  rate  of  mortality.  Isolation  is  a  useful  auxiliary, 
but  it  is  no  substitute.  Vaccination  is  not  claimed  to  be  an  invariable  and 
permanent  preventive  of  small-pox,  but  in  an  immense  majority  of  cases  suc- 
cessful inoculation  renders  the  person  for  many  years  insusceptible.  Com- 
munities in  which  vaccination  and  revaccination  are  thoroughly  and  systemati- 
cally carried  out  are  those  in  which  small-pox  has  the  fewest  victims.  On 
the  other  hand,  communities  in  which  vaccination  and  revaccination  are  per- 
sistently neglected  are  those  in  which  epidemics  are  most  prevalent.  Owing 
to  a  widespread  prejudice  against  vaccination  in  Montreal,  there  grew  up,  be- 
tween the  years  1876  and  1884,  a  considerable  unprotected  population,  and 
the  materials  were  ripe  for  an  extensive  epidemic.  The  soil  had  been  prepared 
and  it  only  needed  the  introduction  of  the  seed,  which  in  due  time  came  with 
the  Pullman-car  conductor  from  Chicago,  on  the  28th  of  February,  1885. 
Within  the  next  ten  months  thousands  of  persons  were  stricken  with  the 
disease,  and  3,164  died.  The  statistics  from  Japan,  published  by  Kitasato 
(1911),  show  strikingly  the  efficacy  of  vaccination  in  that  country.  In  the 
Japanese  army  of  more  than  a  million  men  in  a  war  waged  in  a  country  in 
which  small-pox  was  then  epidemic  there  were  only  362  cases  and  35  deaths. 
He,,,shows  with  great  clearness  the ^  gradual  lessening  of  the  intensity  of  the 
epidemics  in  Japan  as  the  system  of  vaccination  has  been  perfected. 

Although  the  effects  of  a  single  vaccination  may  wear  out,  as  we  say,  and 
the  individual  again  becomes  susceptible  to  small-pox,  yet  the  mortality  in 
such  cases  is  very  much  lower  than  in  persons  who  have  never  been  vaccinated. 
There  is  evidence  that  the  gi'eater  the  number  of  marks  the  greater  the  pro- 
tection in  relation  to  small-pox;  thus,  the  English  Vaccination  Report  states 
that  out  of  4,754  cases  the  death-rate  with  one  mark  was  7.6  per  cent. ;  with 
two  marks,  7  per  cent. ;  with  three  marks,  4.2  per  cent. ;  with  four  marks, 
2.4  per  cent.  W.  M.  Welch's  statistics  of  5,000  cases  on  this  point  give  with 
good  cicatrices  8  per  cent. ;  with  fair  cicatrices,  14  per  cent. ;  with  poor 
cicatrices,  27  per  cent.;  postvaccinal  cases,  16  per  cent.;  un vaccinated  cases^  58 
per  cent. 


SPECIFIC  INFECTIOUS  DISEASES 


m.    VARICELLA  (Chicken-pox) 

Definition. — An  acute  contagious  disease,  characterized  by  an  eruption  of 
vesicles  on  the  skin. 

History. — Ingrassias,  a  distinguished  J^eapolitan  professor,  first  recognized 
the  disease  as  differing  from  small-pox  (1553).  Heberden  gave  it  the  name 
chicken-pox  (1767). 

Etiolo^. — The  disease  occurs  in  epidemics,  but  sporadic  cases  are  also 
met  vith.  It  may  prevail  at  the  same  time  as  small-pox  or  may  follow  or 
precede  epidemics  of  this  disease.  It  is  a  disease  of  childhood;  a  majority  of 
the  cases  occur  between  the  second  and  sixth  years.  Adults  who  have  not  had 
the  disease  in  childhood  are  very  liable  to  be  attacked.  The  specific  germ  has 
not  been  discovered.  There  are  many  reports  of  an  association  with  herpes 
zoster. 

Varicella  is  an  affection  distinct  from  variola  and  without  any  relation 
to  it.  An  attack  of  the  one  does  not  confer  immunity  from  an  attack  of  the 
other.  A  boy,  aged  five,  was  admitted  to  St.  Thomas'  Hospital  with  a  vesicular 
eruption,  and  isolated  in  a  ward  on  the  same  floor  as  the  small-pox  ward.  The 
disease  was  pronounced  chicken-pox  by  Eisdon  Bennett  and  Bristowe.  The 
patient  was  then  removed  and  vaccinated,  with  a  result  of  four  vesicles  which 
ran  a  pretty  normal  course.  On  the  eighth  day  from  the  vaccination  the  child 
became  feverish.  On  the  following  day  the  papules  appeared  and  the  child 
had  a  well-developed  attack  of  small-pox  with  secondary  fever  (Sharkey). 

Symptoms. — After  a  period  of  incubation  of  ten  or  fifteen  days  the  child 
becomes  feverish  and  in  some  instances  has  a  slight  chill.  There  may  be 
vomiting, -and  pains  in  the  back  and  legs.  Convulsions  are  rare.  The  erup- 
tion usually  occurs  within  twenty-four  hours.  It  is  first  see^i  upon  the  trunk, 
either  on  the  back  or  on  the  chest.  It  may  begin  on  the  forehead  and  face. 
At  first  in  the  form  of  raised  red  pajDules,  these  are  in  a  few  hours  trans- 
formed into  hemispherical  vesicles  containing  a  clear  or  turbid  fluid.  As  a 
rule  there  is  no  umbilication,  but  in  rare  instances  the  pocks  are  flattened, 
and  a  few  may  even  be  umbilicated.  They  are  often  ovoid  in  shape  and 
look  more  superficial  than  the  variolous  vesicles.  The  skin  in  the  neighbor- 
hood is  not  often  infiltrated  or  hypergemic.  At  the  end  of  thirty-six  or  f ort}- 
eight  hours  the  contents  of  the  vesicles  are  purulent.  They  begin  to  shrivel, 
and  during  the  third  and  fourth  days  are  converted  into  dark  brownish  crusts, 
which  fall  off  and  as  a  rule  leave  no  scar.  Fresh  crops  appear  during  the  first 
two  or  three  days  of  the  illness,  so  that  on  the  fourth  day  one  can  usually  see 
pocks  in  all  stages  of  development  and  decay.  They  are  always  discrete,  and 
the  number  may  vary  from  eight  or  ten  to  several  hundreds.  As  in  variola, 
a  scarlatinal  rash  occasionally  precedes  the  development  of  the  eruption.  The 
eruption  may  occur  on  the  mucous  membrane  of  the  mouth,  and  occasionally 
in  the  larynx.  In  adults  the  disease  may  be  much  more  severe,  the  initial 
fever  high,  the  rash  very  widespread,  and  the  constitutional  symptoms  com- 
paratively severe,  so  that  the  diagnosis  of  variola  may  be  ?nade — the  so-called 
varicella  variolaformes.  The  fever  in  varicella  is  slight,  but  it  does  not  as  a 
rule  disappear  with  the  appearance  of  the  rash.  The  course  of  the  disease 
is  in  a  large  majority  of  the  cases  favorable,  and  no  ill  effects  folloAv.     The 


SCAELET  FEVEE  337 

disease  may  recur  in  the  same  individual.  There  are  instances  in  which  a 
person  has  had  three  attacks. 

There  are  one  or  two  modifications  of  the  rash  which  are  interesting.  The 
vesicles  may  become  very  large  and  develop  into  regular  bull^,  looking  not 
unlike  ecthyma  or  pemphigus  (varicella  bullosa).  The  irritation  of  the  rash 
may  be  excessive,  and  if  the  child  scratches  the  pocks  ulcerating  sores  may 
form,  which  leave  scars  on  healing.  Cicatrices  after  chicken-pox  are  more  com- 
mon than  after  varioloid. 

In  delicate  children,  particularly  the  tuberculous,  gangrene  (varicella 
escharotica)  may  occur  about  the  vesicles,  or  in  other  parts,  as  the  scrotum. 

Cases  of  hgemorrhagic  varicella  have  been  described  with  cutaneous  ecchy- 
moses  and  bleeding  from  the  mucous  membranes. 

Nephritis  may  occur.  Infantile  hemiplegia  has  occurred  during  an  attack 
of  the  disease.  Death  has  followed  in  an  uncomplicated  case  from  extensive 
involvement  of  the  skin. 

Diagnosis. — The  diagnosis  is  as  a  rule  easy,  particularly  if  the  patient 
has  been  seen  from  the  onset.  When  a  case  comes  under  observation  for  the 
first  time  with  the  rash  well  out,  there  may  be  considerable  difficulty.  The 
abundance  of  the  rash  on  the  trunk  in  varicella  is  most  important.  The 
pocks  in  varicella  are  more  superficial,  more  bleb-like,  have  not  so  deeply  an 
infiltrated  areola  about  them,  and  may  usually  be  seen  in  all  stages  of  develop- 
ment. They  rarely  at  the  outset  have  the  hard,  shotty  feeling  of  those  of 
small-pox.  The  general  symptoms,  the  greater  intensity  of  the  onset,  the 
prolonged  period  of  invasion,  and  the  more  frequent  occurrence  of  prodromal 
rashes  in  small-pox  are  important  points  in  the  diagnosis. 

Death  is  very  rare,  and,  unless  from  the  complications,  raises  a  suspicion 
of  the  correctness  of  the  diagnosis.  Thus  of  the  123  deaths  in  England  and 
Wales  in  1916  ascribed  to  chicken-pox,  it  is  probable,  as  Tatham  suggests, 
that  many  of  these  were  from  unrecognized  small-pox. 

Vaccination  from  the  vesicles  has  been  tried  as  a  preventive  and  seems  to 
have  decreased  the  incidence  in  those  exposed  to  infection. 

No  special  treatment  is  required.  If  the  rash  is  abundant  on  the  face, 
care  should  be  taken  to  prevent  the  child  from  scratching  the  pustules.  A 
soothing  lotion  or  phenol  (3  to  5  per  cent.)  in  vaseline  should  be  applied. 


IV.     SCARLET  FEVER 

Definition. — An  infectious  disease  characterized  by  a  diffuse  exanthem 
and  an  angina  of  variable  intensity. 

History.— In  the  sixteenth  century  Ingrassias  of  Naples  and  Coyttarus  of 
Poitiers  recognized  the  disease;  but  Sydenbam  in  1675  gave  a  full  account  of 
it  under  the  name  febris  scarlatina. 

Etiology. — Xo  one  of  the  acute  infections  varies  so  greatly  in  the  intensity 
of  the  out])reaks,  a  point  to  which  both  Sydenham  and  Bretonneau  called 
attention.  In  some  years  it  is  ■mild;  in  others,  with  equally  widespread  epi- 
demics, it  is  fearfully  malignant.  It  is  a  widespread  affection,  occurring  in 
nearly  all  parts  of  the  globe  and  attacking  all  races. 

Sporadic  cases  occur  from  time  to  time.     The  epidemics  are  most  intense 


338  SPECIFIC  IXFECTIOUS  DISEASES 

in  the  autumii  and  winter.  There  is  an  extraordinary  variability  in  the 
severity  of  the  outbreaks,  which  on  the  whole  appear  to  be  lessening  in  sever- 
ity ;  thus,  in  Boston  from  1894  to  1903  the  ratio  of  cases  per  ten  thousand  has 
ranged  from  45.80  to  16.18,  and  the  mortality  from  3.94  to  0.60.  In  England 
and  Wales  the  disease  is  declining.  In  1883  there  were  over  12,000  deaths;  in 
1903,  4,158;  in  1909,  3,215,  and  in  1916,  1,381  deaths.  Is'ewsholme  attributes 
this  in  part  to  the  general  improvement  in  sanitation  in  the  home  and  to 
hospital  isolation,  and  in  part  to  the  decline  in  the. severity  of  the  disease. 

Seibert's  studies  in  New  York  show  that  the  disease  increases  steadily 
from  week  to  week  until  the  middle. of  May;  the  frequency  diminishes  gradu- 
ally until  the  end  of  June,  and  gradually  increases  through  October,  Novem- 
ber, and  December,  He  associates  the  remarkable  drop  in  July,  August,  and 
September  with  the  closure  of  the  schools  and  the  cessation  of  the  daily  con- 
gregation of  infectious  material  in  small  areas — school-houses  and  play- 
grounds— for  so  many  hours  each  day. 

Age  is 'the  most  important  predisposing  factor.  Ninety  per  cent,  of  the 
fatal  cases  are  under  the  tenth  year.  Sucklings  are  rarely  attacked.  The 
general  liability  to  the  disease  in  childhood  is  less  widespread  than  in  measles. 
Many  escape  in  childhood;  others  escape  until  adult  life;  some  never  take  it. 

Family  susceptibility  is  not  infrequently  illustrated  by  the  death  in 
rapid  succession  of  four  or  five  members.  On  the  other  hand,  individual  re- 
sistance is  common,  and  many  physicians  constantly  exposed  escape.  An  at- 
tack as  a  rule  confers  subsequent  immunity.  In  rare  instances  there  have 
been  one  or  even  two  recurrences. 

The  natives  of  India  are  said  to  enjoy  comparative  immunity. 

Infectivity. — It  is  not  yet  accurately  known  where  in  the  body  the  poison 
is  formed.  It  is  probably  given  off  with  the  secretions  of  the  nose,  throat,  and 
respiratory  tract.  The  mild  angina  of  the  ambulatory  cases  may  convey  the 
disease,  and  in  this  way  it  is  spread  in  schools,  and  the  "return  cases"  may 
find  in  this  way  their  explanation.  More  attention  has  been  paid  to  this 
aspect  of  the  scarlatinal  infection,  and  it  has  been  suggested  that  the  skin  is 
only  infective  by  contamination  with  the  secretions.  The  general  opinion, 
however,  is  that  the  poison  is  given  off  chiefly  from  the  skin,  particularly  when 
desquamating.  Unlike  measles,  the  germ  is  very  resistant  and  clings  tena- 
ciously to  clothing,  to  bedding,  the  furniture  of  the  room,  etc.  Even  after  the 
most  complete  disinfection,  children  who  have  been  removed  from  an  infected 
house  may  catch  the  disease  on  their  return.  The  possibility  of  throat  and 
nose  infection  must  be  considered.  The  intractable  character  of  the  nasal 
discharge  after  scarlet  fever  is  well  recognized  and  this  secretion  appears  to 
be  highly  infectious.  The  chief  organisms  in  it  are  streptococci.  A  third 
person  may  convey  the  disease,  but  undoubted  instances  are  rare. 

The  disease  is  stated  to  have  been  conveyed  by  milk.  Of  99  epidemics 
studied  by  Kober  the  disease  prevailed  in  68  either  at  the  dairy  or  the  milk 
farm.  There  appear  to  be  two  groups  of  cases :  first,  genuine  scarlet  fever,  in 
which  the  infection  is  conveyed  through  the  milk  having  come  in  contact  with 
infected  persons;  and,  secondly,  outbreaks  of  an  infection  resembling  scarlet 
fever,  due  to  disease  of  the  udder  of  the  cows. 

By  SUEGICAL  SCAELATIXA,  first  brought  to  the  attention  of  the  profession 
by  Sir  James  Paget  in  1864,  is  understood  an  erythematous  eruption  follow- 


SCAELET  FEYEE  339 

mg  an  operation  or  occurring  during  septic  infection.  It  differs  from  scarlet 
fever  in  the  large  number  of  adults  attacked,  the  shorter  incubation,  the 
mildness  of  the  throat  symptoms,  the  starting  of  the  eruption  at  the  wound, 
and  the  precocious  desquamation.  Alice  Hamilton,  after  analyzing  174  cases 
reported  in  the  literature,  concludes  that  the  eruption  is  most  frequently  due 
to  septic  infection  and  is  not  truly  scarlatinal,  and  that  in  those  cases  in 
which  the  disease  was  undoubtedly  scarlet  fever  there  is  no  convincing  evidence 
that  the  relation  between  the  wound  and  the  scarlet  fever  was  anything  more 
than  coincidence. 

The  SPECIFIC  GERM  is  not  known.  The  relation  of  the  streptococcus  is 
under  discussion  and  the  trend  of  work  indicates  that  it  is  only  a  secondary 
invader,  and  that  there  is  not  a  specific  streptococcus,  though  some  have  gone 
so  far  as  to  use  streptococcic  immunization  as  a  prophylactic.  The  question 
of  experimental  scarlet  fever  is  still  uncertain. 

Morbid  Anatomy. — Except  in  the  hemorrhagic  form,  the  skin  after  death 
shows  no  traces  of  the  rash.  There  are  no  specific  lesions.  Those  which 
occur  in  the  internal  organs  are  due  partly  to  the  fever  and  nartly  to  infection 
with  pus-organisms. 

The  anatomical  changes  in  the  throat  are  those  of  simple  inflammation, 
follicular  tonsillitis,  and,  in  extreme  grades,  of  diphtheroid  angina.  In  severe 
cases  there  are  intense  lymphadenitis  and  much  inflammatory  oedema  of  the 
tissues  of  the  neck,  which  may  go  on  to  suppuration,  or  even  to  gangrene. 
Streptococci  are  found  abundantly  in  the  glands  and  in  the  foci  of  suppuration. 
The  lymph  glands  and  the  lymphoid  tissue  may  show  hyperplasia  and  the 
spleen,  liver,  and  other  organs  may  be  the  seat  of  widespread  focal  necroses. 
Endocarditis  and  pericarditis  are  not  infrequent.  Myocardial  changes  are 
less  common.  The  renal  changes  vsdll  be  considered  with  the  diseases  of  the 
kidney.  Affections  of  the  respiratory  organs  are  not  frequent.  When  death 
results  from  the  pseudo-membranous  angina,  broncho-pneumonia  is  not  un- 
common.    Cerebro-spinal  changes  are  rare. 

Symptoms. — Incubatiox. — "From  one  to  seven  days,  oftenest  two  to 
four.'-'     McCollom  considered  the  usual  period  to  be  ten  to  fourteen  days. 

IxvASiox. — The  onset  is  as  a  rule  sudden.  It  may  be  preceded  by  a 
slight,  scarcely  noticeable,  indisposition.  An  actual  chill  is  rare.  Vomiting 
is  one  of  the  most  constant  initial  symptoms;  convulsions  are  common.  The 
fever  is  intense;  rising  rapidly,  it  may  on  the  first  day  reach  104°  or  even 
105°.  The  skin  is  unusually  dry  and  to  the  touch  gives  a  sensation  of  very 
pungent  heat.  The  tongue  is  furred,  and  as  early  as  the  first  day  there  may 
be  complaint  of  dryness  of  the  throat.  Cough  and  catarrhal  sj-mptoms  are 
uncommon.  The  face  is  often  flushed  and  the  patient  has  all  the  objective 
features  of  an  acute  fever. 

Eruption. — Usually  on  the  second  day,  in  some  instances  within  the  first 
twenty-four  hours,  the  rash  appears  in  the  form  of  scattered  red  points  on  a 
deep  subcuticular  flush;  at  first  on  the  neck  and  chest,  and  spreading  so 
rapidly  that  by  the  evening  of  the  second  day  it  may  have  invaded  the  entire 
skin.  After  persisting  for  two  or  three  days  it  gradually  fades.  At  its  height 
the  rash  has  a  vivid  scarlet  hue,  quite  distinctive  and  unlike  that  seen  in  any 
other  eruptive  disease.  It  is  an  intense  hyperaemia,  and  the  angemia  produced 
by  pressure  instantly  disappears.    There  may  be  fine  punctiform  haemorrhages, 


340  SPECIFIC  IXFECTIOUS  DISEASES 

which  do  not  disappear  on  pressure.  In  some  cases  the  rash  does  not  become 
uniform  but  remains  patchy,  and  intervals  of  normal  skin  separate  large 
hypersemic  areas.  Tiny  papular  elevations  may  sometimes  be  seen,  but  they 
are  not  so  common  as  in  measles.  With  each  day  the  rash  becomes  of  a 
darker  color,  and  there  may  be  in  parts  even  a  bluish-red  shade.  Smooth  at 
the  beginning,  the  skin  gradually  becomes  rougher,  and  to  the  touch  feels  like 
"goose  skin."  At  the  height  of  the  eruption  sudaminal  vesicles  may  develop, 
the  fluid  of  which  may  become  turbid.  The  entire  skin  may  at  the  same 
time  be  covered  with  small  yellow  vesicles  on  a  deep  red  background — scarla- 
tina miliaris.  McCollom  laid  stress  upon  the  appearance  of  a  punctate  erup- 
tion in  the  arm-pits,  groins,  and  on  the  roof  of  the  mouth  as  proof  of  scarlet 
fever.  Marked  transverse  lines  at  the  bend  of  the  elbow  may  occur  early. 
Occasionally  there  are  pefecMw,  which  in  the  malignant  type  of  the  disease 
become  widespread  and  large.  Small  skin  haemorrhages  are  not  uncommon. 
They  are  sometimes  produced  by  the  pressure  of  the  cuff  of  the  blood-pressure 
apparatus. 

The  eruption  does  not  always  appear  upon  the  face.  There  may  be  a  good 
deal  of  swelling  of  the  skin,  which  feels  uncomfortable  and  tense.  The  itching 
is  variable;  not  as  a  rule  intense  at  the  height  of  the  eruption.  By  the  seventh 
or  eighth  day  the  rash  has  disappeared.  The  mucous  membrane  of  the  palate, 
the  c4ieeks,  and  the  tonsils  present  a  vivid  red,  punctiform  appearance.  The 
tongue  at  first  is  red  at  the  tip  and  edges,  furred  in  the  centre ;  and  through 
the  white  fur  are  often  seen  the  swollen  red  papillse,  which  give  the  so-called 
"strawberry"  appearance  to  the  tongue,  particularly  if  the  child  puts  out  the 
tip  of  the  tongue  between  the  lips.  In  a  few  days  the  "fur''  desquamates  and 
leaves  the  surface  red  and  rough,  and  it  is  this  condition  which  some  writers 
call  the  "strawberry,"  or,  better,  the  "raspberry"  tongue.  Enlargement  of  the 
papillffi  was  the  only  constant  sign  in  1,000  cases  (McCollom).  The  breath 
often  has  a  very  heavy,  sweet  odor. 

The  pharyngeal  symptoms  are:  1.  Slight  redness,  with  swelling  of  the 
pillars  of  the  fauces  and  of  the  tonsils.  2.  A  more  intense  grade  of  swelling 
and  infiltration  of  these  parts  with  a  follicular  tonsillitis.  3.  Diphtheroid 
angina  with  intense  inflammation  of  all  the  pharyngeal  structures  and  swell- 
ing of  the  glands  below  the  jaw,  and  in  very  severe  cases  a  thick  brawny  in- 
duration of  all  the  tissues  of  the  neck. 

The  fever,  which  sets  in  with  such  suddenness  and  intensity,  may  reach 
105°  or  even  106°  F.  It  persists  with  slight  morning  remissions,  gradually 
declining  with  the  disappearance  of  the  rash.  In  mild  cases  the  temperature 
may  not  reach  103°'  F. ;  on  the  other  hand,  in  very  severe  cases  there  may  be. 
hyperpyrexia,  108°  F.,  or  before  death  even  109°  F. 

The  pulse  ranges  from  120  to  150;  in  severe  cases  with  very  high  fever 
from  190  to  200.  The  respirations  show  an  increase  proportionate  to  the 
intensity  of  the  fever.  Leucocytosis  is  usually  present  and  inclusion  bodies 
may  be  seen  in  the  leucocytes.  The  gastro-intestinal  symptoms  are  not  marked 
after  the  initial  vomiting,  and  food  is  usually  well  taken.  In  some  instances 
there  are  abdominal  pains.  The  edge  of  the  spleen  may  be  palpable.  The 
liver  is  not  often  enlarged.  With  the  initial  fever  nervous  symptoms  are 
present  in  a  majority  of  the  cases;  but  as  the  rash  comes  out  the  headache 
and  the  slight  nocturnal  wandering  disappear.     The  urine  has  the  ordinary 


SCAELET  FEVEE 


341 


febrile  characters,  being  scanty  and  high  colored.  Slight  albuminuria  is  by 
no  means  infrequent  during  the  stage  of  eruption.  Careful  examination  of  the 
urine  should  be  made  every  day.  There  is  no  cause  for  alarm  in  the  trace 
of  albumin  which  is  so  often  present,  not  even  if  it  is  associated  with  a  few 
tube  casts. 

Desquamatiox. — With  the  disappearance  of  the  rash  and  the  fever  the 
skin  looks  somewhat  stained,  is  dry,  a  little  rough,  and  gradually  the  upper 
layer  of  the  cuticle  begins  to  separate.  The  process  usually  begins  about  the 
neck  and  chest,  and  flakes  are  gradually  detached.  The  degree  and  character 
of  the  desquamation  bear  some  relation  to  the  intensity  of  the  eruption.  When 
the  latter  has  been  very  vivid  and  of  long  standing  large  flakes  may  be  thrown 
off.     In  rare  instances  the  hair  and  even  the  nails  have  been  shed.     It  must 


Day 

1 

^ 

3 

/J 

^ 

G 

7 

s 

9 

100- 
lOh 
102 

100 
96° 

A 

\J 

A 

A 

J 

Y 

I 

^\ 

Y 

\ 

V 

^ 

V 

A 

V. 

-N 

s, 

sj 

\ 

Chart  X. — Scarlet  Fever. 


not  be  forgotten  that  there  are  cases  in  which  the  desquamation  has  been 
prolonged,  according  to  Trousseau,  even  to  the  seventh  or  eighth  week.  The 
entire  process  lasts  from  ten  to  fifteen  or  even  twenty  days. 

Atypical  Scarlet  Fever. — Mild  and  xVboktive  Forms. — In  cases  of  excep- 
tional mildness  the  rash  may  be  scarcely  perceptible.  During  epidemics,  when 
several  children  of  a  household  are  affected,  one  child  sickens  as  if  with  scarlet 
fever,  and  has  a  sore  throat  and  the  "strawberry  tongue,"  but  the  rash  does 
not  appear — scarlatina  sine  eruptione.  In  school  epidemics  a  third  or  more 
of  the  cases  may  be  without  the  rash.  Desquamation,  however,  may  follow,  and 
in  these  very  mild  forms  nephritis  may  occur. 

Maligxaxt  Scarlet  Fever. — Fulminant  Toxic  Variety. — With  all  the 
characteristics  of  an  acute  intoxication,  the  patient  is  overwhelmed  by  the 
intensity  of  the  poison  and  may  die  v/ithin  twenty-four  or  thirty-six  hours. 
The  disease  sets  in  with  great  severity — high  fever,  extreme  restlessness,  head- 
ache, and  delirium.  The  temperature  may  rise  to  107°  or  even  108°,  in  rare 
cases  even  higher.  Convulsions  may  occur  and  the  initial  delirium  rapidly 
gives  place  to  coma.  The  dyspnoea  may  be  urgent;  the  pulse  is  very  rapid 
and  feeble. 

Hwmorrhagic  Form. — Haemorrhages  occur  into  the  skin,  and  there  are 
hgematuria  and  epistaxis.  In  the  erythematous  rash  scattered  petechise  ap- 
pear, wbich  gradually  heeomo  more  extensive,  and  ultimately  tbe  skin  may  be 


342  SPECIFIC  IIv^FECTIOUS  DISEASES 

universally  involved.  Death  may  take  place  on  the  second  or  on  the  third 
day.  ^Vhile  this  form  is  perhaps  more  common  in  enfeebled  children,  it  may 
attack  adults  apparently  in  full  health. 

Anginose  Form. — The  throat  symptoms  appear  early  and  progress  rap- 
idly; the  fauces  and  tonsils  swell  and  are  covered  with  a  thick  membranous 
exudate,  which  may  extend  to  the  posterior  wall  of  the  pharynx,  forward  into 
the  mouth,  and  upward  into  the  nostrils.  The  glands  of  the  neck  rapidly 
enlarge.  Necrosis  occurs  in  the  tissues  of  the  throat,  the  fetor  is  extreme, 
the  constitutional  disturbance  profound,  and  the  child  dies  with  the  clinical 
picture  of  a  malignant  diphtheria.  Occasionally  the  membrane  extends  into 
the  trachea  and  the  bronchi.  The  Eustachian  tubes  and  the  middle  ear  are 
usually  involved.  When  death  does  not  take  place  rapidly  from  toxgemia 
there  may  be  extensive  abscess  formation  in  the  tissues  of  the  neck  and 
sloughing.  In  the  separation  of  deep  sloughs  about  the  tonsils  the  carotid 
artery  may  be  opened,  causing  fatal  haemorrhage. 

Septicemic  Form. — In  this  there  is  a  marked  secondary  infection  and 
death  occurs  in  the  second  or  third  week  from  severe  toxgemia. 

Complications  and  Sequelae. — Albumixuria. — At  the  height  of  the  fever 
there  is  often  a  slight  trace  of  albumin  in  the  urine,  which  is  not  of  special 
significance.  In  a  majority  of  cases  the  kidneys  escape  without  greater  dam- 
age than  occurs  in  other  acute  febrile  affections. 

Nephritis  is  most  common  in  the  second  or  third  week  and  may  follow 
a  very  mild  attack.  It  may  be  delayed  until  the  third  or  fourth  week.  As 
a  rule,  the  earlier  it  occurs  the  more  severe  the  attack.  It  occurs  in  from 
10  to  20  per  cent,  of  the  cases.    Three  grades  of  cases  may  be  recognized': 

1.  Acute  hgemorrhagic  nephritis.  There  may  be  suppression  of  urine  or 
only  a  small  quantity  of  bloody  fl.uid  laden  with  albumin  and  tube  casts. 
"Vomiting  is  constant,  there  are  convulsions,  and  the  child  dies  with  the  symp- 
toms of  acute  ura3mia.  In  severe  epidemics  there  may  be  many  cases  of  this 
sort,  and  an  acute,  rapidly  fatal,  nephritis  due  to  the  scarlet  fever  poison  may 
occur  without  an  exanthem. 

2.  Less  severe  cases  without  serious  acute  symptoms.  There  is  a  pufEy 
appearance  of  the  eyelids,  with  slight  oedema  of  the  feet;  the  urine  is  dimin- 
ished in  quantity,  smoky,  and  contains  albumin  and  tube  casts.  The  kidney 
symptoms  then  dominate  the  entire  case,  the  dropsy  persists,  and  there  may 
be  effusion  into  the  serous  sacs.  The  condition  may  drag  on  and  become 
chronic,  or  the  patient  may  succumb  to  uraemic  accidents.  Fortunately,  in  a 
majority  of  the  cases  recovery  takes  place. 

3.  Cases  so  mild  that  they  can  scarcely  be  termed  nephritis.  The  urine 
contains  albumin  and  a  few  tube  casts,  but  rarely  blood.  The  oedema  is  ex- 
tremely slight  or  transient,  and  the  convalescence  is  scarcely  interrupted. 
Occasionally,  however,  serious  symptoms  may  supervene.  CEdema  of  the 
glottis  may  prove  rapidly  fatal,  and  in  one  case  of  the  kind  the  child  died  of 
acute  effusion  into  the  pleural  sacs. 

In  other  cases  the  oedema  disappears  and  the  child  improves,  though  he 
remains  pale,  and  a  slight  amount  of  albumin  persists  in  the  urine  for  months 
or  even  for  years.  Eecovery  may  take  place  or  a  chronic  nephritis  may  follow. 
Occasionally  oedema  occurs  without  albuminuria  or  signs  of  nephritis.  Pos- 
sibly it  may  be  due  to  the  angemia;  but  there  are  instances  in  which  marked 


SCARLET  FEVER  343 

changes  have  been  found  in  the  kidney  after  death,  when  the  urine  did  not 
show  the  features  characteristic  of  nephrit'i. 

Arthritis. — There  are  two  forn^s:  first,  the  severe  scarlatinal  pyaemia, 
with  suppuration  of  one  or  more  joints — part  of  a  widespread  streptococcus 
infection.  This  is  an  extremely  serious  and  fatal  form.  Secondly,  scarlatinal 
arthritis,  analogous  to  that  in  gonorrhoea  and  other  infections.  It  occurs  in 
the  second  or  third  week;  many  joints  are  attacked,  particularly  the  small 
joints  of  the  hands.  The  heart  may  be  involved.  Chorea,  subcutaneous 
nodules,  purpura,  and  pleurisy  may  be  complications.  The  outlook  is  usually 
good. 

Cardiac  Complications. — In  the  severe  septic  cases  a  malignant  endo- 
carditis, sometimes  with  purulent  pericarditis,  closes  the  scene.  Simple  endo- 
carditis is  not  uncommon.  It  may  not  be  easy  to  say  whether  the  apex  sys- 
tolic murmur,  so  often  heard,  signifies  a  valvular  lesion.  The  persistence  after 
convalescence,  with  signs  of  slight  enlargement  of  the  heart,  may  alone  decide 
that  the  murmur  indicated  an  organic  change.  As  is  the  rule,  such  cases 
give  no  symptoms.  And,  lastly,  there  may  be  a  severe  toxic  myocarditis, 
sometimes  leading  to  acute  dilatation  and  sudden  death.  It  is  to  be  borne  in 
mind  that  the  cardiac  complications  of  the  disease  are  often  latent. 

Acute  bronchitis  and  broncho-pneumonia  are  not  common.  Empyema 
is  an  insidious  and  serious  complication. 

Ear  Complications. — Common  and  serious,  due  to  extension  of  the  in- 
flammation from  the  throat  through  the  Eustachian  tubes,  they  rank  among 
the  most  frequent  causes  of  deafness  in  children.  The  severe  forms  of  mem- 
branous angina  are  almost  always  associated  with  otitis,  which  goes  on  to 
suppuration  and  to  perforation  of  the  drum.  The  process  may  extend  to  the 
labyrinth  and  rapidly  produce  deafness.  In  other  instances  there  is  suppura- 
tion in  the  mastoid  cells.  In  the  necrosis  which  follows  the  middle-ear  dis- 
ease the  facial  nerve  may  be  involved  and  paralysis  follow.  Later,  still  more 
serious  complications  may  follow,  such  as  thrombosis  of  the  lateral  sinus, 
meningitis,  or  abscess  of  the  brain. 

Adenitis. — In  comparatively  mild  cases  of  scarlet  fever  the  submaxillary 
lymph-glands  may  be  swollen.  In  severer  cases  the  swelling  of  the  neck 
becomes  extreme  and  extends  beyond  the  limits  of  the  glands.  Acute  phleg- 
monous inflammations  may  occur,  leading  to  widespread  destruction  of  tissue, 
in  which  vessels  may  be  eroded  and  fatal  haemorrhage  ensue.  The  suppura- 
tive processes  may  also  involve  the  retro-pharyngeal  tissues. 

The  swelling  of  the  lymph-glands  usually  subsides,  and  within  a  few  weeks 
even  the  most  extensive  enlargement  gradually  disappears.  There  are  rare 
instances,  however,  in  which  the  lymphadenitis  becomes  chronic,  and  the 
neck  remains  with  a  glandular  collar  which  almost  obliterates  its  outline. 
This  may  prove  intractable  to  all  ordinary  measures  of  treatment.  A  case 
came  under  observation  in  which,  two  years  after  scarlet  fever,  the  neck  was 
enormously  enlarged  and  surrounded  by  a  mass  of  firm  brawny  glands. 

jSTervous  Complications. — Chorea  occasionally  complicates  the  arthritis 
and  endocarditis.  Sudden  convulsions  followed  by  hemiplegia  may  occur.  In 
seven  of  a  series  of  120  cases  of  infantile  hemiplegia  the  trouble  came  on  during 
scarlet  fever.  Progressive  paralysis  of  the  limbs  with  wasting  may  present  the 
features  of  a  subacute  ascending  spinal  paralysis.     Thrombosis  of  the  cerebral 


344  SPECIFIC  INFECTIOUS  DISEASES 

veins  may  occur.  Mental  symptoms,  mania,  and  melancholia  have  been  de- 
scribed.    Vagotonia  may  be  marked  in  convalescence. 

Other  rare  complications  and  sequelae  are  oedema  of  the  eyelids,  with- 
out nephritis,  symmetrical  gangrene,  enteritis,  noma,  and  perforation  of  the 
soft  palate. 

The  fever  may  persist  for  several  weeks  after  the  disappearance  of  the 
rash,  and  the  child  may  remain  in  a  septic  or  typhoid  state.  This  so-called 
scarlatinal  typhoid  is  usually  the  result  of  some  chronic  suppurative  process 
about  the  throat  or  the  nose,  occasionally  the  result  of  a  chronic  adenitis,  and 
in  a  few  cases  nothing  whatever  can  be  foimd  to  account  for  the  fever. 

Measles  may  be  concurrent  or  follow  in  the  stage  of  convalescence. 

Eelapse  is  rare.  It  was  noted  in  7  per  cent,  of  12,000  (Caiger),  in  1 
per  cent,  of  1,520  cases  (Xewsholme),  and  in  3  per  cent,  of  5,000  cases  (Mc- 
CoUom). 

Dia^osis. — The  diagnosis  of  scarlet  fever  is  not  difficult,  but  there  are 
cases  in  which  the  true  nature  of  the  disease  is  for  a  time  doubtful.  The  fol- 
lowing are  the  most  common  conditions  with  which  it  may  be  confounded : 

Acute  Exfoliatixg  Dermatitis. — This  pseudo-exanthem  simulates  scar- 
let fever  very  closely.  It  has  a  sudden  onset,  with  fever.  The  eruption 
spreads  rapidly,  is  uniform,  and  after  persisting  for  five  or  six  days  begins 
to  fade.  Even  before  it  has  entirely  gone  desquamation  usually  begins. 
Some  of  these  cases  cannot  be  distinguished  from  scarlet  fever  in  the  stage 
of  eruption.  The  throat  symptoms,  however,  are  usually  absent,  and  the 
tongue  rarely  shows  the  changes  Avhich  are  so  marked  in  scarlet  fever.  In  the 
desquamation  of  this  affection  the  hair  and  nails  are  commonly  affected.  It 
is,  too,  a  disease  liable  to  recur.  Some  of  the  instances  of  second  and  third 
attacks  of  scarlet  fever  have  been  cases  of  this  form  of  dermatitis. 

;Measles^  which  is  distinguished  by  the  longer  period  of  invasion,  the 
characteristic  nature  of  the  prodromes,  and  the  later  appearance  of  the  rash. 
The  greater  intensity  of  the  measly  rash  upon  the  face,  the  more  papular 
character  and  the  irregular  crescentic  distribution  are  distinguishing  features 
in  a  majority  of  the  cases.  Other  points  are  the  absence  in  measles  of  the 
sore  throat,  the  peculiar  character  of  the  desquamation,  the  absence  of  leuco- 
cytosis,  and  the  presence  of  Koplik's  sign. 

RoTHELX, — The  rash  of  rul^ella  is  sometimes  strikingly  like  that  of  scar- 
let fever,  but  in  the  great  majority  of  cases  the  mistake  could  not  arise.  In 
cases  of  doubt  the  general  symptoms  are  our  best  guide. 

Sepic^mia. — The  so-called  puerperal  or  surgical  scarlatina  shows  an 
eruption  which  may  be  identical  in  appearance  with  that  of  scarlet  fever. 

DiPHTHEEiA. — The  practitioner  may  be  in  doubt  whether  he  is  dealing  with 
a  case  of  scarlet  fever  with  intense  membranous  angina,  a  true  diphtheria 
with  an  erythematous  rash,  or  coexisting  scarlet  fever  and  diphtheria.  In  the 
angina  occurring  early  in  and  during  the  course  of  scarlet  fever,  though  the 
clinical  features  may  be  those  of  true  diphtheria,  Loffler's  bacilli  are  rarely 
found.  On  the  other  hand,  in  the  membranous  angina  occurring  during  con- 
valescence the  bacilli  are  usually  present.  The  rash  in  diphtheria  is,  after 
all,  not  so  common,  is  limited  usually  to  the  trunk,  is  not  so  persistent,  and 
is  generally  darker  than  the  scarlatinal  rash. 

Scarlet  fever  and  diphtheria  may  coexist,  but  in  a  case  presenting  ^vide- 


SCAELET  FEVEE  345 

spread  erythema  and  extensive  membranous  angina  with  Loffler's  bacilli  it 
would  puzzle  Hippocrates  to  say  whether  the  two  diseases  coexisted,  or  whether 
it  was  only  an  intense  rash  in  diphtheria.  Desquamation  occurs  in  either 
case.  The  streptococcus  angina  is  not  so  apt  to  extend  to  the  larynx,  nor 
are  recurrences  so  common;  but  it  is  well  to  bear  in  mind  that  general  infec- 
tion may  occur,  that  the  membrane  may  spread  downward  with  great  rapid- 
ity, and,  lastly,  that  all  the  nervous  sequelae  of  diphtheria  may  follow  the 
streptococcus  form. 

Drug  Rashes. — These  are  partial,  and  seldom  more  than  a  transient 
hypersemia  of  the  skin.  Occasionally  they  are  diffuse  and  intense,  and  in 
such  cases  very  deceptive.  They  are  not  associated,  however,  with  the  char- 
acteristic symptoms  of  invasion.  There  is  no  fever,  and  with  care  the  dis- 
tinction can  usually  be  made.  They  are  most  apt  to  follow  the  use  of  bella- 
donna, quinine,  and  iodide  of  potassium.  The  antitoxin  erythema  is  a  fre- 
quent cause  of  doubt,  particularly  in  hospitals  for  infectious  diseases. 

Coexistence  of  other  Diseases. — Of  48,366  cases  of  scarlet  fever  in  the 
Metropolitan  Asylum  Board  Hospitals  which  were  complicated  by  some  other 
disease,  in  1,094  cases  the  secondary  infection  was  diphtheria,  in  899  cases 
chicken-pox,  in  703  measles,  in  404  whooping-cough,  in  55  erysipelas,  in  11 
typhoid  fever,  and  in  1  typhus  fever  (F.  F.  Caiger).  Farnarier  (1904)  could 
collect  only  39  undoubted  cases  of  the  coexistence  of  typhoid  and  scarlet  fever. 

How  Long  Is  a  Child  Infective? — Usually,  after  desquamation  is  com- 
plete, in  four  or  five  weeks  the  danger  is  thought  to  be  over,  but  the  occur- 
rence of  so-called  "return  cases"  shows  that  patients  remain  infective  even  at 
this  stage.  In  1894,  with  2,593  patients  from  the  Glasgow  fever  hospitals 
sent  to  their  homes  convalescent,  fresh  cases  appeared  in  70  of  the  houses 
(Chalmers),  With  15,000  cases  submitted  to  an  average  period  of  isolation  of 
forty-nine  days  or  under,  the  percentage  of  return  cases  was  1.86;  with  an 
average  period  of  fifty  to  fifty-six  days  the  percentage  was  1.12 ;  where  the 
isolation  extended  to  between  fifty-seven  and  sixty-five  days  the  percentage 
of  return  cases  was  1  (Xeech).  This  author  suggests  eight  weeks  as  a  mini- 
mum and  thirteen  weeks  as  a  maximum.  Special  care  should  be  taken  of 
cases  with  rhinorrhoea  and  otorrhoea  and  throat  trouble,  as  the  secretions  from 
these  parts  are  of  great  importance  in  the  conveyance  of  the  disease. 

Prognosis. — As  stated,  the  death-rate  has  been  falling  of  late  years.  Epi- 
demics difi'er  remarkably  in  severity  and  the  mortality  is  extremely  variable. 
Among  the  better  classes  the  death-rate  is  much  lower  than  in  hospital  prac- 
tice. There  are  physicians  who  have  treated  consecutively  a  hundred  or  more 
cases  without  a  death.  On  the  other  hand,  in  hospitals  and  among  the  poorer 
classes  the  death-rate  is  considerable,  ranging  from  5  to  10  per  cent,  in  mild 
epidemics  to  20  or  30  per  cent,  in  the  very  severe.  In  1,000  cases  reported 
from  the  Boston  City  Hospital  by  ]\IcCollom  the  death-rate  was  9.8  per  cent. 
There  is  &  curious  variability  in  the  local  mortality  from  this  disease.  In 
England,  for  example,  in  some  years,  certain  counties  enjoy  almost  immunity 
from  fatal  scarlet  fever.  The  younger  the  child  the  greater  the  danger.  In 
infants  under  one  year  the  death-rate  is'  very  high.  The  great  proportion  of 
fatal  cases  occurs  in  children  under  six  years  of  age.  The  unfavorable  symp- 
toms are  very  high  fever,  early  mental  disturbance  with  great  jactitation,  the 
occurrence  of  haemorrhages  (cutaneous  or  visceral),  intense  diphtheroid  angina 


346  SPECIFIC  INFECTIOUS  DISEASES 

with  cervical  bubo,  and  signs  of  laryngeal  obstruction.  Nephritis  is  always 
a  serious  complication,  and  when  setting  in  with  suppression  of  the  urine  may 
quickly  prove  fatal;  a  large  majority  of  the  cases  recover. 

Prophylaxis -Much  may  be  done  to  prevent  the  spread  of  the  disease  if 

the  physician  exercises  scrupulous  care  in  each  case.  Much  is  to  be  expected 
from  a  rigid  system  of  school  inspection,  and  from  the  more  general  recogni- 
tion of  the  importance  of  the  latent  cases  and  the  persistence  of  the  infection 
in  the  secretions  of  the  nose  and  throat.  The  attendant  in  a  case  of  scarlet 
fever  should  take  the  most  careful  precautions  against  the  conveyance  of  the 
disease,  wearing  a  gown  in  the  room  and  thoroughly  washing  the  hands  and 
face  after  leaving  the  room.  To  the  busy  practitioner  the  minutiae  of  proper 
disinfection  are  irksome,  but  it  is  his  duty  to  carry  out  the  most  rigid  disin- 
fection possible,  and  intelligent  people  expect  it.  The  duration  of  quaran- 
tine varies  with  the  attack:  six  to  eight  weeks  is  the  average  period.  Pa- 
tients with  discharge  from  the  ear  or  nose  require  longer  isolation. 

Treatment.- — The  patient  may  be  treated  at  home  or  sent  to  an  isolation 
hospital.  The  difficulty  in  home  treatment  is  in  securing  complete  isolation. 
The  risks  are  well  illustrated  by  the  careful  studies  of  Chapin,  of  Providence, 
who  found  that  during  eight  years  26.1  per  cent,  of  the  4,412  persons  under 
twenty-one  years  of  age  in  infected  families  took  the  disease.  When  prac- 
ticable, it  is  better  to  send  the  other  children  out  of  the  house.  Chapin's  ex- 
perience on  this  point  is  most  interesting.  In  seventeen  years,  from  652 
families  infected  with  scarlet  tsver,  1,051  children,  none  of  whom  had  had' 
the  disease,  were  removed.  Only  5  per  cent,  were  attacked  while  away  from 
home.  Nineteen  Avho  had  been  sent  away  from  the  infected  houses  were 
attacked  on  their  return.  In  Great  Britain  a  very  considerable  proportion 
of  all  patients  are  removed  from  their  homes.  In  the  segregation  hospital 
groups  of  patients,  from  ten  to  twenty,  are  treated  in  separate  wards. 

The  disease  cannot  be  cut  short.  In  the  presence  of  the  severer  forms  we 
are  too  often  helpless.  There  is  no  disease  in  which  the  successful  issue  and 
the  avoidance  of  complications  depend  more  upon  the  skilled  judgment  of  the 
physician  and  the  care  with  which  his  instructions  are  carried  out. 

The  child  should  be  isolated  and  placed  in  charge  of  a  competent  nurse. 
The  temperature  of  the  room  should  be  constant  and  the  ventilation  thorough. 
The  child  should  wear  a  light  flannel  nightgown,  and  the  bedclothing  should 
not  be  too  heavy.  The  mouth  should  be  kept  clean  and  rinsed  freely  with  a 
mild  antiseptic  solution.  The  diet  should  consist  of  milk,  buttermilk,  whey, 
and  ice  cream;  water  and  fruit  juices  should  be  freely  given.  Cream  and 
lactose  may  be  added  to  the  milk.  With  the  fall  of  the  temperature  the  diet 
may  be  increased  and  the  child  may  gradually  return  to  ordinary  fare.  AYhen 
desquamation  begins  the  child  should  be  thoroughly  rubbed  every  day,  or 
every  second  day,  with  sweet  oil,  or  carbolated  vaseline,'  or  a  5-per-cent.  hydro- 
naphthol  soap,  which  prevents  the  drying  and  the  diffusion  of  the  scales.  An 
occasional  warm  bath  may  then  be  given.  At  any  time  during  the  attack 
the  skin  may  be  sponged  with  warm  water.  The  patient  may  be  allowed  to 
get  up  after  the  temperature  has  been  normal  for  ten  days,  but  for  at  least 
three  weeks  from  this  time  great  care  should  be  exercised  to  prevent  exposure 
to  cold.  It  must  not  be  forgotten  that  the  renal  complications  are  very  apt 
to  occur  during  convalescence,  and  after  all  danger  is  apparently  past.     Ordi- 


SCAELET  FEARER  347 

nary  cases  may  be  given  a  simple  fever  mixture,  and  during  convalescence  a 
bitter  tonic.     The  bowels  should  be  carefully  regulated. 

When  the  fever  is  above  103°  F.  the  extremities  may  be  sponged  with 
tepid  water.  In  severe  cases,  with  the  temperature  rapidly  rising,  this  Avill 
not  suffice,  and  more  thorough  measures  of  hydrotherapy  should  be  practised. 
With  pronounced  delirium  and  nervous  symptoms  the  cold  pack  should  be 
used.  When  the  fever  is  rising  rapidly  but  the  child  is  not  delirious,  he 
should  be  placed  in  a  warm  bath,  the  temperature  of  which  can  be  gradually 
lowered.  The  bath  with  the  Avater  at  80°  is  beneficial.  In  giving  the  cold 
pack  a  rubber  sheet  and  a  thick  layer  of  blankets  should  be  spread  upon  a 
sofa  or  a  bed,  and  over  them  a  sheet  wrung  out  of  cold  water.  The  naked 
child  is  then  laid  upon  it  and  wrapped  in  the  blankets.  An  intense  glow  of 
heat  quickly  follows  the  preliminary  chilling,  and  from  time  to  time  the 
blankets  may  be  unfolded  and  the  child  sprinkled  Math  cold  water.  The 
good  effects  which  follow  this  treatment  are  often  striking,  particularly  in 
allaying  the  delirium  and  jactitation,  and  procuring  quiet  sleep.  Parents 
will  object  less,  as  a  rule,  to  the  warm  bath  gradually  cooled  than  to  any 
other  form  of  hydrotherapy.  The  child  may  be  removed  from  the  warm 
bath,  placed  upon  a  sheet  wrung  out  of  tolerably  cold  water,  and  then  folded 
in  blankets.  The  ice-cap  is  useful  and  may  be  kept  constantly  applied  in 
cases  in  which  there  is  high  fever.  Medicinal  antipyretics  are  not  of  much 
service  in  comparison  with  cold  water.  If  the  child  is  restless  or  sleepless, 
hydrotherapy  is  usually  effectual.  If  not  moderate  doses  of  bromide  may  be 
given.  " 

The  throat  symptoms,  if  mild,  do  not  require  much  treatment.  If  severe, 
the  local  measures  mentioned  under  diphtheria  should  be  used.  The  nose 
should  be  kept  clean,  for  Avhich  a  simple  alkaline  douche,  given  gently,  is  best. 
Cold  applications  to  the  neck  are  to  be  preferred  to  hot,  though  it  is  some- 
times difficult  to  get  a  child  to  submit  to  them.  If  cervical  adenitis  occurs, 
an  ice  bag  should  be  applied,  and  with  the  first  signs  of  suppuration  an  in- 
cision made.  In  connection  with  the  throat,  the  ears  should  be  specially 
looked  after,  and  a  careful  disinfection  of  the  mouth  and  fauces  by  suitable 
antiseptic  solutions  should  be  practised.  When  the  inflammation  extends 
through  the  tubes  to  the  middle  ear,  the  practitioner  should  examine  daily  the 
condition  of  the  drum,  or,  when  available,  a  specialist  should  be  called  in  to 
assist.  The  careful  Avatching  of  this  membrane  day  by  day  and  the  punc- 
turing of  it  if  the  tension  becomes  too  great  may  save  the  hearing  of  the  child. 
With  the  aid  of  cocaine  the  drum  is  readily  punctured.  The  operation  may 
be  repeated  at  inter\'als  if  the  pain  and  distention  return.  No  complication 
of  the  disease  is  more  serious  than  this  extension  of  the  inflammatory  process 
to  the  ear. 

The  nephritis  should  be  dealt  Avith  as  in  ordinary  cases;  indications  for 
treatment  will  be  found  under  the  appropriate  section.  It  is  Avorth  men- 
tioning, hoAvever,  that  Jaccoud  insists  upon  the  great  value  of  milk  diet  in 
scarlet  fever  as  a  preventive  of  nephritis. 

Among  other  indications  for  treatment  in  the  disease  is  cardiac  Aveakness, 
for  Avhich  digitalis,  or  if  urgent  strophanthin  intramuscularly  may  be  given. 
Camphor  (gr.  ii,  0.12  gm.)  should  also  be  given  intramuscularly  and  repeated 
as  necessary. 


348  SPECIFIC  INFECTIOUS  DISEASES 

Serum  Treatment.— As  a  streptococcus  infection  frequently  complicates 
scarlet  fever  and  is  responsible  for  the  secondary  infections,  the  use  of  anti- 
streptococcus  serum  seems  rational,  but  it  has  not  proved  of  great  value  in 
the  acute  stages.  More  is  to  be  expected  from  it  in  the  more  chronic  infec- 
tions, in  which  an  autogenous  vaccine  may  be  useful.  The  dosage  should  be 
small  at  first  and  increased  gradually. 


V.     MEASLES 

(Morhilli) 

Definition. — An  acute,  highly  contagious  fever  with  specific  localization 
in  the  upper  air  passages  and  in  the  skin. 

As  a  cause  of  death  measles  ranks  high  among  the  acute  fevers  of  chil- 
dren. In  1915  there  were  16,445  deaths  from  this  disease  in  England  and 
Wales,  but  only  5,413  deaths  in  1916.  In  the  U.  S.  registration  area  there 
were  10,745  deaths  in  1917.     The  death  rate  is  highest  in  the  second  year. 

History. — Ehazes,  an  Arabian  physician,  in  the  ninth  century  described 
the  disease  with  small-pox,  of  which  it  was  believed  to  be  a  mild  form  until 
Sydenham  separated  them  in  the  seventeenth  century. 

Etiology. — The  liability  to  infection  is  almost  universal  in  persons  unpro- 
tected by  a  previous  attack.  It  is  a  disease  of  childhood,  but,  as  shown  in 
the  widespread  epidemics  in  the  Faroe  Islands  and  in  the  Fiji  Islands,  un- 
protected adults  of  all  ages  are  attacked.  Within  the  first  three  months  of 
life  there  is  a  relative  immunity.  Occasionally  infants  of  a  month  or  six 
weeks  take  the  disease.  Intra-uterine  cases  have  been  described,  and  a  mother 
with  measles  may  give  birth  to  a  child  with  the  eruption,  or  the  rash  may 
appear  in  a  few  days. 

The  disease  is  endemic  in  cities,  and  becomes  epidemic  at  intervals,  pre- 
vailing most  extensively  in  the  cooler  months,  though  this  is  by  no  means  a 
fixed  rule. 

The  germ  of  the  disease  is  unknown.  J.  F.  Anderson  has  shown  that  the 
blood  of  a  patient  inoculated  into  the  Ehesus  monkey  produces  after  eight 
days  a  fever  of  short  duration  with  a  well-marked  slight  exanthem.  The 
contagion  is  present  in  the  blood,  the  secretions  of  the  mouth  and  nose,  and 
in  the  skin.  In  the  eighteenth  century  Monro  and  others  demonstrated  the 
inoculability  of  the  disease.  Direct  contagion  is  the  most  common.  The 
poison  is  probably  not  in  the  expired  air,  but  in  the  particles  of  mucus  and 
in  the  sputum  and  the  secretions  of  the  mouth  and  nose,  which,  dried,  are 
conveyed  with  the  dust.  An  important  point  is  the  contagiousness  of  the 
disease  in  the  pre-eruptive  stage.  A  child  with  only  the  catarrhal  symptoms 
may  be  at  school  and  a  source  of  active  infection.  Indirect  contagion  by 
means  of  fomites  is  very  common.  Measles  may  be  thus  conveyed  by  a  third 
person,  by  clothes,  and  lay  infected  toys.  '  The  germ  soon  loses  its  virulence. 

Eecurrence  is  rare.  Many  cases  of  supposed  second  and  third  attacks 
represent  mistakes  in  diagnosis.  Eelapse  is  occasionally  seen,  the  symptoms 
recurring  at  intervals  from  ten  to  forty  days;  but  it  is  not  always  easy  to  say 
whether  there  may  not  have  been  new  infection  from  without. 


MEASLES  349 

Morbid  Anatomy. — The  catarrhal  and  inflammatory  appearances  seen  post 
mortem  have  nothing  characteristic.  Fatal  cases  show,  as  a  rule,  broncho- 
pneumonia and  an  intense  bronchial  catarrh.  The  lymphatic  elements  all 
over  the  body  are  swollen,  the  tonsils,  the  lymph-glands,  and  the  solitary  and 
agminated  follicles  of  the  intestines.  The  spleen  is  rarely  much  enlarged. 
During  convalescence  latent  tuberculous  foci  are  very  apt  to  become  active. 

Symptoms. — -Ixcubation. — "From  seven  to  eighteen  days;  oftenest  four- 
teen." The  child  shows  no  special  changes,  but  coryza  and  swelling  of  the 
cervical  lymph-glands  may  be  present.  A  leucocytosis  has  been  observed,  and 
the  pulse  is  said  to  be  slow. 

Invasion. — In  this  period,  lasting  from  three  to  four  days,  very  rarely 
five  or  six,  the  child  presents  the  symptoms  of  a  feverish  cold.  The  onset 
may  be  insidious,  or  it  may  start  with  great  abruptness,  even  with  a  con- 
vulsion. There  is  not  often  a  definite  chill.  Headache,  nausea,  and  vomit- 
ing may  usher  in  the  severe  cases.  The  common  catarrhal  symptoms  are 
sneezing  and  running  at  the  nose,  redness  of  the  eyes  and  lids,  and  cough. 
The  fever  is  slight  at  first,  but  gradually  there  is  pungent  heat  of  the  skin 
with  turgescence  of  the  face.  Prodromal  rashes  precede  the  eruption  in 
a  few  cases,  usually  a  blotchy  erythema  or  scattered  macules.  The  tongue  is 
furred  and  the  mucous  membranes  of  the  mouth  and  throat  are  hypergemic, 
and  frequently  show  a  distinct  punctiform  rash.  The  fever  of  the  stage  of 
invasion  may  rise  abruptly;  more  frequently  it  takes  twenty-four  or  forty- 
eight  hours  to  reach  the  fastigium.  The  pulse-rate  increases  with  the  fever, 
and  may  reach  140  or  160  per  minute,  gradually  falling  with  defervescence. 

Eruption. — "The  symptoms  increase  till  the  fourth  day.  At  that  period 
(although  sometimes  a  day  later)  little  red  spots,  just  like  flea-bites,  begin  to 
come  out  on  the  forehead  and  the  rest  of  the  face.  These  increase  both  in 
size  and  number,  group  themselves  in  clusters,  and  mark  the  face  with  largish 
red  spots  of  different  figures.  These  red  spots  are  formed  by  small  red  pap- 
ules, thick  set,  and  just  raised  above  the  level  of  the  skin.  The  fact  that 
they  really  protrude  can  scarcely  be  determined  by  the  eye.  It  can,  however, 
be  ascertained  by  feeling  the  surface  with  the  fingers.  From  the  face — 
where  they  first  appear — these  spots  spread  downward  to  the  breast  and  belly ; 
afterward  to  the  thighs  and  legs''  (Sydenham).  The  papules  may  feel  quite 
shotty,  but  do  not  extend  deeply.  On  the  trunk  and  extremities  the  swelling 
of  the  skin  is  not  so  noticeable,  the  color  of  the  rash  not  so  intense  and  often 
less  uniform.  The  mottled,  blotchy  character  is  seen  most  clearl}'^  on  the 
chest  and  the  abdomen.  It  is  hypergemic  and  disappears  on  pressure,  but  in 
the  malignant  cases  it  may  become  of  a  deep  rose,  inclining  to  purple.  These 
general  symptoms  do  not  abate  with  the  occurrence  of  the  eruption,  but  persist 
until  the  end  of  the  fifth  or  the  sixth  day,  when  they  lessen.  Among  peculi- 
arities of  the  rash  may  be  mentioned  the  development  of  numerous  miliary 
vesicles  and  the  occurrence  of  petechise,  which  are  seen  occasionally  even  in 
cases  of  moderate  severity.  Recession  of  the  rash,  so  much  dwelt  upon  by 
older  writers,  is  rarely  seen.  When  the  "measles  sink  in  suddenly  after  they 
have  begun  to  come  out,  and  then  the  patient  is  seized  with  anxiety  and  a 
swooning  comes  on,  it  is  a  sign  of  speedy  death"  (Rhazes).  In  reality  it  is 
the  failing  circulation  which  causes  the  rash  to  fade. 

Buccal  spots  were  described  by  Fibitow  in  189."),  and  l)y  Koplik  in  1S9G. 


350 


SPECIFIC  INFECTIOUS  DISEASES 


They  are  seen  on  a  level  with  the  bases  of  the  lower  milk  molars  on  either 
side,  or  at  the  line  of  junction  of  the  molars  when  the  jaws  are  closed.  They 
are  white  or  bluish-white  specks,  surrounded  by  red  areolae.  Their  importance 
depends  upon  their  early  appearance  and  remarkable  constancy  in  the  disease 
— six-sevenths  of  all  cases   (Heubner),  97.7  per  cent,  of  214  cases   (Balme). 

The  fauces  may  be  injected,  and  there  is  sometimes  an  eruption  of  scat- 
tered spots  over  the  entire  mucous  membrane  of  the  mouth.  Einger  called 
attention  to  opaque  white  spots  on  the  mucous  membrane  of  the  lips. 

Desquamation". — After  the  rash  fades  desquamation  begins,  usually  in 
the  form  of  fine  scales,  more  rarely  in  large  flakes.  It  bears  a  definite  rela- 
tionship to  the  extent  and  intensity  of  the  rash.  In  mild  cases  desquamation 
may  take  only  a  few  days,  in  severe  cases  several  weeks. 


Day 

. 

s 

3 

i 

S 

G 

7 

8 

lOG 

lol 

102 

100 
9S 

t 

i 

> 

A 

\ 

/ 

\ 

11 

V. 

-• 

\ 

v 

\ 

i 

A 

\ 

L 

^._^ 

^ 

S^*«! 

-• 

Chart  XI. — Measles. 


The  tonsils  and  the  cervical  lymph  glands  may  be  slightly  swollen  and 
sore;  sometimes  tliere  is  a  polyadenitis. 

During  the  course  leucocytosis  is  absent.  Its  presence  generally  points 
to  a  complication.  Myelocytes  are  often  present  in  small  numbers  during  the 
eruption  ( Tileston ) . 

Atypical  Measles. — Variations  in  the  course  of  the  disease  are  not  com- 
mon. There  is  an  attenuated  form,  in  which  the  child  may  be  well  by  the 
fourth  or  fifth  day,  and  an  abortive  form,  in  which  the  initial  symptoms  may 
be  present,  but  no  eruption  appears — morbilli  sine  morhillis. 

Malignant  or  blade  measles  is  seen  most  frequently  in  the  widespread 
epidemics,  but  it  is  also  met  witb  in  institutions,  and  occasionally  in  general 
practice  among  children,  more  rarely  in  adults.  Haemorrhages  occur  into  the 
skin  and  from  the  mucous  membranes,  there  is  very  high  fever,  and  all  the 
features  of  a  profound  toxaemia,  often  with  cyanosis,  dyspnoea,  and  extreme 
cardiac  weakness.     Death  may  occur  froni  the  second  to  the  sixth  day. 

Complications. — Those  of  the  air  passages  are  the  most  serious.  The 
coryza  may  become  chronic  and  lead  to  irritation  of  the  lymphoid  tissues  of 
the  naso-pharynx,  causing  enlarged  tonsils  and  adeuoids,  and  probably  lea^"- 
ing  these  parts  less  able  to  resist  tuberculous  invasion.     Eptsta.ris  is  some- 


MEASLES  351 

times  serious.  Laryngitis  is  not  uncommon :  the  voice  becomes  husky  and 
the  cough  croupy  in  character.  CEdema  of  the  glottis  and  pseudo-membran- 
ous inflammation  are  rare.    Ulceration,  abscess,  and  perichondritis  may  occur. 

Bronchitis  and  Broncho-pneumonia. — In  every  case  of  severe  measles  the 
possibility  of  the  existing  bronchitis  extending  to  the  small  tubes  and  caus- 
ing broncho-pneumonia  has  to  be  considered.  It  is  more  apt  to  occur  at  the 
height  of  the  eruption  or  as  desquamation  begins.  The  high  mortality  in 
institutions  is  due  to  this  complication,  which,  as  Sydenham  remarked,  kills 
more  than  the  small-pox.     (For  the  symptoms,  see  the  section  on  the  subject.) 

Lobar  pneumonia  is  less  common.     Thrombosis  in  veins  has  been  described. 

Severe  stomatitis  may  follow  the  slight  catarrhal  form.  In  institutions 
cancrum  oris  or  gangrenous  stomatitis  is  a  terrible  complication,  attacking 
sometimes  many  children.  Parotitis  occasionally  occurs.  Intestinal  catarrh 
and  acute  colitis  are  special  complications  of  some  epidemics. 

Nephritis  is  less  rare  than  is  stated.  It  is  not  very  uncommon  to  see  cases 
of  chronic  nephritis  which  date  from  an  attack  of  measles.  Vulvitis  may  be 
present  as  part  of  the  general  catarrhal  condition. 

Endocarditis  is  rare.  Arthritis  may  follow  the  fever  or  come  on  at  its 
height.  It  may  be  general  and  severe,  and  in  one  instance  anchylosis  of 
the  jaw  followed  an  attack  of  measles  in  a  child  of  four  years.  The  con- 
junctivitis may  be  followed  by  keratitis.  Otitis  media  is  not  at  all  uncom- 
mon and  may  lead  to  perforation  of  the  drum  or  mastoid  disease.  Hemiplegia 
is  a  most  serious  complication.  In  4  of  a  series  of  120  cases  the  hemiplegia 
came  on  during  measles.  It  usually  persists.  Paraplegia  due  to  acute  myeli- 
tis has  been  described.  Polyneuritis  may  occur  with  widespread  atrophy. 
Acute  mania,  meningitis,  abscess  of  the  brain,  and  multiple  sclerosis  are 
among  the  rare  complications  or  sequelae.  Scarlet  fever  may  occur  with 
measles.     Whooping-cough  not  infrequently  follows  measles. 

Diagnosis. — During  the  prevalence  of  an  epidemic  the  disease  is  easily 
recognized.  Physicians  to  isolation  hospitals  appreciate  the  practical  difficul- 
ties and  patients  with  measles  may  be  sent  to  the  small-pox  hospital;  it  is 
well  to  bear  in  mind  that  in  adults  the  beginning  of  the  eruption  on  the  face, 
its  nodular  character,  and  the  isolation  of  the  spots  may  be  suggestive  of 
variola.  From  scarlet  fever  measles  is  distinguished  by  the  longer  initial 
stage  with  characteristic  symptoms,  and  the  blotchy  irregular  character  of 
the  rash,  so  unlike  the  diffuse  uniform  erythema.  In  measles  the  mouth  (with 
the  early  Koplik  sign),  in  scarlet  fever  the  throat,  is  chiefly  affected.  Occa- 
sionally in  measles,  when  the  throat  is  very  sore  and  the  eruption  pretty  diffuse, 
there  may  at  first  be  difficulty  in  determining  which  disease  is  present,  but  a 
few  days  should  suffice  to  make  the  diagnosis  clear.  As  a  rule  there  is  no 
leucocytosis.  It  may  be  extremely  difficult  to  distinguish  from  rotheln.  The 
shorter  prodromal  stage,  the  absence  of  oculo-nasal  catarrh,  and  the  slighter 
fever  in  many  cases  are  perhaps  the  most  important  features.  It  is  difficult 
to  speak  definitely  about  the  distinctions  in  the  rash,  though  perhaps  the  more 
uniform  distribution  and  the  absence  of  the  crescentic  arrangement  are  more 
constant  in  rotheln.  In  Africans  the  disease  is  easily  recognized ;  the  papules 
stand  out  with  great  plainness,  often  in  groups;  the  hyperaemia  is  to  be  seen 
on  all  but  the  very  black  skins.  The  distribution  of  the  rash,  the  coryza, 
and  the  rash  in  the  mouth  are  important  points.     Of  drug  eruptions,  that 


353  SPECIFIC  INFECTIOUS  DISEASES 

induced  by  copaiba  is  very  like  measles,  but  is  readily  distinguished  by  the 
absence  of  fever  and  catarrh.  Antipyrin,  chloral,  and  quinine  rashes  rarely 
cause  any  difficulty  in  diagnosis.  The  serum  exanthem  of  a  diphtheria  anti- 
toxin may  be  difficult  to  recognize.  In  adults  the  acute  malignant  measles 
may  resemble  typhus  fever.  Occasionally  erythema  multiforme  may  simulate 
measles. 

Prognosis. — The  mortality  from  the  disease  itself  is  not  high,  but  the 
pulmonary  complications  render  it  one  of  the  most  serious  of  the  diseases  of 
children.  In  some  epidemics,  particularly  in  institutions  and  in  armies,  the 
death-rate  may  be  high,  not  so  much  from  the  fever  itself  as  from  the  exten- 
sion of  the  catarrhal  symptoms  to  the  finer  bronchial  tubes.  Imported  in 
1875  from  Sydney  by  H.  M.  S.  Dido  to  the  Fiji  Islands,  40,000  out  of  150,000 
of  the  inhabitants  died  in  four  months.  Panum,  the  distinguished  Danish 
physician,  described  the  widespread  and  fatal  epidemic  which  decimated  the 
inhabitants  of  the  Faroe  Islands  in  1846.  In  private  practice  the  mortality 
is  from  2  to  3  per  cent. ;  in  hospitals  from  6  to  8  or  10  per  cent. 

Prophylaxis, — The  difficulty  is  inherent  in  the  prolonged  incubation  and 
the  four  days  of  invasion,  during  which  the  catarrhal  symptoms  are  marked, 
and  the  disease  is  contagious,  and  one  often  finds  that  the  quarantine  which 
has  been  carried  out  has  been  in  vain.  From  contact  with  cases  in  the  stage 
of  invasion  and  mild  cases  with  scarcely  any  fever  the  disease  is  readily  dis- 
seminated through  schools  and  conveyed  to  healthy  children  in  the  every-day 
contact  with  each  other  on  the  streets,  in  the  squares  and  playgrounds.  Once 
manifested,  the  child  should  be  carefully  quarantined  and  all  possible  pre- 
cautions taken  against  the  spread  of  the  disease  in  the  house.  Some  health 
authorities  quarantine  only  for  five  days  after  the  appearance  of  the  rash, 
unless  there  is  cough  or  discharge  from  the  nose  or  ears. 

Treatment. — ^Confinement  to  bed  in  a  well-ventilated  room,  a  light  diet 
with  abundance  of  water  and  a  siniple  fever  mixture  are  the  only  measiires 
necessary  in  cases  of  uncomplicated  measles.  The  fever  rarely  reaches  a  dan- 
gerous height.  If  it  does  it  may  be  lowered  by  sponging  or  by  the  tepid 
bath  gradually  reduced.  If  the  rash  does  not  come  out  well,  warm  drinks 
and  a  hot  bath  will  hasten  its  maturation.  The  bowels  should  be  freely  opened. 
If  the  cough  is  distressing  compresses  should  be  applied  to  the  chest  and  in- 
halations of  the  compound  tincture  of  benzoin  or  small  doses  of  paregoric  or 
codein  given.  The  patient  should  be  kept  in  bed  for  a  few  days  after  the  fever 
subsides.  During  desquamation  the  skin  should  be  oiled  daily,  and  warm 
baths  given  to  facilitate  the  process.  The  mouth  and  nostrils  should  be  care- 
fully cleansed,  even  in  mild  cases.  The  convalescence  from  measles  is  the 
most  important  stage  and  watchfulness  and  care  may  prevent  serious  pul- 
monary complications.  The  frequency  with  which  the  mothers  of  children 
with  simple  or  tuberculous  broncho-pneumonia  tell  us  that  "the  child  caught 
cold  after  measles,"  and  the  contemplation  of  the  mortality  bills,  should 
make  us  extremely  careful  in  our  management  of  this  affection. 


EUBELLA  35c 


VI.     RUBELLA 


(Rotheln,  German  Measles) 

This  exanthem  has  also  the  names  of  rubeola  notha,  or  epidemic  roseola, 
and,  as  it  is  supposed  to  present  features  common  to  both,  has  been  also 
known  as  hybrid  measles  or  hybrid  scarlet  fever.  It  is  generally  regarded, 
however,  as  a  separate  and  distinct  affection. 

Etiology. — It  is  propagated  by  contagion  and  spreads  with  great  rapidity. 
It  frequently  attacks  adults,  and  the  occurrence  of  either  measles  or  scarlet 
fever  in  childhood  is  no  protection  against  it.  The  epidemics  of  it  are  often 
very  extensive.     The  causal  organism  is  not  known. 

Symptoms. — These  are  usually  mild,  and  it  is  altogether  a  less  serious 
affection  than  measles.  Very  exceptionally,  as  in  the  epidemics  studied  by 
Cheadle,  the  symptoms  are  severe. 

The  stage  of  incubation  is  two  weeks  or  even  longer. 

In  the  stage  of  invasion  there  are  chilliness,  headache,  pains  in  the  back 
and  legs,  and  coryza.  A  macular,  rose-red  eruption  on  the  throat  is  a  constant 
symptom,  and,  indeed,  it  was  on  this  account  that  it  was  originally  regarded 
as  a  hybrid,  having  the  sore  throat  of  scarlet  fever  and  the  rash  of  measles. 
There  may  be  very  slight  fever.  In  30  per  cent,  of  Edwards's  cases  the  tem- 
perature did  not  rise  above  100°.  The  duration  of  this  stage  is  somewhat 
variable.  The  rash  usually  appears  on  the  first  day,  some  writers  say  on  the 
second,  and  others  again  give  the  duration  of  the  stage  of  invasion  as  three 
days.  Griffith  places  it  at  two  days.  The  eruption  comes  out  first  on  the 
face,  then  on  the  chest,  and  gradually  extends  so  that  within  twenty-four 
hours  it  is  scattered  over  the  whole  body.  It  may  be  the  first  symptom  noted 
by  the  mother.  The  eruption  consists  of  a  number  of  round  or  oval,  slightly 
raised  spots,  pinkish-red  in  color,  usually  discrete,  but  sometimes  confiuent. 

The  color  of  the  rash  is  somewhat  brighter  than  in  measles.  The  patches 
are  less  distinctly  crescentic.  After  persisting  for  two  or  three  days  (some- 
times longer),  it  gradually  fades  and  there  is  a  slight  furfuraceous  desquama- 
tion. The  rash  persists  as  a  rule  longer  than  in  scarlet  fever  or  measles,  and 
the  skin  is  slightly  stained  after  it.  In  some  cases  the  rash  is  scarlatiniform, 
which  may  even  follow  a  measly  eruption.  The  lymphatic  glands  of  the  neck 
are  frequently  swollen,  and,  when  the  eruption  is  very  intense  and  diffuse, 
the  lymph-glands  in  the  other  parts  of  the  body. 

There  are  no  special  complications.  The  disease  usually  progresses  favor- 
ably ;  but  in  rare  instances  the  symptoms  are  of  greater  severity.  Albuminuria, 
arthritis,  or  even  nephritis  may  occur.  Pneumonia  and  colitis  have  been 
present  in  some  epidemics.     Icterus  has  been  seen. 

Diagnosis. — The  slightness  of  the  prodromal  symptoms,  the  mildness  or 
the  absence  of  the  fever,  the  more  diffuse  character  of  the  rash,  its  rose-red 
color,  and  the  early  enlargement  of  the  cervical  glands,  are  the  chief  points  of 
distinction  between  rotheln  and  measles. 

The  treatment  is  that  of  a  simple  febrile  affection. 

"Fourth  Disease." — Clement  Dukes,  in  a  paper  on  the  confusion  of  two 
different  diseases  under  the  name  rubella,  describes  what  he  calls  a  "fourth 


354  SPECIFIC  INFECTIOUS  DISEASES 

disease/'  in  which  the  body  is  covered  in  a  few  hours  with  a  diffuse  exanthem 
of  a  bright  red  color,  ahnost  scarlatiniform  in  appearance.  The  face  may 
remain  quite  free.     The  desquamation  is  more  marked  than  in  rotheln. 

Erythema  Infectiosum. — Under  this  term  there  has  been  described  in 
Germany,  particularly  by  Escherich,  a  feebly  contagious  disease,  characterized 
by  a  rose-red,  maculo-papular  rash,  appearing  chiefly  between  the  ages  of  four 
and  twelve.  It  has  occurred  in  epidemic  form  in  the  spring  and  summer. 
It  has  followed  outbreaks  of  measles  or  of  rotheln.  The  most  characteristic 
feature  is  the  morbilliform  eruption  on  the  extremities,  chiefly  on  the  extensor 
surfaces.     The  trunk  as  a  rule  remains  free. 


VII.     EPIDEMIC    PAROTITIS 

(Mumps) 

Definition. — A  specific  infectious  disease,  characterized  by  swelling  of  the 
salivary  glands  and  a  special  liability  to  orchitis  in  males. 

Hippocrates  described  the  disease  and  its  peculiarities — an  afl'ection  of 
children  and  young  male  adults,  the  absence  of  suppuration,  and  the  orchitis. 

Etiolo^. — The  nature  of  the  virus  is  unknown. 

It  is  endemic  in  large  centres  of  population,  and  at  certain  seasons,  par- 
ticularly spring  and  autumn,  the  cases  increase  rapidly.  It  is  met  most  fre- 
quently in  childhood  and  adolescence.  Very  young  infants  and  adults  are 
seldom  attacked.  Males  are  somewhat  more  frequently  affected  than  females. 
In  institutions,  barracks,  and  schools  the  disease  has  been  known  to  attack 
over  90  per  cent,  of  the  residents.  It  may  be  curiously  localized  in  a  city  or 
district,  or  even  in  one  part  of  a  school  or  barrack.  The  disease  is  infectious 
and  spreads  from  patient  to  patient.  The  infection  may  persist  for  as  long 
as  six  weeks.  It  may  be  congenital,  and  Hale  White  has  reported  a  case  in 
which  the  mother  and  her  new-born  child  were  attacked  at  the  same  time. 

A  remarkable  idiopathic,  non-specific  parotitis  may  follow  injury  or  dis- 
ease of  the  abdominal  or  pelvic  organs  (see  Diseases  of  the  Salivary  Glands). 

Foci  of  acute  interstitial  inflammation  have  been  found  post-mortem. 

Symptoms. — The  period  of  incubation  is  from  two  to  three  weeks,  and 
there  are  rarely  any  symptoms  during  this  stage.  The  invasion  is  marked  by 
fever,  which  is  usually  slight,  rarely  rising  above  101°,  but  in  exceptionally 
severe  cases  reaches  103°  or  104°.  The  child  complains  of  pain  just  below 
the  ear  on  one  side,  where  a  slight  swelling  is  noticed,  which  increases  grad- 
ually, and  within  forty-eight  hours  there  is  great  enlargement  of  the  neck 
and  side  of  the  cheek.  The  swelling  passes  forward  in  front  of  the  ear,  the 
lobe  of  which  is  lifted,  and  back  beneath  the  sterno-mastoid  muscle.  The 
other  side  usually  becomes  afi^ected  within  a  day  or  two,  and  the  whole  neck 
is  surrounded  by  a  collar  of  doughy  infiltration.  Only  one  gland  may  be 
involved,  or  an  interval  of  four  or  five  days  may  elapse  before  the  other  side 
is  involved.  The  submaxillary  and  sublingual  glands  become  swollen,  though 
not  always;  in  a  few  cases  they  may  be  alone  attacked.  The  lachrymal 
glands  may  be  invoh^ed.  The  greatest  inconvenience  is  experienced  in  taking 
food,  for  the  patient  is  unable  to  open  the  mouth,  and  even  speech  and  de- 


EPIDEMIC  PAEOTITIS  355 

glutition  become  difficult.  There  may  be  an  increase  in  the  secretion  of 
the  saliva,  but  the  reverse  is  sometimes  the  case.  The  mucous  membrane 
of  the  mouth  and  throat  may  be  slightly  inflamed.  There  is  seldom  great 
pain,  but  an  unpleasant  feeling  of  tension  and  tightness.  There  may  be 
earache,  even  otitis  media,  and  slight  impairment  of  hearing. 

After  persisting  for  from  seven  to  ten  days,  the  swelling  gradually  sub- 
sides and  the  child  rapidly  regaiss  his  strength  and  health  and  is  none  the 
worse  for  the  attack.  Occasionally  the  disease  is  very  severe  and  characterized 
by  high  fever,  delirium,  and  great  prostration.  The  patient  may  even  lapse 
into  a  typhoid  condition. 

Relapse  is  rare,  but  there  may  be  two  or  three  slight  recurrences  within  a 
few  weeks,  in  which  the  cervical  glands  may  enlarge.  A  second  or  even  a 
third  attack  may  occur. 

Orchitis; — Excessively  rare  before  puberty,  it  occurs  usually  about  the 
eighth  day,  and  more  particularly  if  the  boy  is  allowed  to  leave  his  bed.  One 
or  both  testicles  may  be  involved.  The  swelling  may  be  great,  and  occasionally 
effusion  takes  place  into  the  tunica  vaginalis.  The  orchitis  may  occur  before 
the  parotitis,  or  in  rare 'instances  may  be  the  only  manifestation  of  the  infec- 
tion (orchitis  parotidea) .  The  inflammation  increases  for  three  or  four  days, 
and  resolution  takes  place  gradually.  There  may  be  a  muco-purulent  dis- 
charge from  the  urethra.  In  severe  cases  atrophy  may  follow,  fortunately  as 
a  rule  only  in  one  organ;  occurring  in  both  before  puberty,  the  natural  de- 
velopment is  usually  checked.  Even  when  both  testicles  are  atrophied  and 
small,  sexual  vigor  may  be  retained.  The  proportion  of  cases  of  orchitis 
varies  in  different  epidemics;  211  cases  occurred  in  699  cases,  and  103  cases 
of  atrophy  followed  163  instances  of  orchitis  (Comby).  jSTo  satisfactory  ex- 
planation of  this  metastasis  has  been  given.  Military  surgeons,  who  see  much 
of  the  disease  in  young  recruits,  have  suggested  the  transference  of  the  virus 
to  the  penis  with  the  fingers  and  its  transmission  along  the  urethra. 

A  vulvo-vaginitis  sometimes  occurs  in-  girls,  and  the  breasts  may  become 
enlarged  and  tender.  Mastitis  has  been  seen  in  boys.  Involvement  of  the 
ovaries  is  rare.  The  thyroid  gland  may  enlarge  in  the  attack,  and  there  have 
been  features  suggestive  of  acute  pancreatitis. 

Complications  and  Sequelae. — Of  these  the  cerebral  affections  are  perhaps 
the  most  serious.  There  may  be  delirium  and  signs  of  meningeal  irritation 
but  actual  meningitis  is  rare.  Hemiplegia  and  aphasia  may  also  occur.  A 
majority  of  the  fatal  cases  are  associated  with  meningeal  symptoms  which 
are  very  rare  in  comparison  with  the  frequency  of  the  disease.  Acute  mania 
has  occurred,  and  there  are  instances  on  record  of  insanity  following  the 
disease. 

Arthritis,  albuminuria,  nephritis,  with  acute  uraemia  and  convulsions,  en- 
docarditis, pleurisy,  facial  paralysis,  hemiplegia,  and  peripheral  neuritis  are 
occasional  complications.  Suppuration  of  the  gland  is  extremely  rare. 
Gangrene  has  occasionally  occurred.  The  special  senses  may  be  seriously 
involved.  Deafness  may  occur,  and  may  be  permanent.  Affections  of  the 
eye  are  rare,  but  optic  neuritis  with  atrophy  has  been  described. 

Chronic  hypertrophy  of  the  gland  may  follow. 

Diagnosis. — The  diagnosis  of  the  disease  is  usually  easy.  The  position  of 
the  swelling  in  front  of  and  below  the  ear  and  the  elevation  of  the  lobe  on 


356  SPECIFIC  INFECTIOUS  DISEASES 

the  affected  side  definitely  fix  the  locality  of  the  swelling..    In  children  inflam- 
mation of  the  parotid,  apart  from  ordinary  mumps,  is  excessively  rare. 

Treatment. — It  is  well  to  keep  the  patient  in  bed  during  the  height  of  the 
disease.  Special  care  should  be  given  to  the  mouth  by  cleaning  after  feed- 
ing and  the  use  of  akaline  antiseptic  solutions.  The  bowels  should  be  freely 
opened,  and  the  patient  given  a  light  liquid  diet.  No  medicine  is  required 
unless  the  fever  is  high,  in  which  case  aconite  may  be  given.  Cold  com- 
presses may  be  placed  on  the  gland,  but  children,  as  a  rule,  prefer  hot  appli- 
cations. Belladonna  or  ichthyol  ointment  is  sometimes  useful.  Suppura- 
tion is  hardly  ever  to  be  dreaded,  even  though  the  gland  become  very  tense. 
With  delirium  and  head  symptoms  the  ice-cap  may  be  applied.  For  the 
orchitis,  rest,  with  support  and  protection  of  the  swollen  gland  with  cotton- 
wool, is  usually  sufficient. 

VIII.     DENGUE 

Definition. — An  acute  infectious  disease  of  tropical  and  subtropical  re- 
gions, characterized  by  febrile  paroxysms,  pains  in  the  joints  and  muscles,  an 
initial  erythematous  and  a  terminal  polymorphous  eruption.  It  is  known  as 
hreaJc-hone  fever  from  the  atrocious  character  of  the  pain,  and  dandy  fever 
from  the  stiff,  dandified  gait.  The  word  dengue  is  supposed  to  be  derived 
from  a  Spanish,  or  possibly  Hindostanee,  equivalent  of  the  word  dandy. 

History  and  Geographical  Distribution. —The  disease  was  first  recognized 
in  1779  in  Cairo  and  in  Java,  where  Bylon  described  the  outbreak  in  Batavia. 
There  have  been  widespread  epidemics  in  India  and  China.  The  description  by 
Benjamin  Eush  of  the  epidemic  in  Philadelphia  in  1780  is  one  of  the  first 
and  one  of  the  very  best  accounts  of  the  disease.  Between  1821  and  1828  it 
was  prevalent  at  intervals  in  India  and  in  the  Southern  States.  S.  H. 'Dick- 
son gives  a  graphic  description  of  the  disease  as  it  appeared  in  Charleston  in 
1828.  Since  that  date  there  have  been  four  or  five  widespread  epidemics  in 
tropical  countries  and  in  North  America  along  the  Gulf  States,  the  last  in 
1897.  None  of  the  recent  epidemics  extended  into  the  Northern  States,  but 
in  1888  it  prevailed  as  far  north  as  Virginia. 

Etiology. — The  rapidity  of  diffusion  and  the  pandemic  character  are  the 
two  most  important  features  of  dengue.  There  is  no  disease,  not  even  influ- 
enza, which  attacks  so  large  a  proportion  of  the  population.  In  Galveston,  in 
1897,  20,000  people  were  attacked  within  two  months.  The  specific  cause  is 
not  determined  but  it  is  a  filterable  virus.  The  disease  is  transmitted  by  mos- 
quitoes (Stegomyia  calopus,  Culex  fatigansf).  Epidemics  in  Australia  cor- 
responded with  the  distribution  of  the  Stegomyia  calopus  but  there  was  no 
evidence  that  Culex  fatigans  transmitted  the  disease.  Biting  experiments  were 
successful  and  it  was  transmitted  by  injecting  the  blood  subcutaneously.  The 
virus  was  present  in  the  whole  blood,  the  serum,  and  the  fluid  part  of  citrated 
blood. 

As  the  disease  is  rarely  fatal,  no  observations  have  been  made  upon  its 
pathological  anatomy. 

Symptoms. — The  period  of  incubation  is  from  three  to  five  days,  during 
which  the  patient  feels  well.  The  attack  sets  in  suddenly  Avith  headache,  chilly 
feelings,  and  intense  aching  pains  in  the  joints  and  muscles.     The  tempera- 


DENGUE  357 

ture  rises  gradually,  and  may  reach  106°  or  107°.  The  pulse  is  rapid,  and 
there  are  the  other  phenomena  associated  with  acute  fever — loss  of  appetite, 
coated  tongue,  slight  nocturnal  delirium,  and  concentrated  urine.  The  face 
has  a  suffused,  bloated  appearance,  the  eyes  are  injected,  and  the  visible  mu- 
cous membranes  are  flushed.  There  is  a  congested  erythematous  state  of  the 
skin.  Eush's  description  of  the  pains  is  worth  quoting,  as  in  it  ,the  epithet 
break-bone  occurs  in  the  literature  for  the  first  time.  "The  pains  which 
accompanied  this  fever  were  exquisitely  severe  in  the  head,  back,  and  limbs. 
The  pains  in  th^  head  were  sometimes  in  the  back  parts  of  it,  and  at  other 
times  they  occupied  only  the  eyeballs.  In  some  people  the  pains  were  so  acute 
in  their  backs  and  hips  that  they  could  not  lie  in  bed.  In  others  the  pains 
affected  the  neck  and  arms,  so  as  to  produce  in  one  instance  a  difficulty  of 
moving  the  fingers  of  the  right  hand.  They  all  complained  more  or  less  of  a 
soreness  in  the  seats  of  these  pains,  particularly  when  they  occupied  the  head 
and  eyeballs.  A  few  complained  of  their  flesh  being  sore  to  the  touch  in  every 
part  of  the  body.  From  these  circumstances  the  disease  was  sometimes  be- 
lieved to  be  a  rheumatism,  but  its  more  general  name  among  all  classes  of 
people  was  the  break-bone  fever.'^  The  large  and  small  Joints  are  affected, 
sometimes  in  succession,  and  become  swollen,  red,  and  painful.  In  some  cases 
cutaneous  hyperassthesia  has  been  noted.  Hasmorrhage  from  the  mucous 
membranes  was  noted  by  Rush,  and  black  vomit  has  also  been  described. 

The  fever  gradually  reaches  its  maximum  by  the  third  or  fourth  day ;  the 
patient  then  enters  upon  the  apyretic  period,  which  may  last  from  two  to 
four  days,  and  in  which  he  feels  prostrated  and  stiff.  A  second  paroxysm 
of  fever  then  occurs,  and  the  pains  return.  In  a  large  number  of  cases  an 
eruption  is  common,  which,  judging  from  the  description,  has  nothing  dis- 
tinctive, being  sometimes  macular,  like  that  of  measles,  sometimes  diffuse  and 
scarlatiniform,  or  papular,  or  lichen-like.  In  other  instances  the  rash  has 
been  described  as  urticarial,  or  even  vesicular.  The  rash  may  persist  for  a 
month  after  the  symptoms  have  disappeared.  Certain  writers  describe  in- 
flammation and  hypersemia  of  the  mucous  membrane  of  the  nose,  mouth  and 
pharynx.  Enlargement  of  the  lymph-glands  is  not  uncommon,  and  may  per- 
sist for  weeks  after  the  disappearance  of  the  fever.  Convalescence  is  often 
protracted,  and  there  is  a  degree  of  mental  and  physical  prostration  out  of  all 
proportion  to  the  severity  of  the  primary  attack.  The  pains  in  the  joints  or 
muscles,  sometimes  very  local,  may  persist  for  weeks.  Eush  refers  to  the 
former,  stating  that  a  young  lady  after  recovery  said  it  should  be  called 
break-heart,  not  break-bone,  fever.  The  average  duration  of  a  moderate  at- 
tack is  from  seven  to  eight  days.  Dengue  is  very  seldom  fatal.  Dickson  saw 
three  deaths  in  the  Charleston  epidemic. 

Complications  are  rare.  Insomnia  and  occasionally  delirium,  resembling 
somewhat  the  alcoholic  form,  have  been  observed,  and  convulsions  in  children. 
Atrophy  of  the  muscles  may  occur  after  the  attack.  A  relapse  may  occur  even 
as  late  as  two  weeks. 

Diagnosis. — The  diagnosis  of  tlie  disease,  prevailing  as  it  does  in  epidemic 
form  and  attacking  all  classes  indiscriminately,  rarely  offers  any  special  diffi- 
culty. Isolated  cases  might  be  mistaken  at  first  for  rheumatic  fever.  The 
seven-day  f^ver  of  East  Indian  ports  is  believed  to  be  dengue.  It  is  a  sporadic 
fever  of  the  hot  weather,  attacking  a  large  proportion  of   Kiironeans  within 


358  SPECIFIC  INFECTIOUS  DISEASES 

the  first  year  or  two  of  their  arrival.  Possibly,  as  Eogers  thinks,  it  may  be  a 
distinct  disease,  and  it  is  variously  known  in  India  as  ephemeral  fever,  mild 
malaria,  or  simple  continued  fever.  It  is  characterized  by  early  and  severe 
pains  in  the  back  and  limbs,  and  a  fever  of  six  to  seven  days'  duration. 

Treatment. — The  patients  should  be  protected  from  mosquitoes  during  the 
febrile  period.  The  treatment  is  entirely  symptomatic.  Hydrotherapy  may  be 
employed  to  reduce  the  fever.  The  salicylates  or  antipyrin  may  be  tried  for 
the  pains,  which  usually,  however,  require  opium.  During  convalescence  iodide 
of  potassium  is  recommended  for  the  arthritic  pains,  and  tonics  are  indicated. 


IX.     HYDROPHOBIA 

(Lyssa;  Rabies) 

Definition. — An  acute  disease  of  warm-blooded  animals,  dependent  upon 
a  virus  which  is  communicated  by  inoculation  to  man. 

Distribution. -^-Eabies  is  very  variously  distributed.  In  Eussia  it  is  com- 
mon. In  North  Germany  it  is  relatively  rare,  owing  to  the  wise  provision 
that  all  dogs  must  be  muzzled.  In  France  it  is  much  more  common.  In 
England  the  muzzling  order  has  been  followed  by  an  almost  complete  disap- 
pearance of  the  disease  and  there  were  only  4  deaths  from  1901-1916.  In 
the  decennium  ending  with  1890  the  deaths  averaged  29  annually  (Tatham). 
In  the  United  States  there  were  66  deaths  in  the  registration  area  in  1917. 

Etiology. — Dogs  are  especially  liable  to  the  disease.  It  also  occurs  in 
the  wolf,  fox,  skunk,  cat,  horse  and  cow.  Most  animals  are  susceptible;  and 
it  is  communicable  by  inoculation  to  the  rabbit  and  pig.  The  disease  is  propa- 
gated chiefly  by  the  dog.  The  nature  of  the  poison  is  as  yet  unknown.  It  is 
contained  chiefly  in  the  nervous  system  and  in  some,  of  the  secretions,  par- 
ticularly in  the  saliva.  Bartarelli  has  shown  that  the  virus  reaches  the  dog's 
salivary  glands  by  way  of  the  nerves  and  not  through  the  blood-vessels. 

A  variable  time  elapses  between  the  introduction  of  the  virus  and  the 
appearance  of  the  symptoms.  Horsley  stated  that  this  depends  upon  the  fol- 
lowing factors:  "(a)  Age.  The  incubation  is  shorter  in  children  than  in 
adults.  For  obvious  reasons  the  former  are  more  frequently  attacked.  (6) 
Part  infected.  The  rapidity  of  onset  of  the  symptoms  is  greatly  determined 
by  the  part  of  the  body  which  may  happen  to  have  been  bitten.  Wounds  about 
the  face  and  head  are  especially  dangerous;  next  in  order  in  degrees  of  mor- 
tality come  bites  on  the  hands,  then  injuries  on  the  other  parts  of  the  body. 
This  relative  order  is,  no  doubt,  greatly  dependent  upon  the  fact  that  the 
face,  head,  and  hands  are  usually  naked,  while  the  other  parts  are  clothed;  it 
would  also  appear  to  depend  somewhat  upon  the  richness  in  nerves  of  the 
part,  (c)  The  extent  and  severity  of  the  wound.  Puncture  wounds  are  the 
most  dangerous;  the  lacerations  are  fatal  in  proportion  to  the  extent  of  the 
surface  afforded  for  absorption  of  the  virtis.  (d)  The  animal  conveying  the 
infection.  In  order  of  decreasing  severity  come :  first,  the  wolf ;  second,  the 
cat;  third,  the  dog;  and  fourth,  other  animals."  Only  a  limited  number  of 
those  bitten  by  rabid  dogs  become  affected  by  the  disease;  according  to  Hors- 
ley, not  more  than  15  per  cent.     On  the  other  hand,  the  death-rate  of  those 


HYDROPHOBIA  359 

persons  bitten  by  wolves  is  higher,  not  less  than  40  per  cent.  Babes  gives  the 
mortality  as  from  60  to  80  per  cent. 

The  incubation  period  in  man  is  extremely  variable.  The  average  is  from 
six  weeks  to  two  months.  In  a  few  cases  it  has  been  under  two  weeks.  It 
may  be  prolonged  to  three  months.  It  is  stated  that  the  incubation  may  be 
prolonged  for  a  year  or  even  two  years,  but  this  has  not  been  definitely  settled. 

Morbid  Anatomy. — The  important  lesions  consist  in  the  accumulation  of 
leucocytes  around  the  blood-vessels  and  the  nerve-cells,  particularly  the  motor 
ganglion  cells,  of  the  central  nervous  system  (rabic  tubercles  of  Babes).  Es- 
pecial importance  in  the  rapid  diagnosis  of  rabies  is  attached  by  van  Gehuch- 
ten  and  Nelis  to  the  accumulation  of  lymphoid  and  endothelioid  cells  aroundi 
nerve-cells  of  the  sympathetic  and  cerebro-spinal  ganglia.  Negri  described 
in  the  central  nervous  system  irregular  bodies  varying  from  4  to  10  microns  in 
size,  widespread,  frequently  in  the  cells  of  the  cerebellum,  cerebral  cortex  and 
pons,  and  in  the  spinal  cord.  They  are  probably  protozoa,  and  it  is  stated 
that  they  furnish  a  rapid  and  trustworthy  means  of  diagnosis.  The  inocula- 
tion experiments  show  that  the  virus  is  not  present  in  the  liver,  spleen,  or 
kidneys,  but  is  abundant  in  the  spinal  cord,  brain,  and  peripheral  nerves. 

Symptoms. — Three  stages  of  the  disease  are  recognized: 

(a)  Premonitory  stage,  in  which  there  may  be  irritation  about  the  bite, 
pain,  or  numbness.  The  patient  is  depressed  and  melancholy;  and  complains 
of  headache  and  loss  of  appetite.  He  is  irritable  and  sleepless,  and  has  a 
sense  of  impending  danger.  There  is  often  greatly  increased  sensibility.  A 
bright  light  or  a  loud  voice  is  distressing.  The  larynx  may  be  injected,  the 
voice  becoming  husky,  and  the  first  symptoms  of  difficulty  in  swallowing  are 
experienced.     There  is  a  slight  rise  in  the  temperature  and  pulse. 

(&)  Stage  of  Excitement. — This  is  characterized  by  great  excitability 
and  restlessness,  and  an  extreme  degree  of  hypersesthesia.  "Any  afferent 
stimulant — i.  e.,  a  sound  or  a  d.raught  of  air,  or  the  mere  association  of  a 
verbal  suggestion — will  cause  a  violent  reflex  spasm.  In  man  this  symptom 
constitutes  the  most  distressing  feature  of  the  malady.  The  spasms,  which 
affect  particularly  the  muscles  of  the  larynx  and  mouth,  are  exceedingly  pain- 
ful and  are  accompanied  by  an  intense  sense  of  dyspnoea,  even  when  the  glottis 
is  widely  opened  or  tracheotomy  has  been  performed"  (Horsley).  Any  attempt 
to  take  water  is  followed  by  an  intensely  painful  spasm  of  the  muscles  of 
larynx  and  of  the  elevators  of  the  hyoid  bone.  It  is  this  which  makes  the 
patient  dread  the  very  sight  of  water  and  gives  the  name  hydrophobia  to  the 
disease.  These  spasmodic  attacks  may  be  associated  with  maniacal  symptoms. 
In  the  intervals  the  patient  is  quiet  and  the  mind  unclouded.  The  tempera- 
ture in  this  stage  is  usually  elevated  and  may  reach  from  100°  to  103°,  In 
some  instances  the  disease  is  afebrile.  The  patient  rarely  attempts  to  injure 
his  attendants,  and  in  the  intense  spasms  may  be  particularly  anxious  to  avoid 
hurting  any  one.  There  are,  however,  occasional  fits  of  furious  mania,  and 
the  patient  may,  in  the  contractions  of  the  muscles  of  the  larynx  and  pharynx, 
give  utterance  to  odd  sounds.  This  stage  lasts  from  a  day  and  a  half  to  three 
days  and  gradually  passes  into  the — 

(c)  Paralytic  Stage. — In  rodents  the  preliminary  and  furious  stages 
are  absent,  as  a  rule,  and  the  paralytic  stage  may  l)e  marked  from  the  outset 
— the  so-called  dumb  rabies.     This  stage  rarely  lasts  longer  than  from  six  to 


S60  SPECIFIC  INFECTIOUS  DISEASES 

eighteen  hours.  The  patient  then  becomes  quiet ;  the  spasms  no  longer  occur ; 
unconsciousness  gradually  supervenes;  the  heart's  action  becomes  more  and 
more  enfeebled,  and  death  occurs  by  syncope. 

Dia^osis. — In  man  this  offers  no  special  difficulties.  It  is  advisable,  in 
cases  with  any  doubts,  as  soon  as  possible  after  the  injury,  to  secure  the  brain 
of  the  supposed  rabid  animal  for  examination.  The  recognition  of  the  Negri 
bodies  in  smears  of  brain  substance  enables  the  diagnosis  to  be  made  promptly. 

Treatment. — Prophylaxis  is  of  the  greatest  importance,  and  by  a  system- 
atic muzzling  of  dogs  the  disease  can  be  practically  eradicated. 

In  case  of  a  bite  from  a  suspicious  animal,  bleeding  should  be  encouraged, 
the  wound  freely  opened  and  washed  with  bichloride  of  mercury  solution  (1 
to  1,000).  Thorough  cauterization  should  be  done  as  soon  as  possible,  for 
which  pure  carbolic  or  nitric  acid  should  be  used,  being  applied  to  every  part 
of  the  wound.  The  wound  is  washed  with  a  saturated  solution  of  bicarbonate 
of  soda  and  then  with  alcohol.  MTien  once  established  the  disease  is  hope- 
lessly incurable.  No  measures  have  been  found  of  the  slightest  avail,  conse- 
quently the  treatment  must  be  palliative.  The  patient  should  be  kept  in  a 
darkened  room,  in  charge  of  not  more  than  two  attendants.  To  allay  the 
spasm,  chloroform  may  be  administered  and  morphia  given  hypodermically. 
It  is  best  to  use  these  powerful  remedies  from  the  outset,  and  not  to  tem- 
porize with  chloral,  bromide  of  potassium,  and  other  less  potent  drugs.  By 
the  local  application  of  cocaine,  the  sensitiveness  of  the  throat  may  be  dimin- 
ished sufficiently  to  enable  the  patient  to  take  liquid  nourishment.  Some- 
times he  can  swallow  readily.    Fluid  can  be  given  by  the  bowel. 

Preventive  Inoculation. — Pasteur  found  that  the  virus,  when  propa- 
gated through  a  series  of  rabbits,  increases  in  its  virulence;  so  that  whereas 
subdural  inoculation  of  the  brain  of  a  mad  dog  takes  from  fifteen  to  twenty 
days  to  produce  the  disease,  in  successive  inoculation  in  a  series  of  rabbits  the 
incubation  period  is  gradually  reduced  to  seven  days  (virus  fixe).  The  spinal 
cords  of  these  rabbits  contain  the  virus  in  great  intensity,  but  when  they  are 
preserved  in  dry  air  this  gradually  diminishes.  If  now  dogs  are  inoculated 
from  cords  preserved  for  from  twelve  to  fifteen  days,  and  then  from  cords 
preserved  for  a  shorter  period,  i.  e.,  with  a  progressively  stronger  virus,  they 
gradually  acquire  immunity  against  the  disease.  Relying  upon  these  experi- 
ments, Pasteur  began  inoculations  in  the  human  subject,  using,  on  successive 
days,  material  from  cords  in  which  the  virus  was  of  varying  degrees  of  in- 
tensity. 

In  1910,  410  patients  were  treated  at  the  Pasteur  Institute  of  Paris  Avith- 
out  a  death;  in  1908  and  1909,  991  cases  with  2  deaths.  There  has  been  a 
progressive  decline  in  the  number  of  cases  and  in  the  mortality. 

Pseudo-hydrophobia  (Lysso phobia). — This  may  closely  resemble  hydro- 
phobia, but  is  nothing  more  than  a  neurotic  or  hysterical  manifestation.  A 
nervous  person  bitten  by  a  dog,  either  rabid  or  supposed  to  be  rabid,  has  with- 
in a  few  months,  or  even  later,  symptoms  somewhat  resembling  the  true 
disease.  He  is  irritable  and  depressed.  He  constantly  declares  his  condition 
to  be  serious  and  that  he  will  inevii^ably  become  mad.  He  may  have  paroxysms 
in  which  he  says  he  is  unable  to  drink,  grasps  at  his  throat,  and  becomes 
emotional.  The  temperature  is  not  elevated  and  the  disease  does  not  progress. 
It  lasts  much  longer  than  the  true  rabies,  and  is  amenable  to  treatment.     It 


EHEUMATIC  FEVEE  361 

is  not  improbable  that  a  majority  of  the  cases  of  alleged  recovery  in  this 
disease  have  been  of  this  hysterical  form.  Certain  cases  of  acute  bulbar 
paralysis  may  resemble  hydrophobia,  and,  as  already  mentioned,  there  is  a 
form  of  tetanus  "with  hydrophobic  symptoms. 


X.     RHEUMATIC  FEVER 

Definition. — An  acute  infection,  dependent  upon  an  unknown  infective 
agent,  and  characterized  by  arthritis,  myocarditis,  and  a  marked  tendency  to 
inflammation  of  the  endocardium  of  the  valves  of  the  heart. 

Etiology. — Distribution  and  Prevalence. — It  prevails  in  temperate  and 
humid  climates,  and  is  apparently  very  rare  in  the  tropics.  In  the  Eegistrar 
General's  report  for  England  and  Wales  for  1916  there  were  1,88G  deaths 
from  the  disease  and  2,276  deaths  under  the  age  of  twenty  years  from  acute 
endocarditis  and  pericarditis.  The  disease  prevails  more  in  the  northern  lati- 
tudes. In  the  Montreal  General  Hospital  there  were,  for  the  twelve  years 
ending  1903,  2  deaths  in  482  cases  among  12,011  admissions;  at  the  Eoyal 
Victoria  Hospital,  Montreal,  for  ten  years  ending  1903,  3  deaths  in  285  cases 
among  9,286  admissions  (John  McCrae).  At  the  Johns  Hopkins  Hospital 
for  the  fifteen  years  ending  1901  there  were  360  admissions  (330  patients) 
and  9  deaths.  The  general  impression  is  that  the  disease  prevails  more  in 
the  British  Isles  than  elsewhere;  but  the  returns  are  very  imperfect  (this  holds 
good  everywhere). 

Season. — In  London  the  cases  reach  the  maximum  in  the  months  of  Sep- 
tember and  October.  Bell's  statistics  of  456  cases  in  Montreal  show  that 
the  largest  number  was  admitted  in  February,  March,  and  April.  And  the 
same  is  true  in  Baltimore;  55  per  cent,  of  our  cases  were  admitted  in  the 
first  four  months  of  the  year.  The  disease  prevails  most  in  dry  years  or  a 
succession  of  such,  and  is  specially  prevalent  when  the  subsoil  water  is 
abnormally  low  and  the  temperature  of  the  earth  high   (Xewsholme). 

Age. — Young  adults  are  ■  frequently  affected,  but  the  disease  is  common 
in  children.  In  England  the  incidence  in  children  is  very  high.  In 
2,556  examined  by  Langmead,  133  were  definitely  rheumatic  and  in  all  but  18 
the  heart  was  involved.  In  43  per  cent,  of  these  cases  there  was  some 
abnormality  of  the  tonsils  or  pharyngeal  mucosa.  Sucklings  are  rarely 
attacked.  Milton  Miller  analyzed  19  undoubted  cases.  They  have  to  be 
distinguished  from  a  totally  different  affection,  the  pyogenic  arthritis  of 
infants.  Of  456  cases  admitted  to  the  Montreal  General  Hospital  there  were, 
under  fifteen  years,  4.38  per  cent. ;  from  fifteen  to  twenty-five  years,  48.68 
per  cent. ;  from  twenty-five  to  thirty-five  years,  25.87  per  cent. ;  from  thirty- 
five  to  forty-five  years,  13.6  per  cent. ;  above  forty-five  years,  7.4  per  cent.  Of 
our  360  admissions,  110  were  in  the  third  decade  and  65  per  cent,  below  the 
thirtieth  year  of  age.  Ten  per  cent,  of  the  cases  had  the  first  attack  in  the 
first  decade.  Of  655  cases  analyzed  by  Whipham,  only  32  cases  occurred 
under  the  tenth  year  and  80  per  cent,  between  the  twentieth  and  fortieth  years. 
These  figures  do  not  give  the  ratio  of  cases  in  children,  in  whom  the  milder 
types  of  arthritis  are  very  common. 

Sex. — If  all  ages  are  taken,  males  are  affected  oftener  than  females.     Of 


362  SPECIFIC  mFECTIOUS  DISEASES 

our  patients,  239  were  males,  91  females.  In  the  Collective  Investigation 
Eeport  there  were  375  males  and  279  females.  Up  to  the  age  of  twenty, 
however,  females  predominate.  Between  the  ages  of  ten  and  fifteen  girls 
ar^  more  prone  to  the  disease. 

Heredity. — It  is  a  deeply  grounded  belief  that  this  is  a  family  disease, 
but  the  evidence  is  imperfect.  The  not  rare  occurrence  in  severa,l  members 
of  the  same  family  is  used  by  those  who  believe  in  the  infectious  origin  as  an 
argument  in  favor  of  its  being  a  house  disease. 

Chill. — Exposure  to  cold,  a  wetting,  and  a  sudden  change  of  temperature 
are  among  the  factors  in  determining  the  onset  of  an  attack,  but  they  were 
present  in  only  12  per  cent,  of  our  cases. 

Xot  only  does  an  attack  not  confer  immunity,  but,  as  in  pneumonia,  pre- 
disposes the  subject  to  the  disease. 

Rheumatic  Fever  as  an  Acute  Infectious  Disease.- — Eheumatic  fever,  as 
Xewsholme  has  shown,  has  epidemic  prevalence  with  irregular  periodicity,  re- 
curring at  intervals  of  three,  four,  or  six  years,  and  varying  much  in  inten- 
sity. A  severe  epidemic  is  usually  followed  by  two  or  three  years  of  slight 
prevalence.  The  disease  has  features  suggestive  of  septic  infection.  In  the 
character  of  the  fever,  the  arthritis,  the  tendency  to  relapse,  the  sv/eats,  the 
ansemia,  the  leucocytosis,  and,  above  all,  in  the  great  liability  to  endocarditis, 
and  to  involvement  of  the  serous  membranes,  the  disease  resembles  pysemia. 

The  tonsils  are  culture  centres  for  many  septic  organisms,  particularly 
of  the  streptococcus  type.  The  association  of  rheumatic  fever  and  arthritic 
affections  generally  "with  infected  tonsils  is  a  prevailing  view,  but  it  is  an 
old  storv  insisted  on  by  Lasagne  and  other  French  writers  years  ago.  A  not 
inconsiderable  number  of  cases  of  rheumatic  fever  begin  with  tonsillitis.  With 
organisms  isolated  from  the  tonsils  experimental  arthritis  and  endocarditis 
have  been  caused.  The  removal  of  the  tonsils  has  been  followed  by  a  com- 
plete recovery  of  sub-acute  and  chronic  forms  of  arthritis.  This  is  as  far 
as  the  evidence  goes. 

There  is  no  agreement  as  to  the  causal  organism.  On  the  one  hand 
are  those  who  claim  to  have  isolated  a  specific  organism  which  can  be  found 
in  many  of  the  lesions  of  the  disease,  e.  g.,  pericarditis  and  endocarditis,  and 
sometimes  obtained  from  the  blood.  To  this  the  name  of  Micrococcus  rlieu- 
maticus  has  been  given.  On  the  other  hand  many  observers  consider  that  a 
variety  of  streptococci,  usually  of  the  milder  types,  are  concerned.  Many 
or  onanisms,  especially  those  obtained  from  the  tonsils,  cause  arthritis,  endo- 
carditis, etc.,  when  injected  into  the  blood  of  animals,  but  this  does  not 
prove  them  to  be  the  causal  agent  in  rheumatic  fever.  The  question  can 
not  be  regarded  as  settled  but  the  view  that  a  specific  causal  organism  is 
responsible  has  much  to  support  it  and  is  in  agreement  with  the  etiology 
of  acute  infectious  diseases  generally.  There  is  considerable  evidence  against 
the  view  that  it  is  simply  a  mild  pyogenic  infection.  Salicylates  have 
no  effect  on  the  ordinary  streptococcus  .infections,  and  the  clinical  course  in 
the  streptococcus  arthritis  is  very  different ;  rheumatic  joints  never  suppurate. 
The  isolation  of  streptococci  may  simply  indicate  the  presence  of  secondary 
invaders  such  as  occur  in  scarlet  fever  and  small-pox. 

Morbid  Anatomy. — The  affected  joints  show  hyperaemia  and  swelling  of 
the  synovial  membranes  and  of  the  ligamentous  tissues.     The  fluid  in  the 


RHEUMATIC  FEVER  363 

joint  is  tiirbid,  albuminous,  and  contains  leucocytes  and  a  few  fibrin  flakes. 
Rheumatic  fever  rarely  proves  fatal,  except  when  there  are  serious  complica- 
tions, such  as  pericarditis,  endocarditis,  myocarditis,  pleurisy,  or  pneumonia. 
The  changes  in  the  myocardium  are  regarded  as  characteristic  .by  many 
workers.  Klotz  has  drawn  attention  to  the  frequency  of  arterial  lesions, 
especially  in  the  aorta,  which  involve  particularly  the  outer  portion  of  the 
media  and  the  adventitia.  Changes  in  the  coronary  arteries,  an  inflammatory 
fibrosis,  are  common. 

Symptoms. — As  a  rule,  the  disease  sets  in  abruptly,  but  it  may  be  preceded 
by  irregular  pains  in  the  joints,  slight  malmse,  sore  throat,  and  particularly  by 
tonsillitis.  A  definite  rigor  is  uncommon ;  more  often  there  is  slight 
chilliness.  The  fever  rises  quickly,  and  with  it  one  or  more  of  the  joints  become 
painful.  Within  twenty-four  hours  from  the  onset  the  disease  is  fully  mani- 
fest. The  temperature  range  is  from  102°  to  104°.  The  pulse  is  frequent, 
soft,  and  usually  above  100.  The  tongue  is  moist,  and  rapidly  becomes  cov- 
ered with  a  white  fur.  There  are  the  ordinary  symptoms  associated  with  an 
acute  fever,  such  as  loss  of  appetite,  thirst,  constipation,  and  a  scanty,  highly 
acid,  highly  colored  urine.  In  a  majority  of  the  cases  there  are  profuse,  very 
acid  sweats,  of  a  peculiar  sour  odor.  Sudaminal  and  miliary  vesicles  are 
abundant,  the  latter  usually  surrounded  by  a  minute  ring  of  hyperemia.  The 
mind  is  clear,  except  in  the  cases  with  hyperpyrexia.  The  affected  joints  are 
painful  to  move,  soon  become  swollen  and  hot,  and  present  a  reddish  flush. 
The  order  of  frequency  of  involvement  of  the  joints  in  our  series  was  knee, 
ankle,  shoulder,  wrist,  elbow,  hip,  hand, 'foot.  The  joints  are  not  attacked 
together,  but  successively.  For  example,  if  the  knee  is  first  affected,  the  red- 
ness may  disappear  from  it  as  the  wrists  become  painful  and  hot.  The  disease 
is  seldom  limited  to  a  single  articulation.  The  amount  of  swelling  is  variable. 
Extensive  effusion  into  a  joint  is  rare,  and  much  of  the  enlargement  is 
due  to  the  infiltration  of  the  periarticular  tissues  with  serum.  The  swelling 
may  be  limited  to  the  joint  proper,  but  in  the  wrists  and  ankles  it  sometimes 
involves  the  sheaths  of  the  tendons  and  produces  great  enlargement  of  the 
hands  and  feet.  Corresponding  joints  are  often  affected.  In  attacks  of  great 
severity  every  one  of  the  larger  joints  may  be  involved.  The  vertebral, 
sterno-clavicular,  and  phalangeal  articulations  are  less  often  inflamed  than 
in  gonorrhoeal  arthritis.  Perhaps  no  disease  is  more  painful;  the  inability 
to  change  the  posture  without  agonizing  pain,  the  drenching  sweats,  the 
prostration  and  helplessness,  combine  to  make  it  a  most  distressing  affection. 
A  special  feature  is  the  tendency  of  the  inflammation  to  subside  in  one  joint 
while  increasing  in  another. 

The  temperature  range  in  an  ordinary  attack  is  between  102°  and  104°  F. 
In  only  18  of  our  cases  did  the  temperature  rise  above  104°  F.  In  100  it 
reached  103°  F.  or  over.  It  is  peculiarly  irregular,  with  marked  remissions 
and  exacerbations,  and  defervescence  is  usually  gradual.  The  profuse  sweats 
materially  influence  the  temperature  curve.  If  a  two-hourly  chart  is  made 
and  observations  upon  the  sweats  are  noted,  the  remissions  will  usually  be 
found  coincident  with  them.  The  perspiration  is  sour-smelling  and  acid  at 
first ;  but,  when  persistent,  becomes  neutral  or  even  alkaline. 

The  blood  is  profoundly  altered  and  there  is  no  acute  febrile  disease  in 


364  SPECIFIC  IXFECTIOUS  DISEASES 

which  an  ansemia  occurs  with  greater  rapidity.  The  average  leucocyte  count 
in  our  cases  was  about  12,000  per  c.  mm. 

With  the  high  fe^er  a  murmur  may  often  be  heard  at  the  apex  region. 
Endocarditis  is  also  a  common  cause  of  an  apex  bruit.  The  heart  should  be 
carefully  examined  at  the  first  visit  and  subsequently  each  day. 

The  urine  is,  as  a  rule,  reduced  in  amount,  of  high  density. and  high  color. 
It  is  very  acid,  and,  on  cooling,  deposits  urates.  The  chlorides  may  be  greatly 
diminished  or  even  absent.  Formic  acid  is  present  (Walker).  Febrile  albu- 
minuria is  not  uncommon. 

The  so-called  suhacute  rlieumatism  represents  a  milder  form  of  the  dis- 
ease, in  which  all  the  symptoms  are  less  pronounced.  The  fever  rarely  rises 
above  101°;  fewer  joints  are  involved;  and  the  arthritis  is  less  intense.  The 
cases  may  drag  on  for  weeks  or  months.  It  should  not  be  forgotten  that  this 
mild  or  subacute  form  may  be  associated  with  endocarditis  or  pericarditis. 

The  influence  of  age  on  the  manifestations  of  the  disease  is  marked. 
While  the  usual  description  applies  to  the  disease  as  seen  in  adults,  in  young 
children  there  may  not  be  any  pronounced  arthritis,  and  the  discovery  of 
endocarditis  often  suggests  the  diagnosis.  Endocarditis  and  myocarditis  are 
the  prominent  features  in  children  as  arthritis  is  in  adults. 

Complications. — These  are  important  and  serious. 

(a)  ITtpeepyeexia. — The  temperature  may  rise  rapidly  a  few  days  after 
the  onset,  and  be  associated  with  delirium;  but  not  necessarily,  for  the  tem- 
perature may  rise  to  108°  or,  as  in  one  of  Da  Costa's  cases,  110°,  without 
cerebral  symptoms.  Hyperpyrexia  is  most  common  in  first  attacks,  57  of  107 
cases  (Church).  ■  It  is  most  apt  to  occur  during  the  second  week.  Delirium 
may  precede  or  follow  its  onset.  As  a  rule,  with  the  high  fever,  the  pulse  is 
feeble  and  frequent,  the  prostration  is  extreme,  and  finally  stupor  super- 
venes. In  our  series  there  was  no  instance  of  hyperpyrexia,  which  seems  rare 
in  the  United  States. 

(h)  Cakdiac  Affectioxs. —  (1)  Endocarditis  occurs  in  a  considerable 
percentage  of  all  cases.  Of  889  cases,  49-1  had  signs  of  old  or  recent  endo- 
carditis (Church).  The  liability  to  endocarditis  diminishes  as  age  advances. 
Its  incidence  in  our  cases  was  more  than  double  in  patients  who  had  their 
first  attack  before  the  age  of  twenty  years,  compared  with  those  with  the 
first  attack  after  twenty  years'  of  age.  It  increases  directly  with  the  number 
of  attacks.  Of  116  cases,  in  the  first  attack  58.1  per  cent,  had  endocarditis,  63 
per  cent,  in  the  second  attack,  and  71  per  cent,  in  the  third  attack  (Stephen 
Mackenzie).  Thirty-five  per  cent,  of  our  cases  showed  organic  valve  lesions, 
in  96  per  cent,  the  mitral  was  involved,  in  27  per  cent,  the  aortic,  and  in 
23  per  cent,  the  lesions  were  combined.  The  mitral  segments  are  most  fre- 
quently involved  and  the  affection  is  usually  of  the  simple,  verrucose  variety, 
ricerative  endocarditis  is  very  rare.  The  valvulitis  in  itself  is  rarely  dan- 
gerous, producing  few  symptoms,  and  often  overlooked.  Unhappily,  though  the 
valve  at  the  time  may  not  be  seriously  damaged,  the  inflammation  starts 
changes  which  lead  to  sclerosis  and  retraction  of  the  segments,  and  so  to 
chronic  valvular  disease.     Yenous  thrombosis  is  an  occasional  complication. 

(2)  Pericarditis  may  occur  independently  of  or  together  with  endocar- 
ditis. It  may  be  simple  fibrinous,  sero-fibrinous,  or  in  children  purulent. 
Clinically  we  meet  it  more  frequently  in  connection  with  tliis  disease  than 


EHEUMATIC  FEVEE  365 

in  any  other  acute  affection.  It  was  present  in  30  cases  of  our  series — 6  per 
cent. — in  only  four  of  which  did  effusion  occur.  The  physical  signs  are  very 
characteristic.  The  condition  is  described  under  its  appropriate  section.  A 
peculiar  form  of  delirium  may  accompany  rheumatic  pericarditis. 

(3)  Myocarditis  is  probably  always  present  in  some  degree  and  is  especially 
marked  in  connection  with  endopericardial  changes.  As  Sturges  insisted,  the 
term  carditis  is  applicable  to  many  cases.  The  anatomical  condition  is  a 
granular  or  fatty  degeneration  of  the  heart-muscle,  which  leads  to  weakening 
of  the  walls  and  dilatation.  There  is  dilatation  of  the  heart  in  the  majority 
of  cases  during  the  acute  period. 

(c)  Aortitis. — This  is  especially  common  in  children  and  particularly 
with  aortic  endocarditis.  The  enlargement  of  the  aorta  may  be  marked. 
In  some  cases  the  acute  condition  results  in  permanent  dilatation. 

{d)  Pulmonary  Affections. — Pneumonia  and  pleurisy  occurred  in  9.94 
per  cent,  of  3,433  cases  (Stephen  Mackenzie).  They  frequently  accompany 
the  cases  of  endo-pericarditis.  According  to  Howard's  analysis  of  a  large 
number  of  cases,  there  were  pulmonary  complications  in  only  10.5  per  cent, 
of  cases  of  rheumatic  endocarditis;  in  58  per  cent,  of  cases  of  pericarditis;  and 
in  71  per  cent,  of  cases  of  endo-pericarditis.  Congestion  of  the  lung  is  occa- 
sionally found,  and  in  several  cases  has  proved  rapidly  fatal. 

{e)  Xervous  Complications. — These  are  due,  in  part,  to  the  hyper- 
pyrexia and  in  part  to  the  special  action  of  the  toxic  agent.  They  may  be 
grouped  as  follows:  (t)  Cerebral  rheumatism,  as  it  is  called,  which  is 
characterized  by  (a)  Delirium,  associated  with  the  hyperpyrexia  or  the 
tox£emia,  may  be  active  and  noisy  in  character;  more  rarely  it  is  a  low, 
muttering  delirium,  passing  into  stupor  and  coma.  It  may  be  excited  by  the 
salicylate  of  soda,  either  shortly  after  its  administration,  or  more  commonly 
a  few  days  later.  It  was  present  in  only  5  of  our  360  cases,  and  in  4  of 
these  we  thought  the  salicylates  at  fault.  A  peculiar  delirium  occurs  in 
connection  with  rheumatic  pericarditis.  (/3)  Coma,  which  is  more  serious, 
may  occur  without  preliminary  delirium  or  convulsions,  and  prove  rapidly 
fatal.  Certain  of  these  cases  occur  with  hyperpyrexia,  but  others  are  asso- 
ciated with  renal  changes  and  are  evidently  uraemic.  The  coma  may  supervene 
during  the  attack,  or  after  convalescence  has  set  in.  (y)  Convulsions  are 
less  common,  though  they  may  precede  the  coma.  Of  127  observations  cited 
by  Besnier,  there  were  37  of  delirium,  only  7  of  convulsions,  17  of  coma  and 
convulsions,  54  of  delirium,  coma,  and  convulsions,  and  3  of  other  varieties 
(Howard).  "Cerebral  rheumatism"  is  a  very  serious  complication;  among 
107  cases  collected  by  the  Clinical  Society  of  London  there  were  57  deaths, 
(n)  Chorea.  The  relations  of  this  disease  and  rheumatic  fever  will  be  sub- 
sequently discussed.  It  is  sullficient  here  to  say  that  in  only  88  out  of  554 
cases  analyzed  from  the  Infirmary  for  Diseases  of  the  Nervous  System, 
Philadelphia,  were  chorea  and  rheumatism  associated.  It  is  most  apt  to 
develop  in  the  slighter  attacks  in  childhood.  (Hi)  Meningitis  is  extremely 
rare,  though  undoubtedly  it  does  occur.  (iv)  Polyneuritis  has  been  de- 
scribed and  may  follow  hyperpyrexia.  In  one  case  free  venesection  saved 
the  patient's  life.  After  many  months  the  patient  recovered,  but  with  ataxia. 
(/)  Cutaneous  Affections. — -Sweat-vesicles  are  extremely  common  and 
a  red  miliary  rash  may  also  develop.    Scarlatiniform  eruptions  are  occasionally 


366  SPECIFIC  INFECTIOUS  DISEASES 

seen.  Purpura,  with  or  without  urticaria,  and  various  forms  of  erythema 
ma}'  occur.  It  is  doubtful  whetlier  the  cases  of  extensive  purpura  witli 
urticaria  and  artliritis- — peliosis  rlieumatica — belong  to  rheumatic  fever. 

(g)  EiiEUiiATic  XoDULES. — TliesB  curious  structures,  described  originally 
by  Meynet,  occur  in  the  form  of  small  subcutaneous  nodules.  Barlow  and 
Warner,  in  England,  and  T.  B.  Futcher^  in  the  United  States,  have  paid 
special  attention  to  their  varieties  and  importance.  They  vary  in  size  from  a 
small  shot  to  a  large  pea,  and  are  most  numerous  on  the  fingers,  hands,  and 
wrists.  They  also  occur  about  the  elbows,  knees,  the  spines  of  the  vertebrse, 
and  the  scapula.  They  are  not  often  tender.  They  are  more  common 
after  the  decline  of  the  fever  and  in  the  children  with  mitral  valve  disease. 
In  only  5  of  our  patients  were  they  present  during  the  acute  attack.  The 
nodules  may  grow  with  great  rapidity  and  usually  last  for  weeks  or  months. 
They  are  more  common  in  children  than  in  adults,  and  in  the  former  their 
presence  may  be  regarded  as  a  positive  indication  of  rheumatic  fever.  They 
have  been  noted  particularly  in  association  with  rheumatic  endocarditis. 
Subcutaneous  nodules  occur  also  in  migraine,  gout,  and  arthritis  deformans. 
Histologically  they  are  made  up  of  round  and  spindle-shaped  cells.  In 
addition  to  these  firm,  hard  nodules,  there  occur  in  rheumatism  and  in 
chronic  vegetative  endocarditis  remarkable  bodies,  which  have  been  called 
by  Fereol  "nodosites  cutanees  ephemeres." 

(h)    Swelling  or  tenderness  of  the  thyroid  gland  may  be  present. 

Course. — The  course  is  extremely  variable.  It  is,  as  Austin  Flint  first 
showed,  a  self-limited  disease,  and  it  is  not  probable  that  drugs  have  any 
special  influence  xipon  its  duration  or  course.  Gull  and  Sutton,  who  studied 
a  series  of  62  cases  without  special  treatment,  arrived  at  the  same  conclusion. 

Prognosis. — ^Eheumatic  fever  is  the  most  serious  of  all  diseases  with  a  low 
death-rate.  The  mortality  is  rarely  above  2  or  3  per  cent.  Only  9  of  our  330 
patients  died,  2.7  per  cent.,  all  with  endocarditis  and  6  with  pericarditis. 

Sudden  death  in  rheumatic  fever  is  due  most  frequently  to  mj'ocarditis. 
Herringham  has  reported  a  case  in  which  on  the  fourteenth  day  there  was 
fatty  degeneration  and  acute  inflammation  of  the  myocardium.  In  a  few  rare 
cases  it  results  from  embolism.  Alarming  symptoms  of  depression  sometimes 
follow  excessive  doses  of  the  salicylate  of  soda. 

Diagnosis. — Practically,  the  recognition  of  rheumatic  fever  is  usually  easy; 
but  there  are  several  affections  which,  in  some  particulars,  closely  resemble  it. 

(a)  Multiple  Secoxdary  Aetheitis. — Under  this  term  may  be  em- 
braced the  forms  of  arthritis  which  occur  with  or  follow  gonorrhoea,  tonsillitis, 
scarlet  fever,  dysentery,  cerebro-spinal  meningitis,  etc. 

(/;)  Septic  Aetheitis,  which  occurs  in  the  course  of  pyaemia  from  any 
cause,  and  particularly  in  puerperal  fever.  Xo  hard  and  fast  line  can 
be  drawn  between  these  and  the  cases  in  the  first  group:  but  the  inflamma- 
tion rapidly  passes  on  to  suppuration  and  there  is  more  or  less  destruc- 
tion of  the  joints.  The  conditions  uncler  which  the  arthritis  occurs  give  a 
clue  to  the  nature  of  the  case.     Under  this  section  may  be  mentioned: 

(1)  Acute  necrosis  or  acute  osteo-myeJitis  may  be  mistaken  for  rheumatic 
fever.  Sometimes  it  is  multiple.  The  greater  intensity  of  the  local  symptoms, 
the  involvement  of  the  epiphyses  rather  than  the  joints,  and  the  more  serious 
constitutional   disturbances  are  points   to   be   considered.      The   condition   is 


EHEUMATIC  FEVER  367 

unfortunately  often  mistaken  for  acute  arthritis,  and,  as  the  treatment  is 
essentially  surgical,  the  error  may  cost  the  life  of  the  patient. 

(2)  The  acute  arthritic  of  infants  is  usually  confined  to  one  joint  (the  hip 
or  knee),  the  effusion  in  which  rapidly  becomes  purulent.  The  affection  is 
most  common  in  sucklings  and  undoubtedly  pygemic  in  character.  It  may  also 
occur  with  the  gonorrhoeal  ophthalmia  or  vaginitis  of  the  new-born. 

(c)  GoNOCOCCUS  Arthritis. — This  may  give  difficulty  at  the  onset,  but 
there  is  not  the  rapid  shifting  from  joint  to  joint  and  there  is  usually  some 
thickening  about  the  most  affected  joints  in  a  short  time.  A  careful  search  for 
gonococci  is  important  and  the  complement  fixation  test  may  aid. 

{d)  Gout. — While  the  localization  in  a  single,  usually  a  small,  joint,  the 
age,  the  history,  and  the  mode  of  onset  are  features  which  enable  us  to  recog- 
nize acute  gout,  there  are  everywhere  cases  of  acute  arthritis,  called  rheumatic 
fever,  which  are  in  reality  gout.  The  involvement  of  several  of  the  larger 
joints  is  not  so  infrequent  in  gout,  and  unless  tophi  are  present  or  bursitis 
occurs,  the  diagnosis  may  be  difficult. 

(e)  Acute  Arthritis  DeformiAns. — This  may  easily  be  mistaken  for 
rheumatic  fever.  It  may  come  on  with  fever  and  multiple  arthritis,  and  for 
weeks  there  may  be  no  suspicion  of  the  true  nature  of  the  disease.  Gradually 
the  fever  subsides,  but  the  periarticular  thickening  persists.  As  a  rule, 
however,  in  the  acute  febrile  cases  the  involvement  of  the  smaller  joints, 
the  persistence  and  the  early  changes  in  the  articulations  suggest  arthritis 
deformans. 

In  children  the  diagnosis  may  be  very  difficult,  as  arthritis  may  be  slight 
or  entirely  absent.  The  possibility  of  rheumatic  fever  should  be  considered  in 
all  febrile  attacks  in  children  for  which  no  definite  cause  can  be  found.  Spe- 
cial care  should  be  given  to  the  examination  of  the  heart,  particularly  for 
any  signs  of  dilatation  or  endocarditis. 

Tteatment. — The  main  object  should  be  to  bring  the  patient  through  the 
attack  with  an  undamaged  heart  or  with  as  little  injury  as  possible.  The  first 
essential  is  complete  rest,  which  should  be  begun  at  once  and  insisted  upon 
for  as  long  as  is  necessary.  This  is  especially  important  for  children.  The 
bed  should  have  a  smooth,  soft,  yet  elastic,  mattress.  The  patient  should 
wear  a  flannel  nightgown,  which  may  be  opened  all  the  way  down  the  front 
and  slit  along  the  outer  margin  of  the  sleeves.  Three  or  four  of  these  should 
be  made,  so  as  to  facilitate  the  frequent  changes  required  after  the  sweats. 
He  may  wear  also  a  light  flannel  cape  about  the  shoulders.  He  should  sleep 
in  blankets,  not  in  sheets,  so  as  to  reduce  the  chance  of  being  chilled. 

Milk  is  the  most  suitable  diet  and  may  be  diluted  with  alkaline  mineral 
waters.  Fruit  juices,  lemonade  and  oatmeal  or  barley  water  should  be  freely 
given.  The  thirst  is  usually  great  and  may  be  fully  satisfied.  There  is 
no  objection  to  soups  if  the  milk  is  not  well  borne.  As  convalescence  is 
established  a  fuller  diet  may  be  allowed,  but  meat  should  be  used  sparingly. 

Local  treatment  is  usually  necessary.  It  often  suffices  to  wrap  the  affected 
joints  in  cotton.  If  the  pain  is  severe,  hot  cloths  may  be  applied,  saturated 
with  Fuller's  lotion  (carbonate  of  soda,  6  drams,  24  gm. ;  laudanum,  1  oz.,  30 
c.  c. ;  glycerine,  2  oz.,  60  c.  c. ;  and  water,  9  oz.,  270  c.  c.)  or  the  lead  and 
opium  lotion.  Oil  of  wintergreen  is  useful,  tbe  joijit  being  gently  rubbed  with 
it  or  small  amounts  sprinkled  over  flannel,  which  is  then  iipplicd.     Chloroform 


368  SPECIFIC  INFECTIOUS  DISEASES 

liniment  is  also  a  good  application.  Fixation  of  the  joints  is  of  great  service 
in  allaying  the  pain.  Splints,  padded  and  bandaged  with  moderate  firmness, 
will  often  give  comfort.  Friction  is  rarely  well  borne  in  an  acutely  inflamed 
joint.  Cold  compresses  are  sometimes  useful.  The  application  of  blisters 
above  and  below  the  joint  often  relieves  the  pain.  This  is  not  to  be  compared 
with  the  light  application  of  the  Paquelin  cautery.  If  there  is  much  effusion, 
aspiration  of  the  joint  is  useful. 

The  drug  treatment  is  still  far  from  satisfactory,  though  the  introduction 
of  the  salicyl  compounds  has  been  a  great  boon. 

The  Salicyl  Compounds. — Salicin,  introduced  in  1876  by  Maclagan,  may 
be  used  in  doses  of  20  grains  (1.3  gm.)  every  hour  or  two  until  the 
pain  is  relieved.  It  has  the  advantage  of  being  less  depressing  than  the 
salicylate  of  soda.  It  is  also  perhaps  the  best  drug  to  use  for  children. 
Salicylate  of  soda,  15  grain  (1  gm.)  doses  every  three  hours,  is  perhaps  the 
best  for  general  use  in  adults.  After  the  pain  has  been  relieved,  the 
drug  should  be  given  every  four  or  five  hours  until  the  temperature  begins 
to  fall.  Potassium  or  solium  bicarbonate  may  be  given  with  it.  If  sodium 
salicylate  causes  gastric  disturbance  it  can  be  given  by  rectum  in  thin  starch 
solution.  Large  doses  can  be  administered  in  this  way.  Oil  of  wintergreen, 
20  minims  (1.25  c.  c.)  every  two  hours  in  milk,  or  acetyl-salicylic  acid  (gr, 
XV,  1  gm.),  may  be  used  if  the  salicylate  of  soda  disagrees.  There  are 
other  salicyl  compounds,  but  the  best  results  are  obtained  from  the  use  of 
one  or  the  other  of  the  above-named  preparations.  There  can  be  no  question 
as  to  their  eflficacy  in  relieving  the  pain.  Some  observers  consider  that  they 
also  protect  the  heart,  shorten  the  course,  and  render  relapse  less  likely. 

The  Alkaline  Treatment. — The  urine  should  be  rendered  alkaline  as 
soon  as  possible.  Potassium  acetate  and  citrate  in  doses  of  15  grains  (1  gm.) 
each  are  given  every  three  hours  until  the  urine  is  alkaline  and  then  often 
enough  to  keep  it  so.  Potassium  or  sodium  bicarbonate  may  be  given 
with  the  sodium  salicylate.  Fuller's  plan  was  to  give  90  grains  (6  gm.)  of 
sodium  bicarbonate  with  30  grains  (2  gm.)  of  potassium  acetate  in  water, 
rendered  effervescent  at  the  time  of  administration  by  citric  acid  or  lemon- 
juice. 

A  widespread  popular  belief  attributes  marvelous  efficacy  to  bee-stings 
in  all  sorts  of  "rheumatism,"  and  a  formic-acid  treatment  has  been  introduced. 
A  21/2  per  cent,  solution  is  injected  in  the  neighborhood  of  the  painful  joints. 
Ainley  Walker  collected  (B.  M.  J.,  October  10,  1908)  an  interesting  literature 
on  the  subject. 

To  allay  the  pai7i  opium  may  be  given  in  the  form  of  Dover's  powder,  or 
morphia  hypodermically.  The  coal  tar  products  are  useful  sometimes  for  the 
purpose.  During  convalescence  iron  is  indicated  in  full  doses.  Of  the  com- 
plications, hyperpyrexia  should  be  treated  by  the  bath  or  the  cold  pack.  The 
treatment  of  endocarditis  and  pericarditis  and  the  pulmonary  complications 
will  be  considered  under  their  respective  sections.  In  all  the  cardiac  com- 
plications the  importance  of  prolonged  rest  must  be  remembered. 

To  prevent  and  arrest  endocarditis  Caton  urges  the  use  of  a  series  of  small 
blisters  along  the  course  of  the  third,  fourth,  fifth,  and  sixth  intercostal  nerves 
of  the  left  side,  applied  one  at  a  time  and  repeated  at  ditferent  points.     Potas- 


ACUTE  TONSILLITIS  369 

siiim  or  sodium  iodide  is  given  in  addition  to  the  salicylates.     The  patients 
are  kept  in  bed  for  about  six  weeks. 

Tonsils. — With  disease  of  these  and  the  possibility  that  they  are  the  por- 
tals of  entry  for  the  infective  agent,  the  question  arises  as  to  their  removal. 
In  patients  with  diseased  tonsils  in  whom  rheumatic  fever  has  occurred  re- 
moval is  advisable  and  should  be  complete.  In  patients  with  endocarditis 
and  fever  this  may  be  done  apparently  without  risk.  It  is  comparable  to 
the  removal  of  any  local  focus  of  infection  which  is  causing  general  symptoms. 


XI.     ACUTE  TONSILLITIS 

Definition. — An  acute  infection,  sporadic  or  epidemic,  involving  the  struc- 
tures of  the  tonsillar  ring,  usually  due  to  organisms  of  the  streptococcus  class. 

Etiology. — Acute  tonsillitis  occurs  in  sporadic  and  epidemic  forms.  The 
sporadic  variety,  a  common  disease,  is  met  with  in  young  persons  particularly 
at  the  school  age.  Infants  are  rarely  attacked.  Chronic  enlargement  of  the 
lymphatic  structures  of  the  throat  is  an  important  predisposing  cause.  Ex- 
posure to  cold  and  wet  may  bring  on  an  attack.  It  is  directly  communicated 
from  one  child  to  another.  A  not  infrequent  precursor  of  rheumatic  fever, 
Cheadle  described  it  as  one  link  in  the  rheumatic  chain.  It  may  be  directly 
followed  by  endocarditis,  erythema  nodosum,  chorea,  and  acute  nephritis.  In 
Great  Britain  it  prevails  in  the  autumn  months,  in  the  United  States  in 
the  spring.  An  old  notion  held  that  there  was  a  close  relation  between  the 
tonsils  and  the  testes  and  ovaries,  and  F.  J.  Shepherd  called  attention  to 
the  frequency  of  acute  tonsillitis  in  newly  married  persons. 

Epidemic  tonsillitis  is  not  infrequent,  the  cases  increasing  in  the  com- 
munity to  epidemic  proportions.  As  a  rule  it  is  impossible  to  trace  it  to  any 
special  cause.  There  are  remarkable  localized  outbreaks,  sometimes  in  institu- 
tions, which  have  been  trax^ed  to  milk  infection.  The  one  in  Boston  in  1911 
was  exceptionally  severe,  involving  more  than  1,000  persons,  and  the  connec- 
tion with  the  use  of  the  milk  from  one  dairy  seems  to  have  been  clearly  traced. 
More  females  than  males  were  attacked,  and  a  large  proportion  of  the 
cases  were  "adults. 

The  bacteriology  has  been  carefully  studied.  The  tonsils,  swarming 
with  saprophytic  and  pathogenic  germs,  are  the  main  gates  through  which 
the  invaders  try  to  storm  the  town.  Normally  the  protecting  forces  suffice  to 
keep  them  at  bay,  but  now  and  again  a  fiercer  battle  than  usual  rages,  bar- 
ricades have  to  be  set  up  in  the  shape  of  exudates  and  necroses — and  a  local 
tonsillitis  is  the  outward  and  visible  sign  of  the  struggle.  Too  often 
the  enemy  gains  entrance,  and  streptococci,  staphylococci,  pneumococci,  etc., 
pass  to  distant  parts  and  excite  arthritis,  endocarditis,  and  serous  membrane 
inflammations.  In  the  Boston  epidemic  the  streptococcus  was  the  common 
germ,  and  the  same  holds  good  in  the  sporadic  cases. 

Morbid  Anatomy. — The  lacunge  of  the  tonsils  become  filled  with  exuda- 
tion products,  which  form  cheesy-looking  masses,  projecting  from  the  orifices 
of  the  crypts.  Not  infrequently  the  exudations  from  contiguous  lacunse  coa- 
lesce. The  intervening  mucosa  is  usually  swollen,  deep  red  in  color,  and  may 
present  herpetic  vesicles,  or,  in  some  instances,  even  membranous  exudation, 


370  SPECIFIC  INFECTIOUS  DISEASES 

in  which  case  it  may  be  difficult  to  distinguish  the  condition  from  diphtheria. 
The  contents  of  the  crypt  are  made. up  of  micrococci  and  epithelial  debris. 

Symptoms. — Chilly  feelings,  or  even  a  definite  chill,  and  aching  pains  in 
the  back  and  limbs  may  precede  the  onset.  The  fever  rises  rapidly  and  in 
the  case  of  a  young  child  may  reach  105°  F.  on  the  evening  of  the  first  day. 
The  patient  complains  of  soreness  of  the  throat  and  difficulty  in  swallowing. 
On  examination  the  tonsils  are  seen  to  be  swollen  and  the  crypts  present  the 
characteristic  exudate.  The  tongue  is  furred,  the  breath  is  heavy  and 
foul,  and  the  urine  is  highly  colored  and  loaded  with  urates.  In  children  the 
respirations  are  usually  hurried  and  the  pulse  increased  in  rapidity.  Swallow- 
ing is  painful  and  the  voice  often  becomes  nasal.  Slight  swelling  of  ihe 
cervical  glands  is  present. 

In  epidemic  cases  the  fever  may  be  very  high,  the  secondar}^  enlargement 
of  the  glands  considerable,  and  even  the  deeper  tissues  may  be  involved.  The 
complications  are  very  serious:  endocarditis,  pericarditis,  pneumococcic  peri- 
tonitis, and  j)neumonia.  In  the  Boston  epidemic  the  clinical  sequence  was  not 
unlike  that  seen  in  rheumatic  fever — sore  throat,  adenitis,  multiple  arthritis, 
endocarditis,  and  pneumonia.  Febrile  albuminuria  is  common  and  acute 
nephritis  may  follow.  A  diffuse  erythema  may  simulate  scarlet  fever.  Acute 
otitis  media  is  a  frequent  complication  in  children.  Belapses  are  not 
uncommon  and  the  tonsils  may  remain  enlarged.  Occasionally  paralyses 
follow  the  streptococcus  tonsillitis  which  are  identical  with  those  of  diphtheria. 

In  the  sporadic  and  mild  epidemic  form  it  is  rare  to  see  a  fatal  case, 
but  in  severe  outbreaks  the  mortality  from  complications  may  be  three  or 
four  per  cent.     There  were  about  50  deaths  in  the  Boston  epidemic. 

Diagnosis. — It  may  be  difficult  to  distinguish  tonsillitis  from  diphtheria. 
In  the  follicular  form,  the  individual  yellowish-gray  masses,  separated  by  the 
reddish  tonsillar  tissue,  are  very  characteristic ;  whereas  in  diphtheria  the  mem- 
brane is  ashy-gray  and  uniform,  not  patchy.  A  point  of  the  greatest  im- 
portance in  diphtheria  is  that  the  membrane  is  not  limited  to  the  tonsils,  but 
creeps  up  the  pillars  of  the  fauces  and  appears  on  the  uvula.  The  diphtheritic 
membrane,  when  removed,  leaves  a  bleeding,  eroded  surface;  whereas  the 
exudation  of  lacunar  tonsillitis  is  easily  separated,  and  usually  there  is  no 
erosion  beneath  it.  In  all  doubtful  cases  cultures  should  be  made  to  determine 
the  presence  or  absence  of  the  diphtheria  bacillus. 

Treatment. — The  patient  should  be  in  bed  and  stay  there  until  the  attack  is 
over.  The  diet  should  be  liquid  with  soft  foods  added  if  desired.  Warer 
should  be  taken  in  large  amounts.  The  bowels  should  be  moved  freely  by  a 
calomel  and  saline  purge  and  kept  open  by  daily  doses  of  saline  if  required. 
Aconite  in  full  doses  often  acts  beneficially  in  children.  The  combination  of 
salol  and  phenacetine  (of  each,  gr.  iii-v,  0.2-0.3  gm.)  can  be  given  every  three 
hours.  Acetylsalicylic  acid  (gr.  v,  0.3  gm.)  is  often  useful  in  relieving 
symptoms.  Ten  grains  (0.6  gm.)  of  Dover's  powder  or  codein  (gr.  i^, 
0.03  gm.)  may  be  given  at  night.  One  of  the  best  applications  to  the  throat 
is  a  10  per  cent,  solution  of  silver  nitrate.  Gargles  should  only  be  used  if 
they  do  not  cause  pain.  Solutions  of  iron,  iodine,  phenol  (1  per  cent.), 
hydrogen  peroxide  (25  per  cent.)  or  an  alkaline  antiseptic  mixture  may  be 
employed.  The  application  of  sodium  bicarbonate  directly  to  the  tonsils  some- 
times gives  relief.     An  ice  bag  to  the  neck   is  usually  an  advantage.     In 


ACUTE  CATAEEHAL  FEVEE  371 

convalescence  abundant  nourishment  and  a  tonic,  such  as  the  tincture  of  nux 
vomica  (TIX  xv,  1  c.  c),  are  useful. 


XII.     ACUTE  CATARRHAL  FEVER 

(Acute  Coryza) 

Definition. — An  acute  infection  of  the  mucous  membrane  of  the  upper  air 
passages  associated  with  the  presence  of  the  Micrococcus  catarrhalis  alone,  or 
with  other  organisms. 

Etiology. — The  micrococcus  described  by  E.  Pfeiffer  is  a  diplococcus  with 
close  resemblance  to  the  meningococcus  and  the  pneumococcus.  •  It  is  a  nor- 
mal habitant  of  the  throat  and  bronchial  secretions  of  many  persons.  In 
acute  inflammatory  conditions  of  the  upper  air  passages  it  is  found,  some- 
times in  almost  pure  culture,  in  the  sputum.     It  is  readily  cultivated. 

Prevailing  most  extensively  in  the  changeable  weather  of  the  spring  and 
early  winter,  coryza  may  occur  in  epidemic  form,  many  cases  arising  in  a 
community  within  a  few  weeks,  outbreaks  which  are  very  like  though  less 
intense  than  the  epidemic  influenza.  More  often  it  is  a  local  outbreak  among 
the  members  of  a  house  or  of  a  school. 

Symptoms. — The  patient  feels  indisposed,  perhaps  chilly,  has  slight  head- 
ache, and  sneezes  frequently.  In  severe  cases  there  are  pains  in  the  back  and 
limbs.  There  is  usually  slight  fever,  the  temperature  rising  to  101°  F.  The 
pulse  is  quick,  the  skin  is  dry,  and  there  are  all  the  features  of  a  feverish 
attack.  At  first  the  mucous  membrane  of  the  nose  is  swollen,  "stuffed  up," 
and  the  patient  has  to  breathe  through  the  mouth.  A  thin,  clear,  irritating 
secretion  flows,  and  makes  the  edges  of  the  nostrils  sore.  The  mucous  mem- 
brane of  the  tear-ducts  is  swollen,  so  that  the  eyes  weep  and  the  conjunctivae 
are  injected.  The  sense  of  smell  and,  in  part,  the  sense  of  taste  are  lost.  With 
the  nasal  catarrh  there  is  slight  soreness  of  the  throat  and  stiffness  of  the 
neck ;  the  pharynx  looks  red  and  swollen,  and  sometimes  the  act  of  swallowing 
is  painful.  The  larynx  also  may  be  involved  and  the  voice  becomes  husky  or 
is  even  lost.  If  the  inflammation  extends  to  the  Eustachian  tubes  the  hearing 
may  be  impaired.  In  more  severe  cases  there  are  bronchial  irritation  and 
cough.  Occasionally  there  is  an  outbreak  of  labial  or  nasal  herpes.  Usually 
within  thirty-six  hours  the  nasal  secretion  becomes  turbid  and  more  profuse, 
the  swelling  of  the  mucosa  subsides,  the  patient  gradually  becomes  able  to 
breathe  through  the  nostrils,  and  within  four  or  five  days  the  symptoms  dis- 
appear, with  the  exception  of  the  increased  discharge  from  the  nose  and  upper 
pharynx.  There  are  rarely  any  bad  effects  from  a  simple  coryza.  When  the 
attacks  are  frequently  repeated  the  disease  may  becoine  chronic. 

Diagnosis. — This  is  always  easy,  but  caution  must  be  exercised  lest  the 
initial  catarrh  of  measles  or  influenza  be  mistaken  for  the  simple  coryza. 

Treatment. — Many  attacks  are  so  mild  that  the  patients  are  able  to  be 
about  and  attend  to  their  work.  If  there  are  fever  and  constitutional  dis- 
turbance, the  patient  should  be  kept  in  bed  and  take  a  simple  fever  mix- 
ture, and  at  night  a  drink  of  hot  lemonade  and  a  full  dose  of  Dover's 
powder.     Many  persons  find  great  benefit  from  the  Turkish  bath.     For  the 


373  SPECIFIC  mFECTIOUS  DISEASES 

distressing  sense  of  tightness  and  pain  over  the  frontal  sinuses,  cocaine  is 
useful  and  sometimes  gives  immediate  relief.  The  4-per-cent.  solution  may 
be  injected  into  the  nostrils  or  cotton  wool  soaked  in  it  may  be  inserted  into 
them.  Ointments  containing  menthol  and  camphor  may  be  applied  locally. 
When  the  secretion  is  profuse  atropine  can  be  given  in  doses  sufficient  to  lessen 
this.  Simple  saline  or  oily  sprays  are  often  employed  but  should  be  used 
very  gently. 

The  vaccine  treatment  may  be  tried  in  persons  subject  to  recurring  colds, 
especially  as  a  preventive. 


XIII.     FEBRICULA— EPHEMERAL  FEVER 

Definition. — Fever  of  slight  duration,  probably  depending  upon  a  variety 
of  causes,  some  autogenous,  others  extrinsic  and  bacterial. 

A  febrile  paroxysm  lasting  for  twenty-four  hours  and  disappearing  com- 
pletely is  spoken  of  as  ephemeral  fever.  If  it  persists  for  three,  four,  or 
more  days  without  local  affection  it  is  referred  to  as  febricula. 

The  cases  may  be  divided  into  several  groups: 

(a)  Those  which  represent  mild  or  abortive  types  of  the  infectious  dis- 
eases. It  is  not  very  unusual,  during  an  epidemic  of  typhoid,  scarlet  fever, 
or  measles,  to  see  patients  with  some  of  the  prodromal  symptoms  and  slight 
fever,  which  persist  for  two  or  three  days  without  any  distinctive  features. 
Possibly  some  of  the  cases  are  due  to  mild  streptococcus  infections. 

(h)  In  a  larger  group  of  cases  the  symptoms  develop  with  dyspepsia.  In 
children  indigestion  and  gastro-intestinal  catarrh  are  often  accompanied  by 
fever.  Possibly  some  instances  of  longer  duration  may  be  due  to  the  absorption 
of  toxic  substances.  Slight  fever  has  been  known  to  follow  the  eating  of  de- 
composing substances;  but  the  gastric  juice  has  remarkable  antiseptic  prop- 
erties, and  the  frequency  with  which  persons  take  from  choice  articles  which 
are  "high'^  shows  that  poisoning  is  not  likely  to  occur  unless  there  is  existing 
gastro-intestinal  disturbance. 

(c)  Cases  which  follow  exposure  to  foul  odors  or  sewer  gas.  That  a  febrile 
paroxysm  may  follow  a  prolonged  exposure  to  noxious  odors  has  been  suggested. 
The  cases  described  under  this  heading  are  of  two  kinds:  an  acute,  severe 
form  with  nausea,  vomiting,  colic,  and  fever,  followed  perhaps  by  a  condition 
of  collapse  or  coma ;  secondly,  a  form  of  low  fever  with  or  without  chills.  A 
good  deal  of  doubt  exists  about  these  cases  of  so-called  sewer-gas  poisoning. 
Workers  in  sewers  are  remarkably  free  from  disease,  and  in  many  of  the 
reported  cases  the  illness  may  have  been  only  a  coincidence.  There  are  in- 
stances in  which  persons  have  been  taken  ill  with  vomiting  and  slight  fever 
after  exposure  to  the  odor  of  a  very  offensive  post  mortem.  Whether  true 
or  not,  the  idea  is  firmly  implanted  in  the  minds  of  the  laity  that  very  power- 
ful odors  from  decomposing  matters  may  produce  sickness. 

(d)  Many  cases  doubtless  depend  upon  slight  unrecognized  lesions,  such  as 
tonsillitis  or  occasionally  an  abortive  or  larval  pneumonia.  Children  are 
much  more  frequently  affected  than  adults. 

The  symptoms  set  in,  as  a  rule,  abruptly,  though  in  some  instances  there 
may  have  been  preliminary  malaise  and  indisposition.     Headache,  loss  of  ap- 


INFECTIOUS  JAUNDICE  373 

petite,  and  furred  tongue  are  present.  The  urine  is  scanty  and  high-colored, 
the  fever  ranges  from  101°  to  103°,  sometimes  in  children  it  rises  higher. 
The  cheeks  may  be  flushed  and  the  patient  has  the  outward  manifestations  of 
fever.  In  children  there  may  be  bronchial  catarrh  ^ith  slight  cough.  Herpes 
on  the  lips  is  a  common  symptom.  Occasionally  in  children  the  cerebral 
symptoms  are  marked  at  the  outset,  and  there  may  be  irritation,  restlessness, 
and  nocturnal  delirium.  The  fever  terminates  abruptly  by  crisis  from  the 
second  to  the  fourth  day ;  in  some  instances  it  may  continue  for  a  week. 

The  diagnosis  generally  rests  upon  the  absence  of  local  manifestations, 
particularly  the  characteristic  skin  rashes  of  the  eruptive  fevers,  and,  most 
important  of  all,  the  rapid  disappearance  of  the  pyrexia.  The  cases  most 
readily  recognized  are  those  with  acute  gastro-intestinal  disturbance. 

The  treatment  is  that  of  mild  pyrexia — rest  in  bed,  a  laxative,  and  a  fever 
mixture  containing  nitrate  of  potassium  and  sweet  spirits  of  nitre. 


XIV.     INFECTIOUS  JAUNDICE 

(Epidemic  Jaundice:   Spirochetosis  Ictero-HcBmorrhagica;   Weil's  Disease) 

There  are  several  forms  of  infectious  jaundice  which  may  occur  in  epidemic 
form,  due  to  a  variety  of  organisms,  some  of  which  can  be  definitely  de- 
termined. Outbreaks  of  the  disease  have  occurred  in  many  parts  of  the 
world  and  it  was  common  in  the  recent  war.  Certain  forms  may  be 
separated. 

(1)  Epidemic  catarrhal  jaundice. — This  seems  to  be  a  definite  entity, 
the  cause  of  which  is  obscure  but  due  to  a  common  source  rather  than  to 
infection  from  one  to  another.  No  proved  etiological  organism  has  been 
found.  The  early  features  are  abdominal  discomfort,  gastric  symptoms, 
diarrhoea  or  constipation,  fever  for  two  to  four  days,  and  malaise.  Jaundice 
appears  about  the  fourth  day  with  pale  stools  and  bile  in  the  urine.  The 
jaundice  reaches  a  maximum  in  about  ten  days.  There  is  enlargement 
of  the  liver  and  spleen,  with  tenderness  of  the  former.  Dilatation  of  the 
right  heart  is  not  uncommon  but  usually  is  present  for  a  few  days  only. 
The  mortality  in  a  large  series  in  soldiers  was  only  0.4  per  cent.  In  some 
cases  severe  toxsemia  or  icterus  gravis  occurred. 

(2)  Spirochcetosis  ictero-hcemorrhagica. — Discovered  in  Japan  in  1914, 
the  Spirochceta  ictero-hcBmorrhagica  has  been  found  to  be  widely  distributed. 
The  infection  in  rats  has  been  found  in  many  countries.  The  onset  is  often 
acute,  but  may  be  gradual,  with  a  chill,  vertigo,  headache  and  general  pains, 
vomiting,  diarrhoea  and  prostration.  The  temperature  rises  to  102°  or  over. 
Jaundice  appears  about  the  fourth  day,  reaching  the  maximum  about  the 
tenth  day.  Haemorrhage  is  common,  from  the  nose,  gums,  lungs,  stomach 
and  bowel.  Herpes  is  common  and  often  becomes  hfpmorrhagic.  Purpura 
occurs  in  some  cases.  The  liver  may  be  enlarged  and  tender  l)ut  the  spleen 
is  not  enlarged.  Myositis  is  common,  the  muscles  being  very  tender  and 
sometimes  swollen.  Nephritis  may  occur.  Moderate  leucocytosis  is  common. 
The  course  varies  with  the  severity  of  the  attack.  The  fever  usually  lasts 
for  about  ten  days. 


374  SPECIFIC  INFECTIOUS  DISEASES 

The  spirochgetes  are  in  the  blood  in  the  first  week.  They  ma}^  be  found 
on  examination  or  the  infection  may  be  conveyed  to  a  guinea-pig  by  intra- 
peritoneal injection  of  blood.  The  spirochgetes  are  found  in  the  urine  in  the 
later  stages  and  are  agglutinated  by  the  patient's  blood  after  the  second 
week  of  the  attack.  The  mortality  has  varied  greatly:  in  Japan  it  has  been 
30  per  cent,  but  in  some  of  the  armj^  series  was  only  4  to  6  per  cent. 

(3)  WeiVs  Disease. — This  term  is  applied  to  a  disease  described  in  1886 
with  features  much  like  the  preceding,  with  a  high  mortality  and  marked 
splenic  enlargement. 

Treatment. — Eest,  liquid  diet,  water  freely,  alkalies  and  open  bowels,  by 
salines  and  enemata,  are  indicated. 


XV.     MILK-SICKNESS 

This  remarkable  disease  prevails  in  certain  districts  of  the  United  States, 
west  of  the  Alleghany  Mountains,  and  is  connected  with  the  affection  in  cattle 
known  as  the  trembles.  It  prevailed  extensively  in  the  early  settlements 
in  certain  of  the  Western  States  and  proved  very  fatal.  The  general  opinion 
is  that  it  is  communicated  to  man  only  by  eating  the  flesh  or  drinking  the 
milk  of.  diseased  animals.  The  butter  and  cheese  are  also  poisonous.  In  ani- 
mals, cattle  and  the  young  of  horses  and  sheep  are  most  susceptible.  It  is 
stated  that  cows  giving  milk  do  not  themselves  show  marked  symptoms  unless 
driven  rapidly,  and,  according  to  Graff,  the  secretion  may  be  infective  when 
the  disease  is  latent.  When  a  cow  is  very  ill,  food  is  refused,  the  eyes  are 
injected,  the  animal  staggers,  the  entire  muscular  system  trembles,  and  death 
occurs  in  convulsions,  sometimes  with  great  suddenness.  The  disease  is  most 
frequent  in  new  settlements. 

In  man  the  s3'mptoms  are  those  of  a  more  or  less  acute  intoxication.  After 
a  few  days  of  uneasiness  and  distress  the  patient  is  seized  with  pains  in  the 
stomach,  nausea  and  vomiting,  fever  and  intense  thirst.  There  is  usually 
obstinate  constipation.  The  tongue  is  swollen  and  tremulous,  the  breath  is 
extremely  foul,  and,  according  to  Graff,  is  as  characteristic  of  the  disease  as 
is  the  odor  in  small-pox.  Cerebral  S3^mptoms — restlessness,  irritability,  coma, 
and  convulsions — are  sometimes  marked,  and  a  typhoid  state  may  gradually  be 
produced  in  which  the  patient  dies. 

The  duration  is  variable.  In  the  most  acute  form  death  occurs  within 
two  or  three  days.  It  may  last  for  ten  days,  or  even  for  three  or  four  weeks. 
Graff  states  that  insanity  occurred  in  one  case.  The  poisonous  nature  of 
the  flesh  and  milk  has  been  demonstrated.  An  ounce  of  butter  or  cheese, 
or  four  ounces  of  the  beef,  raw  or  boiled,  given  three  times  a  day,  will  kill  a 
dog  within  six  days.  Fortunately,  the  disease  has  become  rare.  ISTo  definite 
pathological  lesions  are  known.  Jordan  and  Harris  studied  a  Xew  ]\Iexico 
epidemic  (1908)  and  found  a  bacillus  (B.  lactimorbi)  with  cultures  of  which 
the  disease  may  be  reproduced  in  other  animals. 


MILIARY  FEVER  375 


XVI.     GLANDULAR  FEVER 

Definition. — An  infectious  disease  of  children,  developing,  as  a  rule,  with- 
out premonitory  signs,  and  characterized  by  slight  redness  of  the  throat,  high 
fever,  swelling  and  tenderness  of  the  lymph-glands  of  the  neck,  particularly 
those  behind  the  sterno-cleido-mastoid  muscles.  The  fever  is  of  short  dura- 
tion but  the  enlargement  of  the  glands  persists  for  ten  days  to  three 
v/eeks. 

In  children  acute  adenitis  of  the  cervical  and  other  glands  with  fever  had 
been  noted  by  many  observers,  but  Pfeiffer  in  1889  called  special  attention 
to  it  under  the  name  of  Druesenfieher.  He  described  it  as  an  infectious  dis- 
ease of  young  children  between  the  ages  of  five  and  eight  years,  characterized 
by  the  above-mentioned  symptoms.  A  good  deal  of  work  has  been  done  in 
connection  with  the  subject,  and  in  the  United  States  West  and  Hamill,  and 
in  England  Dawson  Williams,  have  particularly  emphasized  the  condition. 

Etiology. — It  may  occur  in  epidemic  form.  West,  of  Bellaire,  Ohio, 
described  an  epidemic  of  96  cases  in  children  between  the  ages  of  seven  months 
and  thirteen  years.  Bilateral  swelling  of  the  carotid  lymph-glands  was  a  most 
marked  feature.  In  three-fourths  of  the  cases  the  post-cervical,  inguinal,  and 
axillary  glands  were  involved.  The  mesenteric  glands  were  felt  in  37  cases, 
the  spleen  was  enlarged  in  57,  and  the  liver  in  87  cases.  Coryza  was  not  pres- 
ent, and  there  were  no  bronchial  or  pulmonary  symptoms.  The  nature  of  the 
infection  has  not  been  determined. 

Symptoms. — The  onset  is  sudden  and  the  first  complaint  is  of  pain  on 
moving  the  head  and  neck.  There  may  be  nausea  and  vomiting  and  abdomi- 
nal pain.  The  temperature  ranges  from  101°  to  103°.  The  tonsils  may  be 
a  little  red  and  the  lymphatic  tissues  swollen,  but  the  throat  symptoms  are 
quite  transient  and  unimportant.  On  the  second  or  third  day  the  enlarged 
glands  appear,  and  during  the  course  they  vary  in  size  from  a  pea  to  a  goose- 
egg.  They  are  painful  to  the  touch,  but  there  is  rarely  any  redness  or  swell- 
ing of  the  skin,  though  at  times  there  is  some  puf&ness  of  the  subcutaneous 
tissues  of  the  neck,  and  there  may  be  a  little  difficulty  in  swallowing.  In 
some  instances  there  has  been  discomfort  in  the  chest  and  a  paroxysmal  cough, 
indicating  involvement  of  the  tracheal  and  bronchial  glands.  The  swelling 
of  the  glands  persists  for  from  two  to  three  weeks.  Among  the  serious  fea- 
tures are  the  termination  of  the  adenitis  in  suppuration,  which  seems  rare 
(though  Xeumann  met  with  it  in  13  cases),  and  hgemorrhagic  nephritis. 
Acute  otitis  media  and  retro-pharyngeal  abscess  have  also  been  reported. 

The  outlook  is  favorable.  West  suggests  the  use  of  small  doses  of  calomel 
during  the  height  of  the  trouble. 


XVII.     MILIARY  FEVER— SWEATING  SICKNESS 

The  disease  is  characterized  by  fever,  profuse  sweats,  and  an  eruption  of 
miliary  vesicles.  It  prevailed  and  was  very  fatal  in  England  in  the  fifteenth 
and  sixteenth  centuries,  and  was  made  the  subject  of  an  important  memoir 
by  Johannes  C'aius,  1552.     Of  late  years  it  has  been  confined  entirely  to  cer- 


376  SPECIFIC  INFECTIOUS  DISEASES 

tain  districts  in  France  (Pieardy)  and  Italy.  An  epidemic  of  some  extent 
occurred  in  France  in  1887.  Hirsch  gives  a  chronological  account  of  194 
epidemics  between  1718  and  1879,  many  of  which  were  limited  to  a  single 
village  or  to  a  few  localities.  Occasionally  the  disease  has  become  widely 
spread.  Slight  epidemics  have  occurred  in  Germany,  Austria  and  Switzer- 
land. They  are  usually  of  short  duration,  lasting  only  for  three  or  four  weeks 
— sometimes  not  more  than  seven  or  eight  days.  As  in  influenza,  a  large  num- 
ber of  persons  are  attacked  in  rapid  succession.  In  the  mild  cases  there  is  only 
slight  fever^  with  loss  of  appetite,  and  erythematous  eruption,  profuse  perspira- 
tion, and  an  outbreak  of  miliary  vesicles.  The  severe  cases  present  the 
symptoms  of  intense  infection — delirium,  high  fever,  profound  prostration, 
and  hgemorrhage.  The  death-rate  at  the  outset  of  the  disease  is  usually  high, 
and,  as  is  so  graphically  described  in  the  account  of  some  of  the  epidemics 
of  the  middle  ages,  death  may  occur  in  a  few  hours. 


XVIII.     FOOT-AND-MOUTH  DISEASE— EPIDEMIC 
STOMATITIS— APHTHOUS  FEVER 

Foot-and-mouth  disease  is  an  acute  infectious  disorder  met  Math  chiefly 
in  cattle,  sheep,  and  pigs,  but  attacking  other  domestic  animals.  It  is  of 
extraordinary  activity,  and  spreads  with  "lightning  rapidity'^  over  vast  terri- 
tories. The  nature  of  the  ultra-microscopic  virus  has  not  been  determined. 
In  cattle,  after  a  period  of  incubation  of  three  or  five  days,  the  animal  be- 
comes feverish,  the  mucous  membrane  of  the  mouth  swells,  and  little  grayish 
vesicles  the  size  of  a  hemp  seed  begin  to  develop  on  the  edges  and  lower 
portion  of  the  tongue,  on  the  gums,  and  on  the  mucous  membrane  of  the  lips. 
They  contain  at  first  a  clear  fluid,  which  becomes  turbid,  and  then  they 
enlarge  and  gradually  become  converted  into  superficial  ulcers.  There  is 
ptyalism,  and  the  animals  lose  flesh  rapidly.  In  the  cow  the  disease  is 
also  frequently  seen  about  the  udder  and  teats,  and  the  milk  becomes  yellowish- 
white  in  color  and  of  a  mucoid  consistency. 

The  transmission  to  man  is  by  no  means  uncommon,  and  several  impor- 
tant epidemics  have  been  studied  in  the  neighborhood  of  Berlin.  In  Fried- 
berger  and  Frohner's  Pathology  and  Therapeutics  of  Domestic  Animals  the 
disease  is  thus  described :  "In  man  the  symptoms  are :  fever,  digestive  troubles, 
and  vesicular  eruption  upon  the  lips,  the  buccal  and  pharyngeal  mucous  mem- 
branes (angina)."  The  disease  is  apparently  transmitted  by  contact  and  by 
drinking  the  milk. 

In  widespread  epidemics  there  has  been  sometimes  a  marked  tendency 
to  haemorrhages.  The  disease  runs,  as  a  rule,  a  favorable  course,  but  in 
Siegel's  report  of  an  epidemic  the  mortality  was  8  per  cent. 

When  epidemics  are  prevailing  in  cattle  the  milk  should  be  boiled,  and 
measures  taken  to  isolate  both  the  cattle  and  individuals  who  come  in 
contact  with  them.  The  treatment  is  local,  a  mouth  wash  of  potassium 
permanganate  solution  and  the  application  of  silver  nitrate  to  the  affected 
areas. 


SWINE  FEVEK  377 


XIX.     PSITTACOSIS 

A  disease  in  birds,  characterized  by  loss  of  appetite,  weakness,  diarrhoea, 
convulsions,  and  death.  In  Germany,  France,  and  Italy  a  disease  in  man 
characterized  by  an  atypical  pneumonia,  great  weakness  and  depression,  and 
signs  of  a  profound  infection  has  been  ascribed  to  contagion  from  birds,  par- 
ticularly parrots.  There  have  usually  been  house  epidemics  with  a  very  high 
rate  of  mortality.  A  few  cases  have  been  reported  in  England,  and  Vickery, 
of  Boston,  reported  three  probable  cases.     The  bacteriology  is  doubtful. 


XX.     ROCKY  MOUNTAIN  SPOTTED  FEVER;  TICK  FEVER 

In  the  Bitter-root  Valley  of  Montana  and  in  the  mountains  of  Idaho, 
Nevada,  and  Wyoming  there  is  an  acute  infection  characterized  by  chill,  fever, 
pains  in  back  and  bones,  and  a  macular  rash,  becoming  hgemorrhagic.  It 
was  reported  upon  occasionally  by  army  surgeons — e.  g.,  Wood — but  nothing 
definite  was  known  until  the  studies  of  Wilson  and  Chowning  (1902),  who 
believed  the  disease  to  be  transmitted  by  ticks.  The  studies  of  King  and 
Eicketts  demonstrated  the  transmission  of  the  disease  by  the  tick,  Dermacenior 
venustus.  Wolbach  considers  that  the  cause  of  the  disease  is  a  minute 
parasite  which  he  thinks  is  probably  a  new  organism.  The  lesions  are 
endothelial  cell  proliferation,  local  necrosis  of  endothelium,  and  thrombosis. 
Perivascular  accumulations  of  endothelial  cells  are  common.  The  disease 
is  readily  given  to  the  guinea-pig  and  monkey,  and  is  transmissible  from  one 
animal  to  another  by  the  bite  of  the  tick.  Immunity  is  given  by  an  attack, 
and  in  animals  this  is  transmitted  to  the  young.  After  an  incubation  of  from 
three  to  ten  da3^s  the  disease  begins  with  a  chill,  fever,  and  severe  pains  in  the 
limbs.  The  rash  appears  from  the  second  to  the  seventh  day,  is  macular, 
dark,  and  becomes  hgemorrhagic.  Illustrations  of  it  show  a  rash  not  unlike 
that  of  typhus.  The  skin  is  often  swollen.  Haemorrhages  from  the  mucous 
membranes  are  not  uncommon.  The  temperature  range  is  from  103°  to 
105°  F.,  and  at  the  height  of  the  disease  there  are  delirium  and  stupor.  Con- 
valescence begins  in  the  fourth  week.  The  death-rate  is  high  for  an  eruptive 
fever,  reaching  70  per  cent,  in  Montana,  but  in  Idaho  it  is  not  more  than 
2  or  3  per  cent.  As  a  prophylactic  measure,  destruction  of  the  ticks  by  dip- 
ping or  scouring  the  horses  and  cattle  should  be  carried  out.  The  treatment 
is  that  of  an  acute  infection. 


XXI.     SWINE  FEVER 

A  few  cases  have  been  described  from  accidental  inoculation  in  the  prepa- 
ration of  cultures  and  in  making  post  mortems  upon  pigs.  In  the  course 
of  from  twelve  hours  to  three  days  there  is  swelling  of  the  fingers  of  the 
affected  hand,  which  have  a  blue-red  color,  and  small  nodules  form.  In  some 
of  the  instances  the  course  has  been  like  that'  of  a  painful  erythema  migrans. 


378  SPECIFIC  IXFECTIOUS   DISEASES 

with  swelling  of  the  lymph-glands.     A  specific  serum  has  been  used  with  suc- 
cess in  several  cases. 

XXII.     RAT-BITE  FEVER 

A  remarkable  infection,  following  rat-bite,  characterized  by  brief  febrile 
paroxysms  which  may  recur  at  intervals  for  months. 

The  disease  has  been  known  in  China  and  Japan  for  several  centuries. 
The  features  are  very  unusual.  There  is  a  prolonged  period  of  incubation, 
lasting  in  some  cases  for  many  months.  The  wound,  which  has  run  the 
ordinary  course  and  perhaps  healed,  becomes  swollen,  red,  and  eroded;  an 
ulcer  forms  and  the  regional  lymph-glands  are  involved.  The  fever  sets  in 
suddenly  with  a  chill  and-  lasts  three  or  four  days.  With  its  onset  there  is  a 
skin  rash,  either  erythema  or  a  blotchy  eruption  somewhat  resembling  measles. 
The  patient  feels  very  ill,  there  may  be  pains  in  the  muscles  and  joints 
and  sometimes  delirium.  After  persisting  for  a  few  days,  the  temperature  falls 
and  the  patient  feels  well.  After  a  varying  interval  of  from  a  few  days 
to  a  couple  of  weeks  the  attack  is  repeated,  and  this  may  go  on  for  several 
months  or,  according  to  the  Japanese  reports,  for  several  years.  The  outlook 
is  favorable;  among  49  Japanese  cases  only  1  died. 

In  Border's  last  case  the  boy  was  bitten  on  September  15th.  From  Octo- 
ber 6th  to  11th,  on  the  13th,  14th,  17th,  18th,  19th,  23d,  24th,  25th,  28th  to 
30th,  and  November  4th,  5th,  and  6th,  he  had  attacks  of  fever,  the  temper- 
ature rising  to  between  104°  and  105°  F.,  and  once  reaching  nearly  106°. 
Each  attack  was  associated  with  a  rash. 

Various  organisms  have  been  described.  In  one  of  Herder's  cases  spirilla 
were  seen.  Ogata  describes  a  sporozoan  parasite,  and  Proescher  a  bacillus. 
Japanese  observers  have  reported  spiroch^etes  and  suggested  the  name  Spiro- 
clrceta  morsus-muris.  Patients  recovered  after  treatment  by  mercury  or 
arsphenamine.  Schotmiiller,  Blake  and  Tileston  each  found  a  streptothrix 
in  their  cases.  In  Tileston's  case  the  organisms  were  found  in  fresh  smears  by 
dark-field  illumination.  Blake  isolated  a  streptothrix  in  a  case  which  at 
autopsy  showed  endocarditis,  in  the  vegetations  of  which  the  same  organism 
was  found. 

Teeatmext. — The  wound  should  be  cauterized,  arsphenamine  given  Intra- 
venously, and  the  febrile  paroxysms  treated  symptomatically. 


XXin.     TRENCH  FEVER 

Definition. — An  acute  infection,  with  a  short  period  of  fever,  followed 
by  a  second  rise  or  by  two  or  three  or  more  paroxysms  of  one  or  two  days' 
duration.     The  organism,  as  yet  unknown,  is  transmitted  through  the  louse. 

History. — The  disease  was  first  recognized  in  1915  during  the  War.  As 
it  is  not  likely  to  be  prevalent  in  civil  life  only  a  brief  description  is 
necessary. 

Symptoms. — The  disease  usually  sets  in  acutely  with  chilliness,  headache, 
and  general  pains,  the  latter  sometimes  of  great  severity.  The  fever  is  usually 
not  high  and  of  two  or  three  days'  duration.     After  an  afebrile  period  one  or 


SIX-DAY  FEVER  379 

more  recurrences  lasting  for  one  or  two  days  are  very  characteristic.  In  some 
instances  the  fever  lasted  for  four  or  five  days.  The  greatest  complaint  was 
of  tender  shins.  As  a  rule  there  was  no  swelling  or  redness,  and  the  pain 
was  usually  most  marlced  at  night.  The  course  of  the  fever  and  the  tender 
shins  are  the  two  ^  most  important  aids  in  diagnosis.  Many  cases  were 
regarded  at  first  as  influenza.  There  is  no  specific  treatment.  Complete 
rest  is  important  and  acetylsalicylic  acid  sometimes  relieved  the  pain.  A  local 
application  of  a  saturated  solution  of  magnesium  sulphate  sometimes  gave 
relief. 

XXIV.     ACUTE  ULCERATIVE  CONJUNCTIVITIS 
TRANSMITTED  FROM  RABBITS 

In  the  United  States  there  is  a  disease  of  rodents,  particularly  in  rabbits, 
the  ground  squirrels,  guinea-pigs  and  rats,  characterized  by  enlargement 
of  the  lymph  glands,  and  features  suggestive  of  plague;  but  tlie  organism 
was  isolated  by  McCoy  and  Chapin  and  shown  to  be  the  Bacterium  tularense, 
which  is  possibly  transmitted  by  flies.  Man  is  sometimes  affected,  and 
Wherrey  reported  two  cases  characterized  by  acute  ulcerative  conjunctivitis, 
enlargement  of  the  pre-auricular  and  cervical  glands,  fever  and  great  debility. 
Both  of  the  patients  had  been  cutting  up  wild  rabbits  in  preparation  for 
cooking. 

XXV.     SIX  (SEVEN)  DAY  FEVER 

This  is  described  by  Eogers  as  occurring  in  the  seaports  in  India;  it  is 
uncommon  in  the  tropics  and  is  regarded  by  many  as  a  variety  of  dengue.  An 
organism  of  the  colon  group  has  been  isolated  from  the  blood.  The  disease 
begins  suddenly,  the  temperature  shows  marked  remissions,  skin  rashes  are 
common,  usually  a  blotchy  erythema,  sometimes  with  petechias.  It  terminates 
on  the  sixth  or  seventh  day  by  crisis,  and  when  the  date  of  onset  is  known  the 
defervescence  may  be  predicted  within  a  few  hours.  Rogers  shows  that  the 
disease  is  common  in  India,  and  it  was  described  by  Deakes  in  1911-12  in 
the  Canal  Zone. 


SECTION    II 
DISEASES  DUE  TO  PHYSICAL  AGENTS 

I.     SUNSTROKE;  HEAT  EXHAUSTION 

{Insolation,  Thermic  Fever,  Siriasi^) 

Definition. — Under  these  terms  are  comprised  certain  manifestations  fol- 
lowing exposure  to  excessive  heat,  of  which  thermic  fever  or  sunstroke,  heat 
exhaustion,  and  heat  cramps  are  the  common  forms. 

History. — It  is  one  of  the  oldest  of  recognized  diseases.  The  case  of  the 
son  of  the  Shunammite  woman  (2  Kings,  IV)  is  perhaps  the  oldest  on 
record.  The  Arabians  called  the  symptoms  due  to  excessive  heat  "Siriasis," 
after  Sirius  the  Dog  Star.  Cardan  recognized  it  in  the  sixteenth  century  and 
thought  it  was  apoplexy  due  to  heat — morbus  attonitus.  In  the  eighteenth 
century  Boerhaave  regarded  it  as  phrenitis.  It  was  not  until  the  nineteenth 
century  that  the  Anglo-Indian  surgeons  and  the  physicians  of  the  United 
States  gave  us  a  full  knowledge  of  the  different  affections  due  to  excessive 
heat.  Various  classifications  have  been  suggested,  but  two  chief  forms  are 
everywhere  recognized — heat  exhaustion  and  thermic  fever  or  sunstroke — to 
which  Edsall  added  the  remarkable  heat  cramps  which  occur  in  persons 
working  under  very  high  external  temperatures. 

Distribution. — Sunstroke  occurs  in  the  tropics  and  in  temperate  regions 
during  protracted  heat  waves.  It  is  very  common  in  the  Atlantic  Coast 
cities  of  the  United  States  during  the  hot  spells  of  summer.  Heat  exhaustion 
is  frequently  met  with  in  conditions  similar  to  those  in  which  sunstroke 
takes  place,  and  it  is  not  infrequent  in  the  engine-rooms  of  large  steamships, 
less  often  in  foundries.  In  the  U.  S.  Navy  in  35  years  (to  1913)  there  were 
20  deaths  and  33  invalided  on  account  of  heat  prostration  (Fiske). 

Heat  Exhaustion. — In  the  tropics  and  in  temperate  regions  during  pro- 
tracted heat  waves  many  persons  become  depressed  physically  and  are  unable 
to  work  or  take  nourishment.  In  children  the  condition  is  very  often  asso- 
ciated with  gastro-intestinal  disturbances  and  fever.  The  true  heat  syncope 
is  specially  seen  in  persons  who  have  not  been  in  good  health  or  who  are  in- 
temperate. The  heat  may  be  that  of  the  sun  or  artificial  heat,  as  in  the 
engine-rooms  of  steamers.  The  symptoms  begin  with  giddiness,  nausea,  an 
uncertain,  staggering  gait;  there  is  pallor,  the  pulse  is  small,  the  heart's 
action  weak,  the  respirations  rapid,  and  the  patient  may  quickly  become 
unconscious.  Muscular  spasms,  often  painful,  are  common.  Externally  the 
body  may  be  clammy,  with  sweat,  but  as  a  rule  the  rectal  temperature  is 
decreased.  In  the  axilla  it  may  be  as  low  as  95°  or  96°  F.  Erom 
slight  attacks,  such  as  are  seen  in  steamships,  the  patients  recover  rapidly 

380 


SUNSTEOKE  381 

when  brought  on  deck;  in  other  cases  the  unconsciousness  may  end  in  deep 
coma  and  death. 

Thermic  Fever. — This  is  more  common  in  men  than  in  women  and  chil- 
dren, and  is  principally  seen  in  persons  who  work  in  very  high  external  tem- 
peratures, and  who  are  too  heavily  clad,  or  who  are  addicted  to  alcohol.  In 
India  regiments  on  the  march  are  not  infrequently  attacked.  It  is  more  com- 
mon in  Europeans  than  in  the  dark  races,  but  in  the  United  States  negroes 
are  often  attacked. 

MoEBiD  Anatomy. — Eigor  mortis  occurs  early.  Putrefactive  changes 
may  come  on  with  great  rapidity.  The  venous  engorgement  is  extreme, 
particularly  in  the  cerebrum.  The  left  ventricle  is  contracted  (Wood)  and 
the  right  chamber  dilated.  The  blood  is  usually  fluid ;  the  lungs  are  intensely 
congested.     Parenchymatous  changes  occur  in  the  liver  and  kidneys. 

Symptoms. — The  patient  may  be  struck  down  and  die  within  an  hour, 
with  symptoms  of  heart-failure,  dyspnoea,  and  coma.  This  form,  sometimes 
known  as  the  asphyxial,  occurs  chiefly  in  soldiers  and  is  graphically  described 
by  Parkes.  Death  indeed  may  be  almost  instantaneous,  the  victims  falling  as 
if  struck  upon  the  head.  The  more  usual  form  comes  on  during  exposure, 
with  pain  in  the  head,  dizziness,  a  feeling  of  oppression,  and  sometimes  nausea 
and  vomiting.  Visual  disturbances  are  common,  and  a  patient  may  have 
colored  vision.  Diarrhoea  or  frequent  micturition  may  supervene.  Insensi- 
bility follows,  which  may  be  transient  or  which  deepens  into  a  profound 
coma.  The  patients  are  usually  admitted  to  hospital  in  an  unconscious  state, 
with  the  face  flushed,  the  skin  hot,  the  pulse  rapid  and  full,  and  the  tempera- 
ture ranging  from  107°  to  110°  F.,  or  even  higher.  The  breathing  is  labored 
and  deep,  sometimes  stertorous.  Usually  there  is  complete  relaxation  of  the 
muscles,  but  twitchings,  jactitation,  or  very  rarely  convulsions  may  occur.  The 
pupils  may  at  first  be  dilated,  but  by  the  time  the  patients  are  admitted 
to  hospital  they  are  (in  a  majority)  extremely  contracted.  Petechia  may  be 
present  upon  the  skin.  In  the  fatal  cases  the  coma  deepens,  the  cardiac  pulsa- 
tions become  more  rapid  and  feeble,  the  breathing  becomes  hurried  and  shallow 
and  of  the  Cheyne-Stokes  type.  The  fatal  termination  may  occur  within 
twenty-four  or  thirty-six  hours.  Favorable  indications  are  the  return  of 
consciousness  and  a  fall  in  the  fever.  The  recovery  in  these  cases  may  be 
complete.  In  other  instances  there  are  remarkable  after-effects,  the  most  con- 
stant of  which  is  a  permanent  inability  to  bear  high  temperatures.  Such 
patients  become  very  uneasy  when  the  thermometer  reaches  80°  F.  in  the 
shade.  Loss  of  the  power  of  mental  concentration  and  failure  of  memory  are 
troublesome  sequelae.  Such  patients  are  always  worse  in  the  hot  weather. 
■Occasionally  there  are  convulsions,  followed  by  marked  mental  disturbance. 
Dercum  has  described  peripheral  neuritis  as  a  sequence. 

Many  observers  have  called  attention  to  a  fever  in  the  tropics  which  lasts 
for  a  few  days,  with  no  special  symptoms  other  than  those  of  pyrexia  and 
weakness.  This  may  be  simply  heat  exhaustion.  It  is  not  uncommon  in  the 
Southern  States,  where  it  may  be  mistaken  for  malaria  or  mild  typhoid  fever. 
John  Guiteras,  who  has  unrivalled  knowledge  of  tropical  affections,  regards 
these  conditions  as  directly  due  to  prolonged  high  external  temperatures. 

Diagnosis. — It  is  rarely  difficult  to  distinguish  thermic  fever  from  the 
malignant  types  of  malaria  and  from  the  various  other  forms  of  coma.     The 


382 


DISEASES  DUE  TO  PHYSICAL  AGENTS 


diagnosis  in  heat  exhaustion  or  thermic  fever  is  readily  made.  In  the  one 
the  skin  is  moist,  pale,  and  cool,  the  pulse  small  and  soft,  and  consciousness 
may  remain  till  near  the  end;  whereas  in  the  other  there  is  high  fever  with 
early  unconsciousness. 

Prognosis. — In  the  old,  the  infirm,  and  alcoholic  subjects  the  mortality 
during  a  very  hot  wave  may  be  as  high  as  30  or  40  per  cent.  In  New  York 
and  Philadelphia  the  death-rate  varies  very  much  in  different  seasons. 

Treatment. — In  heat  exhaustion  stimulants  should  be  given  freely,  and 
if  the  temperature  is  below  normal  the  hot  bath  should  be  used.  Ammonia 
may  be  given  if  necessary.     In  thermic  fever  the  indications  are  to  reduce 


my 

JUNE  2 

3 

■1 

HOUR 

p.  •<. 

3    9    1 

on 

12 

*• 

"z 

3 

*    5 

B 

7 

3 

3 

10 

,, 

12 

■J- 

2 

, 

, 

^ 

f. 

^ 

n 

, 

10 

^, 

,. 

•■ 

^ 

. 

rU 

109 
108 
107 
106 
105 
104 
103 
102 
101 
100 
99 
98 
97 
96 
95 
94 
93 
92 
01 

" 

~ 

~ 

■ 

~ 

•  ^ 

X 

-S 

1 

sH 

< 

n 

lU 

III 

n 

y 

T 

lU 

Ul 

tu 

w 

Jl* 

o 

z 

z 

z 

r 

r 

- 

;; 

3 

UJ 

m 

a. 

t 

t 

1 

z 

-1 

-J 

,,, 

'' 

v 

; 

: 

; 

j 

o 

o 

o 

y 

y 

!i 

X 

/^ 

^ 

A 

A 

r 

^ 

/ 

s 

J\ 

^ 

' 

Y 

/ 

V 

N 

/ 

«= 

n  \ 

/ 

1/ 

•i 

v/ 

^n  1  T 

1 

/ 

V 

j». 

^ 

■« 

V 

\ 

/ 

Vl 

'* 

\ 

^ 

< 

' 

I 

^ 

— r* 

1 

} 

... 

~ 

' 

f 

1 

J 

/■<* 

'~ 

i 

I 

=  ULSE 

1 

211 

:  z 

2 

§ 

1 

2 

s 

5 

O 

1 

o 

o 

O 

■^ 

8 

Resp. 

g 

sss 

s 

s 

s 

S 

s 

^' 

s 

*; 

^ 

?. 

S 

5 

3 

Chart  XII. — Case  of  Sunstroke  Treated  by  the  Ice-bath;  Eecovery. 


the  temperature  as  rapidly  as  possible.  Rubbing  the  body  with  ice  was  prac- 
tised at  the  New  York  Hospital  by  Darrach  in  1857,  and  is  an  excellent  proce- 
dure to  lower  the  temperature  rapidly.  The  wet  or  ice  pack  or  the  bath  may 
be  used.  Ice-water  enemata  may  also  be  employed.  In  the  cases  in  which  the 
symptoms  are  those  of  intense  asphyxia,  and  in  which  death  may  take  place  in 
a  few  minutes,  free  bleeding  should  be  practised,  a  procedure  which  saved  Weir 
Mitchell  when  a  young  man.  For  the  convulsions,  chloroform  should  be  given 
at  once.  Of  other  remedies,  the  antipyretics  have  been  employed,  and  may  be 
given  when  there  is  any  special  objection  to  hydrotherapy,  for  which,  however, 
they  cannot  be  substituted. 

Heat  Cramps. — Persons  who  use  the  muscles  while  exposed  to  a  very  high 
temperature  are  liable  to  attacks  of  severe  cramp.  The  condition,  which  has 
been  described  very  thoroughly  by  Edsall,  occurs  principally  in  stokers  in  the 


CAISSON  DISEASE  383 

furnace-rooms  of  steamships  and  in  workers  in  iron,  foundries.  The  spasms 
occur  spontaneously,  chiefly  in  the  muscles  of  the  calves,  the  arms,  and  some- 
times in  the  abdomen;  they  are  often  of  great  intensity  and  very  painful.  A 
movement,  pressure,  or  any  stimulus,  as  electricity,  may  send  the  muscle  into 
spasm  at  once.  In  addition  to  ordinary  cramps  there  are  sometimes  fibrillary 
contractions.  The  attacks  may  last  for  from  12  to  34  hours  and  are  followed 
by  muscular  soreness  and  sometimes  by  great  weakness. 


II.     CAISSON  DISEASE 

(Compressed  Air  Disease;  Diver's  Paralysis) 

Definition. — A  disease  of  caisson  workers  and  divers,  due  to  a  saturation 
of  the  tissues  with  nitrogen  under  the  increased  pressure.  If  the  decompression 
takes  place  quickly,  a  too-rapid  escape  of  the  nitrogen  as  bubbles  into  the  blood 
causes  air  embolism. 

History. — The  French  writers,  Bucquoy,  Foley,  and  Bert,  first  studied  th'i 
disease.  Ley  den  recognized  the  anatomical  changes.  A.  H.  Smith  and  others 
in  the  United  States  contributed  important  papers,  and  the  studies  of  Haldane, 
Leonard  Hill,  and  Boycott  have  thrown  light  upon  the  etiology  and  means 
of  prevention. 

Etiology.- — ^The  cases  are  met  with  chiefly  in  workers  in  caissons  and  tun- 
nels and  in  divers.  "The  higher  the  pressure  and  the  shorter  the  period  of 
decompression  the  greater  is  the  risk"  (Hill).  In  caissons  the  pressure  is 
rarely  30  to  35  pounds,  but  in  the  St.  Louis  bridge  the  pressure  reached  as 
high  as  45  to  50  pounds.  Divers  go  down  to  20  fathoms  with  a  pressure  of 
53  pounds;  the  record  depth  attained  by  divers  is  210  feet  (Hill).  The  dis- 
ease may  also  occur  in  very  deep  mines. 

In  building  the  St.  Louis  bridge  across  the  Mississippi,  among  352  workers- 
there  were  50  cases  of  paralysis  and  14  deaths.  In  constructing  the  East  Ei^^er 
tunnels  in  New  York,  among  10,000  men  employed  there  were  3,692  cases. 
Twenty  fatal  cases  occurred,  with  symptoms  of  nausea,  vomiting,  rapid  pros- 
tration and  paralysis. 

Patholo^. — To  Hoppe-Seyler,  Bucquoy,  and  Paul  Bert  we  owe  a  rational 
explanation  of  the  disease.  During  compression  the  blood  passing  through 
the  lungs  becomes  saturated  with  nitrogen,  which  is  carried  to  the  tissues  until 
the  whole  body  is  saturated.  "The  mass  of  blood  is  about  5  per  cent,  of 
the  body,  and  the  capacity  of  the  tissues  to  dissolve  N  is  estimated  by  Boycott 
as  35  times  that  of  the  blood — in  a  fat  man  considerably  more"  (Hill).  With 
active  work  it  does  not  take  long  to  effect  complete  saturation.  During  de- 
compression the  process  is  just  the  reverse.  "The  blood  gives  up  N  to  the 
alveolar  air  and  returns  to  the  tissues  for  more.  Those  organs  in  which  the 
circulation  is  rapid  will  yield  up  their  N  quickly,  and  those  with  a  sluggish 

circulation  slowly and  at  the  end  of  decompression  a  condition  may 

be  set  up  in  which  the  slow  tissues  still  hold,  say  3  per  cent,  of  N,  while  the 
blood  can  dissolve  only  1  per  cent.  Herein  wd  have  a  danger  of  bubbles 
forming"  (Hill).  The  nitrogen  in  the  body  fluids  begins  to  dissolve  out  as 
soon  as  the  pressure  is  lowered.    This  is  only  harmful  if  the  nitrogen  separates 


384  DISEASES  DUE  TO  PHYSICAL  AGENTS 

in  the  form  of  bubbles.  These  may  form  in  the  blood,  in  the  synovial  fluid  of 
the  joints,  and  in  the  nervous  system.  As  a  rule  a  very  rapid  reduction  in 
pressure  must  occur  before  the  formation  of  the  bubbles  follows.  Experimen- 
tally all  the  symptoms  can  be  produced  in  goats,  and  the  spinal  cord  may 
contain  numerous  air  emboli.  This  vs^as  the  anatomical  lesion  determined  by 
Leyden,  who  found  fissuring  and  laceration  of  the  cord,  which  explains  the 
paraplegia.  Pulmonary  air  embolism  also  occurs  and  is  responsible  for  certain 
features.  In  an  analysis  of  gas  from  the  right  heart,  Erdman  found  80  per 
cent,  of  N  and  20  per  cent,  of  COo. 

Symptoms.- — Within  from  half  an  hour  to  one  hour  after  leaving  the 
caisson,  the  patient  may  have  headache,  giddiness  and  feel  faint,  symptoms 
which  may  pass  off  and  leave  no  further  trouble.  In  other  instances  the 
patients  have  severe  pains  in  the  extremities,  usually  the  legs  and  the  abdo- 
men, sometimes  associated  with  nausea  and  vomiting — attacks  which  the 
workmen  usually  speak  of  as  "the  bends."  The  pains  may  be  of  the  greatest 
intensity  and  associated  with  giddiness  and  vomiting.  The  paralysis,  usually 
of  the  legs,  comes  on  rapidly,  and  varies  in  degree  from  a  slight  paralysis  to 
complete  loss  both  of  motion  and  sensation.  This  occurred  in  15  per  cent,  of 
A.  H.  Smith's  cases  and  in  61  per  cent,  of  the  St.  Louis  cases.  Monoplegia 
and  hemi]3legia  are  rare.  In  extreme  instances  the  attacks  resemble  apoplexy ; 
the  patient  rapidly  becomes  comatose  and  death  occurs  in  a  few  hours.  The 
paraplegia  may  be  permanent,  but  in  slight  cases  it  gradually  disappears  and 
recovery  may  be  complete.  Late  resulting  features  are  spinal  cord  changes, 
chronic  arthritis  and  deafness. 

Prophylaxis. — The  only  safeguard  is  a  gradual  decompression,  which 
obviates  the  risk  of  rapidly  setting  free  the  nitrogen  from  the  tissues.  Hal- 
dane  and  his  colleagues  introduced  what  they  call  the  "Stage  Method," 
which  is  now  widely  adopted  with  the  most  beneficial  results.  For  work  in 
very  high  pressures  the  shifts  should  be  short,  not  more  than  two  hours. 

Treatment. — The  caisson  workers  found  very  early  that  the  best  remedy  for 
"the  bends"  was  immediate  recompression,  and  Andrew  H.  Smith  of  New 
York  introduced  a  medical  air-lock  for  the  Brooklyn  bridge  workers.  The 
workers  should  live  and  sleep  not  far  from  the  works,  where  such  an  air- 
lock should  be  provided  for  immediate  treatment.  Cases  with  severe  symp- 
toms may  be  saved  by  recompression.  Hot  fomentations,  massage  and  hypo- 
dermics of  morphia  may  be  necessary  for  the  extreme  pains. 


III.     MOUNTAIN  SICKNESS 

Definition. — An  illness  associated  with  adaptation  to  low  atmospheric 
pressures,  characterized  by  cyanosis,  nausea,  headache,  intestinal  disturbances, 
hyperpncea  and  sometimes  fainting. 

Patholo^.' — The  symptoms  are  directly  referable  to  want  of  oxygen  pro- 
duced by  the  diminished  pressure  of  the  atmosphere.  Haldane,  Douglas  and 
Henderson  made  an  exhaustive  study  of  the  process  of  accommodation  in  a 
five  weeks'  residence  at  the  top  of  Pike's  Peak.  After  acclimatization  the 
symptoms  above  mentioned  disappeared,  but  dyspnoea,  blueness  and  periodic 
breathing  are  apt  to  follow  exertion.    The  alveolar  carbon  dioxide  pressure  was 


GAS  POISONING  385 

reduced  from  about  40  mm.  to  about  27  mm.  during  rest,  which  corresponded 
to  an  increase  of  about  50  per  cent,  in  the  ventilation  of  the  lung  alveoli..  This 
process  of  accommodation  is  associated  with  a  remarkable  increase  in  the  red 
blood  corpuscles  and  hemoglobin  to  120  to  150  per  cent.  These  authors 
conclude  that  the  acclimatization  is  largely  due  to  increased  secretory  activity 
of  the  alveolar  epithelium,  to  the  greater  lung  ventilation  and  to  the  increased 
haemoglobin  production. 

The  disturbance  known  as  "Aviators'  Sickness"  also  involves  the  problem 
of  a  low  barometric  pressure.  The  pressure  of  the  oxygen  in  the  arterial 
blood  in  high  altitudes  may  be  higher  than  in  the  alveolar  air.  Active  secretion 
of  oxygen  occurs  in  the  lungs ;  that  is  the  passage  of  oxygen  is  accelerated  and 
this  apparently  has  a  selective  action.  There  is  a  tendency  to  bradycardia  in 
aviators  after  a  sudden  descent,  which  is  probably  a  part  of  a  vagobulbar 
syndrome. 

Symptoms. — The  symptoms  just  given,  which  are  the  most  important,  pass 
away  gradually,  but  may  return  on  exertion.  In  feeble  persons  the  heart's 
action  may  be  weak  and  intermittent,  and  syncope  may  follow  any  effort. 
Whymper  in  the  ascent  of  Chimborazo  at  a  height  of  16,000  feet  had  head- . 
ache,  fever,  gasping  respiration  and  great  weakness.  Nausea,  vomiting,  bleed- 
ing at  the  nose,  ringing  in  the  ears  and  palpitation  are  not  infrequent  symp- 
toms. 

IV.     GAS  POISONING 

Carbon  Monoxide. — Acute  cases  of  poisoning  with  illuminating  gas  are 
comparatively  common.  The  frequency  of  chronic  gas  poisoning  is  difficult 
to  state.  In  occupations  about  furnaces  in  many  trades  and  in  mining  (carbon 
monoxide  derived  from  the  explosive)  there  are  possibilities  of  poisoning. 
The  chief  effect  of  the  carbon  monoxide  is  to  displace  the  oxygen  from  the 
oxyhemoglobin  and  so  reduce  the  oxygen-carrying  function. 

The  main  symptoms  are  a  general  feeling  of  illness,  headache,  vertigo, 
nausea  and  vomiting,  and  marked  muscular  weakness.  If  the  dose  is  large 
the  subject  becomes  drowsy  and  then  unconscious.  Muscular  twitchings  and 
convulsions  often  occur.  At  this  stage  the  respiration  is  usually  rapid,  the 
pulse  is  rapid  also,  and  usually  weak.  Cyanosis  is  marked,  accompanied  by  a 
peculiar  redness  of  the  skin.  The  blood  has  a  bright  red  color.  Pulmo- 
nary complications  are  important,  particularly  broncho-pneumonia,  and  any 
of  them  may  appear  some  time  after  the  poisoning.  A  great  variety  of  nervous 
sequels  have  resulted,  neuritis,  tremor,  paralyses,  etc. 

In  chronic  poisoning,  headache,  vertigo,  nausea,  weakness  and  sometimes 
mental  disturbance  are  common.  The  diagnosis  is  rarely  in  doubt  in  the  acute 
cases.  The  odor  of  the  breath  may  be  characteristic  and  the  spectroscopic  test 
is  positive. 

The  treatment  consists  in  removal  from  the  poisoned  atmosphere,  free  use 
of  oxygen  with  artificial  respiration  in  some  form,  free  venesection  with  trans- 
fusion of  blood  or  the  administration  of  salt  solution  subcutaneously.  Active 
stimulation  should  be  given  when  necessary. 

Carbon  Bisulphide. — This  is  used  to  treat  india  rubber  and  poisoning  may 
occur.     Headache,   vertigo,  insomnia   and    depression   are   common.      Subse- 


386  DISEASES  DUE  TO  PHYSICAL  AGENTS 

qaently  areas  of  anaesthesia  may  occur  and  parsesthesias  of  various  kinds. 
Vision  and  taste  may  both  show  changes.  A  great  variety  of  symptoms  from 
disturbance  of  the  nervous  system  results  and  organic  nervous  diseases  may 
be  closely  simulated.  Prophylactic  measures  are  usually  successful  and  the 
treatment  is  symptomatic. 

Gas-poisoning  in  War. — Our  interest  is  now  concerned  with  the  after-effects 
in  those  who  were  gassed.  Several  possibilities  exist.  (1)  The  psychical  result 
is  a  factor  in  some  eases,  but  time  should  help  the  majority  of  them.  (2)  Actual 
damage  to  the  respiratory  tract.  Some  show  this  but  the  exact  effects  are  diffi- 
cult to  estimate;  chronic  bronchitis  and  emphysema  are  the  most  important. 

(3)  Changes  in  the  respiratory  exchange  which  may  be  a  permanent  result. 

(4)  There  is  no  evidence  that  there  is  any  increased  liability  to  tuberculosis. 


SECTION  III 
THE  INTOXICATIONS 

I.     ALCOHOLISM 

(a)  Acute  Alcoholism. — When  a  large  quantity  of  alcohol  is  taken,  the 
influence  is  chiefly  on  the  nervous  system,  and  is  manifested  in  muscular  inco- 
ordination, mental  disturbance,  and,  finally,  narcosis.  The  individual  pre- 
sents a  flushed,  sometimes  slightly  cyanosed  face,  the  pulse  is  full,  respira- 
tions deep  but  rarely  stertorous.  The  pupils  are  dilated.  The  temperature 
is  frequently  below  normal,  particularly  if  the  patient  has  been  exposed  to 
cold.  Perhaps  the  lowest  reported  temperatures  have  been  in  cases  of  this 
sort.  An  instance  is  on  record  in  which  the  patient  on  admission  to  hospital 
had  a  temperature  of  24°  C.  (ca.  75°  F.),  and  ten  hours  later  the  temperature 
had  not  risen  to  91°  F.  The  unconsciousness  is  rarely  so  deep  that  the  pa- 
tient cannot  be  roused  to  some  extent,  and  in  reply  to  questions  he  mutters 
incoherently.  Muscular  twitchings  may  occur,  but  rarely  convulsions.  The 
breath  has  a  heavy  alcoholic  odor.  The  respirations  may  be  slow;  in  one 
case  they  were  only  six  in  the  minute. 

The  diagnosis  is  not  difficult,  yet  mistakes  are  frequently  made.  Persons 
are  brought  to  a  hospital  by  the  police  supposed  to  be  drunk  when  in  reality 
they  are  dying  from  apoplexy.  Too  great  care  caunot  be  exercised,  and  the 
patient  should  receive  the  benefit  of  the  doubt.  In  some  instances  the  mis- 
take has  arisen  from  the  fact  that  a  person  who  has  been  drinking  heavily 
has  been  stricken  with  apoplexy.  In  this  condition  the  coma  is  usually  deeper, 
stertor  is  present,  and  there  may  be  evidence  of  hemiplegia  in  the  greater 
flaccidity  of  the  limbs  on  one  side.  The  diagnosis  will  be  considered  in  the 
section  upon  ursemic  coma. 

Dipsomania  is  a  form  of  acute  alcoholism  seen  in  persons  with  a  strong 
hereditary  tendency  to  drink.  Periodically  the  victims  go  "on  a  spree,"  but 
in  the  intervals  they  are  entirely  free  from  any  craving  for  alcohol. 

(b)  Chronic  Alcoholism. — In  moderation,  wine,  beer,  and  spirits  may  be 
taken  throughout  a  long  life  without  impairing  the  general  health. 

The  poisonous  effects  of  alcohol  are  manifested  ( 1 )  as  a  functional  poison, 
as  in  acute  narcosis;  (2)  as  a  tissue  poison,  in  which  its  effects  are  seen  on 
the  parenchymatous  elements,  particularly  epithelium  and  nerve,  producing 
a  slow  degeneration,  and  on  the  blood  vessels,  causing  thickening  and  ulti- 
mately fibroid  changes;  and  (3)  as  a  checker  of  tissue  oxidation,  since  tbe  alco- 
hol is  consumed  in  place  of  the  fat.  This  leads  to  fatty  changes  and  some- 
times to  a  condition  of  general  steatosis. 

The  chief  effects  of  chronic  alcohol  poisoning  may  be  thus  summarized : 
Nervous  System. — Functional  disturbance   is  common.     Unsteadiness  of 
the  muscles  in  performing  any  action  is  a  constant  feature.     The  tremor  is 

387 


388  INTOXICATIONS 

best  seen  in  the  hands  and  in  the  tongue.  The  mental  processes  may  be  dull, 
particularly  in  the  early  morning  hours,  and  the  patient  is  unable  to  transact 
any  business  until  he  has  had  his  accustomed  stimulant.  Irritability  of  tem- 
per, forgetfulness,  and  a  change  in  the  moral  character  of  the  individual 
gradually  come  on.  The  judgment  is  seriously  impaired,  the  will  enfeebled, 
and  in  the  final  stages  dementia  may  supervene.  An  interesting  combination 
of  symptoms  in  chronic  alcoholics  is  characterized  by  peripheral  neuritis,  loss 
of  memory,  and  pseudo-reminiscences — that  is,  false  notions  as  to  the  patient's 
position  in  time  and  space,  and  fabulous  explanations  of  real  occurrences. 
The  peripheral  neuritis  is  not  always  present;  there  may  be  only  tremor  and 
jactitation  of  the  lips,  and  thickness  of  the  speech,  with  visual  hallucinations. 
The  meiital  condition  was  described  by  Jackson  and  by  Wilks.  Korsakoff 
speaks  of  it  as  a  psychosis  polyneuritica,  and  the  symptom-complex  is  some- 
times called  by  his  name.  The  relation  of  chronic  alcoholism  to  insanity  has 
been  much  discussed.  It  is  one  of  the  important  elements  in  the  strain  which 
leads  to  mental  breakdown.  Epilepsy  may  result  directly  from  chronic  drink- 
ing. It  is  a  hopeful  form,  and  may  disappear  entirely  with  a  return  to  habits 
of  temperance. 

There  is  a  remarkable  condition  in  chronic  alcoholism  termed  "wet  brain/' 
in  which  a  heavy  drinker,  who  may  perhaps  have  had  attacks  of  delirium 
tremens,  begins  to  get  drowsy  or  a  little  more  befuddled  than  usual ;  gradually 
the  stupor  deepens  until  he  becomes  comatose,  in  which  state  he  may  remain 
for  weeks.  There  may  be  slight  fever,  but  there  are  no  signs  of  paralysis,  and 
no  optic  neuritis.  The  urine  may  be  normal.  The  lumbar  puncture  yields 
a  clear  fluid,  but  under  high  pressure.  In  one  patient  who  died  at  the  end  of 
six  weeks,  there  Were  the  anatomical  features  of  a  serous  meningitis. 

No  characteristic  changes  are  found  in  the  nervous  system.  Hsemorrhagic 
pachymeningitis  is  not  very  uncommon.  There  are  opacity  and  thickening  of 
the  pia-arachnoid  membranes,  with  more  or  less  wasting  of  the  convolutions. 
These  are  in  no  way  peculiar  to  chronic  alcoholism,  but  are  found  in  old 
persons  and  in  chronic  wasting  diseases.  In  the  very  protracted  cases  there 
may  be  chronic  encephalo-meningitis  with  adhesions  of  the  membranes.  Finer 
changes  in  the  nerve-cells,  their  processes,  and  the  neuroglia  have  been  de- 
scribed.    The  alcoholic  neuritis  will  be  considered  later. 

Digestive  System. — Catarrh  of  the  stomach  is  the  most  common  symptom. 
The  toper  has  a  furred  tongue,  heavy  breath,  and  in  the  morning  a  sensation 
of  sinking  at  the  stomach  until  he  has  had  his  dram.  The  appetite  is  usu- 
ally impaired  and  the  bowels  are  constipated.  In  beer-drinkers  dilatation  of 
the  stomach  is  common. 

Alcohol  produces  definite  changes  in  the  liver,  leading  ultimately  to  the 
various  forms  of  cirrhosis.  In  Welch's  laboratory  J.  Friedenwald  caused 
typical  cirrhosis  in  rabbits  by  the  administration  of  alcohol.  The  effect  is  a 
primary  degenerative  change  in  the  liver-cells.  A  special  vulnerability  of  the 
liver-cells  is  necessary  in  the  etiology  of  alcoholic  cirrhosis.  There  are  cases 
in  which  comparatively  moderate  drinking  for  a  few  years  has  been  followed 
by  cirrhosis;  on  the  other  hand,  the  livers  of  persons  who  have  been  steady 
drinkers  for  thirty  or  forty  years  may  show  only  a  moderate  grade  of  sclerosis. 
For  years  before  cirrhosis  develops  heavy  drinkers  may  present  an  enlarged 
and  tender  liver,  with  at  times  swelling  of  the  spleen.     With  the  gastric  and 


ALCOHOLISM  389 

hepatic  disorders  the  facies  often  becomes  very  characteristic.  The  venules 
of  the  cheeks  and  nose  are  dilated;  the  latter  becomes  enlarged,  red,  and  may 
present  the  condition  known  as  acne  I'osacea.  The  eyes  are  watery,  and  con- 
junctiva hypersemic  and  sometimes  bile-tinged. 

The  heart  and  arteries  in  chronic  topers  show  degenerative  changes,  and 
alcoholism  is  a  factor  in  causing  arterio-sclerosis.  Steell  pointed  out  the  fre- 
quency of  cardiac  dilatation  in  these  cases. 

Kidneys. — The  influence  of  chronic  alcoholism  upon  these  organs  is  by  no 
means  so  marked.  According  to  Dickinson  the  total  of  renal  disease  is  not 
greater  in  the  drinking  class,  and  he  holds  that  the  effect  of  alcohol  on  the 
kidneys  has  been  much  overrated.  Formad  directed  attention  to  the  fact  tbat 
in  a  large  proportion  of  chronic  alcoholics  the  kidneys  are  increased  in  size. 
The  Guy's  Hospital  statistics  support  this  statement,  and  Pitt  notes  that  in 
43  per  cent,  of  the  bodies  of  hard  drinkers  the  kidneys  were  hypertrophied 
without  showing  morbid  change.  A  granular  kidney  may  result  indirectly 
through  the  arterial  changes. 

It  was  formerly  thought  that  alcohol  was  in  some  way  antagonistic  to 
tuberculous  disease,  but  the  reverse  is  the  case  and  chronic  drinkers  are  much 
more  liable  to  both  acute  and  pulmonary  tuberculosis.  It  is  probably  alto- 
gether a  question  of  altered  tissue-soil,  the  alcohol  lowering  the  vitality  and 
enabling  the  bacilli  to  develop  and  grow  more  readily. 

(c)  Delirium  tremens,  an  incident  in  chronic  alcoholism,  results  from  the 
long-continued  action  of  the  poison.  The  condition  was  first  accurately 
described  early  in  the  19th  century  by  Sutton,  of  Greenwich,  who  had  numerous 
opportunities  for  studying  the  different  forms  among  sailors.  One  of  the 
most  careful  studies  of  the  disease  was  made  by  Ware,  of  Boston.  A  spree  in 
a  temperate  person,  no  matter  how  prolonged,  is  rarely  if  ever  followed  by 
delirium  tremens;  but  in  the  case  of  an  habitual  drinker  a  temporary  excess 
may  bring  on  an  attack  or  it  follows  the  sudden  withdrawal  of  alcohol.  An 
accident,  a  sudden  shock,  or  an  acute  inflammation,  particularly  pneumonia, 
may  determine  the  onset.  It  is  especially  apt  to  occur  in  drinkers  admitted 
to  hospitals  for  injuries,  especially  fractures,  and,  as  this  seems  most  likely 
to  occur  when  alcohol  is  withdrawn,  it  is  well  to  give  such  patients  a  moderate 
amount  of  alcohol.  At  the  outset  of  the  attack  the  patient  is  restless  and 
depressed  and  sleeps  badly;  after  a  day  or  two  the  characteristic  delirium  sets 
in.  The  patient  talks  constantly  and  incoherently;  he  is  incessantly  in  motion, 
and  desires  to  go  out  and  attend  to  some  imaginary  business.  Hallucinations 
of  sight  and  hearing  develop.  He  sees  objects  in  the  room,  such  as  rats  or 
mice,  and  fancies  that  they  are  crawling  over  his  body.  The  terror  inspired 
by  these  imaginary  objects  is  great  and  the  patients  need  to  be  watched  con- 
stantly, for  in  their  delusions  they  may  jump  out  of  the  window  or  escape. 
Auditory  hallucinations  are  not  so  common,  but  the  patient  may  complain  of 
hearing  animals  or  the  threats  of  imaginary  enemies.  There  is  much  mus- 
cular tremor;  the  tongue  is  covered  with  a  thick  white  fur  and  is  tremulous. 
The  pulse  is  soft,  rapid,  and  readily  compressed.  There  is  usually  fever,  but 
the  temperature  rarely  registers  above  102°  or  103°.  In  fatal  cases  it  may 
be  higher.  Insomnia  is  a  constant  feature.  On  the  third  or  fourth  day  in 
favorable  cases  the  restlessness  abates,  the  patient  sleeps,  and  improvement 
gradually   sets   in.      The   tremor   persists   for   some   days,   the   balliicinatiouf; 


390  INTOXICATIONS 

gradually  disappear,  and  the  appetite  returns.  In  more  serious  cases  the  in- 
somnia persists,  the  delirium  is  incessant;,  the  pulse  becomes  more  frequent 
and  feeble,  the  tongue  dry,  the  prostration  extreme,  and  death  takes  place 
from  gradual  heart-failure. 

Some  regard  mania  a  potu  as  a  distinct  form  in  which  the  onset  is  sudden 
and  the  patients  are  very  violent,  but  hallucinations  and  terror  are  rare. 

There  is  a  condition  termed  acute  hallucinosis,  in  which  auditory  halluci- 
nations are  marked,  orientation  is  retained,  and  the  mental  disturbances  are 
fixed.  Ideas  of  persecution  are  common.  There  are  intermediate  forms  be- 
tween this  and  the  ordinar}-  delirium  tremens. 

DiAGXosis. — The  clinical  picture  can  scarcely  be  confounded  with  any 
other.  Cases  with  fever  may  be  mistaken  for  meningitis.  The  most  common 
error  is  to  overlook  some  local  disease,  such  as  pneumonia,  or  an  injury,  as 
a  fractured  rib,  which  in  a  chronic  drinker  may  precipitate  an  attack  of 
delirium  tremens.  In  every  instance  a  careful  examination  should  be  made, 
particularly  of  the  lungs.  It  is  to  be  remembered  that  in  the  severer  forms, 
particularly  the  febrile  cases,  congestion  of  the  bases  of  the  lungs  is  by  no 
means  uncommon.  Another  point  to  be  borne  in  mind  is  the  fact  that  pneu- 
monia of  the  apex  may  be  accompanied  by  similar  delirium. 

Pkogxosis. — Eecovery  takes  place  in  a  large  proportion  of  the  cases  in  pri- 
vate practice.  In  hospital  practice,  particularly  in  large  city  hospitals  to  which 
debilitated  patients  are  taken,  the  death-rate  is  higher.  Gerhard  states  that  of 
1,241  cases  admitted  to  the  Philadelphia  Hospital  121  proved  fatal.  Eecur- 
rence  is  frequent,  indeed,  the  rule,  if  the  drinking  is  kept  up. 

Treatment. — i^cute  alcoholism  rarely  requires  any  special  measures,  as  the 
patient  sleejDs  off  the  effects  of  the  debauch.  In  the  case  of  profound  alco- 
holic conia  it  may  be  advisable  to  wash  out  the  stomach,  and  if  collapse  symp- 
toms occur  the  limbs  should  be  rubbed  and  hot  applications  made  to  the  body. 
Should  convulsions  supervene,  chloroform  may  be  carefully  administered.  In 
the  acute,  violent  alcoholic  mania  the  hypodermic  injection  of  apomorphia, 
one-eighth  of  a  grain  (0.008  gm.),  is  usually  very  effectual,  causing  nausea 
and  vomiting,  and  rapid  disappearance  of  the  maniacal  symptoms. 

Chronic  alcoholism  is  a  condition  very  difficult  to  treat,  and  once  fully 
established  the  habit  is  rarely  abandoned.  The  most  obstinate  cases  are  those 
with  marked  hereditary  tendency.  Withdrawal  of  the  alcohol  is  the  first 
essential.  This  is  most  effectually  accomplished  by  placing  the  patient  in  an 
institution,  in  which  he  can  be  carefully  watched.  The  absence  of  temptation 
in  institution  life  is  of  special  advantage.  For  the  sleeplessness  the  bromides 
or  hyoscine  may  be  employed.  Quinine  and  strychnine  in  tonic  doses  may  be 
given.  Prolonged  seclusion  in  a  suitable  institution  is  in  reality  the  only 
effectual  means  of  cure.  When  an  hereditary  tendency  exists  a  lapse  into  the 
drinking  habit  is  almost  inevitable. 

In  delirium  tremens  the  patient  should  be  confined  to  bed  and  carefully 
watched  night  and  day.  The  danger  of  escape  in  these  cases  is  very  great,  as 
the  patient  imagines  himself  pursued  by  enemies  or  demons.  Flint  mentions 
the  case  of  a  man  who  escaped  in  his  nightclothes  and  ran  barefooted  for  fif- 
teen miles  on  the  frozen  ground  before  he  was  overtaken.  The  patient  should 
not  be  strapped  in  bed,  as  this  aggravates  the  delirium ;  sometimes,  however,  it 
may  be  necessary,  in  which  case  a  sheet  tied  across  the  bed  may  be  sufficient. 


MOEPHIA  HABIT  391 

and  this  is  certainly  better  than  violent  restraint  by  three  or  four  men.  Alco- 
hol should  be  withdrawn  at  once  unless  the  pulse  is  feeble. 

Delirium  tremens  is  a  disease  which,  in  a  large  majority  of  cases,  runs  a 
course  very  slightly  influenced  by  medicine.  The  indications  for  treatment 
are  to  procure  sleep  and  to  support  the  strength.  In  mild  cases  half  a  dram 
(2  gm.)  of  bromide  of  potassium  combined  with  tincture  of  capsicum  may  be 
given  every  three  hours.  Chloral  is  often  of  great  service,  and  may  be  given 
without  hesitation  unless  the  heart's  action  is  feeble.  Good  results  sometimes 
follow  the  hypodermic  use  of  hyoscine  (gr.  1/100,  0.00065  gm.).  Opium  must 
be  used  cautiously.  A  special  merit  of  Ware's  work  was  the  demonstration 
that  on  an  expectant  plan  of  treatment  the  percentage  of  recoveries  was 
greater  than  with  the  indiscriminate  use  of  sedatives,  which  had  been  in 
vogue  for  many  years.  When  opium  is  indicated  it  should  be  given  as 
morphia,  hypodermically.  The  effect  should  be  carefully,  watched,  and,  if 
after  three  or  four  quarter-grain  doses  have  been  given  the  patient  is  still 
restless  and  excited,  it  is  best  not  to  push  it  farther.  Eepeated  doses  of  trional 
(grs.  XV,  1  gm.)  every  four  hours  may  be  tried.  Lambert  advises  ergotin  hypo- 
dermically in  both  the  acute  and  chronic  alcoholism.  With  acidosis  alkalies 
and  water  should  be  given  freely.  When  fever  is  present  the  tranquilizing 
effects  of  a  douche  or  bath  may  be  tried,  or  the  cold  or  warm  packs.  The 
large  doses  of  digitalis  formerly  employed  are  not  advisable. 

Careful  feeding  is  the  most  important  element  in  the  treatment  of  these 
cases.  Milk  and  concentrated  food  should  be  given  at  stated  intervals.  If 
the  pulse  becomes  rapid  and  shows  signs  of  flagging,  alcohol  may  be  given  in 
combination  with  the  aromatic  spirit  of  ammonia. 


II.     MORPHIA  HABIT 

Taken  at  first  to  allay  pain,  a  craving  for  the  drug  is  gradually  engendered, 
and  the  habit  in  this  way  acquired.  The  effects  of  the  constant  use  of  opium 
vary  very  much.  In  the  East,  where  opium-smoking  is  as  common  as  tobacco- 
smoking  with  us,  the  ill  effects  are,  according  to  good  observers,  not  very  strik- 
ing. Taken  as  morphia  and  hypodermically,  as  is  the  rule,  it  is  very  injurious, 
but  a  moderate  amount  may  be  taken  for  years  without  serious  damage. 

The  habit  is  particularly  prevalent  among  women  and  physicians  who  use 
the  hypodermic  syringe  for  the  alleviation  of  pain,  as  in  neuralgia  or  sciatica. 
The  acquisition  of  the  habit  as  a  pure  luxury  is  rare. 

Symptoms. — The  symptoms  at  first  are  slight  and  for  months  there  may  be 
no  (listurbance  of  health.  There  are  exceptional  instances  in  which  for  a 
period  of  years  excessive  amounts  have  been  taken  without  deterioration  of  the 
mental  or  bodily  functions.  As  a  rule,  the  dose  necessary  to  obtain  the  desired 
sensation  has  gradually  to  be  increased.  As  the  effects  wear  off  the  victim 
experiences  sensations  of  lassitude  and  mental  depression,  accompanied  often 
with  slight  nausea  and  epigastric  distress,  or  even  recurring  colic,  which  may 
be  mistaken  for  appendicitis.  The  confirmed  opium-eater  usually  has  a  sallow, 
pasty  complexion,  is  emaciated,  and  becomes  prematurely  gray.  He  is  restless, 
irritable,  and  unable  to  remain  quiet  for  any  time.  Itching  is  a  common 
symptom.     The  sleep  is  disturbed,  the  appetite  and  digestion  are  deranged, 


392  INTOXICATIONS 

and  except  when  directly  under  the  influence  of  the  drug  the  mental  condition 
IS  one  of  depression.  Occasionally  there  are  profuse  sweats,  which  may  be 
preceded  by  chills.  The  pupils,  except  when  under  the  direct  influence  of 
the  drug,  are  dilated,  sometimes  unequal.  In  one  case  there  was  a  persistant 
oedema  of  the  legs  without  sufficient  renal  changes  or  ansemia  to  account  for  it. 
Persons  addicted  to  morphia  are  inveterate  liars,  and  no  reliance  whatever  can 
be  placed  upon  their  statements.  In  many  instances  this  is  not  confined  to 
matters  relating  to  the  vice.  In  women  the  symptoms  may  be  associated  with 
those  of  pronounced  hysteria  or  neurasthenia.  The  practice  may  be  continued 
for  an  indefinite  time,  usually  requiring  increase  in  the  dose  until  ulti- 
mately enormous  quantities  may  be  needed  to  obtain  the  desired  effect. 
Finally  a  condition  of  asthenia  is  induced,  in  which  the  victim  takes  little  or 
no  food  and  dies  from  the  extreme  bodily  debility.  An  increase  in  the  dose 
is  not  always  necessary,  and  there  are  habitues  who  reach  the  point  of  satis- 
faction with  a  daily  amount  of  2  or  3  grains  of  morphia,  and  who  are  able 
to  carry  on  successfully  for  many  years  the  ordinary  business  of  life.  They 
mav  remain  in  good  physical  condition,  and  indeed  often  look  rudd3\ 

Treatment. — The  treatment  is  extremely  difficult,  and  can  rarely  be  suc- 
cessfully carried  out  by  the  general  practitioner.  Isolation,  systematic  feeding, 
and  gradual  withdrawal  of  the  drug  are  the  essential  elements.  As  a  rule, 
the  patients  must  be  under  control  in  an  institution  and  should  be  in  bed  for 
the  first  ten  days.  It  is  best  in  a  majority  of  cases  to  reduce  the  morphia 
gradually.  The  sufferings  of  the  patients  are  usually  very  great,  more  particu- 
larly the  abdominal  pains,  sometimes  nausea  and  vomiting,  and  the  distressing 
restlessness.  Usually  within  a  week  or  ten  days  the  opium  may  be  entirely 
withdrawn.  In  all  cases  the  pulse  should  be  carefully  watched  and,  if  feeble, 
the  aromatic  spirit  of  ammonia  and  digitalis  should  be  given.  For  the  extreme 
restlessness  a  hot  bath  is  serviceable.  The  sleeplessness  is  the  most  distressing 
symptom,  and  various  drugs  may  have  to  be  resorted  to,  particularly  hyoscine 
and  sulphonal  and  sometimes,  if  the  insomnia  persists,  morphia  itself. 

It  is  essential  in  the  treatment  of  a  case  to  be  certain  that  the  patient  has 
no  means  of  obtaining  morphia.  Even  under  the  favorable  circumstances  of 
seclusion  in  an  institution  and  constant  watching,  patients  may  practise  de- 
ception. After  an  apparent  cure  the  patients  are  only  too  apt  to  lapse  into 
the  habit. 

The  condition  is  one  which  has  become  so  common,  and  is  so. much  on 
the  increase,  that  physicians  should  exercise  the  utmost  caution  in  prescrib- 
ing morphia,  particularly  to  female  patients.  Under  no  circumstances  should 
a  patient  be  allowed  to  use  the  hypodermic  syringe,  and  it  is  even  safer  not 
to  intrust  this  dangerous  instrument  to  the  hands  of  the  nurse. 

Heroin. — Of  recent  years  the  use  of  heroin  has  increased  in  the  United 
States.  This  addiction  seems  less  serious  than  morphinism;  it  requires  the 
same  treatment. 

III.     LEAD  POISONING 

{PJumhism,  Saturnism) 

Etiology. — The  disease  is  widespread,  particularly  in  the  lead  industries 
and  among  plumbers,  painters,  and  glaziers.     In  1916  there  were  60  deaths 


LEAD  POISOXING  393 

in  England  and  Wales,  of  which  55  were  due  to  occupational  poisoning.  In  the 
United  States  it  is  not  easy  to  get  accurate  statistics.  In  the  registration  area 
there  were  147  deaths  in  1917.  Alice  Hamilton  reports  358  cases  with  16 
deaths  in  23  white  lead  factories  during  the  16  months  to  May  1,  1911.  The 
metal  is  introduced  into  the  system  in  many  forms.  Miners  usually  escape,  but 
those  engaged  in  the  smelting  of  lead-ores  are  oft^n  attacked.  Animals  in  the 
neighborhood  of  smelting  furnaces  have  suffered  with  the  disease,  and  even 
the  birds  that  feed  on  the  berries  in  the  neighborhood  may  be  affected.  Men 
engaged  in  the  white-lead  factories  are  particularly  prone  to  plumbism.  Acci- 
dental poisoning  may  come  in  many  ways;  most  commonly  by  drinking  water 
which  has  passed  through  lead  pipes  or  been  stored  in  lead-lined  cisterns. 
Wines  and  cider  which  contain  acids  quickly  become  contaminated  in  contact 
with  lead.  It  was  the  frequency  of  colic  in  certain  of  the  cider  districts  of 
Devonshire  which  gave  the  name  of  Devonshire  colic,  as  the  frequency  of  it 
in  Poitou  gave  the  name  coKca  Pictonum.  Among  the  innumerable  sources 
of  accidental  poisoning  may  be  mentioned  milk,  various  sorts  of  beverages, 
hair  dyes,  false  teeth,  and  thread.  A  few  cases  have  followed  the  retention 
of  lead  bullets  in  gun-shot  wounds.  Given  medicinally,  lead  rarely  causes 
poisoning,  but  we  had  in  the  Johns  Hopkins  Hospital  four  cases  following  the 
use  of  lead  and  opium  pills  for  dysentery,  of  which  cause  Miller  collected  manv 
cases  from  the  literature.  It  has  followed  the  use  of  Emplastrum  Diachylon 
to  produce  abortion,  and  there  is  a  case  reported  in  an  infant  from  the  applica- 
tion of  lead-water  on  the  mother's  nipples.  One  grain  every  three  hours  for 
three  days,  and  two  grains  every  three  hours  for  one  day,  have  caused  signs 
of  poisoning.  A  serious  outbreak  of  lead-poisoning  occurred  in  Philadelphia, 
owing  to  adulteration  of  a  baking-powder  with  chromate  of  lead,  used  to  give 
a  yellow  tint  to  the  cakes. 

All  ages  are  attacked,  but  children  are  relatively  less  liable.  The  largest 
number  of  cases  occur  between  thirty  and  forty.  According  to  Oliver,  females 
are  more  susceptible  than  males.  They  are  much  more  quickly  brought  under 
its  influence,  and  in  an  epidemic  in  which  a  thousand  cases  were  involved  the 
proportion  of  females  to  males  was  four  to  one.  Miscarriage  is  common,  and 
it  is  rare  for  a  woman  working  in  lead  to  carry  a  child  to  term.  It  also 
destroys  the  reproductive  power  in  man. 

The  lead  gains  entrance  through  the  lungs,  the  digestive  organs,  or  the 
skin.  Poisoning  may  follow  the  use  of  cosmetics  containing  lead.  Through 
the  lungs  it  is  freely  absorbed.  The  chief  channel,  according  to  Oliver,  is  the 
digestive  system.  It  is  rapidly  eliminated  by  the  kidneys  and  skin,  and  is 
present  in  the  urine  of  lead-workers.  The  susceptibility  is  remarkably  varied. 
The  symptoms  may  be  manifest  within  a  month  of  exposure.  On  the  other 
hand,  Tanquerel  (des  Planches)  met  with  a  case  in  a  man  who  had  been  a 
lead-worker  for  fifty-two  years.  E.  E.  Hayhurst  examined  100  painters,  in- 
not  one  of  whom  were  there  symptoms  of  acute  plumbism  but  70  showed  in 
varying  degrees  symptoms,  signs,  or  after-effects  of  chronic  plumbism;  a  lead- 
line on  the  gums  was  present  in  19  cases. 

Morbid  Anatomy. — Small  quantities  of  lead  occur  in  the  body  in  health. 
J.  J.  Putnam's  reports  show  that  of  150  persons  not  presenting  symptoms  of 
lead-poisoning  traces  of  lead  occurred  in  the  urine  of  25  per  cent.  Of  264 
deaths  in  persons  subjects  of  plumbism  32  were  due  to  an  encephalopathy,  43 


394  mTOXICATIONS 

to  nephritis,  47  to  cerebral  haemorrhage,  43  to  paralysis,  44  to  lead  poisoning, 
38  to  tuberculosis,  and  40  to  various  maladies,  pneumonia,  heart  disease, 
aneurism,  etc.     (Legge). 

In  chronic  poisoning  lead  is  found  in  the  various  organs.  The  affected 
muscles  are  j^ellow,  fatty,  and  fibroid.  The  nerves  present  the  features  of  a 
peripheral  degenerative  neuritis.  The  cord  and  the  nerve-roots  are,  as  a  rule, 
uninvolved.  In  the  primary  atrophic  form  the  ganglion  cells  of  the  anterior 
horns  are  probably  implicated.  In  the  acute  fatal  cases  there  may  be  the  most 
intense  entero-colitis. 

Symptoms. — Acute  Forii. — We  do  not  refer  here  to  the  accidental  or 
suicidal  cases,  which  present  vomiting,  pain  in  the  abdomen,  and  collapse 
symptoms.  In  workers  in  lead  there  are  several  manifestations  which  follow 
a  short  time  after  exposure  and  set  in  acutely.  There  may  be,  in  the  first 
place,  a  rapidly  developing  ansemia.  Acute  neuritis  has  been  described,  and 
convulsions,  epilepsy,  and  a  delirium,  which  may  be  not  unlike  that  produced 
by  alcohol.  There  are  cases  in  which  the  gastro-intestinal  symptoms  are 
intense  and  rapidly  prove  fatal.  These  acute  forms  occur  more  frequently  in 
persons  recently  exposed,  and  more  often  in  winter  than  in  summer.  Da  Costa 
reported  the  onset  of  hemiplegia  after  three  days'  exposure  to  lead. 

Chronic  Poisoxing. —  (a)  Blood  Changes. — A  moderate  grade  of  anaemia, 
the  so-called  saturnine  cachexia,  is  usually  present.  The  corpuscles  do  not 
often  fall  below  50  per  cent.  Many  of  the  red  cells  show  a  remarkable  granu- 
lar, basophilic  degeneration  when  stained  with  Jenner's  stain,  or  with  poly- 
chrome methylene  blue.  Grawitz  first  demonstrated  their  presence  in  cases 
of  pernicious  anaemia,  and  Pepper  (tertius)  and  White  showed  that  they  were 
constantly  present  in  lead-poisoning.  Observations  by  A^aughan  and  others 
have  shown  that  such  granulations  are  found  in  the  blood  in  a  great  variety 
of  conditions,  even  in  normal  blood,  but  that  they  are  most  numerous  in 
lead-poisoning,  in  which  their  occurrence  in  large  numbers  is  of  value  in 
diagnosis.  Cadwalader  has  shown  the  constant  presence  of  nucleated  red 
blood-corpuscles  even  when  the  anaemia  is  of  very  slight  grade. 

(&)  The  blue  line  on  the  gums  is  a  valuable  indication,  but  is  not  in- 
variably present.  Two  lines  must  be  distinguished:  one,  at  the  margin  be- 
tween the  gums  and  teeth,  is  on,  not  in  the  gums,  and  is  readily  removed  by 
rinsing  the  mouth  and  cleansing  the  teeth.  The  other  is  the  characteristic 
blue-black  line  at  the  margin  of  the  gum.  The  color  is  not  uniform,  but  being 
in  the  papilla  of  the  gums  the  line  is,  as  seen  with  a  magnifying-glass,  inter- 
rupted. The  lead  is  absorbed  and  converted  in  the  tissues  into  a  black 
sulphide  by  the  action  of  sulphuretted  hydrogen  from  the  tartar  of  the  teeth. 
The  line  may  form  in  a  few  days  after  exposure  (Oliver)  and  disappear  within 
a  few  weeks,  or  may  persist  for  many  months.  Philipson  noted  the  occur- 
rence of  a  black  line  in  miners,  due  to  the  deposition  of  carbon. 

The  most  important  symptoms  of  chronic  lead-poisoning  are  colic,  lead- 
palsy,  and  the  encephalopathy.  Of  these,  the  colic  is  the  most  frequent.  Of 
Tanquerel's  cases,  there  were  1,217  of  colic,  101  of  paralysis,  and  72  of 
encephalopathy. 

(c)  Colic  is  the  most  common  symptom  of  chronic  lead-poisoning.  It 
is  often  preceded  by  gastric  or  intestinal  symptoms,  particularly  constipation. 
The  pain  is  over  the  whole  abdomen.     The  colic  is  usually  paroxysmal  and 


LEAD  POISONING  395 

relieved  by  pressure.  There  is  often  between  the  paroxysms  a  dull,  heavy 
pain.  There  may  be  vomiting.  During  the  attack,  as  Riegel  noted,  the  pulse 
is  increased  in  tension  and  the  heart's  action  is  retarded.  Attacks  of  pain  with 
acute  diarrhoea  may  recur  for  weeks  or  even  for  three  or  four  years. 

Certain  of  the  cases  with  colic  may  present  the  features  of  an  acute  intra- 
abdominal inflammatory  condition.  A  case  may  be  admitted  to  the  surgical 
wards  with  a  diagnosis  of  appendicitis,  or  simulate  intestinal  obstruction. 
Localized  pain,  slight  fever,  and  moderate  leucocytosis  may  be  present.  The 
history,  the  presence  of  a  blue  line  on  the  gums,  and  the  blood  changes  are  of 
importance  in  differential  diagnosis. 

(d)  Lead-palsy. — This  is  rarely  a  primary  manifestation.  Among  54 
cases  of  lead-poisoning  treated  in  the  J.  H.  H.  and  dispensary  there  were 
30  cases  of  lead-paralysis  (H.  M.  Thomas).  The  upper  limbs  are  most  fre- 
quently affected.  In  26  cases  the  arms  alone  were  affected,  and  18  of  these 
showed  the  typical  double  wrist-drop.  In  7  the  right  arm  alone  was  involved, 
and  in  one  the  left.  In  4  cases  both  arms  and  legs  were  attacked.  The  onset 
may  be  acute,  subacute,  or  chronic.  It  usually  occurs  without  fever.  In  its 
distribution  it  may  be  partial,  limited  to  a  muscle  or  to  certain  muscle  groups, 
or  generalized,  involving  in  a  short  time  the  muscles  of  the  extremities  and 
the  trunk.  The  muscles  most  used  are  often  attacked.  Madame  Dejerine- 
Klumpke  described  the  following  localized  forms:  (1)  Antebrachial  type, 
paralysis  of  the  extensors  of  the  fingers  and  of  the  wrist.  In  this  the  musculo- 
spiral  nerve  is  involved,  causing  the  characteristic  wrist-drop.  The  supinator 
longus  usually  escapes.  In  the  long-continued  flexion  of  the  carpus  there  may 
be  slight  displacement  backward  of  the  bones,  with  distention  of  the  synovial 
sheaths,  so  that  there  is  a  prominent  swelling  over  the  wrist  known  as 
Gruebler's  tumor.  (2)  Brachial  type,  which  involves  the  deltoid,  the  biceps, 
the  brachialis  anticus,  and  the  supinator  longus,  rarely  the  pectorals.  The 
atrophy  is  of  the  scapulo-humeral  form.  It  is  bilateral,  and  sometimes  follows 
the  first  form,  but  it  may  be  primary.  ( 3 )  The  Aran-Duchenne  type,  in  which 
the  small  muscles  of  the  hand  and  of  the  thenar  and  hypothenar  eminences 
are  involved.  The  atrophy  is. marked,  and  may  be  the  first  manifestation. 
Mobius  has  shown  that  this  form  is  particularly  marked  in  tailors.  (4)  The 
peroneal  type.  According  to  Tanquerel,  the  lower  limbs  are  involved  in  the 
proportion  of  13  to  100  of  the  upper  limbs.  The  lateral  peroneal  muscles,  the 
extensor  communis  of  the  toes,  and  the  extensor  proprius  of  the  big  toe  are 
involved,  producing  the  steppage  gait.  (5)  Laryngeal  form.  Adductor 
paralysis  was  noted  by  Morell  Mackenzie  and  others  in  lead-palsy. 

Generalized  Palsies. — There  may  be  a  slow,  chronic  paralysis,  gradually 
involving  the  extremities,  beginning  with  the  classical  picture  of  wrist-drop. 
More  frequently  there  is  a  rapid  generalization,  producing  complete  paralysis 
in  all  the  muscles  of  the  parts  in  a  few  days.  It  may  pursue  a  course  like 
an  ascending  paralysis,  associated  with  rapid  wasting  of  all  four  liml)s.  Such 
cases,  however,  are  very  rare.  Death  has  occurred  by  involvement  of  the  dia- 
phragm. Oliver  reports  a  case  of  Philipson's  in  which  complete  paralysis 
supervened.  In  one  patient  with  generalized  paralysis  this  began  in  the  legs 
after  but  two  weeks'  work  as"  an  enameler.  It  spread  rapidly,  so  that  in  a 
little  over  a  week  he  was  bedridden,  and  on  admission  to  the  hospital  nearly 
every  muscle  below  the  neck  was  involved.     The  diaphragm  was  coinpletely 


396  mTOXICATIONS 

paralyzed.  He  was  walking  about  when  he  left  the  hospital,  though  there  was 
still  some  weakness.  Dejerine-Klumpke  also  recognized  a  febrile  form  of  gen- 
eral paralysis  which  may  closely  resemble  the  subacute  spinal  paralysis  of 
Duchenne. 

There  is  also  a  primary  saturnine  muscular  atrophy  in  which  the  weak- 
ness and  wasting  come  on  together.  It  is  this  form,  according  to  Gowers, 
which  most  frequently  assumes  the  Aran-Duchenne  type. 

The  electrical  reactions  are  those  of  lesions  of  the  lower  motor  segment. 
The  reaction  of  degeneration  in  its  different  grades  may  be  present,  depending 
upon  the  severity.  Usually  with  the  onset  of  the  paralysis  there  are  pains  in 
the  legs  and  joints.     Sensation  may,  however,  be  unaffected. 

(e)  The  cerebral  symptoms  are  numerous.  Seven  of  our  cases  showed 
marked  cerebral  involvement.  One  had  delusions  and  maniacal  excitement 
and  had  to  be  removed  to  an  asylum.  In  other  cases  there  occurred  transient 
delirium,  attacks  of  unconsciousness,  and  in  one  case  convulsions.  Optic 
neuritis  or  neuro-retinitis  may  occur.  Hysterical  symptoms  occasionally  occur 
in  girls.  Convulsions  are  not  uncommon,  and  in  an  adult  the  possibility  of 
lead-poisoning  should  always  be  considered.  True  epilepsy  may  follow  the 
convulsions.  An  acute  delirium  may  occur  with  hallucinations.  The  patients 
may  have  trance-like  attacks,  which  follow  or  alternate  with  convulsions.  A 
few  cases  of  lead  encephalopathy  finally  drift  into  lunatic  asylums.  Tremor 
is  one  of  the  commonest  manifestations  of  lead-poisoning. 

(/)  Arteriosclerosis. — Lead-workers  are  notoriously  subject  to  arterio- 
sclerosis with  contracted  kidneys  and  hypertrophy  of  the  heart.  The  cases 
usually  show  distinct  gouty  deposits,  particularly  in  the  big-toe  joint;  but 
in  the  United  States-  acute  gout  in  lead-workers  is  rare.  According  to  Sir 
William  Eoberts,  the  lead  favors  the  precipitation  of  the  crystalline  urates. 

Prognosis. — In  the  minor  manifestations  this  is  good.  According  to  Gow- 
ers,  the  outlook  is  bad  in  the  primary  atrophic  form  of  paralysis.  Convulsions 
are,  as  a  rule,  serious,  and  the  mental  symptoms  which  succeed  may  be  perma- 
nent.   Occasionally  the  wrist-drop  persists. 

Treatment. — Prophylactic  measures  should  be  taken  at  all  lead-works,  but, 
unless  employees  are  careful,  poisoning  is  apt  to  occur  even  under  the  most 
favorable  conditions.  Cleanliness  of  the  hands  and  of  the  finger-nails,  fre- 
quent bathing,  and  the  use  of  respirators  when  necessary  should  be  insisted 
upon.  When  the  lead  is  in  the  system  the  iodide  of  potassium  should  be  given 
in  from  5-  to  10-grain  (0.3-0.6  gm.)  doses  three  times  a  day.  For  the 
colic  local  applications  and,  if  severe,  morphia  may  be  used.  A  morning  purge 
of  magnesium  sulphate  may  be  given.  For  the  ansemia  iron  should  be  used. 
In  the  very  acute  cases  it  is  well  not  to  give  iodide,  as,  according  to  some 
writers,  the  liberation  of  the  lead  which  has  been  deposited  in  the  tissues  may 
increase  the  severity  of  the  symptoms.  For  the  local  palsies  massage  and 
the  constant  current  should  be  used.  Bulletin  No.  95  (1911)  of  the  Bureau 
of  Labor,  Washington,  contains  an  elaborate  study  of  industrial  lead-poisoning 
in  Europe  by  Oliver,  and  of  the  conditions  in  the  United  States  by  Alice 
Hamilton  and  John  B.  Andrews. 


AESENICAL  POISONING  397 


IV.     BRASS  POISONING 

Workers  in  brass,  a  compound  of  copper  and  zinc,  and  in  bronze,  an  alloy 
of  copper  and  tin,  are  not  nearly  so  subject  to  poisoning  as  workers  in  lead 
and  arsenic.  Brass  polishers  and  those  exposed  to'  the  dust  have  the  hair 
stained  somewhat  green  and  there  is  often  a  slight  greenish  deposit  in  the 
teeth  and  gums.  It  is  said  that  there  may  be  a  green  tint  to  the  perspiration, 
even  after  a  thorough  bath. 

The  dust  may  cause  an  itching  of  the  skin,  the  so-called  "brass  itch." 
The  fumes  arising  from  molten  brass  give  rise  to  very  peculiar  symptoms, 
the  so-called  "brass-workers'  ague,"  with  "smelters'  shakes"  and  "zinc  chills," 
not  an  uncommon  malady  among  the  outpatients  at  the  Johns  Hopkins 
Hospital.  The  symptoms  are  an  acute  chill,  which  comes  on  some  hours  after 
exposure  to  the  molten  metal,  sweating  and  a  feeling  of  nausea ;  there  may 
be  vomiting,  great  thirst,  a  rapid,  feeble  pulse,  a  rise  of  temperature,  never 
high,  and  in  the  course  of  a  couple  of  hours  very  profuse  sweating.  The  entire 
attack  may  last  for  six  or  eight  hours,  or  the  patient  may  be  ill  for  a  day. 
Many  of  our  patients  used  to  say  that  they  were  more  liable  to  it  on  Monday, 
after  Sunday's  rest.  It  occurs  exclusively  in  the  brass  foundries  and  where 
zinc,  either  alone  or  with  an  alloy,  is  heated  to  boiling.  A  large  percentage 
of  the  workers  are  susceptible.  It  does  not  seem  to  impair  the  health  very 
much,  yet  it  is  notorious  how  short-lived  are  the  brass-workers  in  Birmingham. 
Hayhurst  has  shown  how  widely  spread  the  malady  is  among  the  workers  in 
zinc  in  the  United  States. 

In  treatment  an  emetic  and  a  brisk  purge  may  give  relief.  The  drinking 
of  milk  and  taking  of  .sodium  bicarbonate  are  advised. 


V.     ARSENICAL  POISONING 

Acute  poisoning  by  arsenic  is  common,  particularly  by  Paris  green  and 
such  mixtures  as  "Eough  on  Eats,"  -which  are  used  to  destroy  vermin  and 
insects.  The  chief  symptoms  are  intense  pain  in  the  stomach,  vomiting,  and, 
later,  colic,  with  diarrhoea  and  tenesmus;  occasionally  the  symptoms  are  those 
of  collapse.  If  recovery  takes  place,  paralysis  may  follow.  The  treatment 
should  be  similar  to  that  of  other  irritant  poisons — rapid  removal  with  the 
stomach  pump,  the  promotion  of  vomiting,  and  the  use  of  milk  and  eggs. 
Moist  ferric  hydroxide  (half  an  ounce  of  Tct.  ferri  chloridi  in  a  glass  of  water 
and  add  magnesia  to  excess)  should  be  given  freely. 

Chronic  Arsenical  Poisoning. — Arsenic  is  used  extensively  in  the  arts, 
particularly  in  the  manufacture  of  colored  papers,  artificial  flowers,  and  in 
many  of  the  fabrics  employed  as  clothing.  The  glazed  green  and  red  papers 
used  in  kindergartens  also  contain  arsenic.  It  is  present,  too,  in  many  wall- 
papers and  carpets.  Much  attention  has  been  paid  to  this  question,  as 
instances  of  poisoning  have  been  thought  to  depend  upon  wall-papers '  and 
other  household  fabrics.  The  arsenic  compounds  may  be  either  in  the  form 
of  solid  particles  detached  from  the  paper  or  as  gaseous  volatile  bodies  formed 
from  arsenical  organic  matter  by  the  action  of  several  moulds,  notably  Peni' 


398  INTOXICATIONS 

cilinm  hrevicaule,  Mucor  mucedo,  etc.  (Gosio).  In  moisture,  and  at  a  tem- 
perature of  from  60°  to  95°  F.,  a  volatile  compound  is  set  free,  probably 
"an  organic  derivative  of  arsenic  pentoxide"  (Sanger).  The  chronic  poison- 
ing from  fabrics  and  wall-papers  may  be  due,  according  to  this  author,  to  the 
ingestion  of  minute  continued  doses  of  this  derivative.  Contaminated  glucose, 
used  in  manufacturing  "beer,  caused  a  widespread  epidemic  of  poisoning  at 
Manchester.  The  associated  presence  of  selenium  compounds  may  have  played 
a  part  in  the  production  of  the  poisoning  (Tunnicliffe  and  Eosenheim). 
Arsenic  is  eliminated  in  all  the  secretions,  and  has  been  found  in  the  milk. 
J.  J.  Putnam  has  shown  that  it  is  not  uncommon  to  find  traces  of  arsenic  in 
the  urine  of  many  persons  in  apparent  health.  The  effects  of  moderate  quan- 
tities of  arsenic  are  not  infrequently  seen  in  medical  practice.  In  chorea  and 
in  pernicious  anaemia  steadily  increasing  doses  are  often  given  until  the 
patient  takes  from  15  to  20  drops  of  Fowler's  solution  three  times  a  day. 
Flushing  and  hyperaemia  of  the  skin,  puffiness  of  the  eyelids  or  above  the  eye- 
brows, nausea,  vomiting,  and  diarrhoea  are  the  most  common  symptoms.  Eed- 
ness  and  sometimes  bleeding  of  the  gums  and  salivation  occur.  In  the 
protracted  administration  of  arsenic  patients  may  complain  of  numbness  and 
tingling  in  the  fingers.  Cutaneous  pigmentation  and  keratosis  are  very 
characteristic,  and,  as  a  late  rare  sequence  of  the  latter,  epithelioma.  In 
chorea  neuritis  has  occurred,  and  a  patient  with  Hodgkin's  disease  had  multiple 
neuritis  after  taking  §  i^  5  j  of  Fowler's  solution  in  seventy-five  days,  during 
which  time  there  were  fourteen  days  on  which  the  drug  was  omitted. 

In  the  Manchester  epidemic  nearly  all  cases  presented  signs  of  neuritis 
and  lesions  of  the  skin.  In  some  the  sensory  disturbances  predominated, 
in  others  the  motor,  the  individuals  being  unable  to  walk  or  to  use  their  hands. 
In  a  certain  number  there  was  muscular  incoordination,  resembling  that  of 
tabes  dorsalis.  Eapid  muscular  atrophy  characterized  some  cases.  In  not  a 
few  a  condition  of  erythromelalgia  was  present.  Occasionally  a  catarrh  of  the 
respiratory  and  alimentary  tracts  was  the  chief  feature.  Pigmentation,  kera- 
tosis, and  herpes  were  the  most  characteristic  cutaneous  manifestations. 

How  far  similar  symptoms  are  to  be  attributed  to  the  small  quantities  of 
arsenic  absorbed  from  Avall-papers  and  fabrics  is  by  some  considered  doubt- 
ful. That  children  and  adults  may  take  with  impunity  large  doses  for  months 
without  unpleasant  effects,  and  the  fact  of  the  gradual  establishment  of  a 
toleration  which  enables  Styrian  peasants  to  take  as  much  as  8  grains  of 
arsenious  acid  in  a  day,  speak  strongly  against  it.  On  the  other  hand,  as 
Sanger  states,  we  do  not  know  accurately  the  effects  of  many  of  the  compounds 
in  minute  and  long-continued  doses,  notably  the  arsenates. 

Ai'senical  jmralys^is  has  the  same  characteristics  as  lead-palsy,  but  the  legs 
are  more  affected  than  the  arms,  particularly  the  extensors  and  peroneal 
group,  so  that  the  patient  has  the  characteristic  steppage  gait  of  peripheral 
neuritis.  The  electrical  reaction  in  the  muscles  may  be  disturbed  before  there 
is  any  loss  of  power,  and  when  the  patient  is  asked  to  extend  the  wrist  fully  and 
to  spread  the  fingers  slight  weakness  may  be  detected  early. 

Treatment. — Active  elimination  by  the  bowels  and  kidneys  is  advisable  and 
the  treatment  of  special  conditions  as  indicated. 


FOOD  POISONING  399 


VI.     FOOD  POISONING 

There  may  be  "death  in  the  pof'  from  many  causes.  Food  poisons  mav 
be  endogenous  or  exogenous.  Those  articles  in  which  the  poison  is  of  endoge- 
nous origin  can  scarcely  be  designated  as  foods.  The  poisonous  mushroom, 
for  example,  is  often  mistaken  for  the  edible  form.  The  former  is  injurious 
because  it  normally  produces  a  highly  poisonous  alkaloid,  muscarine.  Cer- 
tain fish  also  produce  normal  physiological  but  toxic  products.  When  eaten 
by  mistake,  as  frequently  occurs  in  the  West  Indies  and  Japan,  these  fish  may 
cause  poisonous  symptoms.  The  exogenous  origin  of  food  poisons  is  by  far 
the  commonest.  Under  this  head  come  those  foods  which  are  rendered  poison- 
ous by  accidental  contamination  from  outside  sources.  Food  may  contain 
specific  organisms,  as  of  tuberculosis  or  trichinosis;  milk  and  other  foods  may 
become  infected  with  typhoid  bacilli,  and  so  convey  the  disease. 

Animals  (or  insects,  as  bees)  may  feed  on  substances  which  cause  their 
flesh  or  products  to  be  poisonous  to  man.  The  grains  used  as  food  may  be 
infected  with  fungi  and  cause  the  epidemics  of  ergotism,  etc.  Foods  of  all 
sorts  may  become  contaminated  with  the  bacteria  of  putrefaction,  the  products 
of  which  may  be  highly  poisonous. 

The  term  "ptomaine  poisoning"  has  been  popularized  to  such  an  extent  that 
it  is  used  synonymously  with  food  poisoning  but  true  ptomaine  poisoning  is 
very  rare.  The  term  ptomaine  was  introduced  by  the  Italian  chemist,  Selmi, 
to  designate  basic  alkaloidal  products  formed  in  putrefaction.  ]\Iytilotoxin, 
found  in  poisonous  mussels,  is  of  this  class,  and  is  by  far  the  most  poisonous 
of  the  known  ptomaines. 

Among  the  more  common  forms  are  the  following: 

Meat  Poisoning". — Outbreaks  of  disease  due  to  poisons  of  bacterial  origin 
or  due  to  chemical  changes  in  meat  are  not  uncommon.  Several  groups  of 
cases  have  been  recognized. 

(a)  From  the  colon  bacillus  or  the  typho-coli  group  of  organisms,  which 
occupy  a  position  intermediate  between  the  typhoid  and  colon  bacillus.  In 
severe  forms  symptoms  come  on  a  few  hours  after  eating  the  meat;  violent 
vomiting,  purging,  pains  in  the  abdomen  and:  collapse  and  death  may  occur 
within  twenty-four  hours.  The  temperature  may  be  subnormal.  Individuals 
react  very  differently,  as  shown  in  the  remarkable  outbreak  investigated  by 
McWeeney  in  Limerick.  Among  73  cases  every  grade  of  severity  Avas  seen, 
from  severe  cholera  nostras  to  headache  with  slight  fever.  Indeed,  there  were 
cases  without  symptoms,  but  with  the  typhoid  blood  reaction. 

Some  of  these  cases  have  a  close  resemblance  to  paratyphoid  B  infection, 
and,  as  Durham  pointed  out,  the  bacilli  are  divisible  into  two  groups :  The 
Gaertner  type  {B.  enteritidis)  and  the  Aertryck  type.  The  organism  may  be 
isolated  from  the  stools,  rarely  from  the  blood,  and  the  specific  serum  reactions 
are  found.    Carriers  have  been  the  source  of  infection  in  some  cases. 

The  important  matter  in  connection  with  this  type  of  poisoning  is  the 
unaltered  appearance  of  the  meat.  The  danger  seems  greatest  from  beef  and 
veal,  and  in  Germany  has  particularly  followed  the  use  of  meat  from  cattle 
ill  with  some  septic  or  diarrhceal  condition.  Pork  is  a  not  infrequent  cause 
in  England,  and  severe  attacks  have  followed  the  eating  of  pork  pies. 


400  INTOXICATIONS 

(b)  Meat  poisoning  associated  with  putrefaction.  Here  alterations  of  ap- 
pearance, of  smell  and  taste  are  usually  present.  The  products  are  those  of 
protein  hydrolysis,  various  aromatic  compounds,  but  more  particularly  the 
bodies  known  as  putrescine,  cadaverine  and  sepsin.  How  far  these  bodies 
themselves  are  responsible  for  the  symptoms,  how  far  they  are  due  to  infection 
with  associated  organisms,  particularly  the  proteus  and  the  colon  bacilli,  has 
not  been  definitely  settled.  Many  cases  of  food  poisoning  have  been  reported 
as  due  to  proteus  and  its  toxins.  This  organism  was  found  to  be  the  cause  of 
a  severe  outbreak  due  to  eating  potato  salad. 

(c)  Botulism. — Poisoning  due  to  Bacillus  botulinus.  The  organism  was 
discovered  by  van  Ermengem  in  a  ham,  the  eating  of  which  gave  rise  to  50 
cases  of  botulism.  Formerly  regarded  as  exclusively  a  form  of  meat  poisoning, 
•it  has  been  shown  by  Dickson  and  his  co-workers  that  the  toxin  may  be  found 
in  vegetable  products,  especially  when  "home-canned."  The  condition  is  a 
true  intoxication,  the  toxin  being  formed  in  the  food  and  absorbed  by  the 
gastro-intestinal  tract.  It  is  destroyed  by  heating  to  the  boiling  point.  The 
toxin  causes  marked  thrombus  formation  both  in  arteries  and  veins  with 
hyperEemia  and  hgemorrhages  in  the  meninges  and  central  nervous  system. 
It  is  doubtful  if  there  is  a  specific  action  on  the  nerve  ganglion  cells.  The 
symptoms,  which  appear  in  from  four  to  thirty  hours,  are  weakness,  disturb- 
ance of  vision,  diplopia  and  loss  of  accommodation.  Paralysis  of  the  eye 
muscles  is  common  and  any  of  the  motor  cranial  nerves  may  be  involved. 
Vertigo  and  incoordination  are  common.  Sensation  remains  xmdisturbed. 
Dryness  of  the  mouth  and  pharynx,  constriction  of  the  throat  with  difficulty 
in  speaking  and  swallowing  follow.  There  is  obstinate  constipation.  In  fatal 
cases  death  occurs  in  from  four  to  eight  days  from  cardiac  or  respiratory 
failure.  The  treatment  is  symptomatic;  the  stomach  should  be  washed  and 
the  bowels  emptied.    Water  should  be  given  freely. 

Certain  game  birds,  particularly  the  grouse,  are  poisonous  in  special  dis- 
tricts and  at  certain  seasons.  It  is  interesting  to  note  that  mutton  and  lamb 
have  thus  far  not  been  implicated  as  a  cause  of  food  poisoning. 

Poisoning  by  Meat  Products. —  (a)  The  poisonous  effects  which  follow 
the  drinking  of  milk  infected  with  saprophytic  bacteria  are  considered  in  the 
section  on  the  diarrhoea  of  infants. 

(&)  Cheese  Poisoning. — Various  milk  products,  ice  cream,  custard,  and 
cheese,  may  prove  highly  poisonous.  In  one  epidemic  Vaughan  and  Novy 
isolated  from  cheese  a  substance  belonging  to  the  poisonous  albumins,  and  in 
an  extensive  ice-cream  epidemic  Vaughan  and  Perkins  found  in  the  ice  cream 
a  highly  pathogenic  bacillus,  but  its  toxin  has  not  been  separated.  The 
symptoms  are  those  of  acute  gastro-intestinal  irritation. 

Poisoning  by  Shell-fish  and  Fish. — (a)  Mussel  Poisoning. — Brieger  sep- 
arated a  ptomaine — mytilotoxin — which  exists  chiefly  in  the  liver  of  the 
mussel.  The  observations  of  Schmidtmann  and  Cameron  have  shown  that  the 
mussel  from  the  open  sea  only  becomes  poisonous  when  placed  in  filthy  waters. 

Dangerous,  even  fatal,  effects  may  follow  the  eating  of  either  raw  or  cooked 
mussels.  The  symptoms  are  those  of  an  acute  poisoning  with  profound  action 
on  the  nervous  system,  and  without  gastro-intestinal  manifestations.  There 
are  numbness  and  coldness,  no  fever,  dilated  pupils,  and  rapid  pulse ;  death 
occurs  sometimes  within  two  hours  Avith  collapse  symptoms.     In  an  epidemic 


FOOD  POISOXIXG  401 

at  AYilhelmshafen,  Germany.,  in  1885,  nineteen  persons  were  attacked,  four 
of  whom  died.  Salkowski  and  Brieger  isolated  the  mytilotoxin  from  speci- 
mens of  the  mussels.  Poisoning  occasionally  follows  the  eating  of  oysters 
which  are  stale  or  decomposed.     The  symptoms  are  usually  gastro-intestinal. 

(h)  Fish  Poisoning. — There  are  two  distinct  varieties:  in  one  the  poison 
is  a  physiological  product  of  certain  glands  of  the  fish,  in  the  other  it  is  a 
product  of  bacterial  growth.  The  salted  sturgeon  used  in  parts  of  Eussia 
has  sometimes  proved  fatal  to  large  numbers  of  persons.  In  the  middle  parts 
of  Europe  the  barb  is  stated  to  be  sometimes  poisonous,  producing  the  so-called 
"harhen  cholera."  In  China  and  Japan  various  species  of  the  tetrodon  are 
also  toxic,  sometimes  causing  death  within  an  hour,  with  symptoms  of  intense 
disturbance  of  the  nervous  system. 

Grain  and  Vegetable  Food  Poisoning. —  (a)  Ergotism. — The  prolonged  use 
of  meal  made  from  grains  contaminated  with  the  ergot  fungus  {claviceps  pur- 
purea) causes  a  series  of  symptoms  known  as  ergotism,  epidemics  of  which 
have  prevailed  in  different  parts  of  Europe.  Two  forms  of  this  chronic 
ergotism  are  described — the  one,  gangrenous,  is  believed  to  be  due  to  the 
sphacelinic  acid,  the  other,  convulsive  or  spasmodic,  is  due  to  the  cornutin. 
In  the  former  gangrene  affects  the  extremities — usually  the  toes  and  fingers, 
less  commonly  the  ears  and  nose.  Preceding  the  onset  of  the  gangrene 
there  are  usually  anaesthesia,  tingling,  pains,  spasmodic  movements  of  the 
muscles,  and  gradual  blood  stasis  in  certain  vascular  territories. 

The  nervous  manifestations  are  very  remarkable.  After  a  prodromal  stage 
of  ten  to  fourtegh  days,  in  which  the  patient  complains  of  weakness,  headache, 
and  tingling  sensations  in  different  parts  of  the  body,  perhaps  accompanied 
with  slight  fever,  symptoms  of  spasm  develop,  producing  cramps  in  the  mus- 
cles and  contractures.  The  arms  are  flexed  and  the  legs  and  toes  extended. 
These  spasms  may  last  from  a  few  hours  to  many  days  and  relapses  are  fre- 
quent. In  severer  cases  epilepsy  develops  and  the  patient  may  die  in  convul- 
sions. Mental  symptoms  are  common,  manifested  sometimes  in  a  prelimi- 
nary delirium,  but  more  commonly,  in  the  chronic  poisoning,  as  melancholia 
or  dementia.  Posterior  spinal  sclerosis  occurs  in  chronic  ergotism.  In  the 
interesting  group  of  29  cases  studied  by  Tuczek  and  Siemens  9  died  at  various 
periods  after  the  infection,  and  four  post  mortems  showed  degeneration  of  the 
posterior  columns.  A  condition  similar  to  tabes  dorsalis  is  gradually  pro- 
duced by  this  slow  degeneration  in  the  spinal  cord. 

(&)  Lathyrism  (Lupinosis). — An  affection  produced  by  the  use  of  meal 
from  varieties  of  vetches,  chiefly  the  Lathyrus  sativus  and  L.  cicera.  The 
grain  is  popularly  known  as  the  ^chick-pea.  The  grains  are  usually  powdered 
and  mixed  with  the  meal  from  other  cereals  in  the  preparation  of  bread.  As 
early  as  the  seventeenth  century  it  was  noticed  that  the  use  of  flour  with  which 
the  seeds  of  the  Lathyrus  were  mixed  caused  stiffness  of  the  legs.  The  subject 
did  not  attract  much  attention  before  the  studies  of  James  Irving,  in  India, 
who,  between  1859  and  1868  in  several  communications,  describecl  a  form  of 
spastic  paraplegia  affecting  many  of  the  inhabitants  in  certain  regions  of 
India  and  due  to  the  use  of  meal  made  from  the  Lathyrus  seeds.  It  also 
produces  a  spastic  paraplegia  in  animals.  The  Italian  observers  describe  a 
similar  form  of  paraplegia,  and  it  has  been  observed  in  Algiers.  The  condition 
is  that  of  a  spastic  paralysis,  involving  chiefly  the  legs,  which  may  proceed 


402  INTOXICATIONS 

to  complete  paraplegia.  The  arms  are  rarely,  if  ever,  affected.  It  is  evidently 
a  slow  sclerosis  due  to  the  influence  of  this  toxic  agent. 

(c)  Potato-poisoning. — Potatoes  contain  normally  a  very  small  amouut 
(about  0.06  per  cent.)  of  the  poisonous  principle  solanin,  and,  under  certain 
circumstances,  may  contain  the  poison  in  amounts  suificient  to  cause  grave 
disturbance.  The  increase  is  due  to  the  action  of  at  least  tvs^o  species  of 
bacteria,  B.  solaniferuni  non-colorahile  and  B.  solaniferum  colorahile,  and 
occurs  in  those  tubers  Avhich,  during  growth,  have  lain  partially  exposed  above 
ground,  and  in  those  which,  during  storage,  have  become  well  sprouted.  An 
extensive  outbreak  of  potato-poisoning  occurred  in  1899  in  a  German  regi- 
ment, fifty-six  members  of  which,  after  eating  sprouted  potatoes,  were  seized 
with  chills,  fever,  headache,  vomiting,  diarrhoea,  colic,  and  great  prostration. 
Many  were  jaundiced  and  several  collapsed,  but  all  recovered.  Samples  of 
the  remaining  potatoes  yielded  0.38  per  cent,  of  solanin,  and  this  would  in- 
dicate that  a  full  portion  must  have  contained  about  5  grains, 

{d)  The  "Vomiting  Sickness"  of  Jamaica  is  due  to  poisoning  by  spoiled 
ackees — the  fruit  of  Blighia  sapida.  Children  are  especially  susceptible;  the 
main  features  are  vomiting, .  convulsions  and  coma ;  the  average  duration  is 
twelve  hours;  the  death  rate  is  85  per  cent.  (Scott). 

Anaphylaxis. — Some  individuals  have  a  h3'per-susceptibility  to  certain  pro- 
teins and  this  may  result  in  very  diverse  phenomena.  The  sensitization  may 
be  natural  or  acquired  and  in  the  latter  case  may  be  due  to  absorption  from 
the  digestive  tract.  The  features  are  very  variable;  in  an  infant  susceptible 
to  cow's  milk  there  may  be  vomiting,  diarrhoea,  urticaria  or  erythema,  dyspnoea 
and  prostration  ^vith  a  weak  and  rapid  pulse.  Some  chronic  skin  affections, 
such  as  eczema,  perhaps  psoriasis,  certain  forms  of  erythema  and  urticaria,  and 
some  cases  of  asthma  are  due  to  this  cause.  Milk,  eggs,  meat,  shell  fish,  straw- 
berries, etc,  are  among  the  !oods  concerned.  The  use  of  skin  tests  made  with 
the  isolated  protein  is  an  important  diagnostic  measure. 

Treatment. — The  source  of  the  infection  must  be  ascertained  and  the  of- 
fending food  destroyed.  The  stomach  should  be  washed  out  and  the  bowels- 
evacuated  bv  a  brisk  saline  purge.  Saline  infusions,  hypodermic  or  intra- 
venous, may  promote  the  elimination  of  the  toxins. 

In  the  cases  of  atiapliylaxis  it  may  be  possible  to  avoid  the  particular  food 
to  which  the  patient  is  sensitized.  Otherwise  an  immunity  may  be  obtained 
by  giving  very  minute  doses  of  the  protein  concerned,  insufficient  to  produce  a 
reaction,  and  gradually  increasing  the  amount.  Children  often  lose  the  hyper- 
susceptibility  as  they  grow  older. 


SECTION"  IV 
DEFICIENCY  DISEASES 

I.     PELLAGRA 

Definition. — A  deficienc}^  disease,  with  periodical  manifestations  character- 
ized by  gastro-intestinal  disturbances,  skin  lesions,  and  a  tendency  to  changes 
in  the  nervous  system. 

Historidal. — The  disease  appears  to  have  been  endemic  in  Spain  by  1735 
and  the  first  description  is  by  Cazal  (1762),  who  named  it  nml  de  la  rosa. 
It  existed  in  Italy  in  1750  and  was  described  in  1771  by  FrapoUi,  who  gave 
it  the  name  of  pellagra  (rough  skin).  By  the  eighteenth  century  it  had 
spread  over  northern  Italy  and  had  appeared  in  France  and  Eoumania.  It 
is  quite  probable  that  there  have  been  sporadic  cases  in  the  United  States  for 
the  last  fifty  years. 

Distribution. — The  disease  is  prevalent  in  parts  of  southern  Europe,  par- 
ticularly in  Italy  and  Eoumania.  It  exists  in  Spain,  Portugal,  France,  Egypt 
and  the  United  States,  in  the  southern  part  of  which  country  the  disease  has 
spread  with  extraordinary  rapidity.  In  1917  there  were  3,666  deaths  in  the 
registration  area.  Better  diagnosis  can  hardly  explain  the  frequency,  as 
the  disease  is  so  striking  in  its  manifestations  that  many  cases  could  hardly 
be  overlooked.  There  is  evidence  that  the  disease  is  to  some  extent  one  of 
particular  localities,  as  beri-beri ;  it  is  also  a  disease  of  the  country  more  than 
of  the  cities.  This  applies  particularly  to  Europe,  but  in  the  United  States 
many  towns  and  villages  show  a  number  of  cases.  As  regards  the  influence 
of  place,  the  number  of  cases  in  the  asylums  of  the  United  States  is  signifi- 
cant.    A  few  cases  have  occurred  in  England. 

Etiology. — There  are  two  main  views,  one  that  it  is  due  to  a  defect  in  the 
diet — a  lack  of  vitamines,  in  other  words,  a  deficiency  disease,  and  the  other 
that  it  is  due  to  infection  of  some  kind.  If  the  latter  be  the  case  the  infec- 
tious agent  is  apparently  not  conveyed  directly  from  person  to  person.  In 
the  Italian  institutions,  where  a  large  number  of  pellagrins  are  treated,  no 
attendant  has  contracted  the  disease.  If  due  to  food  deficiency,  the  accused 
article  is  corn  (maize),  comparable  to  the  part  thought  to  be  played  by  rice 
in  beri-beri.  The  experiments  of  Goldberger  and  Wheeler  support  the  dietetic 
view.  Eleven  prisoners  were  kept  on  ordinary  diet  from  February  4  to  April 
19,  1915,  from  which  date  until  October  31,  1915,  they  received  a  restricted 
diet  lacking  meat,  eggs,  milk,  beans,  peas  and  other  proteins.  The  food  was 
chiefly  maize,  rice,  sweet  potatoes,  brown  gravy,  syrup,  sugar  and  cofl^ee — 
all  of  the  best  quality.  Within  five  months  six  of  the  eleven  volunteers  had 
dermatitis  said  by  experts  to  be  pellagra. 

Age. — The  disease  occurs  at  any  age,  but  tlie  majority  of  cases  are  be- 

403 


404  DEFICIENCY  DISEASES 

tween  twenty  and  forty  years.  As  regards  races,  the  negro  is  more  susceptible 
than  the  white,  and,  in  reference  to  sex,  women  are  apparently  slightly  more 
susceptible  than  men. 

Occupation. — In  Europe  the  disease  is  almost  confined  to  laborers  of  the 
poorer  classes,  but  this  is  not  true  of  the  United  States. 

Season. — The  disease  occurs  particularly  in  the  spring  and  sometimes  in 
the  autumn,  both  in  its  onset  and  recurrences. 

Patholo^. — There  is  nothing  characteristic  in  the  morbid  anatomy.  In 
the  acute  cases  there  may  be  atrophy  of  the  walls  of  the  intestines,  fatty  de- 
generation of  the  internal  organs  and  changes  in  the  nervous  system.  The 
alterations  in  the  cord  are  fairly  constant.  There  is  degeneration  of  the  lat- 
eral columns  in  the  dorsal  region  and  of  the  posterior  columns  in  the  cervical 
and  dorsal  regions.  In  the  brains  of  patients  with  mental  deterioration 
atrophy  of  the  cerebrum  is  found. 

Symptoms. — These  vary  markedly  in  severity,  usually  appearing  in  the 
spring  and  sometimes  in  the  autumn.  There  is  ahvays  a  tendency  to  recur- 
rence, and  with  each  succeeding  attack  more  damage  is  done,  particularly  to 
the  nervous  system.  The  onset  is  usually  in  the  spring  with  indefinite  symp- 
toms, such  as  weakness,  headache,  and  depression. 

Digestive  Tract. — ^Disturbance  of  the  alimentary  tract  is  usually  an  early 
symptom.  In  the  mouth  there  may  be  sensations  of  heat,  with  loss  of  taste. 
Stomatitis  is  common,  the  mucous  membrane  is  very  red,  ulcers  may  appear 
and  the  epithelium  is  stripped  off,  leaving  a  raw  surface  so  that  chewing  is 
painful.  Anorexia,  nausea  and  vomiting  are  common ;  there  is  also  diarrhoea, . 
sometimes  dysentejy,  often  severe  and  accompanied  by  pain,  the  stools  being 
serous  or  bloody.     It  may  alternate  with  constipation. 

Skin:— The  erythema  usually  begins  on  the  backs  of  the  hands  and  at 
first  resembles  an  ordinary  sunburn.  There  may  be  puffy  swelling.  The  af- 
fected areas  are  symmetrical  and  sharply  defined  as  a  rule,  extending  above 
the  wrist  and  down  to  the  last  finger  joint.  The  face,  neck  and  feet  may  be 
affected  in  the  same  way.  The  process  may  not  advance  any  further,  the 
skin  becomes  darker  and  desquamates,  after  which  some  pigmentation  remains. 
In  other  cases  vesicles  and  bullae  form,  containing  serum  or  pus.  These  dry 
gradually,  with  the  production  of  fissures.  After  drying  and  desquamation 
the  skin  may  have  a  dry  appearance  and  a  deep  red  color.  With  repeated 
attacks  the  skin  may  become  indurated,  thickened  and  dark  in  color;  later 
atrophy  and  thinning  may  follow.  Exposure  to  the  sun  may  have  an  influence 
on  the  eruption,  but  is  not  the  cause.  The  erythema  occurs  sometimes  on  pro- 
tected parts. 

ISTervous  System. — Headache  and  vertigo  are  common.  Mental  features 
are  often  marked,  among  which  are  confusion,  dullness,  lassitude,  irritability, 
feelings  of  anxiety  and  depression,  change  in  the  disposition,  and  hallucina- 
tions of  sight  and  hearing.  These  may  progress  to  profound  depression  and 
ultimately  to  dementia.  Mania  occurs  sometimes  and  suicidal  tendencies  are 
not  uncommon.  The  symptoms  due  to  changes  in  the  cord  vary  with  the 
lesion.  A  spastic  condition,  disturbances  of  sensation,  paralysis  of  the  sphinc- 
ters, or  loss  of  the  reflexes  of  the  legs  may  be  found. 

The  blood  shows  no  special  features  beyond  those  of  a  secondary  anasmia. 
The  temperature  is  usually  normal  except  in  some  of  the  acute  cases. 


PELLAGRA  405 

Clinical  Forms. — The  disease  occurs  in  two  main  forms,  an  acute  and  a 
chronic  recurrent  form.  In  the  acute  form  there  are  fever,  marked  prostra- 
tion, severe  diarrhoea,  delirium  or  stupor  and  a  rapid  downward  course.  Death 
may  occur  in  a  few  weeks  from  the  onset.  These  cases  seem  to  be  more  fre- 
quent in  the  United  States  than  in  Europe.  In  the  chronic  form  the  mani- 
festations are  not  severe,  but  tend  to  recur  each  year,  and  each  attack  leaves 
the  patient  in  a  worse  condition.  There  is  always  the  tendency  to  mental  de- 
terioration which  occurs  in  fully  10  per  cent,  of  the  cases.  Death  occurs  from 
exhaustion  and  cachexia,  or  some  intercurrent  disease.  Fortunately,  succeed- 
ing attacks  are  not  necessarily  more  severe  than  the  preceding  ones.  There 
are  instances  of  this  form  persisting  for  twenty-five  years.  Cases  without 
the  skin  lesions — pellagra  sine  pellagra — have  been  described. 

Diagnosis. — A  typical  case  offers  no  difficulties,  but  in  the  absence  of  the 
skin  lesions  considerable  difficulty  may  be  experienced.  Scurvy  might  give  dif- 
ficulty, but  the  absence  of  the  other  features  of  pellagra  should  be  conclusive. 
Skin  lesions  of  the  nature  of  erythema  might  cause  confusion,  but  the  absence 
of  the  general  features  removes  doubt.  The  study  of  the  stools  differentiates  it 
from  sprue.  The  psychical  features  might  suggest  general  paresis,  but  the 
skin  lesions  and  digestive  disturbance  should  make  the  diagnosis  clear.  The 
acute  cases  might  be  mistaken  for  various  infections,  but  the  erythema  and 
gastro-intestinal  features  should  prevent  this. 

Prognosis. — In  the  United  States  the  outlook  is  regarded  as  serious,  if  not 
as  regards  death,  certainly  as  regards  ultimate  recovery.  In  Europe,  where 
the  disease  has  existed  for  a  long  time,  the  prognosis  is  more  favorable,  and 
in  Italy  in  some  years  the  mortality  was  only  4  per  cent.  In  cases  with  acute 
features  or  fever  the  prognosis  is  grave  and  signs  of  severe  toxaemia  or  of 
mental  involvement  are  ominous.  Erythema  of  a  moist  character  is  regarded 
as  a  grave  sign.  Any  complications  should  be  regarded  seriously.  The  prog- 
nosis is  best  in  the  chronic  cases  without  mental  features.  The  outlook  is 
serious  in  asylum  cases. 

Prophylaxis. — "Peasant  life,  poverty,  and  polenta  (corn)"  have  been  given 
as  the  causal  factors.  Improvement  in  the  living  conditions  and  good  sani- 
tation are  important  points  in  the  prevention.  Too  much  corn  or  maize  should 
not  be  used,  particularly  in  institutions.  The  experiments  noted  above  sug- 
gest that  it  is  a  deficiency  disease  which  may  possibly  be  eradicated  by  a  proper 
diet,  as  has  been  the  case  with  beri-beri.  A  sufficient  amount  of  milk,  eggs, 
meat  and  vegetables,  especially  beans,  is  important. 

Treatment. — The  patient  should  be  placed  in  the  best  general  conditions 
and  a  change  of  diet  and  climate  is  advisable.  Eest  in  bed  is  necessary  while 
the  symptoms  are  acute.  The  diet  should  be  as  nutritious  as  possible  and  the 
diarrhoea  need  not  interfere  with  taking  sufficient  nourishment.  Fresh  milk, 
buttermilk,  eggs,  fresh  meat  and  fresh  or  dried  vegetables  should  be  taken 
in  full  amounts.  Salt  should  be  given  freely.  There  is  no  proof  that  we 
have  any  remedy  with  a  specific  infiuence.  Arsenic  has  been  given  by  the 
mouth  or  by  injection.  Atoxyl  and  arsphenamine  have  been  used  in  ordinary 
dosage,  but  arsenic  by  mouth,  as  Fowler's  solution,  is  apparently  more  useful. 
Transfusion  of  blood,  both 'from  healthy  individuals  and  those  who  have 
recovered  from  the  disease,  has  been  done  apparently  with  good  results  in 
some  cases.     Symptomatic  treatment  and  a  proper  diet  seem  to  have  been  as 


406  DEFICIENCY  DISEASES 

successful  as  any  special  measure  and  should  be  given  as  demanded  by  the 
conditions  in  each  patient. 


II.     BERI-BERI 

(KakJce,  Endemic  Multiple  Neuritis) 

Definition. — A  deficiency  disease  due  to  the  absence  of  certain  elements 
of  the  food,  the  so-called  vitamines,  and  characterized  clinically  by  multiple 
neuritis,  anasarca,  and  muscular  atrophy. 

It  seems  probable  that  several  forms  of  multiple  neuritis  have  been  de- 
scribed under  the  term  beri-beri.  The  form  which  is  particularly  common 
in  China  and  Japan  is  due  to  a  diet  deficient  in  the  special  vitamine  which 
occurs  in  the  outer  layer  of  rice. 

History. — The  disease  is  believed  to  be  of  great  antiquity  in  China,  and 
is  possibly  mentioned  in  the  oldest  known  medical  treatise.  In  the  early 
years  of  the  nineteenth  century  it  attracted  much  attention  among  the  Anglo- 
Indian  surgeons,  and  we  may  date  the  modern  scientific  study  of  the  disease 
from  Malcolmson's  monograph,  published  at  Madras  in  1835.  The  opening 
of  Japan  gave  an  opportunity  to  the  European  physicians  holding  university 
positions,  particularly  Anderson,  Baelz,  Scheube,  and  Grimm,  to  investigate  the 
disease.  The  studies  of  Japanese  physicians,  particularly  Miura  and  Takagi, 
and  of  Dutch  physicians  in  the  East,  have  contributed  much  to  our  knowledge. 
The  studies  of  Schaumann,  Eraser,  Stanton,  and  others  and  the  dietetic  ex- 
periments in  the  Philippines  have  confirmed  tlje  older  views  that  it  is  a  dis- 
order depending  upon  an  imperfect  dietary. 

Distribution. — It  is  specially  prevalent  among  the  Malays,  Chinese  and 
Japanese,  and  during  the  Eussian  war  more  than  50,000  cases  occurred  in 
the  Japanese  army.  It  prevails  excessively  in  the  Philippines.  In  India  it 
is  less  common.  Localized  outbreaks  have  occurred  in  Australia.  It  prevails 
in  parts  of  South  America,  and  in  the  West  Indies.  It  is  met  with  among 
the  fishermen  of  Norway  and  of  the  Newfoundland  Banks.  It  occurs  also  in 
asylums,  in  which  there  have  been  severe  outbreaks  in  the  United  States,  and 
in  the  Eichmond  Asylum,  Dublin,  in  the  years  1894,  1896  and  1897  under 
conditions   of   over-crowding. 

Etiology. — Two  main  views  have  prevailed :  That  it  is  an  acute  infec- 
tion and  that  it  is  a  disorder  of  metabolism.  Numerous  bacteriological  studies 
have  not  determined  the  presence  of  any  definite  organism.  On  the  other 
hand,  the  work  of  the  past  few  years  has  confirmed  the  food  theory  widely  held 
in  Japan.  Studies  in  the  Far  East  leave  no  doubt  that  the  disease  is  there 
due  to  a  diet  of  rice  from  which  the  pericarp  has  been  removed,  in  what  is 
called  "polishing"  or  "milling."  This  is  an  old  story,  as  the  Dutch  knew  of 
the  association  of  the  disease  with  rice,  and  it  was  by  modifying  the  rice  diet 
of  the  sailors  that  Takagi  eradicated  beri-beri  from  the  Japanese  navy.  Brad- 
don  showed  the  importance  of  the  retention  of  the  pericarp  for  the  pre- 
vention of  the  disease.  Schaumann's  experiments,  amply  confirmed  by  Fraser 
and  Stanton,  leave  no  question  that  beri-beri  is  associated  with  a  diet  freed 
from  the  materials  existing  in  the  pericarp.    Whether  these  are  the  phosphorus 


BERI-BERI  407 

compounds,  as  Schaumann  believes,  or  unknown  substances,  the  so-called  vita- 
mines,  as  Fraser  and  Stanton  hold,  has  not  been  settled. 

That  beri-beri  occurs  in  ships  and  in  institutions  may  be  explained  by  the 
fact  that  in  the  dietary,  though  it  may  not  be  of  rice,  similar  compounds  are 
lacking.  On  the  other  hand,  certain  French  workers  in  the  East  hold  that 
white  rice  alone  does  not  produce  the  disease,  and  that  there  must  be  some 
other  factor,  since  the  great  majority  of  rice-eaters  in  the  East  are  immune. 

Other  factors  are  overcrowding,  as  in  ships,  jails  and  asylums,  hot  and 
moist  seasons,  and  exposure  to  wet.  Males  are  more  subject  to  the  disease, 
than  females.     Under  good  hygienic  conditions  Europeans  rarely  contract  it. 

Morbid  Anatomy. — The  most  constant  and  striking  features  are  changes 
in  the  peripheral  nerves  and  degenerative  inflammation  involving  the  axis 
cylinder  and  medullary  sheaths.  In  acute  cases  this  is  found  not  only  in 
the  peripheral  nerves,  but  also  in  the  vagus  and  phrenic.  The  fibres  of  the 
voluntary  muscles,  as  well  as  of  the  myocardium,  are  much  degenerated. 

Symptoms. — The  incubation  period  is  unknown,  but  it  probably  extends 
over  several  months.     The  following  forms  are  recognized  by  Scheube : 

(a)  The  incomplete  or  rudimentary  form  which  often  sets  in  with 
catarrhal  symptoms,  followed  by  pains  and  weakness  in  the  limbs  and  a  lower- 
ing of  the  sensibility  in  the  legs,  with  the  occurrence  of  parsesthesia.  Slight 
oedema  sometimes  appears.  After  a  time  parsesthesia  is  felt  in  other  parts 
of  the  body,  and  the  patient  may  complain  of  palpitation  of  the  heart,  uneasy 
sensations  in  the  abdomen,  and  sometimes  shortness  of  breath.  There  may  be 
weakness  and  tenderness  of  the  muscles.  After  lasting  from  a  few  days  to 
many  months,  these  symptoms  all  disappear,  but  with  the  return  of  the  warm 
weather  there  may  be  a  recurrence.  One  of  Scheube's  patients  suffered  in  this 
way  for  twenty  years. 

(b)  The  atrophic  form  sets  in  with  much  the  same  symptoms,  but  the 
loss  of  power  in  the  limbs  progresses  more  rapidly,  and  very  soon  the  patient 
is  no  longer  able  to  walk  or  to  move  the  arms.  The  atrophy,  which  is  asso- 
ciated with  a  good  deal  of  pain,  may  extend  to  the  muscles  of  the  face.  The 
oedematous  symptoms  and  heart  troubles  play  a  minor  role  in  this  form,  which 
is  known  as  the  dry  or  paralytic  variety. 

(c)  The  Wet  or  Dropsical  Form. — Setting  in  as  in  the  rudimentary 
variety,  the  cedema  soon  becomes  the  most  marked  feature,  extending  over  the 
whole  subcutaneous  tissue,  and  associated  with  effusions  into  the  serous  sacs. 
The  atrophy  of  the  muscles  and  disturbance  of  sensation  are  not  guch  promi- 
nent symptoms,  but  palpitation  and  rapid  action  of  the  heart  and  dyspnoea 
are  common.     The  wasting  may  not  be  apparent  until  the  dropsy  disappears. 

(d)  The  acute,  pernicious,  or  cardiac  form  is  characterized  by  threat- 
enings  of  an  acute  cardiac  failure,  coming  on  rapidly  after  the  existence  of 
slight  symptoms,  such  as  occur  in  the  rudimentary  form.  Death  may  follow 
within  twenty-four  hours;  more  commonly  the  symptoms  extend  over  several 
weeks.     Widespread  paralysis  with  anaesthesia  may  be  present. 

The  mortality  varies  greatly,  from  2  or  3  per  cent,  to  40  or  50  per  cent, 
among  the  coolies  in  certain  settlements  of  the  Malay  Archipelago. 

Diagnosis. — In  tropical  countries  there  is  rarely  any  dillieulty.  In  cases 
of  peripheral  neuritis,  ^.ssociated  with  oedema,  coming  from  tropical  ports, 
the  possibility  of  this  disease  should  be  remembered.     The  peculiar  epidemic 


408  DEFICIENCY  DISEASES 

dropsy  of  Calcutta  and  Bengal  is  probably  beri-beri.  G-reig  has  shown  it  to 
be  a  nutritional  disorder   associated  with  the  use   of  polished  rice. 

Prophylaxis. — Much  has  been  done  to  prevent  the  disease,  particularly  in 
Japan.  There  has  been  no  more  remarkable  triumph  of  modern  hygiene  than 
Takagi's  dietetic  reforms  in  the  Japanese  navy.  Everywhere  in  the  East  a 
change  in  the  diet  has  been  followed  by  the  disappearance  of  the  disease.  In 
the  Straits  Settlements  a  group  of  men  took  No.  1  polished  white  Siam  rice, 
and  developed  beri-beri  within  sixty  days.  A  group  that  took  unpolished  rice 
remained  free  from  the  disease.  By  exchange  of  clothing,  contact,  living  to- 
gether, the  disease  was  not  conveyed  from  one  group  to  the  other.  Then  the 
group  that  had  partaken  of  the  unpolished  rice  was  fed  with  polished  rice, 
and  within  two  months  developed  beri-beri. 

The  change  of  diet  in  the  Philippine  Scouts  instituted  on  September  30th, 
1909,  has  been  followed  by  remarkable  results.  Instead  of  20  ounces  of  highly 
milled  rice,  the 'amount  was  limited  to  16  ounces  of  unpolished  rice.  The 
number  of  admissions  for  the  disease  in  1908  and  1909  in  a  strength  of  men 
of  5,000  was  619  and  558.  In  1910  there  were  50  cases,  and  in  the  first  five 
months  of  1911  only  one  case.  Chamberlain  states  that  the  Philippine  ex- 
periments bear  out  at  every  point  the  polished  rice  theory  of  the  etiology. 
After  having  been  continuously  present  for  five  years  at  the  Culion  Leper  Col- 
ony in  the  Philippines,  beri-beri  disappeared  entirely  in  the  nine  months  after 
the  use  of  unpolished  rice. was  enforced  (Heiser). 

Treatment. — It  is  a  very  chronic  and  obstinate  malady.  A  nutritious  diet, 
without  much  rice,  rest  in  bed,  purgation  for  the  dropsy,  cardiac  stimulants, 
and  the  usual  measures  for  the  neuritis  are  the  important  factors  in  the  treat- 
ment. Salicylates  and  saline  laxatives  are  used  in  Japan,  If  the  cardiac 
features'  are  marked  the  usual  treatment  with  active  stimulation  should  be 
employed.  When  the  oedema  has  subsided  massage,  passive  movements,  and 
electricity  may  be  used  for  the  atrophic  muscles. 


III.     SCURVY 

(ScorhutiLs) 

Definition. — A  disorder  of  metabolism  of  unknown  origin,  characterized  by 
great  debility,  with  anaemia,  a  spongy  condition  of  the  gums,  and  a  tendency 
to  haemorrhages. 

Etiology. — The  disease  has  been  known  from  the  earliest  times,  and  has 
prevailed  particularly  in  armies  in  the  field  and  among  sailors  on  long  voyages. 
It  has  been  well  called  "the  calamity  of  sailors."  Owing  largely  to  the  efforts 
of  Lind  and  to  a  knowledge  of  the  conditions  upon  which  the  disease  depends, 
scurvy  has  gradually  disappeared  from  the  naval  service.  In  the  mercantile  ma- 
rine cases  still  occasionally  occur,  owing  to  the  lack  of  proper  and  suitable  food. 

In  parts  of  Eussia  scurvy  is  endemic.  In  the  United  States  scurvy  is  not  a 
very  rare  disease.  To  the  hospitals  in  the  seaport  towns  sailors  are  now  and 
then  admitted  with  it.  In  large  almshouses  outbreaks  occasionally  occur.  A 
very  great  increase  of  foreign  population  of  a  low  gra4e  has  in  certain  districts 
made  the  disease  not  at  all  uncommon.     In  the  mining  districts  of  Pennsyl- 


SCUEVY  409 

vania  the  Hungarian,  Bohemian,  and  Italian  settlers  are  not  Infrequently 
attacked.  McGrew  has  reported  43  cases  in  Chicago,  limited  entirely  to  Poles. 
He  ascertained  that  in  a  large  proportion  of  the  cases  the  diet  was  composed 
of  bread,  strong  coffee,  and  meat.  Occasionally  one  meets  with  scurvy  among 
quite  well-to-do  people.  Some  years  ago  scurvy  was  not  infrequent  in  the 
large  lumbering  camps  in  the  Ottawa  Valley.  In  Great  Britain  and  Ireland 
it  has  become  very  rare;  only  302  cases  were  admitted  to  the  Seaman's  Hos- 
pital in  the  twenty-two  years  ending  1896  (Johnson  Smith).  It  is  not  un- 
common in  the  South  African  natives. 

The  cause  is  unknown;  there  are  three  theories  of  the  disease: 

(a)  That  it  is  the  result  of  an  absence  of  those  ingredients  in  the  food 
which  are  supplied  by  fresh  vegetables.  What  these  constituents  are  has  not 
yet  been  definitely  determined,  whether  the  potassium  salts  or  the  absence  of 
the  organic  salts  present  in  fruits  and  vegetables.  It  may  be  due  to  a  diet  lack- 
ing in  physical  rather  than  chemical  constituents.  Wright  has  brought  for- 
ward evidence  which  suggests  that  it  may  be  an  acid  intoxication.  That  it  is 
not  due  to  an  absence  of  fresh  vegetables  or  the  salts  of  fruits  and  vegetables 
seems  to  have  been  settled  by  Nansen  and  his  comrades,  Avho,  living  for  months 
under  the  most  unfavorable  hygienic  surroundings,  but  eating  fresh  bear's 
meat  and  bear's  blood,  escaped  scurvy. 

(&)  That  it  is  due  to  toxic  materials  in  the  food — some  unknown  organic 
poison  the  product  of  decomposition. 

(c)  In  opposition  to  these  chemical  views  it  is  urged  that  the  disease 
depends  upon  a  specific   (as  yet  unknown)   micro-organism. 

Other  factors  play  an  important  part,  particularly  physical  and  moral 
influences — overcrowding,  dwelling  in  cold,  damp  quarters,  and  prolonged 
fatigue  under  depressing  influences,  as  during  the  retreat  of  an  army.  Among 
prisoners,  mental  depression  plays  an  important  role.  It  is  stated  that  the 
disease  has  broken  out  in  the  French  convict  ships  en  route  to  ISTew  Caledonia 
even  when  the  diet  was  amply  sufficient.  Nostalgia  is  sometimes  an  important 
element.  It  is  an  interesting  fact  that  prolonged  starvation  in  itself  does  not 
necessarily  cause  scurvy.  Not  one  of  the  professional  tasters  displayed  any 
scorbutic  symptom.  The  disease  attacks  all  ages,  but  the  old  are  more  sus- 
ceptible to  it.  Sex  has  no  special  influence,  but  during  the  siege  of  Paris  it 
was  noted  that  the  males  attacked  were  greatly  in  excess  of  the  females. 

Morbid  Anatomy. — The  anatomical  changes  are  marked,  though  by  no 
means  specific,  and  are  chiefly  those  associated  with  hsemorrhage.  The  blood 
shows  a  severe  anemia,  without  leucocytosis.  The  skin  shows  the  ecchymoses 
evident  during  life.  There  are  hsemorrhages  into  the  muscles,  and  occasion- 
ally about  or  even  into  the  joints.  Hssmorrhages  occur  in  the  internal  organs, 
particularly  on  the  serous  membranes  and  in  the  kidneys  and  bladder.  The 
gums  are  swollen  and  sometimes  ulcerated.  Ulcers  are  occasionally  met  with 
in  the  ileum  and  colon.  Haemorrhages  into  the  mucous  membranes  are  ex- 
tremely common.  The  spleen  is  enlarged  and  soft.  Parenchymatous  changes 
are  constant  in  the  liver,  kidneys,  and  heart. 

Symptoms. — The  disease  is  insidious  in  its  onset.  Early  symptoms  are 
loss  in  weight,  progressive  weakness,  and  pallor.  Very  soon  the  gums  are 
noticed  to  be  swollen  and  spongy,  to  bleed  easily,  and  in  extreme  cases  to  pre- 
sent a  fungous  appearance.     These  changes,  regarded  as  characteristic,  are 


410  DEFICIENCY  DISEASES 

sometimes  absent.  The  teeth  may  become  loose  and  even  fall  out.  Actual 
necrosis  of  the  jaw  is  not  common.  The  breath  is  excessively  foul.  The 
tongue  is  swollen^,  but  may  be  red  and  not  much  furred.  The  salivary  glands 
are  occasionally  enlarged.  Hsemorrhages  beneath  the  mucous  membranes  of 
the  mouth,  especially  on  the  hard  palate,  are  common.  The  skin  becomes  dry 
and  rough,  and  ecch}Tnoses  soon  appear,  first  on  the  legs  and  then  on  the 
arms  and  trunk,  and  particularly  into  and  about  the  hair-follicles.  They  are 
petechial,  but  may  become  larger,  and  when  subcutaneous  may  cause  distinct 
swellings.  In  severe  cases,  particularly  in  the  legs,  there  may  be  effusion 
between  the  periosteum  and  the  bone,  forming  irregular  nodes,  which  may 
break  down  and  form  foul-looking  sores.  The  slightest  bruise  or  injury 
causes  haemorrhages  into  the  injured  part.  CEdema  about  the  ankles  is  com- 
mon. The  '"'scurvy  sclerosis,"  seen  oftenest  in  the  legs,  is  a  remarkable  in- 
filtration of  the  subcutaneous  tissues  and  muscles,  forming  a  brawny  indura- 
tion, the  skin  over  which  may  be  blood-stained.  Haemorrhages  from  the  mu- 
cous membranes  are  less  constant;  epistaxis  is,  however,  frequent.  Haemopty- 
sis and  haematemesis  are  uncommon.  Haematuria,  often  microscopic,  is  com- 
mon and  bleeding  from  the  bowels  may  occur  in  severe  cases. 

Palpitation  of  the  heart  and  feebleness  and  irregularity  of  the  impulse 
are  prominent  symptoms.  The  heart  may  be  enlarged,  especially  the  right 
ventricle.  The  rate  may  be  increased.  A  haemic  murmur  can  usually  be 
heard  at  the  base.  Heemorrhagic  infarction  of  the  lungs  and  spleen  has  been 
described.  Eespiratory  symptoms  are  not  common.  The  appetite  is  im- 
paired, and  owing  to  the  soreness  of  the  gums  the  patient  is  unable  to  chew 
the  food.  Constipation  is  more  frequent  than  diarrhoea.  The  urine  is  often 
albuminous.  The  amount  is  usually  reduced  and  the  specific  gravity  is  high. 
The  statements  with  reference  to  the  inorganic  constituents  are  contradictory. 
Some  authorities  have  found  the  phosphates  and  potassium  salts  to  be  de- 
ficient; others  hold  that  they  are  increased. 

There  are  mental  depression,  indifference,  in  some  cases  headache,  and 
in  the  later  stages  delirium.  Cases  of  convulsions,  or  hemiplegia,  and  of 
meningeal  haemorrhage  have  been  described.  Eemarkable  ocular  symptoms 
are  occasionally  met  with,  such  as  night-blindness  or  day-blindness.  Changes 
in  the  optic  disk  have  been  found. 

In  advanced  cases  necrosis  of  the  bones  may  occur,  and  in  young  persons 
even  separation  of  the  epiphyses.  There  are  instances  in  which  the  cartilages 
have  separated  from  the  sternum.  The  callus  of  a  recently  repaired  fracture 
has  been  known  to  undergo  destruction.  Fever  is  not  present,  except  in  the 
later  stages,  or  when  secondary  inflammations  in  the  internal  organs  appear. 
The  temperature  may,  indeed,  be  sometimes  below  normal.  Acute  arthritis 
is  an  occasional  complication. 

Diagnosis. — No  difficulty  is  met  in  the  recognition  of  scurvy  when  a  nuni- 
ber  of  persons  are  affected  together.  In  isolated  cases,  however,  the  disease 
is  distinguished  with  difficulty  from  certain  forms  of  purpura.  The  associa- 
tion with  manifest  insufficiency  in  diet,  and  the  rapid  amelioration  with  suit- 
able food,  are  points  by  which  the  diagnosis  can  be  readily  settled,     rsvijg 

Prognosis. — The  outlook  is  good,  unless  the  disease  is  far  advanced  and  the 
conditions  persist  which  lead  to  its  occurrence.  The  mortality  now  is  Tarely 
great.     Death  results  from  gradual  heart-failure,  occasionally  from  sudden 


SCUEVY  411 

syncope.  Meningeal  haemorrhage,  extravasation  into  the  seroiis  cavities,  en- 
tero-colitis,  and  other  intercnrrent  affections  may  prove  fatal. 

Prophylaxis. — The  regulations  of  the  Board  of  Trade  require  that  a  suffi- 
cient supply  of  antiscorbutic  articles  of  diet  be  taken  on  each  ship;  so  that 
now,  except  as  the  result  of  accident,  scurvy  is  rare  in  sailors. 

Treatment. — The  juice  of  two  or  three  lemons  or  oranges  daily  and  a  diet 
of  plenty  of  meat  and  fresh  vegetables  suffice  to  cure  all  cases  of  scurvy,  unless 
far  advanced.  When  the  stomach  is  much  disordered,  small  quantities  of 
scraped  meat  and  milk  should  be  given  at  short  intervals,  and  orange  juice  in 
gradually  increasing  quantities.  Mashed  potato,  mixed  with  milk,  is  useful. 
As  the  patient  gains  in  strength  the  diet  may  be  more  liberal,  and  he  may 
eat  freely  of  potatoes,  cabbage,  water-cresses,  and  lettuce.  The  stomatitis 
causes  the  greatest  distress  and  a  permanganate  of  potash  or  dilute  carbolic 
acid  solution  forms  the  best  mouth-wash.  A  tolerably  strong  solution  of 
nitrate  of  silver  applied  to  the  gums  is  very  useful.  The  constipation  is  best 
treated  with  large  enemata.  For  other  conditions,  such  as  haemorrhages  and 
ulcerations,  suitable  measures  must  be  employed. 

INFANTILE    SCURVY 

(Barloiv's  Disease) 

A  special  form  of  scurvy  occurs  in  children  in  consequence  of  imperfect 
food  supply.  W.  B.  Cheadle  and  Gee,  in  London,  described  in  very  young 
children  a  cachexia  associated  with  hsemorrhage.  Cheadle  regarded  the  cases 
as  scurvy  ingrafted  on  a  rickety  stock.  Gee  called  his  cases  periosteal  cachexia. 
Cases  had  previously  been  regarded  as  acute  rickets. 

A  few  years  later  Barlow  made  an  exhaustive  study  of  the  condition  with 
careful  anatomical  observations.  'The  affection  is  now  recognized  as  infantile 
scurvy,  and  is  called  Barlow's  disease.  The  American  Pa3diatric  Society  col- 
lected 379  cases  in  1898  in  the  United  States.  Of  these,  the  hygienic  sur- 
roundings were  good  in  303.  A  majority  of  the  patients  were  under  twelve 
months.  The  proprietary  foods,  particularly  malted  milk  and  condensed  milk, 
seem  to  be  the  most  important  factors  in  j^roducing  the  disease.  There  are 
instances  in  which  it  has  developed  in  breast-fed  infants,  and  in  others  fed 
on  the  carefully  prepared  milk  of  the  Walker-Gordon  laboratories. 

The  following  clinical  summary  is  taken  from  Barlow's  description : 

"So  long  as  it  is  left  alone  the  child  is  tolerably  quiet;  the  lower  limbs 
are  kept  drawn  up  and  still;  but  when  placed  in  its  bath  or  otherwise  moved 
there  is  continuous  crying,  and  it  soon  becomes  clear  that  the  pain  is  con- 
nected with  the  lower  limbs.  kX  this  period  the  upper  limbs  may  be  touched 
with  impunity,  but  any  attempt  to  move  the  legs  or  thighs  gives  rise  to 
screams.  Xext,  some  obscure  swelling  may  be  detected,  first  on  one  lower 
limb,  then  on  the  other,  though  it  is  not  absolutely  symmetrical.  .  .  ,  The 
swelling  is  ill-defined,  but  is  suggestive  of  thickening  round  the  shafts  of  the 
bones,  beginning  above  the  epiphyseal  junctions.  Gradually  the  bulk  of  the 
limbs  affected  becomes  visibly  increased.  .  .  .  The  position  of  the  limbs  be- 
comes somewhat  different  from  what  it  was  at  the  outset.  Instead  of  being 
.flexed  they  lie  everted  and   immobile,  m  a  state  of  pseudo-paralysis.  .  .  . 


4i2  DEFICIENCY  DISEASES 

About  this  time,  if  not  before,  great  weakness  of  the  back  becomes  manifest. 
A  little  swelling  of  one  or  both  scapula?  may  appear,  and  the  upper  limbs 
may  show  changes.  These  are  rarely  so  considerable  as  the  alterations  in 
the  lower  limbs.  There  may  be  swelling  above  the  wrists,  extending  for  a  short 
distance  up  the  forearm,  and  some  swelling  in  the  neighborhood  of  the  epi- 
physes of  the  humerus.  There  is  symmetry  of  lesions,  but  it  is  not  absolute; 
and  the  limb  affection  is  generally  consecutive,  though  the  involvement  of  one 
limb  follows  very  close  upon  another.  The  Joints  are  free.  In  severe  cases 
another  symptom  may  now  be  found — namely,  crepitus  in  the  regions  adjacent 
to  the  junctions  of  the  shafts  with  epiphyses.  .  The  upper  and  lower  extremi- 
ties of  the  femur,  and  the  upper  extremity  of  the  tibia,  are  the  common 
sites  of  such  fractures;  but  the  upper  end  of  the  humerus  may  also  be  so 
affected.  ...  A  very  startling  appearance  may  be  observed  at  this  period  in 
the  front  of  the  chest.  The  sternum,  with  the  adjacent  costal  cartilages 
and  a  small  portion  of  the  contiguous  ribs,  seems  to  have  sunk  bodily  back, 
en  Hoc,  as  though  it  had  been  subjected  to  some  violence  which  had  fractured 
several  ribs  in  the  front  and  driven  them  back.  Occasionally  thickenings  of 
varying  extent  may  be  found  on  the  exterior  of  the  vault  of  the  skull,  or 
even  on  some  of  the  bones  of  the  face.  .  .  .  Here  also  must  be  mentioned  a 
remarkable  eye  phenomenon.  There  develops  a  rather  sudden  proptosis  of  one  ^ 
eyeball,  with  puffiness  and  very  slight  staining  of  the  upper  lid.  Within  a 
day  or  two  the  other  eye  presents  similar  appearances,  though  they  may  be  of 
less  severity.  The  ocular  conjunctiva  may  show  a  little  ecchymosis,  or  may 
be  quite  free.  With  respect  to  the  constitutional  symptoms  accompanying  the 
above  series  of  events  the  most  important  feature  is  the  profound  anaemia 
which  is  developed.  .  .  .  The  anaemia  is  proportional  to  the  amount  of  limb  in- 
volvement. As  the  case  proceeds  there  is  a  certain  earthy-colored  or  sallow 
tint,  which  is  noteworthy  in  severe  cases,  and  when  once  this  is  established 
bruise-like  ecchymoses  may  appear,  and  more  rarely  small  purpura.  Emacia- 
tion is  not  a  marked  feature,  but  asthenia  is  extreme  and  suggestive  of  muscu- 
lar failure.  The  temperature  is  very  erratic ;  it  is  often  raised  for  a  day  or 
two,  when  successive  limbs  are  involved,  especially  during  the  tense  stage, 
but  is  rarely  above  101°  or  102°  F.  At  other  times  it  may  be  normal  or  sub- 
normal."    If  the  teeth  have  appeared  the  gums  may  be  spongy. 

In  young  children  with  difficulty  in  moving  the  lower  limbs,  or  in  whom 
paralysis  is  suspected,  the  condition  should  always  be  looked  for.  What  is 
known  sometimes  as  Parrot's  disease,  or  syphilitic  pseudo-paralysis,  may  be 
confounded  with  it.  In  it  the  loss  of  motion  is  more  or  less  sudden  in  the 
upper  or  lower  limbs,  or  in  both,  due  to  a  solution  of  continuity  and  separa- 
tion of  the  cartilage  at  the  end  of  the  diaphysis.  There  are  usually  crepita- 
tion and  much  pain  on  movement. 

The  essential  lesion  is  a  subperiosteal  blood  extravasation,  which  causes  the 
thickening  and  tenderness  in  the  shafts  of  the  bones.  In  some  instances  there 
is  hemorrhage  in  the  intramuscular  tissue. 

The  prophylaxis  is  most  important.  The  proprietary  forms  of  condensed 
milk  and  preserved  foods  for  infants  should  not  be  used.  The  fresh  cow's 
milk  should  be  substituted,  and  a  teaspoonful  of  meat-juice  or  gravy  may 
be  given  with  a  little  mashed  potato.  Orange-juice  or  lemon-juice  should  be 
given  three  or  four  times  a  day.     Eecovery  is  usually  prompt  and  satisfactory. 


SECTION  V 

DISEASES  OF  METABOLISM 

I.    GOUT 

{Podagra) 

Definition. — A  disorder  of  metabolism  associated  with  retention  of  uric 
acid  and  of  other  purin  bodies  in  the  body,  characterized  clinically  by  attacks 
of  acute  arthritis,  the  deposition  of  sodium-biurate  in  and  about  the  joints, 
and  by  the  occurrence  of  irregular  constitutional  symptoms. 

Etiology. — The  purin  bodies,  adenin,  guanin,  hypoxanthin,  xanthin,  and 
uric  acid,  result  from  the  transformation  of  the  nucleo-proteins  of  the  food  and 
of  the  tissues  by  ferments  or  enzymes,  each  one  of  which  has  its  own  specific 
action.  Among  the  proteolytic  enzymes  nuclease  has  a  universal  distribution, 
and,  no  matter  what  the  source  of  the  nucleo-protein,  it  sets  free  adenin  and 
guanin.  Specific  enzymes  also  liberate  uric  acid  from  the  nucleo-proteins  of 
the  tissues  and  from  the  purins  of  the  food.  Once  formed,  the  difficulty  is  to 
get  rid  of  uric  acid,  and  this  appears  to  be  one  essential  factor  in  the  etiology 
of  gout.  Birds  and  serpents,  imable  to  oxidize  it,  excrete  large  quantities. 
"All  mammals,  with  the  important  exception  of  man,  are  able  to  destroy  uric 
acid  rapidly  and  in  considerable  quantities.  This  destruction  is  an  oxidation 
accomplished  by  a  specific  enzyme  called  uricase,  and  the  reaction  seems  to 
consist  of  the.  removal  of  one  of  the  carbon  atoms  from  the  uric  acid,  thus 
converting  it  into  the  more  readily  soluble  allantoin"  (Wells).  These  trans- 
forming enzymes  are  very  variously  distributed  in  the  body;  nuclease  is  pres- 
ent in  all  cells,  adenase  and  the  xanthin  enzyme  are  not  so  widely  distributed. 
Uricase,  on  which  the  uricolytic  power  of  the  different  tissues  depends,  is  pres- 
ent chiefly  in  the  liver  and  kidneys  of  mammals,  and  to  a  less  degree  in  the 
muscles.  Man  alone  seems  to  have  a  difficulty  in  oxidizing  uric  acid.  Even  on 
a  purin-free  diet  he  excretes  daily  a  certain  amount,  and  purin-rich  food  is  at 
once  followed  by  a  rise.  In  other  mammals  it  is  readily  oxidized  into  allan- 
toin, of  which  human  urine  never  contains  more  than  a  trace. 

Gout,  then,  can  not  be  regarded  as  loss  of  the  power  of  a  given  individual  to 
destroy  uric  acid;  since  this  does  not  appear  to  be  an  active  function  in  the 
human  body.  Loss  of  power  to  eliminate  favors  the  deposition  of  uric  acid, 
and  individuals  who  can  not  get  rid  easily  of  their  purins,  endogenous  or  ex- 
ogenous, may  be  said  to  be  gouty. 

There  is  a  form  of  gout  in  swine,  characterized  by  a  deposit  of  guanin  in 
the  muscles — the  chalky  flakes  which  are  so  often  seen  in  old  Virginia  and 
Westphalian  hams — and  it  has  been  found  that  the  pig's  liver  is  deficient  in 
the  enzyme  guanase,  which  in  other  animals  oxidizes  this  purin  body.     We 

413 


414  DISEASES  OF  METABOLISM 

can  not  say  yet  how  great  is  the  part  played  by  Tiric  acid  in  human  gout  and 
how  much  by  the  other  purin  bodies,  but  recent  work  favors  the  view  that 
imperfect  elimination  rather  than  imperfect  oxidation  of  the  purin  bodies 
is  the  chief  factor  in  the  disease. 

The  normal  daily  output  of  uric  acid  is  from  0.4  to  1.5  gm.,  and  it  is 
greater  by  day  than  by  night.  The  amount  from  the  intake  of  the  exogenous 
oxy-purins  varies  from  40  to  60  per  cent,  of  the  total  parin  content.  The 
more  active  the  functions  of  the  body  the  greater  the  discharge.  Severe  ex- 
ertion, fever  and  exposure  to  cold  increase  the  output.  The  amount  is  greatly 
influenced  by  food,  particularly  when  rich  in  purin  bases.  For  example,  after 
a  meal  containing  sweetbread  the  amount  may  l)e  doubled.  In  gouty  persons 
the  output  is  low,  and  there  are  cases  of  tophaceous  gout  in  which,  in  the  in- 
tervals between  the  attacks,  the  excretion  was  nil  (Futcher).  With  the  onset 
of  an  attack  the  output  rises,  and  the  phosphoric  acid  is  also  greatly  increased, 
as  shown  in  Chart  XIII. 

Predisposing  Factoes. — Heredity  is  important.  In  from  50  per  cent,  to 
60  per  cent,  of  all  cases  the  disease  existed  in  the  parents  or  grandparents,  and 
the  transmission  is  more  marked  on  the  male  side.  ]\Iales  are  more  subject 
than  females.  It  is  rarely  seen  before  the  thirtieth  year,  though  <;ases  have 
occurred  before  puberty,  and  even  in  infants  at  the  breast. 

Alcohol  is  an  important  factor  in  the  etiolog}^  Fermented  liquors  are 
more  apt  to  cause  it  than  distilled  spirits,  and  the  disease  is  much  more  com- 
mon in  England  and  in  Germany,  the  countries  which  consume  the  largest 
amount  of  beer  per  capita.  The  disease  is  common  in  the  United  States,  and 
is  perhaps  on  the  increase.  As  Futcher  pointed  out,  gout  is  only  one-third 
less  frequent  at  the  Johns  Hopkins  Hospital  than  at  St.  Bartholomew's  Hos- 
pital, London.  Among  18,000  patients  (J.  H.  H.)  there  were  59  cases  of 
gout;  all  but  three  in  whites,  and  all  in  males  but  two  (Futcher). 

Food  pays  a  role  of  importance  equal  to  alcohol.  Overeating  without 
exercise  is  a  predisposing  cause.  But  the  disease  is  by  no  means  coniined  to 
the  well-to-do.  A  combination  of  poor  food,  defective  hygiene  and  the  ex- 
cessive consumption  of  malt  liquors  makes  "poor  man's  gout"  not  infrequent. 

Occupation  is  of  great  importance,  and  the  disease  is  much  more  common 
in  workers  in  breweries,  and  in  persons  who  deal  in  any  way  with  alcohol. 

It  is  not  uncommon  in  persons  of  great  mental  and  bodily  vigor.  Among 
distinguished  members  of  our  profession  who  have  been  terrible  sufferers  were 
the  elder  Scaliger,  Jerome  Cardan  and  Sydenham.  This  statement  of  the 
latter,  however,  that  "more  wise  men  than  fools  are  victims"  of  the  affection, 
does  not  hold  good  to-day.  The  celebrated  Pirckheimer  wrote  a  famous 
"Apology  for  Gout"  (1521),  and  there  is  nmeh  truth  in  what  Podagra  says: 
"For  I  take  no  pleasure  in  those  hard,  rough,  rusticke,  agresticke  kind  of 
people,  who  never  are  at  rest,  but  always  exercise  their  bodies  with  hard 
labors,  are  ever  moyling  and  toyling,  do  seldom  or  never  give  themselves  to 
pleasure,  do  endure  hunger,  which  are  content  with  a  slender  diet."  (Eng- 
lish Edition,  1617.) 

Among  the  directly  exciting  causes  of  an  attack  may  be  mentioned  a 
meal  with  large  quantities  of  rich  food  and  too  much  to  drink;  worry,  or  a 
sudden  mental  shock,  and  in  sensitive  persons  a  slight  injury  or  accident 
may  be  followed  liy  acute  arthritis. 


GOUT 


415 


Pathology. — The  hlood  contains  an  excess  of  uric  acid.  The  average 
amount  in  156  non-gouty  patients  was  1.7  mgs.  per  100  gm.  of  blood  with 
variations  from  0.7  to  4.5  mgs.  (Adler  and  Eagle).  Pratt's  studies  in  21 
gouty  patients  showed  an  average  of  3.7  mgs.  per  100  gm.  of  blood.     The  high 


Cirms. 

JANUARY 

FEBRUARY 

Grms. 

25-20 
26.27 
27-28 
28-2'J 
29-30 
30-31 

1( 

16 
t.1 
%.i 

a.2 
t.1 

10 
L» 

L8 
LT 

L8 
L5 
L* 
LS 
L2 
LI 
LO 
0.0 
0.8 
0.7 
0.S 
0.6 
0.1 
0.3 
0.8 
0.1 

1.3 

1=2 
Ivl 
1.0 
0.9 

- 

A 

re 

■a< 

;o 

PI 

.Of 

pt 

oi 

ic 

A( 

ii 

( 

H 

iVL 

m 

U1 

d 

Q) 

1 

■s 

1 

u 

^ 

e 

>> 

a 

^ 

{ 

• 

m 

p 

i 

y 

0 

d 

0.7 
0.6 
0.5 
0.i 
0.3 
0.2 
0.1 

c 

>> 

n 

j 

X 

V 

' 

S 

o 

<D 

■A 

?r 

F 

i 

fn 

CD 

3 

S 

,o 

1  * 

>i 

■is, 

... 

- 

._ 

- 

O 

3 

.2: 

- 

- 

Id 

- 

... 

/i 

3  AVe 

•age 

Vric 

A 
;n 

!XC 

... 

CM 

- 

- 

... 

- 

- 

- 

- 

■a 

;; 

f 

1 

rt 

m 

53 

5 

hn 

> 

p 

o 

a 

a 

0) 

^ 

•& 

« 

1 

s 

bi 

o 

^  s 

J= 

.« 

3 

!^ 

J3 

» 

t 

s 

c 

-.2 

< 

i! 

1 

M 

-.il- 

~ 

- 

3 

■^ 

'2 

: 

; 

• 

\ 

3 

4J 

'Pi 

ftp 

p: 

f 

\ 

\ 

S 

% 

s 

^ 

C 

c« 

, 

^ 

■\ 

0 

I 

^ 

<j 

H 

'd 

■& 

^ 

\ 

' 

o 

1 

\ 

\ 

fc, 

i 

^ 

V 

&! 

r 

J 

- 

L 

owernorin^ 

11^ 

ic 

mit 

... 

L, 
r 

J 

I 

i 

_^ 

V 

... 

- 

1 

J 

... 

JEor  uric 

a 

1 

I 

r 

^ 

1 

^ 

/ 

1 

\ 

T 

A 

/ 

V. 

s 

j 

1 

1 

/ 

1 

\ 

V 

I 

/ 

1 

\ 

y 

- 

• 

J 

\ 

V 

\ 

/ 

/ 

i 

\ 

\/ 

^ 

/ 

1 

> 

\ 

r 

- 

'" 

^ 

\ 

/ 

... 

- 

... 

- 

- 

\ 

^ 

y 

- 

- 



.... 

... 

._. 

... 

... 

V 

... 

... 

- 

... 

A 

- 

f- 

- 

> 

/ 

V 

A 

f' 

^ 

/ 

V 

\ 

- 

1 

\ 

I 

^ 

\ 

V 

, 

Black,  Urlcacid  in  grammes           ^^'  Phosphoric  Acid  in  errammes 

Chart  XIII. — Uric  Acid  and  Phosphoric  Acid  Output  in  Case  oj  Acute, 


uric  acid  content  is  generally  constant  in  gout  and  the  amount  is  apparSHTly 
greater  during  an  attack  than  in  the  intervals.  This  excess,  also,  is  not 
peculiar  to  gout,  but  occurs  -in  leukaemia  and  chlorosis.  The  red  cells  in  the 
"lead-gout'^  cases  may  show  basophilic  granular  staining. 

The  important  changes  are  in  the  articular  tissues.     The  first  joint  of  the 


416  DISEASES  OF  METABOLISM 

great  toe  is  most  frequently  involved;  then  the  ankles,  knees,  and  the  small 
joints  of  the  hands  and  wrists.  The  deposits  may  be  in  all  the  joints  of  the 
lower  limbs  and  absent  from  those  of  the  upper  limbs  (Norman  Moore).  If 
death  takes  place  during  an  acute  paroxysm,  there  are  signs  of  inflammation, 
hypereemia,  swelling  of  the  ligamentous  tissues,  and  of  effusion  into  the  joint. 
The  primary  change,  according  to  Ebstein,  is  a  local  necrosis,  due  to  the 
presence  of  an  excess  of  urates  in  the  blood.  This  is  seen  in  the  cartilage 
and  other  articular  tissues  in  which  the  nutritional  currents  are  slow.  In 
these  areas  of  coagulation  necrosis  the  reaction  is  always  acid  and  the  neutral 
urates  are  deposited  in  crystalline  form,  as  insoluble  acid  urate.  The  articu- 
lar cartilages  are  first  involved.  The  gouty  deposit  may  be  uniform,  or  in 
small  areas.  Though  it  looks  superficial,  the  deposit  is  invariably  interstitial 
and  covered  by  a  thin  lamina  of  cartilage.  The  deposit  is  thickest  at  the  part 
most  distant  from  the  circulation.  The  ligaments  and  fibro-cartilage  ulti- 
mately become  involved  and  are  infiltrated  with  biurate  deposits,  the  so- 
called  chalk-stones,  or  tophi.  These  are  usually  covered  by  skin;  but  in  some 
cases,  particularly  in  the  metacarpo-phalangeal  articulations,  this  ulcerates 
and  the  chalk-stones  appear  externally.  The  synovial  fluid  may  also  contain 
crystals.  In  very  long-standing  cases,  owing  to  an  excessive  deposit,  the  joint 
becomes  immobile.  The  marginal  outgrowths  in  gouty  arthritis  are  true 
exostoses  (Wynne).  The  cartilage  of  the  ear  may  contain  tophi,  which  are 
seen  as  whitish  nodules  at  the  margin  of  the  helix.  The  cartilages  of  the  nose, 
eyelids,  and  larynx  are  less  frequently  affected. 

Of  changes  in  the  internal  organs  those  in  the  renal  and  vascular  systems 
are  the  most  important.  The  kidney  changes  believed  to  be  characteristic 
of  gout  are:  (a)  A  deposit  of  urates  chiefly  iu  the  region  of  the  papillse. 
This,  however,  is  less  common  than  is  usually  supposed.  Norman  Moore 
found  it  in  only  12  out  of  80  cases.  The  apices  of  the  pyramids  show  lines 
of  whitish  deposit.  Ebstein  described  areas  of  necrosis  in  both  cortex  and 
medulla,  in  the  interior  of  which  were  crystalline  deposits  of  urate  of  soda. 
(&)  An  interstitial  nephritis,  either  the  ordinary  "contracted  kidney"  or  the 
arterio-sclerotic  form,  neither  of  v^iiich  is  in  any  way  distinctive. 

Arterio-sclerosis  and  cardiac  hypertrophy  are  very  constant  lesions.  Con- 
cretions of  urate  of  soda  may  occur  on  the  valves.     Myocarditis  is  common. 

Changes  in  the  respiratory  system  are  rare.  Deposits  have  been  found  in 
the  vocal  cords,  and  uric-acid  crystals  have  been  found  in  the  sputum  of  a 
gouty  patient  (J.  W.  Moore). 

Symptoms. — Gout  is  usually  divided  into  acute,  chronic,  and  irregular 
forms. 

Acute  Gout. — Premonitory  symptoms  are  common — twinges  of  pain  in 
the  small  joints  of  the  hands  or  feet,  nocturnal  restlessness,  irritability  of 
telnper,  and  dyspepsia.  The  urine  is  acid,  scanty,  and  high-colored.  It  de- 
posits trates  bn  cooling,  and  there  may  be  transient  albuminuria.  There 
may  be  traces  of  sugar  (gouty  glycosuria).  Before  an  attack  the  output  of 
uric  acid  is  low  and  is  also  diminished  in  the  early  part  of  the  paroxysm.  The 
relation  of  uric  and  phosphoric  acids  to  the  acute  attacks  is  well  represented 
in  Chart  XIII,  prepared  by  Futcher.  Both  are  extremely  low  in  the  intervals, 
but  reach  normal  limits  shortly  after  the  onset  of  the  acute  symptoms.  The 
phosphoric  acid  and  uric  acid  show  almost  parallel  curves.     The  patient  was 


GOUT  417 

on  a  very  light  fixed  diet  at  the  time  the  determinations  were  made.  In  some 
instances  the  throat  is  sore,  and  there  may  be  dyspnoea.  The  attack  sets  in 
usually  in  the  early  morning  hours.  The  patient  is  aroused  by  a  severe 
pain  in  the  metatarso-phalangeal  articulation  of  the  big  toe,  and  more  com- 
monly on  the  right  than  on  the  left  side.  The  pain  is  agonizing,  and,  as 
Sydenham  says,  "insinuates  itself  with  the  most  exquisite  cruelty  among  the 
numerous  small  bones  of  the  tarsus  and  metatarsus,  in  the  ligaments  of  which 
it  is  lurking.^'  The  joint  swells  rapidly,  and  becomes  hot,  tense,  and  shiny. 
The  sensitiveness  is  extreme,  and  the  pain  makes  the  patient  feel  as  if  the 
joint  were  being  pressed  in  a  vice.  There  is  fever,  and  the  temperature  may 
rise  to  103°  to  103°  F.  Toward  morning  the  severity  of  the  symptoms  sub- 
sides, and,  although  the  joint  remains  swollen,  the  day  may  be  passed  in  com- 
parative comfort.  The  symptoms  recur  the  next  night,  and  the  "fit,"  as  it 
is  called,  usually  lasts  for  from  five  to  eight  days,  the  severity  of  the  symptoms 
gradually  abating.  There  is  usually  a  moderate  leucocytosis  during  the 
acute  manifestations.  Other  joints  may  be  involved,  particularly  the  tarsal 
joints.  The  inflammation,  however  intense,  never  goes  on  to  suppuration. 
With  the  subsidence  of  the  swelling  the  skin  desquamates.  The  tarsus  alone 
may  be  involved  and  so  obstinate  may  be  the  inflammation  that  the  question 
of  surgical  interference  may  be  raised  in  the  belief  that  it  is  tuberculous  or 
suppurative.  After  the  attack  the  general  health  may  be  much  improved. 
As  Aretseus  remarks,  a  person  in  the  interval  has  won  the  race  at  the  Olym- 
pian games.  Recurrences  are  frequent.  Some  patients  have  three  or  four 
attacks  in  a  year;  others  suffer  at  longer  intervals. 

The  term  retrocedent  or  suppressed  gout  is  applied  to  serious  internal 
symptoms,  coincident  with  a  rapid  disappearance  or  improvement  of  the  local 
signs.  Very  remarkable  manifestations  may  occur  under  these  circumstances. 
The  patient  may  have  severe  gastro-intestinal  symptoms — pain,  vomiting,  diar- 
rhoea, and  great  depression — and  death  may  occur  during  such  an  attack.  Or 
there  may  be  cardiac  manifestations — dyspnoea,  pain,  and  irregular  action 
of  the  heart.  In  some  instances,  in  which  the  gout  is  said  to  attack  the  heart, 
an  acute  pericarditis  proves  fatal.  So,  too,  there  may  be  marked  cerebral 
manifestations — ^^delirium  or  coma,  and  even  apoplexy — but  in  a  majority  of 
these  instances  the  symptoms  are,  in  afl  probability,  ursemic. 

Chronic  Gout. — With  increased  frequency  in  the  attacks,  the  articular 
symptoms  persist  for  a  longer  time,  and  gradually  many  joints  become  af- 
fected. Deposits  of  urates  take  place,  at  first  in  the  articular  cartilages  and 
then  in  the  ligaments  and  capsular  tissues;  so  that  in  the  course  of  years  the 
joints  become  swollen,  irregular,  and  deformed.  The  feet  are  usually  first 
affected,  then  the  hands.  In  severe  cases  there  may  be  extensive  concretions 
about  the  elbows  and  knees  and  along  the  tendons  and  in  the  bursas.  The  tophi 
appear  in  the  ears.  Finally,  a  unique  clinical  picture  is  produced  whicn  can 
not  be  mistaken  for  that  of  any  other  affection.  The  skin  over  the  topfhi  may 
rupture  or  ulcerate,  and  about  the  knuckles  the  chalk-stones  may  be  freely 
exposed.  Patients  with  chronic  gout  are  usually  dyspeptic,  often  of  a  sallow 
complexion,  and  show  signs  of  arterio-sclerosis.  The  pulse  tension  is  increased, 
the  vessels  are  stiff',  and  the  left  ventricle  is  hypertrophied.  The  urine  is 
•increased  in  amount,  is  of  low  specific  gravity,  and  usually  contains  a  slio'ht 
amount  of  albumin,  with  a  few  liyaline  casts.     Severe  cramps  invnlving  the 


418  DISEASES  OF  METABOLISM 

calf,  abdominal,  and  thoracic  muscles  are  common.  Intercurrent  attacks  of 
acute  polyarthritis  may  occur,  in  which  the  joints  become  inflamed,  and  the 
temperature  ranges  from  101°  to  103°  F.  There  may  be  pain,  redness,  and 
swelling  of  several  joints  without  fever.  Uremia,  pleurisy,  pericarditis,  peri- 
tonitis, and  meningitis  are  common  terminal  affections. 

Irregular  Gout. — This  is  a  motley,  ill-defined  group  of  symptoms,  mani- 
festations of  a  condition  of  disordered  nutrition,  to  which  the  terms  gouty 
diathesis  or  lithcemic  state  have  been  given.  Cases  are  seen  in  members  of 
gouty  families,  who  may  never  themselves  have  suffered  from  the  acute  dis- 
ease', and  in  persons  who  have  lived  not  wisely  but  too  well,  who  have  eaten 
and  drunk  largely,  lived  sedentary  lives,  and  yet  have  been  fortunate  enough 
to  escape  an  acute  attack.  It  is  interesting  to  note  the  various  manifestations 
in  a  family  with  marked  hereditary  disposition.  The  daughters  often  escape, 
while  one  son  may  have  gouty  attacks  of  great  severity,  even  though  he  lives 
a  temperate  life  and  tries  in  every  way  to  avoid  the  conditions  favoring  the 
disorder.  Another  son  has,  perhaps,  only  the  irregular  manifestations  and 
never  the  acute  articular  affection.  While  the  irregular  features  are  perhaps 
more  often  met  with  in  the  hereditary  affection,  they  are  by  no  means  infre- 
quent in  persons  who  appear  to  have  acquired  the  disease.  The  tendency  in 
some  families  is  to  call  evevy  affection  gouty.  Even  infantile  complaints, 
such  as  eczema,  naso-pharyngeal  vegetations,  and  enuresis,  are  often  regarded, 
without  sufficient  grounds,  as  evidences  of  the  family  ailment.  Among  the 
commonest  manifestations  of  irregular  gout  are  the  following: 

(a)  Cutaneous  Eruptions. — Garrod  and  others  have  called  special  atten- 
tion to  the  frequent  association  of  eczema  with  the  gouty  habit. 

(5)  Gastro-intestinal  Disorders. — Attacks  of  what  is  termed  ^'biliousness," 
in  which  the  tongue  is  furred,  the  breath  foul,  and  the  bowels  constipated, 
are  not  uncommon  in  gouty  persons.     A  gouty  parotitis  is  described. 

(c)  Cardio-vascuJar  Symptoms. — With  gout  arterio-sclerosis  is  frequently 
associated.  The  blood  tension  is  persistently  high,  the  vessel  walls  become 
stiff,  and  cardiac  and  renal  changes  gradually  occur.  In  this  condition  the 
symptoms  may  be  renal,  as  when  the  albuminuria  becomes  more  marked,  or 
dropsical  symptoms  supervene.  The  manifestations  may  be  cardiac,  when 
the  hypertrophy  of  the  left  ventricle  fails  and  there  are  palpitation,  irregular 
action,  and  ultimately  a  condition  of  asystole.  Or,  finally,  the  manifestations 
may  be  vascular,  and  thrombosis  of  the  coronary  arteries  may  cause  sudden 
death,  or,  as  most  frequently  happens,  cerebral  hsemorrhage  occurs.  It  makes 
but  little  difference  whether  we  regard  this  condition  as  primarily  an  arterio- 
sclerosis or  as  a  gouty  nephritis ;  the  point  to  be  remembered  is  that  the  nutri- 
tional disorder  with  which  an  excess  of  uric  acid  is  associated  induces  in  time 
increased  tension,  arterio-sclerosis,  chronic  interstitial  nephritis,  and  changes 
in  the  myocardium.  Pericarditis  is  not  an  infrequent  terminal  complica- 
tion. Phlebitis  is  a  troublesome  and  not  very  uncommon  complication.  It 
may  arise  in  connection  with  varicose  veins  of  the  legs  or  occur  in  many 
venous  districts  in  succession  or  simultaneously. 

(d)  Nervous  Manifestations. — Headache,  migraine  attacks,  neuralgias, 
sciatica,  and  para?sthesias  are  not  imcommon.  A  common,  gouty  manifesta- 
tion, upon  which  Duckworth  has  laid  stress,  is  the  occurrence  of  hot  or  itch- 
ing feet  at  night.     Plutarch  mentions  that  Strabo  called  this  "the  lisping  of 


GOUT  419 

the  gout."  Cramps  in  the  legs  may  he  very  troublesome.  Hutchinson  called 
attention  to  hot  and  itching  eyeballs.  Associated  or  alternating  with  this 
symptom  there  may  be  attacks  of  episcleral  congestion.  Apoplexy  is  a  com- 
mon termination  and  meningitis  may  occur,  usually  basilar. 

(e)  U  in  nary  Disorders. — The  urine  is  highly  acid  and  high-colored,  and 
may  deposit  crystals  of  uric  acid  on  standing.  Transient  and  temporary 
increase  in  this  ingredient  cannot  be  regarded  as  serious.  In  many  cases  of 
chronic  gout  the  amount  may  be  diminished,  and  increased  only  at  certain 
periods,  forming  the  so-called  uric-acid  showers.  A  sediment  of  uric  acid 
in  a  urine  does  not  necessarily  mean  an  excess.  It  is  often  dependent  on  the 
inability  of  the  urine  to  hold  it  in  solution.  Sugar  is  found  intermittently 
in  the  urine  of  gouty  persons — gouty  glycosuria.  It  may  pass  into  true  dia- 
betes, but  is  usually  very  amenable  to  treatment.  Oxaluria  may  also  be  pres- 
ent. Gouty  persons  are  specially  prone  to  calculi,  Jerome  Cardan  to  the  con- 
trary, who  reckoned  freedom  from  stone  among  the  chief  of  the  dotia  podagrce. 
Minute  quantities  of  albumin  are  very  common  in  gouty  persons,  and, 
when  the  renal  changes  are  well  established,  tube-casts.  Urethritis,  with 
a  purulent  discharge,  may  arise,  so  it  is  stated,  usually  at  the  end  of  an  at- 
tack.    It  ma}'  occur  spontaneously,  or  follow  a  pure  connection. 

(/)  Pulmonary  Disorders. — There  are  no  characteristic  changes,  but 
chronic  bronchitis  occurs  with  great  frequency  in  persons  of  a  gouty  habit. 

{g)  Of  eye  afEections,  iritis,  glaucoma,  hsemorrhagic  retinitis,  and  sup- 
purative panophthalmitis  have  been  described. 

X-rays. — The  changes  in  the  bones  consist  of  small  dark  areas  on  the 
plates,  circular  in  outline,  with  clear,  sharp  borders.  They  are  usually  found 
in  the  epiphysis  of  the  affected  joints,  especially  of  the  fingers,  and  are  due 
to  the  absorption  of  bone  areas  in  which  sodium  urate  has  been  deposited. 

Dia^osis. — Eecurring  attacks  of  arthritis,  limited  to  the  big  toe  or  to 
the  tarsus,  occurring  in  a  member  of  a  gouty  family,  or  in  a  man  who  has 
lived  too  well,  leave  no  question  as  to  the  nature  of  the  trouble.  There  are 
many  cases  of  gout,  however,  in  which  the  feet  do  not  suffer  most  severely. 
After  an  attack  or  two  in  one  toe,  other  joints  may  be  affected,  and  it  is  just 
in  such  cases  of  polyarthritis  that  the  difficulty  in  diagnosis  is  apt  to  arise.  We 
have  had  cases  admitted  for  the  third  or  fourth  time  with  involvement  of 
three  or  more  of  the  larger  joints.  The  presence  of  tophi  has  settled  the  nature 
of  a  trouble  which  in  the  previous  attacks  had  been  regarded  as  rheumatic. 
The  following  are  suggestive  points  in  such  cases :  ( 1 )  The  patient's  habits 
and  occupation.  In  the  United  States  the  brewery  men  and  barkeepers  are 
often  affected.  (2)  The  presence  of  tophi.  The  ears  should  always  be  in- 
spected in  a  case  of  polyarthritis.  The  diagnosis  may  rest  with  a  small 
tophus.  The  student  should  learn  to  recognize,  on  the  ear  margin,  Woolner's 
tip,  fibroid  nodules,  and  small  sebaceous  tumors.  The  last  are  easily  recog- 
nized microscopically.  The  needle-shaped  sodium  biurate  crystals  are  dis- 
tinctive of  the  tophi.  (3)  The  condition  of  the  urine.  The  uric-acid  output 
is  usually  very  low  during  the  intervals  of  the  paroxysm.  At  the  height  of 
the  attack  the  elimination,,  as  a  rule,  is  greatly  increased.  (4)  The  gouty 
polyarthritis  may  be  afebrile.  A  patient  with  three  or  four  joints  red,  swol- 
len, and  painful  in  rheumatic  fever  has  pyrexia,  and,  while  it  may  be  present 
and  often  is  in  gout,  its  absence  is  a  valuable  diagnostic  sign.     !Many  cases 


420  DISEASES  OF  METABOLISM 

go  a-begging  for  a  diagnosis.  A  careful  study  of  the  patient's  habits  as  to 
beer  drinking,  of  the  location  of  the  initial  arthritic  attacks,  and  the  ex- 
amination for  tophi  in  the  ears  will  prevent  many  cases  being  mistaken  for 
rheumatic  fever  or  arthritis  deformans.  Lastly,  in  doubtful  forms  of  arthritis 
a  careful  study  of  the  purin  metabolism  is  of  value.  The  estimation  of  the 
amount  of  endogenous  uric  acid  in  the  blood  and  the  delayed  excretion  of 
exogenous  purins  are  important. 

Prognosis.— "Once  goutj-,  always  gouty''  is  usually  true,  but  by  care  the 
frequency  and  intensity  of  attacks  can  be  reduced.  As  regards  the  dura- 
tion of  life,  the  state  of  the  circulation  and  kidneys  is  the  important. factor. 

Treatment. — Hygiexic. — Individuals  who  have  inherited  a  tendency  to 
gout,  or  who  have  shown  any  manifestations  of  it,  should  live  temperately, 
abstain  from  alcohol,  and  eat  moderately.  An  open-air  life,  with  plenty  of 
exercise  and  regular  hours,  does  much  to  counteract  an  inborn  tendency  to 
the  disease.  The  skin  should  be  kept  active  and  an  occasional  Turkish  bath 
is  advantageous.  The  patient  should  dress  warmly,  avoid  rapid  alterations  in 
temperature,  and  be  careful  not  to  have  the  skin  suddenly  chilled. 

Dietetic. — With  few  exceptions,  persons  over  forty  eat  too  much,  and 
the  first  injunction  to  a  gouty  person  is  to  keep  his  appetite  within  reasonable 
bounds,,  to  eat  at  stated  hours,  and  to  take  plenty  of  time  at  his  meals.  In 
the  matter  of  food,  quantity  is  a  factor  of  more  importance  than  quality  with 
many  gouty  persons.  As  Sir  William  Eoberts  well  says,  "Nowhere  perhaps 
is  it  more  necessary  than  in  gout  to  consider  the  man  as  well  as  the  ailment, 
and  very  often  more  the  man  than  the  ailment."' 

The  weight  of  opinion  leans  to  the  use  of  a  modified  nitrogenous  diet, 
without  excess  in  starchy  and  saccharine  articles  of  food.  Foods  rich  in 
purins,  such  as  bouillon,  beef  extracts,  sweetbreads,  liver,  kidneys,  and  brain, 
should  be  avoided.  Milk  and  eggs  are  particularly  useful,  owing  to  their  being 
purin  free.  Fresh  vegetables  and  fruits  may  be  used  freely,  but  strawberries 
and  bananas  should  be  avoided. 

Ebstein  urged  strongly  the  use  of  fat  in  the  form  of  good  fresh  butter, 
from  21^  to  Sy2  ounces  in  the  day.  He  held  that  stout  gouty  subjects  not 
only  do  not  increase  in  weight  with  plenty  of  fat  in  the  food,  but  that  they 
actually  become  thin  and  the  general  condition  improves  very  much.  Hot 
bread  of  all  sorts  and  the  various  articles  of  food  prepared  from  Indian  corn 
should,  as  a  rule,  be  avoided.  Eoberts  advised  gouty  patients  to  restrict  as 
far  as  practicable  the  use  of  common  salt,  since  the  sodium  biurate  very  read- 
ily- crystallizes  out  in  tissues  with  a  high  percentage  of  sodium  salts.  In 
this  matter  of  diet  each  individual  case  must  receive  separate  consideration. 
There  are  very  few  conditions  in  the  gouty  in  which  alcohol  is  required. 
Whenever  indicated,  whisky  will  be  found  perhaps  the  most  serviceable.  While 
all  are  injurious  to  these  patients,  some  are  much  more  so  than  others,  par- 
ticularly malted  liquors,  champagne,  port,  and  a  very  large  proportion  of  all 
the  light  wines. 

Mineral  Waters. — All  forms  may  be  said  to  be  beneficial  in  gout,  as  the 
main  element  is  the  water,  and  the  ingredients  are  usually  indifferent.  Much 
of  the  humbuggery  in  the  profession  still  lingers  about  mineral  waters,  more 
particularly  about  the  so-called  lithia  waters. 

The  question  of  the  utility  of  alkalies  in  the  treatment  of  gout  is  closely 


DIABETES  MELLITUS  421 

connected  with  this  subject  of  mineral  waters.  This  deep-rooted  belief  in  the 
profession  was  shaken  by  Sir  William  Eoberts,  who  claimed  to  have  shown 
that  alkalescence  as  such  has  no  influence  whatever  on  the  sodium  biurate. 
The  sodium  salts  are  believed  by  this  author  to  be  particularly  harmful,  but, 
in  spite  of  all  the  theoretical  denunciation  of  the  use  of  the  sodium  salts,  the 
gouty  from  all  parts  of  the  world  flock  to  those  very  Continental  springs  in 
which  these  salts  are  most  predominant.  Of  the  mineral  springs  best  suited 
for  the  gouty  may  be  mentioned,  in  the  United  States,  those  of  Saratoga, 
Bedford,  and  the  A^Hiite  Sulphur;  Buxton  and  Bath,  in  England;  in  France, 
Aix-les-Bains  and  Contrexeville ;  and  in  Germany,  Carlsbad,  AYildbad,  Hom- 
burg,  and  Marienbad.  Excellent  results  are  claimed  for  mineral  waters  with 
special  radio-active  properties.  The  efficacy  in  reality  is  in  the  water,  in  the 
way  it  is  taken,  on  an  empty  stomach,  and  in  large  quantities ;  and  the  import- 
ant accessories  in  the  modified  diet,  proper  hours,  regular  exercises,  with  baths, 
douches,  etc.,  play  a  very  important  role  in  the  "cure." 

Medical  Teeatment. — In  an  acute  attack  the  limb  should  be  elevated 
and  the  affected  joint  wrapped  in  cotton-wool.  Warm  fomentations,  or 
Fuller's  lotion,  may  be  used.  The  local  hot-air  or  passive  hypersemia  treat- 
ment may  be  tried.  A  brisk  mercurial  purge  is  always  advantageous  at  the 
outset.  The  wine  or  tincture  of  colchicum,  in  doses  of  20  to  30  minims  (1.2 
to  2  c.  c.)  may  be  given  every  four  hours  in  combination  with  the  citrate  of 
potash.  The  action  of  the  colchicum  should  be  carefully  watched;  its  effect 
is  most  marked  when  free  purgation  follows.  It  has  in  a  majority  of  the 
cases  a  powerful  influence  over  the  symptoms — relieving  the  pain,  and  re- 
ducing, sometimes  with  great  rapidity,  the  swelling  and  redness.  It  should 
be  stopped  as  soon  as  it  has  relieved  the  pain.  Cinchophen  (atophan)  is  often 
useful  in  doses  of  15  grains,  1  gm.,  three  or  four  times  a  day.  It  may  also 
be  helpful  in  the  subacute  and  chronic  forms.  In  cases  in  which  the  pain 
and  sleeplessness  are  distressing  and  do  not  yield  to  treatment,  morphia  is 
necessary.  The  patient  should  be  placed  on  a  diet  chiefly  of  milk  and  barley- 
water.  During  convalescence  the  diet  should  be  increased  slowly  and  gradu- 
ally the  patient  may  resume  the  diet  previously  laid  down. 

In  some  of  the  subacute  intercurrent  attacks  sodium  salicylate  or  a.cetyl- 
salicylic  acid  may  be  useful.  The  chronic  and  irregular  forms  are  best 
treated  by  the  dietetic  and  hygienic  measures  already  noted.  Potassium  iodide 
is  sometimes  useful,  Albu  speaks  favorably  of  lemon-juice  as  a  remedy.  The 
vegetable  acids  are  converted  in  the  system  into  alkaline  carbonates,  thus 
enabling  the  blood  to  keep  the  uric  acid  compounds  in  solution,  and  facilitating 
their  elimination. 

Where  the  arthritic  attacks  are  confined  to  one  joint,  such  as  the  great- 
toe  joint,  surgical  interference  may  be  considered.  Eiedel  reports  two  suc- 
cessful cases  in  which  he  removed  the  entire  joint  capsule  of  the  big-toe  joint, 
with  permanent  relief. 

II.     DIABETES  MELLITUS 

Definition. — A  disease  of  metabolism  in  general  with  especial  disturbance 
of  carbohydrate  metabolism  in  which  the  normal  utilization  of  carbohydrate 
is  impaired  with  an  increase  in  the  sugar  content  of  the  blood  and  consequent 


422  DISEASES  OF  METABOLISM 

glycosuria.  There  is  a  tendency  to  subsequent  disturbance  of  the  fat  metab- 
olism with,  resulting  acidosis   (Ketosis). 

History. — The  disease  was  known  to  Celsus.  Aretseus  first  used  the  term 
diabetes^  calling  it  a  wonderful  affection  "melting  down  the  flesh  and  limbs 
into  urine."  He  suggested  that  the  disease  got  its  name  from  the  Greek  word 
signifying  a  syphon.  Willis  in  the  seventeenth  century  gave  a  good  descrip- 
tion and  recognized  the  sweetness  of  the  urine  "as  if  there  has  been  sugar 
and  honey  in  it."  Dobson  in  1776  demonstrated  the  presence  of  sugar,  and 
EoUo  in  1797  wrote  an  admirable  account  and  recommended  the  use  of  a  meat 
diet.  The  modern  study  of  the  disease  dates  from  Claude  Bernard's  demon- 
stration of  the  glycogenic  function  of  the  liver  in  1857. 

Etiology. — The  enzymes  of  the  intestinal  mucosa  convert  the  starches  and 
sugars  of  the  food  into  monosaccharides — dextrose,  galactose  and  levulose — 
which  pass  into  the  portal  circulation,  but  the  major  portion  remains  in  the 
liver,  where  it  is  converted  into  glycogen.  The  percentage  of  sugar  in  the 
systemic  blood  remains  constant — 0.06  to  0.11  per  cent.  Part  of  the  sugar 
passes  to  the  muscles,  where  it  is  stored  as  glycogen.  The  total  storage 
capacity  of  the  liver  is  estimated  at  about  one-tenth  of  its  weight,  i.  e.,  about 
150  gms.  for  an  ordinary  organ  weighing  1,500  gms.  ISTot  all  of  the  glycogen 
comes  from  the  carbohydrates;  a  small  part  in  health  is  derived  from  the 
proteins  and  fats.  This  treble  process  of  transformation,  storage  and  re- 
transformation  of  the  sugars  is  effected  by  special  enzymes,  which  are  fur- 
nished by  internal  secretions,  chiefly  of  the  pancreas  and  hypophysis,  and  are 
directly  influenced  by  the  nervous  system.  According  to  Claude  Bernard  the 
sugar  is  simply  warehoused  on  demand  in  the  liver,  and  given  out  to  the 
muscles  which  need  it  in  their  work.  In  any  case,  the  sugar,  one  of  the  chief 
fuels  of  the  body,  is  burned  up,  supplying  energy  to  the  muscles,  and  is 
eliminated  as  CO2  and  water.  The  nature  of  the  intermediate  stages  of  the 
transformation  is  still  under  discussion. 

The  following  are  the  conditions  which  influence  the  appearance  of  sugar 
in  the  urine: 

(a)  Excess  of  Cakbohydrate  Intake. — In  a  normal  state  the  sugar  in 
the  blood  is  about  0.1  per  cent.  In  diabetes  the  percentage  is  usually  from 
0.2  to  0.4  per  cent.  The  hyperglycemia  is  immediately  manifested  by  the 
appearance  of  sugar  in  the  urine.  The  healthy  person  has  a  definite  limit 
of  carbohydrate  assimilation;  the  total  storage  capacity  for  glycogen  is  esti- 
mated at  about  300  gms.  Following  the  ingestion  of  enormous  amounts  of 
carbohydrates  the  liver  and  the  muscles  may  not  be  equal  to  the  task  of  storing 
it;  the  blood  content  of  sugar  passes  beyond  the  normal  limit  and  the  renal 
cells  immediately  begin  to  get  rid  of  the  surplus.  Like  the  balance  at  the 
Mint,  which  is  sensitive  to  the  correct  weight  of  the  gold  coins  passing  over 
it,  they  only  react  at  a  certain  point  of  saturation.  Fortunately  excessive 
quantities  of  pure  sugar  itself  are  not  taken.  The  carbohydrates  are  chiefly 
in  the  form  of  starch,  the  digestion  and  absorption  of  which  take  pkce  slowly, 
so  that  this  so-called  alimentary  glycosuria  very  rarely  occurs,  though  enor- 
mous quantities  may  be  taken.  The  assimilation  limit  of  a  normal  fasting 
individual  for  sugar  itself  is  about  250  gms.  of  grape  sugar,  and  considerably 
less  of  cane  and  milk  sugar.  Clinically  one  meets  with  many  cases  in  which 
glycosuria  is  present  as  a  result  of  excessive  ingestion  of  carbohydrates,  par- 


DIABETES  MELLITUS  423 

ticiilarly  in  stout  persons  and  heavy  feeders — so-called  lipogenic  diabetes — a 
form  very  readily  controlled. 

(&)  Disturbances  in  the  jSTervous  System. — Bernard  shows  that  there 
was  a  centre  in  the  medulla — the  diabetic  centre — puncture  of  which  is  fol- 
lowed by  hyperglycasmia  due  to  an  increased  outflow  of  sugar  from  the  liver 
warehouse.  He  demonstrated  that  the  efferent  path  of  this  influence  was 
through  the  splanchnic  nerves  and  the  afferent  through  the  vagi.  The  exact 
location  of  this  centre  has  never  been  determined,  and  its  precise  role  in  the 
carbohydrate  metabolism  is  obscure.  Clinically,  however,  it  has  long  been 
known  that  many  lesions  of  the  nervous  system  cause  glycosuria — tumors, 
'particularly  those  in  the  neighborhood  of  the  medulla,  injuries  both  to  the 
brain  and  to  the  upper  part  of  the  spinal  cord,  meningitis,  and  hgemorrhage. 
Some  of  these  may  disturb  Bernard's  centre  in  the  medulla,  but  many  of  them 
disturb  the  internal  secretion  of  the  hypophysis.  Clinically,  glycosuria  aris- 
ing from  disturbances  in  the  nervous  system  is  not  an  important  variety. 

(c)  Disturbances  of  the  Internal  Secretions. — The  part  played  in 
the  carbohydrate  metabolism  by  the  ductless  glands  is  of  the  first  importance. 
Though  not  yet  fully  understood,  the  following  are  the  chief  points,  so  far 
aa  they  bear  on  clinical  work : 

(1)  Pancreatic  Secretion. — Extirpation  of  the  pancreas  in  a  dog  is 
followed  by  hyperglycasmia  and  prolonged  glycosuria,  which  is  not  relieved  by 
feeding  pancreas  to  the  animal,  but  which  is  checked  if  experimentally  a  por- 
tion of  healthy  organ  from  another  dog  is  inserted  into  the  portal  circulation. 
The  pancreas  contains  structures  known  as  ''the  islands  of  Langerhans," 
which,  from  the  work  of  Opie  and  others,  are  believed  to  furnish  an  internal 
secretion  necessary  to  normal  carbohydrate  metabolism.  A  portion  of  the 
organ  separated  from  the  rest,  and  its  duct  ligated,  atrophies,  but  a  tissue 
remains  composed  of  enlarged  islands  of  Langerhans.  If  the  remainder  of 
the  pancreas  be  removed,  this  atrophied  portion  is  able  to  ward  off  glycosuria ; 
but  if  this  is  removed  glycosuria  appears  immediately  (W.  G.  MacCallum). 
In  some  way  the  secretion  furnished  by  this  organ  is  essential  to  the  proper 
preparation  of  the  sugars.  Cohnheim  suggests  a  correlation  of  this 
internal  secretion  with  a  muscle  enzyme,  to  which  it  acts  as  an  amboceptor, 
and  that  it  is  by  the  combined  action  of  these  two  glycolytic  bodies  that  the 
sugars  are  normally  burned  up  in  the  muscles.  Many  diseases  of  the  pancreas 
are  associated  with  glycosuria,  some  with  permanent  diabetes.  Hsemorrhagic 
pancreatitis,  cancer,  calculus,  chronic  interstitial  pancreatitis,  catarrh  of  the 
ducts  may  all  be  associated  with  a  profound  disturbance  in  the  metabolism 
of  the  sugars.  In  fact,  there  is  no  one  organ  the  disease  of  which  is  more 
constantly  associated  with  glycosuria,  and  the  studies  of  Opie  warrant  the 
belief  that  the  essential  factor  is  a  disturbance  of  the  function  of  the  internal 
secretion  provided  by  the  islands  of  Langerhans. 

(2)  Hypophysis. — It, was  long  known  that  glycosuria  occurred  in  tumors 
of  the  region  of  the  hypophysis,  particularly  in  acromegaly,  and  it  follows 
fractures  of  the  base  of  the  skull.  Experimentally,  Cusljing  and  his  students 
have  shown  that  the  posterior  lobe  of  the  pituitary  gland  has  an  important 
influence  in  carbohydrate  metabolism.  The  secretion  of  this  portion  of  the 
gland  is  discharged  into  the  third  ventricle,  and  any  operative  disturbance 
of  it,  or  of  the  infundil)ulum,  is  at  once  followed  by  glycosuria,  and  l)y  a  re- 


^34  DISEASES  OF  METABOLISM 

markable  lowering  of  the  assimilation  limit  for  sugars.  On  the  other  hand,  a 
deficiency  of  this  secretion,  or  the  removal  of  this  portion  of  the  gland  alone, 
is  followed  by  a  remarkable  increased  tolerance  for  carbohydrates. 

Clinically,  this  sequence  is  not  infrequently  seen.  A  tumor  which  at  first 
irritates  the  gland,  as  in  the  early  stages  of  acromegaly,  may  cause  glycosuria, 
but  later,  as  the  posterior  lobe  of  the  gland  is  destroyed,  there  is  an  extraordi- 
narily high  assimilation  limit  for  sugars,  and  associated  with  it  a  great  in- 
crease in  the  deposition  of  fat  in  the  body,  a  syndrome  to  be  referred  to  later. 
Intravenous  or  subcutaneous  injection  of  the  extract  of  the  posterior  lobe 
promptly  lowers  this  high  assimilation  limit  for  carbohydrates. 

(3)  Adrenals  and  Thyroids. — We  have  less  positive  information  about 
the  relation  of  carbohydrate  metabolism  to  the  internal  secretions  of  these 
glands.  Glycosuria  does  not  necessarily  follow  lesions  of  the  adrenals,  but 
epinephrin  has  a  powerful  influence  on  the  carbohydrate  metabolism,  and  gly- 
cosuria may  be  readily  produced  in  animals  by  subcutaneous  injection,  and 
by  the  local  application  of  epinephrin  to  the  pancreas.  Clinically,  we  know 
practically  nothing  of  an  adrenal  gtycosuria.  It  does  not  occur  in  Addison's 
disease.  It  has  occasionally  been  noticed  in  the  prolonged  therapeutic  use  of 
epinephrin.  In  disturbances  of  the  thyroid  gland  glycosuria  is  not  uncom- 
mon. There  is  a  lowered  tolerance  for  sugar  in  Graves'  disease  which  is 
sometimes  associated  Avith  a  true  diabetes,  and  in  the  remarkable  instances  of 
acute  myxoedema  the  amount  of  sugar  in  the  urine  may  be  large.  The  use 
of  thyroid  extract  is  occasionally  followed  by  glycosuria.  On  the  other  hand, 
patients  may  take  the  extract  continuously  for  many  years  without  glycosuria. 

Possibly  the  glycosuria  associated  with  pregnancy  is  due  to  a  disturbance 
in  the  internal  secretions.  It  is  a  transient  condition,  usually  disappearing 
with  parturition,  and  rarely  leads  to  diabetes.  It  may  recur  in  successive 
pregnancies. 

{d)  Disturbances  in  the  Function  of  the  Liver. — One  of  the  most 
remarkable  features  in  carbohydrate  metabolism  is  that  the  great  warehouse 
of  the  sugars  may  be  damaged  to  any  degree  without  causing  hyperglycaemia 
or  glycosuria.  Whether  or  not  there  is  a  type  of  disease  to  which  the  name 
of  "liver  diabetes"  may  be  given  is  doubtful.  There  are  cases  of  cirrhosis  of 
the  liver  and  of  gallstones — particularly  those  associated  with  enlargement  of 
the  organ — in  which  glycosuria  is  present,  but  they  are  probably  all  asso- 
ciated with  coincident  affections  of  the  pancreas.  In  the  "bronze  diabetes," 
which  is  accompanied  by  great  hypertrophy  of  the  liver,  the  glycosuria  is 
probably  pancreatic. 

(e)  Disturbances  in  the  Kidney  Functions. — Disease  of  the  kidneys 
is  rarely  associated  with  glycosuria.  Occasionally  one  finds  it  in  chronic 
nephritis,  but  the  existence  of  a  true  diabetes  depending  upon  renal  changes 
has  not  been  proved.  There  is  a  remarkable  experimental,  diabetes  of  great 
interest  in  connection  with  carbohydrate  metabolism.  If  phloridzin,  a  glu- 
coside  prepared  from  the  bark  of  the  apple-tree,  is  given  by  mouth  or  subcu- 
taneously  to  man  or  animals  glycosuria  results,  and  even  continues  on  a 
nitrogenous  diet,  and  in  man  when  fasting.  The  amount  of  sugar  excreted 
may  be  large,  yet  there  is  no  hyperglycsemia.  It  seems  that  the  sugar  is 
directly  manufactured  by  the  kidney  epithelium,  and  largely  from  the  proteins. 

(/)   Miscellaneous  Disturbances. — The  carbohydrate  metabolism  may 


DIABETES  MELLITUS  425 

be  upset  in  acute  fevers,  in  many  of  which  a  transient  glycosuria  is  present. 
It  is  not  uncommon  after  the  administration  of  ether,  less  so  after  chloro- 
form. Metabolic  disturbances  in  gout  are  not  infrequently  associated  with 
glycosuria,  and  cachexias  and  profound  anaemias  may  be  accompanied  by 
transient  glycosuria.  A  mental  shock,  a  severe  nervous  strain  and  worry 
precede  many  cases.  Patients  suffocated  by  smoke,  or  poisoned  by  coal  gas, 
may  have  sugar  in  the  urine. 

Incidence. — According  to  statistics  diabetes  appears  to  be  about  as  fre- 
quent in  the  United  States  as  in  European  countries.  In  England  and  Wales 
the  deaths  increased  from  2,767  in  1902  to  4,542  in  1916.  The  disease  is  on  the 
increase  in  the  United  States.  The  statistics  for  1870  gave  2.1 ;  for  1890,  3.8 ; 
for  1900,  9.3;  and  for  1915,  17.5  deaths  to  the  100,000  population.  This 
may  be  due  to  the  great  increase  in  the  consumption  of  sugar.  Among  27,618 
patients  admitted  to  the  medical  wards  of  the  Johns  Hopkins  Hospital  in 
twenty-two  years  there  were  276  cases  of  diabetes,  or  one  per  cent. 

Hereditary  influences  play  an  important  role  and  cases  are  on  record 
of  its  occurrence  in  many  members  of  the  same  family.  Morton,  who  calls 
the  disease  hydrops  ad  matulam  (Phthisiologia,  1689),  records  a  remarkable 
family  in  which  four  children  were  affected,  one  of  which  recovered  on  a  milk 
diet  and  diascordium.  An  analysis  of  the  cases  in*our  series  gave  only  6  cases 
with  a  history  of  diabetes  in  relatives  (Pleasants).  Naunyn  obtained  a  fam- 
ily history  of  diabetes  in  35  out  of  201  private  cases,  but  in  only  7  of  157 
hospital  cases.  There  are  instances  of  the  coexistence  of  the  disease  in  man 
and  wife.  Among  516  married  pairs  collected  by  Senator,  in  which  either 
husband  or  wife  was  diabetic,  in  18  cases  the  second  partner  had  become  dia- 
betic.    Similarity  in  habits  probably  accounts  for  this. 

Sex. — Men  are  more  frequently  affected  than  women,  the  ratio  being 
about  three  to  two.  Of  the  276  cases  of  diabetes  referred  to,  179  were  in 
males  and  97  in  females  (Futcher).  It  is  a  disease  of  adult  life;  a  majority 
of  the  cases  occur  from  the  third  to  the  sixth  decade.  Of  the  276  cases,  the 
largest  number — ^70 — occurred  between  fifty  and  sixty  years  of  age. 

Diabetes  in  Children. — This  usually  occurs  among  the  better  classes. 
Hereditary  influences  are  marked.  The  course  of  the  disease  is,  as  a  rule, 
much  more  rapid  than  in  adults.  While  the  disease  is  usually  severe  there 
are  not  infrequent  cases  of  a  mild  type.  One  case  is  mentioned  of  a  child  ap- 
parently born  with  glycosuria,  who  recovered  in  eight  months. 

Persons  of  a  neurotic  temperament  are  often  affected.  It  is  a  disease  of 
the  higher  classes.  Van  Noorden  states  that  the  statistics  for  London  and 
Berlin  show  that  the  number  of  cases  in  the  upper  ten  thousand  exceeds  that 
in  the  lower  hundred  thousand  inhabitants. 

Eace. — Hebrews  seem  especially  prone  to  it;  one-fourth  of  Frerichs'  pa- 
tients were  of  the  Semitic  race.  Diabetes  is  comparatively  rare  in  the  colored 
race,  but  not  so  uncommon  as  was  formerly  supposed.  Of  the  series  of  276 
cases,  29,  or  10.6  per  cent.,  were  in  negroes. 

Metabolism,  in  Diabetes. — Glycosuria,  neurotic,  dietetic  or  toxic,  may  be 
a  matter  of  simple  overflow,  but  the  essence  of  true  diabetes  is  a  waste  of  the 
carbohydrates,  which  hurry  through  the  body,  in  great  part  never  warehoused 
as  glycogen.  Why  this  should  be,  whether  the  liver  and  muscles  are  at  fault 
in  refusing  to  transform  the  carbohydrate,  or  whether  the  defect  is  the  en- 


426  DISEASES  OF  METABOLISM 

zymes  of  the  ductless  glands,  are  problems  awaiting  solution.  Naunyn  held 
that  hyperglycemia  is  due  to  a  failure  of  the  liver  and  muscles  to  store  up 
glycogen  as  in  health.  On  the  other  hand,  Lepine,  Opie,  and  others  support 
the  view  that  the  glycolytic  ferments  are  lacking— the  former  may  depend  on 
the  latter.  In  either  case  the  result  is  a  failure  of  the  normal  oxidation  of 
the  carbohydrates.  Hyperglycsemia  is  responsible  for  the  thirst  and  the  polyu- 
ria, and  there  is  a  very  considerable  daily  loss  of  energy  in  warming  the 
liquids  taken  to  the  temperature  of  the  body,  according  to  Benedict  and  Joslin 
nearly  6  per  cent,  of  the  total  heat  of  the  day;  and  it  is  this  excess  of  sugar 
in  the  system  that  renders  the  body  so  favorable  a  culture  medium  for  pus 
organisms.  There  is  loss  of  energy  with  the  steady  waste  of  sugar  fuel; 
practically  every  gram  of  sugar  excreted  in  the  urine  results  in  a  loss  of  4.1 
calories,  consequently  a  diabetic  patient  excreting  100  grams  of  sugar  and  20 
grams  of  /3-oxybutyric  acid  loses  500  calories  in  this  way,  so  that  the  patients 
are  apt  to  be  underfed,  unless  this  loss  is  made  up  by  a  full  amount  of  other 
food  (Benedict  and  Joslin).  Studies  upon  the  respiratory  quotient — which  is 
the  ratio  between  the  CO2  given  out  and  the  0  taken  in  by  a  healthy  individual 
on  a  mixed  diet  (expressed  by  the  fraction  0.9) — favor  the  view  that  there  is 
failure  in  the  proper  combustion  of  the  carbohydrates.  Benedict  and  Joslin 
conclude  that  a  respiratory  quotient  above  0.74  indicates  a  fairly  liberal  sup- 
ply of  glycogen  stored  in  the  body;  while  a  respiratory  quotient  of  0.70,  or 
below  that,  indicates  that  the  patient  has  no  available  carbohydrates,  and  has 
lost  in  a  measure  the  power  of  storing  them.  And  here  comes  the  special 
danger;  as  the  carbohydrates  pass  through  the  body  unburned,'  the  energy 
must  be  provided  from  the  proteins  and  fats.  The  metabolism  of  the  former 
does  not  appear  to  be  seriously  disturbed,  and  the  carbohydrate  portion  of 
the  protein  molecule  is  well  tolerated  and  in  part  supplies  the  place  of  the  lost 
sugars.  The  danger  is  in  the  metabolism  of  the  fats.  The  carbohydrates  are 
not  used  as  fuel;  the  proteins  are  easily  utilized,  but  apparently  it  takes  so 
much  draugiit  to  burn  them  that  not  enough  is  left  to  consume  the  fats  com- 
pletely; and  the  products  of  incomplete  combustion  accumulate  in  the  system 
and  suffocate  the  patient  as  effectually  as  does  the  CO  of  a  charcoal  stove. 
The  chief  product  of  this  incomplete  combustion  of  the  fats  is  the  ^-oxybuty- 
ric  acid,  which  itself  is  the  source  of  the  diacetic  acid  and  acetone,  and  the 
special  danger  of  the  disease  is  now  recognized  to  be  the  production  of  an 
acidosis  in  consequence  of  this  imperfect  fat  metabolism.  One  of  the  most 
valuable  advances  in  our  knowledge  of  the  metabolism  of  the  disease  has  been 
the  work  of  Beddard,  Pembrey  and  Spriggs  and  more  recently  of  Poulton, 
who  have  shown  that  the  amount  of  COg  in  the  alveolar  air  may  be  taken  as  a 
measure  of  the  acidosis.  The  acetone  bodies  in  the  urine  indicate  a  large 
production  in  the  body  but  this  may  have  been  completely  compensated.  The 
blood  examination  is  more  important  to  determine  the  degree  of  accumulation 
and  with  even  slight  degrees  there  are  changes  in  the  alveolar  air. 

The  CO2  tension  of  the  alveolar  air  is  reduced.  In  slight  acidosis  this  is 
between  32  and  38  mm.  Hg,  in  moderate  acidosis  28  to  32  mm.  Hg,  and  in 
severe  acidosis  less  than  28  mm.  Hg  (normal  38-45  mm.  Hg).  The  lowest 
figure  noted  by  Joslin  was  9  mm.  Hg. 

Renal  Diabetes. — This  term  is  applied  to  a  condition  in  which  there  is 
glycosuria  without  increase  of  the  sugar  in  the  blood.     In  it  the  glycosuria 


DIABETES  MELLITUS  427 

is  independent  of  the  carbohydrate  intake  and  the  blood  sugar  is  normal  or  de- 
creased in  amount.  The  kidney  cells  allow  sugar  to  escape.  As  a  rule  it  is 
discovered  accidentally  as  there  are  rarely  any  symptoms.  The  condition  is 
rare  and  the  patients  should  be  followed  for  a  long  time  to  exclude  Diabetes 
Mellitus. 

Morbid  Anatomy. — The  nervous  system  shows  no  constant  lesions.  In  a 
few  instances  there  have  been  tumors  or  sclerosis  in  the  medulla,  or  a  cysti- 
cercus  has  pressed  on  the  floor.  A  secondary  multiple  neuritis  is  not  rare,  and 
to  it  the  so-called  diabetic  tabes  is  probably  due,  and  changes  occur  in  the 
posterior  columns  of  the  cord  similar  to  those  which  have  been  found  in  per- 
nicious aneemia.  In  the  sympathetic  system  the  ganglia  have  been  enlarged 
and  in  some  instances  sclerosed.  The  heart  is  hypertrophied  in  some  cases. 
Endocarditis  is  very  rare.  Arterio-sclerosis  is  common.  The  lungs  show  im- 
portant changes.  Acute  broncho-pneumonia  or  lobar  pneumonia  (either  of 
which  may  terminate  in  gangrene)  and  tuberculosis  are  common.  The  so- 
called  diabetic  phthisis  is  always  tuberculous  and  results  from  a  caseating 
broncho-pneumonia.  In  rare  cases  there  is  a  chronic  interstitial  pneumonia, 
non-tuberculous.  Fat  embolism  of  the  pulmonary  vessels  may  occur  in  con- 
nection with  diabetic  coma. 

The  liver  is  usually  enlarged;  fatty  degeneration  is  common.  In  the  so- 
called  diabetic  cirrhosis — the  cirrhosis  piginentaire — the  liver  is  enlarged  and 
sclerotic,  and  cachexia  develops  with  melanoderma.  Dilatation  of  the  stomach 
with  enlargement  of  the  duodenum  and  colonic  stasis  are  common. 

Pancreas. — Of  15  autopsies  in  27  fatal  cases,  in  9  the  pancreas  was  found 
atrophic.  In  one  of  these  fat  necroses  were  present,  in  another  calculi.  Hya- 
line degeneration  of  the  islands  of  Langerhans  is  a  special  feature  in  certain 
cases.     Chronic  interstitial  pancreatitis  is  common. 

The  'kidneys  show  a  diffuse  nej)hritis  with  fatty  degeneration.  Hyaline 
change  is  often  found  in  the  tubal  epithelium,  particularly  of  the  descending 
limb  of  the  loop  of  Henle,  and  in  the  Malpighian  tufts. 

Symptoms. — Acute  and  chronic  forms  are  recognized,  but  there  is  no  es- 
sential difference  between  them,  except  that  in  the  former  the  patients  are 
younger,  the  course  is  more  rapid,  and  the  emaciation  more  marked. 

The  onset  is  gradual,  and  either  frequent  micturition  or  inordinate  thirst 
first  attracts  attention.  Very  rarely  it  sets  in  rapidly,  after  a  sudden  emotion, 
an  injury,  or  after  a  severe  chill.  When  fully  established  the  disease  is  char- 
acterized by  great  thirst,  the  passage  of  large  quantities  of  saccharine  urine,  a 
voracious  appetite,  and,  as  a  rule,  progressive  emaciation. 

Among  the  general  symptoms  thirst  is  one  of  the  most  distressing.  Large 
quantities  of  water  are  required  to  keep  the  sugar  in  solution  and  for  its  ex- 
cretion in  the  urine.  The  amount  of  fluid  consumed  will  be  found  to  bear  a 
deflnite  ratio  to  the  quantity  excreted.  Instances,  however,  are  not  uncommon 
of  pronounced  diabetes  in  which  the  thirst  is  not  excessive;  but  in  such  cases 
the  amount  of  urine  passed  is  never  large.  The  thirst  is  most  intense  an  hour 
or  two  after  meals.  As  a  rule,  the  digestion  is  good  and  the  appetite  inordi- 
nate. The  condition  is  sometimes  termed  bulimia  or  polyphagia.  Lumbar 
pain  is  common. 

The  tongue  is  usually  dry,  red,  and  glazed,  and  the  saliva  scanty.     The 


428  DISEASES  OF  METABOLISM 

gums  may  become  swollen,  and  in  the  later  stages  aphthous  stomatitis  is 
common.     Constipation  is  the  rule. 

In  spite  of  the  enormous  amount  of  food  consumed  a  patient  may  become 
rapidly  emaciated.  This  loss  of  flesh  bears  some  ratio  to  the  polyuria,  and 
when,  under  suitable  diet,  the  sugar  is  reduced,  the  patient  may  gain  in  flesh. 
The  skin  is  dry  and  harsh,  and  sweating  rarely  occurs,  except  when  tuberculo- 
sis coexists.  Drenching  sweats  have  been  known  to  alternate  with  excessive 
polyuria.  General  pruritus  or  pruritus  pudendi  may.be  very  distressing,  and 
occasionally  is  one  of  the  earliest  symptoms.  The  temperature  is  often  sub- 
normal; the  pulse  is  usually  frequent,  and  the  tension  increased.  Many  dia- 
betics do  not  show  marked  emaciation.  Patients  past  the  middle  period  of  life 
may  have  the  disease  for  years  without  much  disturbance  of  the  health,  and  may 
remain  well  nourished.  These  are  the  cases  of  the  diahete  gras  in  contradistinc- 
tion to  diahete  maigre. 

The  Urine. — The  amount  varies  from  3  to  4  litres  in  mild  cases  to  15 
to  20  litres  in  very  severe  cases.  In  rare  instances  the  quantity  of  urine  is 
not  much  increased.  Under  strict  diet  the  amount  is  much  lessened,  and  in 
intercurrent  febrile  affections  it  may  be  reduced  to  normal.  The  specific 
gravity  is  high,  ranging  from  1.025  to  1.045 ;  but  in  exceptional  cases  it  may 
be  low,  1.013  to  1.020.    The  highest  specific  gravity  recorded  is  by  Trousseau — 

1.074.     Very  high  specific  gravities — 1.070  -\ suggest  fraud.     The  urine 

is  pale  in  color,  almost  like  water,  and  has  a  sweetish  odor  and  a  distinctly 
sweetish  taste.  The  reaction  is  acid.  Sugar  is  present  in  varying  amounts. 
In  mild  cases  it  does  not  exceed  li/o  or  2  per  cent.,  but  it  may  reach  from  5 
to  10  per  cent.  The  total  amount  excreted  in  the  twenty-four  hours  may 
range  from  10  to  20  ounces  (320  to  640  grams)  and  in  exceptional  cases  from 
1  to  2  pounds. 

Ketonuria. — The  ketone  bodies,  acetone,  diacetic  acid  and  y8-oxybutyric 
acid  are  present,  sometimes  in  small  amounts  in  mild  cases  but  increasing  with 
the  severity  of  the  disease ;  and  are  indications  of  acidosis.  In  coma  the  excre- 
tion of  /3-oxybutyric  acid  may  be  as  much  as  100  gm.  or  more  a  day. 

Glycogen  has  also  been  found  in  the  urine,  and  in  rare  instances  sugars 
other  than  glucose  occur,  lactose,  levulose,  and  pentose,  and  to  these  conditions 
the  term  melituria  is  sometimes  applied.    Albumin  is  not  infreqvient. 

Pneumaturia,  gas  in  the  urine,  due  to  fermentation  in  the  bladder,  is  oc- 
casionally met  with.  Cammidge's  reaction  may  be  present.  Fat  may  be  passed 
in  the  urine  in  the  form  of  a  fine  emulsion  (lipuria). 

Blood  in  Diabetes. — The  water  content  is  lower  than  normal.  Poly- 
cythgemia  may  be  present  to  6  or  8  millions  of  red  cells  per  cmm.  Towards 
the  end  and  with  complications  there  may  be  a  leucocytosis  and  the  leucocytes 
may  contain  glycogen.  Hyperglycemia  is  rarely  above  0.4  per  cent.  The 
increase  in  the  blood  sugar  may  persist  after  glycosuria  has  disappeared. 

The  alkalinity  is  lessened  and  the  specific  gravity  reduced.  Lipsemia  is 
present  in  many  cases  and  may  be  readily  recognized  by  the  presence  of  danc- 
ing'particles  among  the  red  cells  in  a  slide  of  fresh  blood.  The  blood  lipoids 
are  increased  from  the  normal  figure  of  about  0.6  per  cent.- to  0.83  per  cent, 
in  mild  cases,  to  0.9  in  moderately  severe  and  1.4  per  cent,  in  severe  cases 
(Joslin).     Lipsemia  may  be  present  without  acidosis  and  is  sometimes  due  to 


DIABETES  MELLITUS  429 

surcharging  of  the  blood  stream  with  the  products  of  fatty  digestion  as  in 
the  normal  lipfemia  of  sucklings. 

Complications. —  {a)  Coma  {Acidosis) — There  are  three  groups  of  cases: 
(1)  Typical  dyspnceic  coma,  the  air-hunger  of  Kussmaul,  in  which  with 
loud  and  deep  in-  and  expirations,  the  pulse  grows  weak,  and  the  patient 
gradually  fails  and  dies,  sometimes  within  twenty-four  hours.  The  breath 
very  often  has  the  fruity  odor  of  acetone.  It  may  come  on  without  any  pre- 
monition and  the  patient  may  waken  out  of  sleep  in  dyspnoea.  An  acyanotic 
dyspnoea  is  one  of  the  best  indications  of  acidosis.  (2)  Cases  in  which,  with- 
out any  previous  dyspnoea  or  distress,  the  patient  is  attacked  with  headache,  a 
feeling  of  intoxication,  thick  speech  and  a  staggering  gait,  and  gradually  falls 
into  deep  coma.  (3)  Cases  in  which,  particularly  after  exertion,  the  patient 
is  attacked  suddenly  with  weakness,  giddiness  and  fainting;  the  hands  and 
feet  are  cold  and  livid,  the  pulse  small,  respiration  rapid;  the  patient  becomes 
drowsy,  and  death  occurs  within  a  few  hours.  Dyspepsia,  constipation,  ab- 
dominal pain,  marked  irritability  and  restlessness  may  precede  the  onset  of 
coma  and  should  suggest  its  possibility. 

(&)  Cutaneous. — Boils  and  carbuncles  are  extremely  common.  Painful 
onychia  may  occur.  Eczema  is  also  met  with,  and  at  times  an  intolerable 
itching.  In  women  the  irritation  of  the  urine  may  cause  the  most  intense 
pruritus  pudendi,  and  in  men  a  balanitis.  Earer  affections  are  xanthoma  and 
purpura.  Gangrene  is  not  uncommon,  and  is  associated  usually  with  arterio- 
sclerosis. Perforating  ulcer  of  the  foot  occurred  in  7  of  276  cases.  Bronzing 
of  the  skin  {diabete  bronze)  occurs  in  certain  cases  in  which  the  diabetes  arises 
as  a  late  event  in  the  disease  known  as  hgemochromatosis,  which  is  further 
characterized  by  pigmentary  cirrhosis  of  the  liver  and  pancreas.  With  the 
onset  of  severe  complications  the  tolerance  of  the  carbohydrates  is  much  in- 
creased.    Profuse  sweats  may  occur. 

(c)  PuLMOXARY. — The  patients  are  not  infrequently  carried  off  by  acute 
pneumonia,  which  may  be  lobar  or  lobular.  Gangrene  is  very  apt  to  super- 
vene, but  the  breath  does  not  necessarily  have  the  foul  odor  of  ordinary  gan- 
grene. Abscess  following  lobar  jDneumonia  occurred  in  one  of  our  cases.  Tu- 
berculous broncJio-pneumonia  is  common  and  may  run  a  rapid  course. 

(d)  Eenal. — Albuminuria  is  a  tolerably  frequent  complication.  The 
amount  varies  greatly,  and,  when  slight,  does  not  seem  to  be  of  much  moment. 
CEdema  of  the  feet  and  ankles  is  not  an  infrequent  symptom.  General  ana- 
sarca is  rare,  however,  owing  to  the  marked  polyuria.  It  is  sometimes  asso- 
ciated with  arterio-sclerosis.  It  occasionally  precedes  the  occurrence  of  the 
diabetic  coma.     Occasionally  cystitis  is  a  troublesome  symptom. 

(e)  ISTeevous  System.' — Peripheral  Seuriiis. — Xeuralgia,  numbness  and 
tingling,  uncommon  symptoms  in  diabetes,  are  probably  minor  neuritic  mani- 
festations. The  involvement  may  be  general  of  the  upper  and  lower  extremi- 
ties. Sometimes  it  is  unilateral,  or  the  neuritis  may  be  in  a  single  nerve — 
the  sciatic  or  the  third  nerve.    Herpes  zoster  may  occur. 

Diabetic  Tahes  (so-called). — This  is  a  peripheral  neuritis,  characterized  by 
lightning  pains  in  the  legs,  loss  of  knee-jerk — which  may  occur  without  the 
other  symptoms — and  a  loss  of  power  in  the  extensors  of  the  feet.  The  gait 
is  the  characteristic  steppage,  as  in  alcoholic,  and  other  forms  of  neuritic  par- 
alysis.   Changes  in  the  posterior  columns  of  the  cord  have  been  found. 


430  DISEASES  OF  METABOLISM 

Diabetic  Paraplegia.— This  is  also  in  all  probability  due  to  neuritis.  There 
are  cases  in  which  power  has  been  lost  in  both  arms  and  legs. 

Mental  Symptoms. — The  patients  are  often  morose,  and  there  is  a  strong 
tendency  to  become  hypochondriacal.  Some  patients  display  an  extraordinary 
degree  of  restlessness  and  anxiety. 

(/)  Special  Senses.— Cataract  is  liable  to  occur,  and  with  rapidity  in 
young  persons.  Diabetic  retinitis  closely  resembles  the  albuminuric  form. 
Hemorrhages  are  common.  Sudden  amaurosis,  similar  to  that  which  occurs 
in  ursemia,  may  occur.  Paralysis  of  the  muscles  of  accommodation  may  be 
present;  and,  lastly,  atrophy  of  the  optic  nerves.  Aural  symptoms  may  come 
on  with  great  rapidity,  either  an  otitis  media,  or  in  some  instances  inflamma- 
tion of  the  mastoid  cells.     Ocular  tension  may  be  lowered  in  coma. 

(g)  Sexual  Function. — Impotence  is  common,  and  may  be  an  early 
symptom.  Conception  is  rare;  if  it  occurs,  abortion  is  apt  to  follow.  A  dia- 
betic mother  may  bear  a  healthy  child;  there  is  no  known  instance  of  a  dia- 
betic mother  bearing  a  diabetic  child.  The  course  of  the  disease  is  usually 
aggravated  after  delivery. 

Diagnosis. — There  is  no  difficulty  in  determining  the  presence  of  sugar 
in  the  urine  if  the  proper  tests  are  applied.  Alcapton  may  prove  very  decep- 
tive, and  in  one  reported  case  of  ochronosis  (Osier)  a  diagnosis  of  diabetes 
was  made  by  four  or  five  of  the  leading  physicians  in  Europe,  one  of  whom 
was  an  authority  on  diabetes.  Deception  may  be  practised.  One  patient  had 
urine  with  a  specific  gravity  of  1.065,  but  the  reactions  were  for  cane  sugar; 
and  there  is  a  case  in  the  literature  in  which,  when  the  cane  sugar  fraud  was 
detected,  the  woman  bought  grape  sugar  and  put  it  into  her  bladder. 

To  determine  whether  the  case  is  one  of  simple  glycosuria  or  diabetes  is 
not  always  easy,  as  the  one  readily  merges  into  the  other.  The  younger  the 
individual  the  greater  the  probability  that  the  case  is  true  diabetes.  It  is  well 
to  test  the  assimilation  limit;  100  grams  of  glucose  given  in  solution  two 
hours  after  a  breakfast  of  a  roll  and  butter  with  coffee  should  not  give  gly- 
cosuria. To  do  so  indicates  a  deficiency  in  the  capacity  to  store  carbohydrates 
and  a  possibility  that  diabetes  may  follow.  Transient  glycosuria  occurs  in  a 
great  many  conditions  already  mentioned.  For  practical  purposes  the  common 
form  is  that  met  with  in  persons  above  50  years  of  age,  who  eat  and  drink  too 
much  and  tend  to  grow  stout.  The  detection  of  a  little  sugar  in  the  urine  may 
have  the  great  advantage  of  frightening  the  patient  into  a  more  rational  mode 
of  life.  The  forms  following  ansesthesia,  accidents,  business  worries,  fright  and 
that  which  occurs  in  pregnancy  are,  as  a  rule,  readily  controlled. 

Prognosis. — The  younger  the  patient  the  less  likely  is  recovery.  In  chil- 
dren the  disease  may  run  a  very  rapid  course,  and  death  may  occur  within  a 
few  weeks,  or  a  child  may  die  in  coma  before  the  condition  has  been  recog- 
nized. On  the  other  hand,  in  persons  over  fifty  sugar  may  be  present  in  the 
urine  for  years  without  any  impairment  of  strength  or  health.  The  outlook 
is  good  in  the  fat,  bad  in  the  lean.  It  is  particularly  good  in  the  stout,  active, 
business  man,  whose  glycosuria  has  come  on  as  a  result  of  worry,  work,  and 
excess  in  food  and  drink.  An  early  diagnosis,  obesity  and  a  gain  in  tolerance 
are  hopeful  features. 

The  following  steps  should  be  taken  to  estimate  the  gi'avity  of  a  case. 
The  carbohydrate  tolerance  should  be  estimated  and  the  presence  of  acetone 


DIABETES  MELLITUS  431 

and  diacetic  acid  determined,  as  they  usually  indicate  a  serious  disturbance  in 
the  fat  metabolism.  It  is  well  to  remember  that  the  acetone  bodies  may  be 
only  temporarily  present,  and  it  is  not  necessary  to  sign  the  patient's  death 
warrant  so  soon  as  they  appear.  A  patient  may  live  for  many  years  with 
traces,  and  they  may  disappear  after  having  been  present  for  months. 

Treatment. — In  families  with  a  marked  predisposition  to  the  disease  the 
•use  of  starchy  and  saccharine  articles  of  diet  should  be  restricted.  The  per- 
sonal hygiene  of  a  diabetic  patient  is  of  the  first  importance.  Sources  of 
worry  should  be  avoided,  and  he  should  lead  an  even,  quiet  life,  if  possible 
in  an  equable  climate.  The  heat  waste  should  be  prevented  by  wearing  warm 
clothes  and  avoiding  cold.  A  warm,  or,  if  tolerably  robust,  a  cold,  bath  should 
be  taken  every  day.  An  occasional  Turkish  bath  is  useful.  Systematic,  mod- 
erate exercise  should  be  taken.  When  this  is  not  feasible,  massage  should  be 
given. 

Diet. — Each  patient  presents  his  own  problem  and  must  be  studied  indi- 
vidually. The  endeavor  should  be  made  to  keep  the  urine  sugar  free  and  acid 
free.  In  this  the  proper  use  of  fasting,  as  advocated  by  Allen,  is  of  great  aid 
but  it  should  not  be  employed  carelessly.  The  object  of  treatment  is  to  in- 
increase  the  carbohydrate  tolerance;  it  is  important  not  to  overtax  the  pa- 
tient's powers  of  using  carbohydrates  by  giving  more  than  he  can  utilize.  In 
mild  cases  the  carbohydrate  intake  may  be  gradually  reduced,  sugar  as  such 
being  cut  off  first  and  the  carbohydrate  intake  reduced  by  a  certain  propor- 
tion each  day  until  the  urine  is  sugar  free.  In  the  medium  and  severe  cases 
fasting  is  useful.  The  purpose  of  it  should  be  explained  to  the  patient  and 
his  co-operation  secured.  The  time  of  fasting  required  to  render  the  urine 
sugar  free  varies  from  one  to  five  days.  The  patient  should  be  put  to  bed; 
water  may  be  taken  freely  and  tea  or  coffee  allowed  (without  sugar,  or  cream)- 
if  desired.  If  sugar  persists  after  the  second  day  of  fasting  300  c.  c.  of  meat 
broth  or  bouillon  may  be  given.  >  When  the  urine  is  sugar  free  it  is  necessary 
to  determine  the  carbohydrate  tolerance. 

The  profession,  and  much  more  the  diabetic  patient,  owes  much  to  E.  P. 
Joslin  of  Boston  for  his  studies  on  diabetes.    We  quote  some  of  his  directions : 

"In  severe,  long-standing,  complicated,  obese  and  elderly  cases,  as  well  as 
in  all  cases  with  acidosis,  or  in  any  case  if  desired,  without  otherwise  chang- 
ing habits  or  diet,  omit  fat,  after  two  days  omit  protein  and  then  halve  the 
carbohydrates  daily  until  the  patient  is  taking  only  10  grams;  then  fast.  In 
other  cases  begin  fasting  at  once.  Fast  four  days,  unless  earlier  sugar-free. 
Allow  water'  freely,  tea,  coffee  and  thin,  clear  meat  broths  as  desired." 

"If  glycosuria  persists  at  the  end  of  four  days,  give  1  gram  protein  or  0.5 
gram  carbohydrate  per  kilogram  body  weight  for  two  days  and  then  fast  again 
for  three  days  unless  earlier  sugar-free.  If  glycosuria  remains,  repeat  and  then 
fast  for  one  or  two  days  as  necessary.  If  there  is  still  sugar,  give  protein  as 
before  for  four  days,  then  fast  one,  and  then  gradually  increase  the  periods 
of  feeding,  one  day  each  time,  until  fasting  one  day  each  week.  I  have  seen 
no  uncomplicated  case  fail  to  get  sugar-free  by  this  method." 

"When  the  twenty-four-hour  urine  is  free  from  sugar,  give  5  to  10  grams 
carbohydrate  (150  to  300  grams  of  5  per  cent,  vegetables)  and  continue  to 
add  5  to  10  grams  carbohydrate  daily  up  to  50  grams  or  more  until  sugar 
appears." 


432  DISEASES  OF  METABOLISM 

"When  the  urine  has  been  sugar-free  for  three  days^,  add  about  20  grams 
protein  and  thereafter  15  grains  protein  daily  in  the  form  of  egg-white,  fish 
or  lean  meat  (chicken)  until  the  patient  is  receiving  1  gram  protein  per  kilo- 
gram body  weight  or  less  if  the  carbohydrate  tolerance  is  zero." 

"Add  no  fat  until  the  protein  reaches  1  gram  per  kilogram  body  weight 
(unless  the  protein  tolerance  is  below  this  figure)  and  the  carbohydrate  tol- 
erance has  been  determined,  but  then  add  5  to  25  grams  daily,  according  to 
previous  acidosis,  until  the  patient  ceases  to  lose  weight  or  receives  in  the 
total  diet  about  30  calories  per  kilogram  body  weight." 

"The  return  of  sugar  demands  fasting  for  twenty-four  hours  or  until  sugar- 
free.  Eesume  the  former  diet  gradually,  adding  fat  last  in  order  to  maintain 
as  high  a  carbohydrate  tolerance  as  possible,  sacrificing  body  weight  for  this 
purpose.     This  rule  should  be  inflexibly  followed,  especially  with  children." 

"Whether  sugar  reappears  in  the  urine  or  not  it  is  desirable  upon  one  day 
each  week  to  rest  that  function  of  the  body  which  controls  the  assimilation  of 
sugar  by  either  a  complete  fast  day  or  a  diet  of  low  caloric  value.  My  plan 
is  patterned  on  the  following  rule:  Whenever  the  tolerance  is  less  than  20 
grams  carbohydrate,  fasting  should  be  practised  one  day  in  seven;  when  the 
tolerance  is  over  20  grams  carbohydrate,  cut  the  diet  in  half  on  one  day  each 
week  (half -day)." 

Days  of  Eeduced  Diet. — In  every  case  it  is  wise  to  restrict  the  diet  on  one 
day  a  week.  In  mild  cases  the  quantity  of  carbohydrate  should  be  reduced  to 
one-half  or  one-third  of  the  usual  amount.  In  moderate  or  severe  cases  a  com- 
plete fast  of  one  day  is  advisable.  A  day  when  only  eggs  and  the  5  per  cent, 
vegetables  are  taken  is  also  an  advantage.  The  exact  amount  allowed  in  any 
case  must, depend  on  the  carbohydrate  tolerance:  the  lower  this  is  the  greater 
importance  of  a  fast  day. 

Saccharine  may  be  used  in  place  of  sugar.  It  is  an  advantage  in  using 
vegetables  which  are  boiled  in  cooking,  to  do  the  boiling  in  three  different 
waters.  All  the  water  should  be  removed  after  each  boiling.  This,  reduces 
the  amount  of  carbohydrate.  It  is  well  to  do  this  with  patients  who  demand 
bulk  in  the  diet. 

The  patient  should  keep  an  accurate  record  of  his  diet  and  the  amounts 
taken.  It  is  well  for  him  to  have  scales  to  determine  the  exact  weights  so 
that  the  intake  is  known  accurately.  Tables  of  food  values  are  of  assistance 
in  determining  the  amount  of  protein,  carbohydrate  and  fat  in  the  diet.  He 
should  be  taught  to  examine  the  urine  for  sugar,  daily  in  severe  cases,  once 
or  twice  a  week  in  milder  cases.  It  is  not  necessary  for  the  patient  to  gain 
weight  or  even  to  equal  his  former  normal  weight. 

Medical  Treatment.— This  is  not  satisfactory  and  there  is  no  drug  which 
appears  to  have  a  direct  curative  influence.  Opium, and  its  derivatives  are 
sometimes  useful  for  irritable  patients  but  are  rarely  required.  Potassium 
bromide  may  be  given  for  the  same  purpose.  The  use  of  arsenic  has  been 
recommended  and  is  indicated,  either  alone  or  with  iron  in  case  of  anaemia. 
The  bowels  should  be  kept  freely  open  and  for  this  such  drugs  as  mineral  oil, 
cascara,  senna  and  phenolphthalein  are  most  useful.  Purging  should  be 
avoided. 

Coma. — The  urine  should  be  watched  carefully  for  acetone  and  diacetic 
acid.     Their  presence  is  a  sign  for  reduction  in  the  diet,  especially  the  fats. 


DIABETES  MELLITUS 


433 


QUANTITY  OF  FOOD  Required  by  a  Severe  Diabetic  Patient  Weighing  60  kilograms. 

(Joslin.) 

Food                                                              Quantity  Grams  Calories  per  Gram  Total  Calories 

Carbohydrate 10  4  40 

Protein 75  4  300 

Fat 150  9  1,350 

Alcohol 15  7  105 


1,795 


STRICT  DIET.      (Foods  without  sugar.)      Meats,  Poultry,  Game,  Fish,  Clear  Soups, 
Gelatine,  Eggs,  Butter,  Olive  Oil,  Coffee,  Tea  and  Cracked  Cocoa. 


FOODS   ARRANGED    APPROXIMATELY   ACCORDING   TO    CONTENT    OF    CARBOHYDRATES 


5%  + 

10%   + 

15%   + 

20%  + 

Lettuce                           Cauliflower 

Onions 

Green  Peas 

Potatoes 

Spinach                          Tomatoes 

Squash 

Artichokes 

Shell  Beans 

59     Sauerkraut                     Rhubarb 
3     String  Beans                 Egg  Plant 

Turnip 

Parsnips 

Baked  Beans 

Carrots 

Canned  Lima 

Green  Corn 

P9     Celery                             Leeks 

2     Asparagus                      Beet  Greens 

Okra 

Beans 

Boiled  Rice 

Mushrooms 

Boiled  Macaroni 

S     Cucumbers                    Water  Cress 
53     Brussels  Sprouts          Cabbage 

Beets 

fH     Sorrel                              Radishes 

>     Endive                            Pumpkin 

Dandelion  Greens        Kohl-Rabi 

Swiss  Chard                  Sea  Kale 

Vegetable  Marrow 

Ripe  Olives  (20  per  cent,  fat) 
Grape  Fruit 


Lemons 

Oranges 

Cranberries 

Strawberries 

Blackberries 

Gooseberries 

Peaches 

Pineapples 

Watermelon 


Apples 

Pears 

Apricots 

Blueberries 

Cherries 

Currants 

Raspberries 

Huckleberries 


Plums 
Bananas 


Butternuts 
P     Pignolias 
13 


Brazil  Nuts 
Black  Walnuts 
Hickorj' 
Pecans 
Filberts 


Almonds 
Walnuts  (Eng.) 
Beechnuts 
Pistachios 
Pine  Nuts 


Peanuts 


40% 
Chestnuts 


■2  5 


Unsweetened  and  Unspiced  Pickle 
Clams  Oysters 

Scallops  lyiver 

Fish  Roe 


30  grams  (1  oz.;                                                                         Protein        Fat  Carbohydrates         Calories 

CONTAIN  APPROXIMATELY'  GKAMS 

Oatmeal 5                    2  20  110 

Meat  (uncooked) 6                    2  0  40 

"     (cooked) 8                    3  0  60 

Potato 10  6  25 

Bacon 5                   15  0  155 

Cream,  40% 1                   12  1  120 

20%, 16  1  60 

Milk 112  20 

Bread 3                    0  18  90 

Rice 3                     0  24  110 

Butter 0                   25  0  240 

Egg  (one) 0                      5  0  75 

Brazil  Nuts 5                  20  2  210 

Orange  (one) 0                     0  10  40 

Grape  Fruit  (one) 0                     0  10  40 

Vegetables  from  5-6%  groups 0.5                 0  1  6 


1  gram  protein  contains  4  calories. 

1      "      carbohydrate  contains  4  calories. 

1      "      fat  contains  9  calories. 

1      "      alcohol  contains  7  calories. 


1  kilogram — 2.2  pounds. 
6.25  grams  protein  contain  1  gram  nitrogen. 
A  patient   "at   rest"   requires  30   calories  per  kilogram 
body  weight. 


Chart  XIV. — Diabetic  Food  Tables.     (Joslin.) 


434  DISEASES  OF  METABOLISM 

If  sugar  is  present  fasting  is  usually  indicated.  If  signs  of  coma  appear  the 
patient  should  be  put  to  bed  and  kept  as  quiet  as  possible.  The  stomach  should 
be  washed  out  and  the  bowels  moved  by  enema.  Fluid  should  be  given  freely 
to  an  amount  of  1,000  c.  c.  every  six  hours,  as  thin  broth,  tea,  coffee  or  water 
by  mouth.  If  necessary  some  may  be  given  by  rectum.  If  this  is  not  possible 
the  fluid  should  be  given  subcutaneously  or  intravenously.  If  the  patient  has 
been  on  full  diet,  cut  out  the  fat,  but  continue  the  same  amount  of  protein 
and  carbohydrate,  the  latter  being  given  in  simple  form,  such  as  thin  oatmeal 
gruel,  orange  juice,  milk  or  bread.  At  least  a  gram  of  carbohydrate  per  kilo 
of  body  weight  may  be  given.  If  the  circulation  is  failing,  digitalis  should 
be  given.  Joslin  advises  against  the  rise  of  alkalies  and  while  the  general 
practice  has  been  to  give  sodium  bicarbonate  his  opinion  carries  great  weight. 
If  alkali  has  been  given  he  advises  a  reduction  in  the  dose  of  30  grams  a  day. 

Of  the  comijlications,  the  pruritus  and  eczema  are  best  treated  by  cooling 
lotions  of  boric  acid  or  hyposulphite  of  soda  (1  ounce;  water,  1  quart),  or  the 
use  of  ichthyol  and  lanolin  ointment.  With  co-existing  pulmonary  tuber- 
culosis the  usual  diabetic  treatment  can  be  employed. 

The  decision  as  to  the  performance  of  an  operation  should  be  carefully 
made.  The  patient  should  be  given  a  thorough  study  and  put  in  the  best  pos- 
sible condition  so  that  he  is  sugar  and  acid  free. 


in.    DIABETES  INSIPIDUS 

Definition. — A  chronic  affection  characterized  by  the  passage  of  large 
quantities  of  normal  urine  of  low  specific  gravity. 

The  condition  is  to  be  distinguished  from  diuresis  or  polyuria,  which  is 
a  frequent  symptom  in  hysteria  and  some  forms  of  nephritis.  There  may  be 
excessive  polyuria  with  abdominal  tumors  and  aneurism,  tuberculous  perito- 
nitis and  carcinoma.  Willis  in  1674  first  recoguized  the  distinction  between 
a  saccharine  and  non-saccharine  form  of  diabetes. 

Etiology. — The  disease  is  most  common  in  young  persons.  Of  the  85  cases 
collected  by  Strauss,  9  were  under  five  years;  12  between  five  and  ten  years; 
36  between  ten  and  twenty-five  years.  Males  are  more  frequently  attacked  than 
females.  The  affection  may  be  congenital.  A  hereditary  tendency  has  been 
noted  in  many  instances,  the  most  extraordinary  of  which  has  been 
reported  by  Weil.  Of  91  members  in  four  generations,  23  had  persistent 
polyuria  without  any  deterioration  in  health. 

It  may  follow  injury  to  the  base  of  the  skull.  It  is  sometimes  associated 
with  adiposity  and  defective  genital  development  (pituitary  disease).  Recent 
observations  have  shown  a  striking  relationship  between  pituitary  disease  and 
diabetes  insipidus.  In  some  cases  it  is  due  to  insufficiency  of  the  pars  inter- 
media of  the  pituitary  body.  In  a  case  reported  by  Gushing  there  was  polyuria 
for  three  months  after  a  sellar  decompression  operation,  regarded  as  due  to 
an  irritative  lesion  of  the  pituitary.  Tumors,  lesions  of  the  medulla  and 
pituitary,  malignant  metastases  in  the  pituitary,  injury  and  syphilis,  usually 
basal  and  meuingitic,  are  possible  factors.  Hemianopsia  is  present  in  a  num- 
ber of  the  cases.  Disturbance  of  the  function  of  the  pituitary  gland,  more 
particularly  the  pars  intermedia,  may  be  regarded  as  the  essential  factor,  cer- 


DIABETES  INSIPIDUS  435 

tainly  in  a  large  percentage  of  cases.  Gushing  lias  advanced  the  suggestion 
that  disturbance  of  the  pituitary  function  through  its  autonomic  nervous  con- 
nections may  be  the  explanation  of  the  polyuria  which  occurs  in  functional 
nervous  disturbance. 

Clinical  Classification. — There  are  two  forms:  primary  or  idiopathic,  in 
which  there  is  no  evident  organic  basis,  and  secondary  or  symptomatic,  in 
which  there  is  evidence  of  disease  in  the  brain  or  elsewhere.  Of  9  cases  re- 
ported by  Futcher,  4  belonged  to  the  former  and  5  to  the  latter  group.  Trous- 
seau stated  that  the  parents  of  children  with  diabetes  insipidus  frequently 
have  glycosuria  or  albuminuria.  The  disease  has  followed  rapidly  the  copious 
drinking  of  cold  water,  or  a  drinking  bout,  or  has  set  in  during  the  conva- 
lescence from  an  acute  disease.  The  secondary  or  symptomatic  form  is  almost 
always  associated  with  injury  or  disease  of  the  nervous  system,  traumatism  to 
i;he  head  or,  in  some  cases,  to  the  trunk.  In  some  cases  the  functional  capacity 
of  the  kidney  to  eliminate  salt  and  urea  is  diminished. 

Morbid  Anatomy. — There  are  no  constant  anatomical  lesions.  The  kid- 
neys have  been  found  enlarged  and  congested.  The  hladder  has  been  found 
hypertrophied.  Dilatation  of  the  ureters  and  of  the  pelves  of  the  kidneys  has 
been  present.  Death  has  not  infrequently  resulted  from  chronic  pulmonary 
disease.     Very  varied  lesions  have  been  met  with  in  the  nervous  system. 

Symptoms. — The  disease  may  come  on  rapidly,  as  after  a  fright  or  an  in- 
jury; more  commonly  it  is  gradual.  A  copious  secretion  of  urine,  with  in- 
creased thirst,  is  the  prominent  feature.  The  amount  of  urine  in  the  twenty- 
four  hours  may  range  from  20  to  40  pints,  or  even  more.  Trousseau  speaks 
of  a  patient  who  consumed  50  pints  of  fluid  daily  and  passed  about  56  pints 
of  urine  in  the  twenty-four  hours.  In  two  of  our  cases  the  amount  passed 
was,  greater  than  that  ingested  in  liquids  and  solids.  The  specific  gravity  is 
low,  1.001  to  1.005 ;  the  color  is  extremely  pale  and  watery.  The  total  solid 
constituents  may  not  be  reduced.  The  amount  of  urea  has  sometimes  been 
found  in  excess.  Abnormal  ingredients  are  rare.  Muscle-sugar,  inosite,  has 
been  occasionally  foimd.  Albumin  is  rare.  Traces  of  sugar  have  been  met 
with.  N'aturally,  with  the  passage  of  such  enormous  quantities  of  urine,  there 
is  a  proportionate  thirst,  and  the  only  inconvenience  of  the  disease  is  the 
necessity  for  frequent  micturition  and  frequent  drinking.  The  appetite  is 
usually  good,  rarely  excessive  as  in  diabetes  mellitus;  but  Trousseau  tells  of 
the  terror  inspired  by  one  of  liis  patients  in  the  keepers  of  those  eating-houses 
where  bread  was  allowed  without  extra  charge  to  the  extent  of  each  customer's 
wishes,  and  says  that  the  man  Avas  paid  to  stay  away.  The  patients  may  be 
well  nourished  and  healthy-looking.  The  disease  in  many  instances  does  not 
appear  to  interfere  in  any  way  with  the  general  health.  The  perspiration  is 
naturally  slight  and  the  skin  is  harsh.  The  amount  of  saliva  is  small  and  the 
mouth  usually  dry.  The  tolerance  of  alcohol  is  remarkable,  and  patients  have 
been  known  to  take  a  couple  of  pints  of  brandy,  or  a  dozen  or  more  bottles  of 
wine,  in  the  day. 

Course. — This  depends  largely  upon  the  nature  of  the  primary  trouble. 
Sometimes,  with  organic  disease,  eiiher  cerebral  or  abdominal,  the  general 
health  is  much  impaired;, the  patient  becomes  thin,  and  rapidly  loses  strength. 
In  the  essential  or  idiopathic  cases  good  health  may  be  maintained  for  an 
indefinite  period,  and  the  affection  has  persisted  for  fifty  years.    Death  usually 


436  DISEASES  OF  METABOLISM 

results  from  some  intercurrent  affection.     Spontaneous  cure  may  take  place. 

Diagnosis. — A  low  specific  gravity  and  the  absence  of  sugar  in  the  urine 
distinguish  the  disease  from  diabetes  mellitus.  Hysterical  polyuria  may  some- 
times simulate  it  very  closely.  The  amount  of  urine  may  be  enormous,  and 
only  the  develoj)ment  of  other  hysterical  manifestations  may  enable  the  diag- 
nosis to  be  made.  This  condition  is,  however,  always  transitory.  In  certain 
cases  of  chronic  nephritis  a  very  large  amount  of  urine  of  low  specific  gravity 
may  be  passed,  but  the  presence  of  albumin  and  hyaline  casts,  high  blood  pres- 
sure, stiff  vessels,  and  hypertrophied  left  ventricle  make  the  diagnosis  easy. 

Treatment. — Xo  attempt  should  be  made  to  reduce  the  amount  of  liquid. 
In  some  cases  gradual  reduction  of  the  protein  and  salt  intake  is  useful.  This 
should  be  done  gradually.  Administration  of  the  posterior  lobe  of  the  pitui- 
tary has  been  useful.  As  a  rule  this  has  to  be  given  by  injection,  but  in  some 
cases  the  giving  of  the  gland  extract  by  mouth  has  been  effectual.  Lumbar 
puncture  has  been  followed  by  marked  improvement  and  should  be  tried. 
Theocin  is  sometimes  useful  in  doses  of  5  grains  (0.3  gm.)  three  times  a  day. 
Antisyphilitic  treatment  should  be  thoroughly  tried  in  patients  with  a  sus- 
picious history  or  a  positive  Wassermann  reaction. 


IV.     RICKETS   (RACHITIS) 

Definition. — A  disease  of  infants,  characterized  b}'  impaired  nutrition  of 
the  entire  body  and  alterations  in  the  growing  bones. 

Glisson,  the  anatomist  of  the  liver,  accurately  described  the  disease  in 
1650.  The  name  is  derived  from  the  old  English  word  wrichhen,  to  twist. 
Glisson  suggested  to  change  the  name  of  rachitis,  from  the  Greek  pdxts,  the 
spine,  as  it  was  one  of  the  first  parts  affected,  and  also  from  the  similarity 
in  the  sound  to  rickets. 

Etiology. — Eickets  exists  in  all  parts  of  the  world,  but  is  particularly 
marked  among  the  poor  of  the  larger  cities,  who  are  badly  housed  and  ill  fed. 
It  is  much  more  common  in  Europe  than  in  America.  In  Vienna  and  London 
from  50  to  80  per  cent,  of  all  the  children  at  the  clinics  present  signs  of  rick- 
ets. It  is  a  comj)aratively  rare  disease  in  Canada.  In  the  cities  of  the  L^nited 
States  it  is  very  prevalent,  particularly  among  the  children  of  the  negro  and 
of  the  Italian  races.  Want  of  sunlight,  impure  air,  confinement,  and  lack  of 
exercise  are  important  factors.  Prolonged  lactation  and  suckling  the  child 
during  pregnancy  are  accessory  infiuences  in  some  cases. 

There  is  no  evidence  that  the  disease  is  hereditary. 

Eickets  affects  male  and  female  children  equally.  It  is  a  disease  of  the 
first  and  second  years  of  life,  rarely  beginning  before  the  sixth  month.  Jenner 
described  a  late  rickets,  in  which  form  the  disease  may  not  appear  until  the 
ninth  or  even  until  the  twelfth  year,  or  later  (the  osteomalacia  of  puberty). 
X  faulty  diet  is  a  factor  in  the  production  of  the  disease.  A  deficiency  of  fat 
assimilation  is  suggested.  Like  scurvy,  rickets  may  be  found  in  the  families 
of  the  wealthy  under  perfect  hygienic  conditions.  It  is  most  common  in  chil- 
dren fed  on  condensed  milk,  the  various  proprietary  foods,  cow's  milk,  and  food 
rich  in  starches.  "An  analysis  of  the  foods  on  which  rickets  is  most  fre- 
quently and  certainly  produced  shows  invariably  a  deficiency  in  two  of  the 


RICKETS  437 

chief  elements  so  plentiful  in  the  standard  food  of  young  animals — namely, 
animal  fat  and  proteid''  (Cheadle).  Bland  Sutton's  interesting  experiment 
with  the  lion's  cubs  at  the  "Zoo"  illustrates  this  point.  When  milk,  pounded 
bones,  and  cod-liver  oil  were  added  to  the  meat  diet  the  rickets  disappeared, 
and  for  the  first  time  in  the  history  of  the  society  the  cubs  were  reared.  As- 
sociated with  the  defect  in  food  is  a  lack  of  proper  assimilation  of  the  lime 
salts. 

Morbid  Anatomy. — Glisson's  original  description  of  the  external  appear- 
ances of  a  rickety  child  is  remarkably  complete;  indeed,  his  monograph  is  an 
enduring  monument  to  the  skill  and  powers  of  obserTation  of  this  great  physi- 
cian. "(1)  An  irregular  or  unusual  proportion  of  its  parts.  The  head  is  evi- 
dently larger  than  normal,  and  the  face  fatter  in  respect  to  the  other  parts. 
...  (2)  The  external  members  and  muscles  of  the  who^^e  body  are  seen  to  be 
delicate  and  emaciated,  as  though  consumed  by  atrophy  or  tabes,  and  this 
(so  far  as  we  know)  is  always  observed  in  those  dead  of  this  affection.  (3) 
The  whole  skin,  both  the  true  and  the  fleshy  and  fatty  layers,  is  flaccid  and 
rather  pendulous,  like  a  loose  glove,  so  that  you  think  it  could  hold  much 
more  flesh.  (4)  About  the  joints,  especially  in  the  wrists  and  ankles,  there 
are  certain  protuberances  which,  if  opened,  are  seen  to  arise,  not  in  the  fleshy 
or  membranous  parts,  but  in  the  ends  of  the  bones  themselves,  especially  in 
their  epiphyses.  (5)  The  joints,  limbs,  and  habitus  of  all  these  external  parts 
are  less  firm  and  rigid,  less  inflexible  than  in  other  dead  bodies,  and  the  neck 
scarcely  becomes  rigid,  a  frigore,  post  mortem,  or  to  a  less  extent  than  in  other 
cadavers.  (6)  The  chest  externally  is  thin  and  much  narrowed,  especially 
beneath  the  scapulae,  as  though  compressed  from  the  sides,  and  the  sternum 
accuminated  like  the  keel  of  a  ship  or  the  breast  of  a  fowl.  (7)  The  ends  of 
the  ribs  which  join  with  the  cartilages  of  the  sternum  are  nodular,  like  the  ends 
of  the  wrists  and  ankles."  He  also  described  the  prominent  abdomen,  the 
enlarged  liver,  and  the  changes  in  the  mesenteric  glands. 

The  lones  show  the  most  important  changes,  particularly  the  ends  of  the 
long  bones  and  the  ribs.  Between  the  shaft  and  epiphyses  a  slight  bulging  is 
apparent,  and  on  section  the  zone  of  proliferation,  which  normally  is  repre- 
sented by  two  narrow  bands,  is  greatly  thickened,  bluish  in  color,  more  ir- 
regular in  outline,  and  very  much  softer.  The  width  of  this  cushion  of  car- 
tilage varies  from  5  to  15  mm.  The  line  of  ossification  is  also  irregular  and 
more  spongy  and  vascular  than  normal.  The  periosteum  strips  off  very 
readily  from  the  shaft,  and  beneath  it  there  may  be  a  spongy  tissue  not  unlike 
decalcified  bone.  The  practical  outcome  of  these  changes  is  an  imperfect  ossi- 
fication, so  that  the  bone  has  neither  the  natural  rate  of  growth  nor  the  nor- 
mal firmness.  In  the  cranium  there  may  be  large  areas,  particularly  in  the 
parieto-occipital  region,  in  which  the  ossification  is  delayed,  producing  the  so- 
called  cranio-tabes,  so  that  the  bone  yields  readily  to  pressure  with  the  finger. 
There  are  localized  depressed  spots  of  atrophy,  which,  on  pressure,  give  the 
so-called  "parchment  crackling.-"  Flat  hyperostoses  arise  on  the  outer  table, 
particularly  on  the  frontal  and  parietal  bones,  producing  the  characteristic 
broad  forehead  with  prominent  frontal  eminences,  a  condition  sometimes  mis- 
taken for  hydrocephalus.  , 

Kassowitz,  the  leading  authority  on  the  anatomy  of  rickets,  regards  the 
hyperaemia  of  the  periosteum,  the  marrow,  the  cartilage,  and  of  the  bone  itself 


438  DISEASES  OF  METABOLISM 

as  the  primary  lesion,  out  of  which  all  the  others  arise.  It  is  interesting  to  note 
that  Glisson  attributed  rickets  to  disturbed  nutrition  by  arterial  blood,  and 
believed  the  changes  in  the  long  bones  to  be  due  to  excessive  vascularity. 

The  chemical  analysis  of  rickety  bones  shows  a  marked  diminution  in  the 
calcareous  salts,  which  may  be  as  low  as  25  or  35  per  cent. 

The  liver  and  spleen  are  usually  enlarged,  and  sometimes  the  mesenteric 
glands.  As  Gee  suggested,  these  conditions  probably  result  from  the  general 
state  of  the  health  associated  with  rickets.  Beneke  has  described  a  relative 
increase  in  the  size  of  the  arteries  in  rickets. 

Symptoms. — The  disease  comes  on  insidiously  about  the  period  of  denti- 
tion, before  the  child  begins  to  walk.  Mild  grades  of  it  are  often  overlooked. 
In  many  cases  digestive  disturbances  precede  the  appearance  of  the  character- 
istic lesions,  and  the  nutrition  of  the  child  is  markedly  impaired.  There  is 
usually  slight  fever,  the  child  is  irritable  and  restless,  and  sleeps  badly.  If  he 
has  already  walked,  he  now  shows  a  marked  disinclination  to  do  so,  and  seems 
feeble  and  unsteady  in  his  gait.  Sir  William  Jenner  called  attention  to  three 
general  symptoms  of  great  importance :  First,  a  diffuse  soreness  of  the  body, 
so  that  the  child  cries  when  an  attempt  is  made  to  move  it,  and  prefers  to  keep 
perfectly  still.  Secondly,  slight  fever  (100°  to  101.5°  F.),  with  nocturnal 
restlessness,  and  a  tendency  to  throw  off  the  bedclothes.  This  may  be  partly 
due  to  the  fact  that  the  general  sensitiveness  is  such  that  even  their  weight 
may  be  distressing.  Thirdly,  profuse  sweating,  particularly  about  the  head 
and  neck,  so  that  in  the  morning  the  pillow  is  soaked  with  perspiration. 

The  tissues  become  soft  and  flabby;  the  skin  is  pale;  and  from  a  healthy, 
plump  condition  the  child  becomes  puny  and  feeble.  The  muscular  weakness 
may  be  marked,  particularly  in  the  legs,  and  paralysis  may  be  suspected.  This 
so-called  pseudo-paresis  of  rickets  results  in  part  from  the  flabby,  weak  con- 
dition of  the  legs  and  in  part  from  the  pain  associated  with  the  movements. 
Coincident  with,  or  following  closely  upon,  the  general  symptoms  the  charac- 
teristic skeletal  lesions  are  observed.  Among  the  first  of  these  to  appear  are 
the  changes  in  the  ribs,  at  the  junction  of  the  bone  with  the  cartilage,  forming 
the  so-called  rickety  rosary.  When  the  child  is  thin  these  nodules  may  be 
distinctly  seen,  and  in  any  case  can  be  easily  made  out  by  touch.  They  very 
rarely  appear  before  the  third  month.  They  may  increase  in  size  up  to  the 
second  year,  and  are  rarely  seen  after  the  fifth  year.  The  thorax  undergoes 
important  changes.  Just  outside  the  junction  of  the  cartilages  with  the  ribs 
there  is  an  oblique,  shallow  depression  extending  downward  and  outward. 
A  transverse  curve,  sometimes  called  Harrison's  groove,  passes  outward  from 
the  level  of  the  ensiform  cartilage  toward  the  axilla,  and  may  be  deepened  at 
each  inspiration.  It  is  rendered  more  prominent  by  the  eversiou  and  promi- 
nence of  the  costal  border.  The  sternum  projects,  particularly  in  its  lower 
half,  forming  the  so-called  pigeon  or  chicken  breast.  These  changes  in  the 
thorax  are  not  peculiar,  however,  to  rickets,  and  are  much  more  commonly 
associated  with  hypertrophy  of  the  tonsils,  or  any  trouble  which  interferes 
with  the  free  entrance  of  air  into  the  lungs.  The  spine  is  often  curved  pos- 
teriorly, the  processes  are  prominent ;  lateral  curvature  is  not  so  common. 

The  liead  of  a  rickety  child  usuaHy  looks  large  in  proportion  both  to  the 
body  and  the  face,  and  the  fontanelles  remain  open  for  a  long  time.  There  are 
.ireas,   particularly   in   the   parieto-occipital   regions,  in   which  ossification   is 


EICKETS  439 

imperfect;  and  the  bone  may  yield  to  the  pressure  of  the  finger,  a  condition 
to  which  the  term  cranio-tabes  has  been  given.  Coincidently  with  this,  hyper- 
plasia proceeds  in  the  frontal  and  parietal  eminences,  so  that  these  portions  of 
the  skull  increase  in  thickness,  and  may  form  irregular  bosses.  In  one  type 
the  skull  may  be  large  and  elongated,  with  the  top  considerably  flattened.  In 
another,  and  perhaps  more  common,  case  the  shape  of  the  skull,  when  seen 
from  above,  is  rectangular — the  caput  quadratum.  The  skull  looks  large  in 
proportion  to  the  face.  The  forehead  is  broad  and  square,  and  the  frontal 
eminences  marked.  The  anterior  fontanelle  is  late  in  closing,  and  may  remain 
open  until  the  third  or  fourth  year.  The  skin  is  thin,  the  veins  are  full  ancl 
prominent,  and  the  hair  is  often  rubbed  from  the  back  of  the  skull. 

On  placing  the  ear  over  the  anterior  fontanelle,  or  in  the  temporal  region, 
a  systolic  murmur  may  frequently  be  heard.  This  condition,  first  described 
by  John  D.  Fisher,  of  Boston,  in  1833,  is  heard  with  the  greatest  frequency 
in  rickets,  but  its  presence  and  persistence  in  perfectly  healthy  infants  have 
been  amply  demonstrated.  The  murmur  is  rarely  present  after  the  fifth  year, 
A  knowledge  of  the  existence  of  this  systolic  brain  murmur  may  prevent  errors. 
A  case  has  been  reported  as  an  instance  of  tumor  of  the  brain. 

Changes  occur  in  the  bones  of  the  face,  chiefly  in  the  maxillge,  which  are 
reduced  in  size.  The  normal  process  of  dentition  is  much  disturbed;  indeed, 
late  teething  is  one  of  the  marked  features  in  rickets.  The  teeth  which  appear 
may  be  small  and  badly  formed. 

In  the  upper  limbs  changes  in  the  scapulge  are  not  common.  The  clavicle 
may  be  thickened  at  the  sternal  end,  and  there  may  be  thickening  near  the 
attachment  of  the  sterno-cleido  muscle.  The  most  noticeable  changes  are 
at  the  lower  ends  of  the  radius  and  ulna.  The  enlargement  is  at  the  junction- 
area  of  the  shaft  and  epiphysis.  Less  evident  enlargements  may  occur  at  the 
lower  end  of  the  humerus.  In  severe  cases  the  natural  shape  of  the  bones  of 
the  arm  may  be  much  altered,  since  they  have  had  to  support  the  weight  of 
the  child  in  crawling  on  the  floor.  The  changes  in  the  pelvis  are  of  special 
importance,  particularly  in  female  children,  as  in  extreme  cases  they  lead  to 
great  deformity,  with  narrowing.  In  the  legs,  the  lower  end  of  the  tibia  first 
becomes  enlarged;  and  in  slight  cases  it  may  alone  be  aifected.  In  the  severe 
forms  the  upper  end  of  the  bone,  the  corresponding  parts  of  the  fibula,  and 
the  lower  end  of  the  femur  become  greatly  thickened.  If  the  child  walks,  slight 
bowing  of  the  tibiae  inevitably  results.  In  more  advanced  cases  the  tibiae,  and 
even  the  femora,  may  be  arched  forward.  In  other  instances  the  condition  of 
knock-knee  occurs.  Unquestionably  the  chief  cause  of  these  deformities  is 
the  weight  of  the  body,  but  muscular  action  takes  part  in  it.  The  green-stick 
fracture  is  not  uncommon  in  the  soft  bones  of  rickets. 

These  changes  in  the  skeleton  proceed  slowly,  and  the  general  symptoms 
vary  a  good  deal  with  their  progress.  The  child  becomes  more  or  less  ema- 
ciated, though  ^'fat  rickets"  is  by  no  means  uncommon,  and  a  child  may  be 
well  nourished  but  "pasty"  and  flabby.  Fever  is  not  constant,  but  in  actively 
progressing  changes  in  the  bone  there  is  usually  a  slight  pyrexia.  The  abdo- 
men is  large,  "pot-bellied,"  due  partly  to  flatulent  distention,  partly  to  en- 
largement of  the  liver,  and  in  severe  cases  to  diminution  of  the  volume  of  the 
thorax.  The  spleen  is  often  enlarged  and  readily  palpable.  The  urine  is  stated 
to  contain  an  excess  of  lime  salts.    There  is  usually  slight  anaemia,  the  haemo- 


440  DISEASES  OF  METABOLISM 

globin  is  absolutely  and  relatively  decreased;  a  leueocytosis  may  or  may  not 
be  present;  it  is  more  common  with  enlargement  of  the  spleen  (Morse).  Many 
rickety  children  show  marked  nervous  symptoms ;  irritability^  peevishness,  and 
sleeplessness  are  constantly  present.  Jenner  called  attention  to  the  close  re- 
lationship which  existed  betAveen  rickets  and  infantile  convulsions,  particularly 
to  the  fits  which  occur  after  the  sixth  month.  Tetany  is  by  no  means  uncom- 
mon. It  involves  most  frequently  the  arms  and  hands;  occasionally  the  legs 
as  well.  Laryngismus  stridulus  is  a  common  complication,  and  though  not, 
as  some  state,  invariably  associated,  yet  it  is  certainly  much  more  frequent  in 
ricket}^  than  in  other  children.  Severe  rickets  interferes  seriously  with  the 
growth  of  a  child.  Extreme  examples  of  rickety  dwarfs  are  not  uncommon. 
Acute  rickets,  so-called,  is  in  reality  a  manifestation  of  scurvy,  and  has  been 
described  with  that  disease. 

Prognosis. — The  disease  is  never  in  itself  fatal,  but  the  condition  of  the 
child  is  such  that  it  is  readily  carried  ofE  by  intercurrent  affections,  particu- 
larly those  of  .the  resjoiratory  organs.  Spasm  of  the  larynx  and  convulsions 
occasionally  cause  death.  In  females  the  deformity  of  the  pelvis  is  serious, 
as  it  may  lead  to  difficulties  in  parturition. 

Treatment. — The  better  the  condition  of  the  mother  during  pregnancy  the 
less  likelihood  is  there  of  the  development  of  rickets  in  the  child.  Eapidly 
repeated  pregnancies  and  suckling  of  a  child  during  pregnancy  seem  impor- 
tant factors  in  the  production  of  the  disease.  Of  the  general  treatment,  at- 
tention to  the  feeding  of  the  child  is  the  first  consideration.  If  the  mother 
is  unhealthy,  or  cannot  nurse  the  child,  a  suitable  wet-nurse  should  be  pro- 
vided, or  the  child  must  be  artificially  fed,  in  which  case  cow's  milk,  diluted 
according  to  the  age  of  the  child,  should  constitute  the  chief  food.  Care 
should  be  taken  to  examine  the  stools,  and  if  curds  are  present  the  child  is 
taking  too  much,  or  it  is  not  sufficiently  diluted.  Barley-water  and  carefully 
strained  and  well-boiled  oatmeal  gruel  form  excellent  additions  to  the  milk. 

The  child .  should  be  warmly  clad  and  in  the  fresh  air  and  sunshine  the 
greater  part  of  the  day.  The  child  should  be  bathed  daily  in  warm  water. 
Careful  friction  with  sweet  oil  is  very  advantageous,  and,  if  properly  per- 
formed, allays  rather  than  aggravates  the  sensitiveness.  Special  care  should 
be  taken  to  prevent  deformity.  The  child  should  not  be  allowed  to  walk,  and 
for  this  purpose  splints  applied  so  as  to  extend  beyond  the  feet  are  very  ef- 
fective. Of  medicines,  phosphorus  has  been  warmly  recommended  by  Kasso- 
witz,  and  also  by  Jacobi.  The  child  may  be  given  gr.  1/120  (0.0005  gm.) 
two  or  three  times  a  day,  dissolved  in  olive  oil.  The  best  preparation  is  the 
elixir  phosphori,  six  to  ten  minims  (0.36  to  0.6  c.  c.)  three  times  a  day 
(Jacobi).  Cod-liver  oil,  in  doses  of  from  a  half  to  one  teaspoonful,  is  very 
advantageous.  The  syrup  of  the  iodide  of  iron  may  be  given  with  the  oil.  The 
digestive  disturbances,  together  with  the  complications,  should  receive  ap- 
propriate treatment.  Polyglandular  therapy  is  said  to  have  been  useful,  given 
on  the  possibility  that  the  internal  secretions  are  at  fault. 

V.     OBESITY 

Definition. — A  disorder  of  metabolism  characterized  by  excessive  deposit 

of  fat  in  the  body. 


OBESITY  441 

Etiology. — Corpulence,  an  overgrowth  of  the  bodily  fat,  an  "oily  dropsy," 
as  Byron  termed  it,  is  a  common  condition  which  may  be  a  source  of  great 
bodily  and  mental  distress.  Primarily  it  results  from  inadequate  oxidation  of 
the  food  stuffs,  associated  either  with  excessive  absorption  of  the  materials 
which  produce  fat,  or  with  incomplete  combustion.  Both  factors  probably 
take  part.  It  is  not  always  due  to  excessive  intake  of  food;  many  stout  per- 
sons are  light  eaters.  On  the  otber  hand,  there  are  cases  in  which  the  increase 
in  weight  is  directly  due  to  an  excessive  consumption  of  food.  There  is  a 
marked  hereditary  tendency.  *  Certain  races  are  prone  to  obesity,  and  women 
are  more  often  affected  than  men. 

Fat  metabolism  is  as  yet  imperfectly  understood;  it  is  under  the  control 
of  the  internal  secretions.  We  see  the  deposition  of  fat  in  connection  with 
many  processes  with  which  the  internal  secretions  are  concerned.  At  puberty 
there  is  a  great  increase  in  the  fat  deposits,  particularly  of  the  skin.  Follow- 
ing castration  there  is  an  increase  in  the  amount  of  subcutaneous  fat.  Eunuchs 
as  a  rule  are  very  stout.  At  the  menopause  increase  in  weight  is  common, 
and  during  both  pregnancy  and  lactation  the  subcutaneous  fat  may  be  greatly 
increased. 

In  only  one  point  have  we  positive  knowledge  as  to  the  internal  secretions 
controlling  fat  metabolism.  It  has  been  known  that  tumors  of  the  pituitary 
gland  or  in  its  neighborhood  may  be  associated  with  general  adiposity  and 
sexual  infantilism  (Frohlich's  syndrome).  The  studies  of  Cushing  and  his 
students  have  shown  that  the  pituitary  body  influences  carbohydrate  metab- 
olism, and  that  with  the  removal  of  the  posterior  lobe  there  is  a  great  increase 
in  the  body  weight.  There  seems  to  be  a  definite  hypophysial  syndrome  of 
increased  tolerance  for  carbohydrates  with  adiposity.  Many  of  the  cases  of 
extreme  obesity  in  young  persons  are  due  to  hypopituitarism.  The  remark- 
able acute  obesity,  in  which  as  much  as  70  pounds  may  be  gained  in  six 
months,  probably  depends  upon  perversions  of  some  internal  secretions. 

Symptoms. — Inconvenience  caused  by  the  bulk,  and  loss  of  good  looks 
in  women,  are  the  features  for  which  we  are  usually  consulted.  While  fat  is 
no  sign  of  health,  the  great  bulk  may  be  consistent  with  remarkable  vigor  and 
activity.  Shortness  of  breath,  embarrassed  cardiac  action,  difficulty  in  walk- 
ing are  the  most  common  complaints.  In  children  obesity  is  very  often  asso- 
ciated with  careless  habits  in  eating  and  lack  of  proper  control  on  the  part 
of  parents.  The  condition  is  increasing,  particularly  in  the  United  States, 
where  one  sees  an  extraordinary  number  of  very  stout  children.  A  remarkable 
phenomenon  associated  with  excessive  fat  is  an  uncontrollable  tendency  to 
sleep — like  the  fat  boy  in  Pickwick.  It  is  probable  that  this  narcolepsy  is 
a  manifestation  of  disturbed  internal  secretions. 

Treatment. — In  women  obesity  is  a  very  distressing  state,  accompanied 
with  all  sorts  of  inconveniences  and  discomforts.  With  a  marked  hereditary 
tendency  not  much  can  be  expected.  The  famous  George  Cheyne,  who  was 
a  man  of  enormous  bulk,  reduced  himself  by  dieting  from  thirty-two  stones 
(448  pounds)  to  proper  dimensions.  One  of  his  aphorisms  says :  "Every 
wise  man  after  Fifty  ought  to  begin  and  lessen  at  least  the  quantity  of  his 
Aliment,  and  if  he  would  continue  free  from  great  and  dangerous  Distempers 
and  preserve  his  Senses  and  Faculties  clear  to  the  last,  he  ought  every  seven 
years  to  go  on  abating  gradually  and  sensibly,  and  at  last  descend  out  of  life 


442  DISEASES  OF  METABOLISM 

as  he  ascended  into  it,  even  into  a  Child's  Diet/'  Put  in  other  words,  it  reads 
— We  eat  too  much  after  forty  years  of  age. 

In  the  case  of  children  very  much  may  be  done  by  regulating  the  diet, 
reducing  the  starches  and  fats  in  the  food,  not  allowing  them  to  eat  sweets, 
and  encouraging  systematic  exercises.  In  the  case  of  women  who  tend  to  grow 
stout  after  child-bearing  or  at  the  climacteric,  in  addition  to  systematic  exer- 
cises, they  should  be  told  to  avoid  taking  too  much  food,  and  particularly  to 
reduce  the  starches'  and  sugars.  There  are  a  number  of  methods  or  systems 
in  vogue  at  present.  In  the  celebrated  one  of  Banting  the  carbohydrates  and 
fats  were  excluded  and  the  amount  of  food  was  greatly  reduced, 

Oertel's  method  is  given  under  the  treatment  of  fatty  heart.  He  reduces 
the  amount  of  liquid  taken,  and  this  is  practically,  too,  the  so-called  Schwen- 
inger cure,  in  which  liquids  are  allowed  only  two  hours  after  the  food. 

Von  Noorden's  dietary  is  as  follows:  Eight  o'clock,  80  grams  of  lean, 
cold  meat,  25  grams  of  bread,  one  cup  of  tea,  with  a  spoonful  of  milk,  no 
sugar.  Ten  o'clock,  one  egg.  Twelve  o'clock,  a  cup  of  strong  meat  broth. 
One  o'clock,  a  small  plate  of  meat  soup  flavored  with  vegetables,  150  grams 
of  lean  meat  of  one  or  two  sorts,  partly  fish,  partly  flesh,  100  grams  of  potatoes 
with  salad,  100  grams  of  fresh  fruit,  or  compote  without  sugar.  Three  o'clock, 
a  cup  of  black  coffee.  Four  o'clock,  200  grams  of  fresh  fruit.  Six  o'clock,  a, 
quarter  of  a  litre  of  milk,  if  desired,  with  tea.  Eight  o'clock,  125  grams  of 
cold  meat,  or  180  grams  of  meat  weighed  raw  and  grilled,  and  eaten  with 
pickles  or  radishes  and  salad,  30  grams  of  Graham  bread,  and  two  or  three 
spoonfuls  of  cooked  fruit  without  sugar.  He  believes  it  more  satisfactory  to 
give  in  addition  to  the  three  meals  smaller  quantities  of  food  at  shorter  inter- 
vals, so  as  to  obviate  the  tendency  to  weakness  which  these  patients  often  ex- 
perience. In  addition  he  allows  twice  in  the  day  a  glass  of  wine.  The  use 
of  mineral  water,  weak  tea,  or  lemonade  is  not  limited  at  the  meal  times  or  in 
the  intervals.    An  occasional  "hunger-day"  is  given. 

In  the  treatme7it  of  extreme  obesity  it  is  very  much  better  that  the  patient 
should  be  in  hospital,  or  under  the  care  of  a  nurse,  who  will  undertake  the 
proper  weighing  and  administration  of  the  food.  The  amount  of  fluid  in- 
gested should  not  be  reduced  below  one  litre  a  day.  Many  of  these  patients 
are  anaemic,  even  with  a  florid  appearance,  and  for  them  iron  in  full  doses  is 
advisable. 

The  thyroid  extract  should  be  used  only  in  a  systematic  "cure."  One 
grain  three  times  a  day  is  a  sufficient  dose  at  first.  'In  conjunction  with  the 
diet  and  exercises  it  is  useful,  but  it  should  not  be  ordered  indiscriminately 
to  fat  persons.  Pituitary  gland  extracts  have  also  been  used.  The  use  of  in- 
voluntary or  passive  exercise  by  means  of  electricity  is  useful,  especially  in 
the  reduction  of  regional  fat. 


VI.     THE  LIPOMATOSES 

Various  forms  of  localized  deposits  of  fat  may  be  considered  here,  and  we 
follow  the  division  in  Lyon's  thorough  study  of  these  conditions  {Archives  of 
Internal  Medicine,  VI,  1). 

I.  Adiposis  Dolorosa  (Dercum's  Disease). — In  the  words  of  the  original 


LIPOMATOSES  443 

description  this  is  a  disorder  characterized  by  irregular  symmetrical  deposits 
of  fatty  masses  in  various  portions  of  the  body,  preceded  or  attended  by  pain, 
and  associated  sometimes  with  asthenia  and  psychical  changes. 

The  lipomatous  masses  are  diffuse  and  symmetrical,  involving  the  abdo- 
men, chest,  arms  or  legs ;  or  localized  on  the  limbs  or  trunk.  The  hands,  face 
and  feet  are  usually  spared.  The  pain  is  sometimes  spontaneous  and  is  easily 
excited  by  pressure.  Asthenia,  not  always  present,  may  be  a  marked  feature. 
The  patients  are  often  irritable  and  there  are  cases  with  mental  changes. 
Sometimes  the  skin  over  the  areas  of  infiltration  is  markedly  hypersesthetic. 
The  affection  is  more  common  in  females.  Xine  or  ten  autopsies  have  been 
made,  none  of  which  threw  clear  light  on  the  pathology.  Quite  possibly  it 
is  a  disturbance  of  the  internal  secretions. 

II.  Nodular  Circumscribed  Lipomatosis. — The  cases  are  common.  The 
lipomata  are  distributed  in  various  localities  and  vary  in  size  from  small 
encapsulated  nodules  to  large  circumscribed  tumors,  solitary  or  multiple,  some- 
times symmetrically  placed.  They  may  be  painful,  and  Lyon  calls  attention 
to  the  fact  that  the  accessory  features  of  asthenia  and  psychical  changes  may 
also  be  present. 

III.  Diffuse  Symmetrical  Lipomatosis  of  the  Neck. — This  remarkable  af- 
fection, also  called  adeno-lipomatosis,  is  characterized  by  symmetrical  fatty 
infiltrations,  either  simple  or  lobulated,  of  the  subcutaneous  tissues,  forming 
a  huge  collar  about  the  neck.  It  may  occur  in  this  part  alone,  or  other  limited 
lipomata  are  found  elsewhere.  Males  are  much  more  frequently  attacked  than 
females.  The  tumors  interfere  but  little  with  health,  but  as  they  increase  the 
condition  becomes  very  disfiguring.  There  are  sometimes  constitutional  symp- 
toms. The  name  "ar/eno-lipomatosis"  has  been  given  because  scattered 
throughout  the  diffuse  fatty  masses  there  are  small  firm  nodules  of  lymphatic 
tissue — sometimes  hsmo-lymph  glands. 

IV.  Cerebral  Adiposity  {Dystrophia  Adiposo-Genitalis,  Frohlich). — A 
condition  of  obesity  may  occur  in  connection  with  tumors  of  the  hypophysis, 
or  adjacent  parts,  associated  with  a  hypoplasia  of  the  genital  organs  and  a 
condition  of  infantilism.  The  condition  will  be  discussed  in  the  section  on 
internal  secretions,  as  it  appears  from  the  researches  of  Gushing  to  be  associ- 
ated with  the  perversion  of  the  function  of  the  pituitary  gland. 

V.  Pseudo-Lipoma. — Sydenham  made  the  keen  observation  that  in  hys- 
terical patients  there  were  sometimes  swellings,  which  neither  yielded  to  the 
impress  of  the  finger  nor  left  a  mark.  Charcot  described  the  condition  as 
"hysterical  oedema,"'  of  which  there  is  both  a  blue  and  a  white  variety. 

Many  of  these  subcutaneous  infiltrations,  just  as  in  the  soft,  supraclavicu- 
lar pad,  so  common  in  stout  women,  are  due  to  fat,  and  French  writers  de- 
scribe all  grades  of  transition  from  a  pseudo-oedema  to  a  true  lipoma. 

Treatment. — This  is  not  satisfactory.  A  trial  of  thyroid  extract  in  small 
doses  is  advisable,  but  it  is  well  to  suspend  its  use  for  a  week  in  every  month. 
Extracts  of  other  glands  may  also  be  tried.  In  patients  with  signs  of  tumor 
of  the  hypophysis  surgical  measures  should  be  considered. 


444  DISEASES  OF  METABOLISM 


Vn.     H.EMOCHROMATOSIS 

Definition. — A  disorder  of  metabolism  characterized  by  a  deposition  of  an 
iron-containing  pigment  in  the  glandular  organs,  and  by  an  increase  in  the 
normal  pigmentation  with  which  is  associated  a  progressive  sclerosis  of  various 
organs,  and,  in  a  large  proportion  of  the  cases,  diabetes.  The  disease  was 
first  described  by  von  Eecklinghausen. 

Etiology. — Of  the  cases  on  record  the  great  majority  had  diabetes.  Only 
one  occurred  in  a  woman.  In  the  majority  of  the  patients,  middle-aged  men, 
there  seemed  to  be  no  marked  predisposing  causes,  though  Blumer  maintains 
that  alcohol  plays  an  important  part. 

Pathology. — On  autopsy  the  ochre  or  bronze  color  of  the  organs  is  the 
striking  feature.  The  liver  is  large  and  sclerotic :  the  spleen  also  enlarged, 
and  the  pancreas  either  small  and  atrophic  or  fatty  and  fibroid.  The  lymph 
nodes  are  also  pigmented.  The  pigment  is  hsemosiderin  or  iron-reacting.  It 
is  chiefly  in  the  cells  of  the  glands,  in  the  muscle  cells  of  the  heart,  and  in  the 
lymph  nodes.  The  amount  in  the  various  organs  is  enormous,  a  hundred  times 
the  normal  in  the  liver,  for  example.  The  hsemof uscin,  the-  non-iron-reacting 
pigment,  varies  in  different  amounts,  and  it  has  a  yellow  tint,  and  is  found 
chiefly  in  the  connective  tissue  cells.     The  blood  shows  no  special  changes. 

The  pathogenesis  is  obscure,  and  Sprunt,  whose  study  {Archives  of  Internal 
Medicine,  July.  1911)  contains  an  admirable  summary  of  pur  knowledge, 
concludes  that  there  is  no  evidence  of  abnormal  blood  destruction,  and  that 
it  is  a  primary  disorder  of  metabolism,  "implicating  many  of  the  body  tissues, 
and  manifested  by  a  change  in  the  chromogenic  groups  of  the  proteid  molecule 
with  the  deposition  of  pigments.'"' 

Eons  and  Oliver  produced  an  identical  condition  in  rabbits  by  repeated 
transfusions  of  blood,  so  that  large  amounts  were  being  constantly  destroyed. 

Clinical  Features. — There  are  two  groups  of  cases,  the  larger  one  in  which 
diabetes  is  present,  and  the  smaller  in  which  there  is  no  sugar  in  the  urine. 
The  former  group  is  spoken  of  by  the  French  as  diabete  bronze,  which  has  the 
features  of  a  severe  diabetes  with  weakness,  progressive  pigmentation  of  the 
skin,  and  an  enlarged  liver.  The  pigmentation  of  the  skin  which  is  the  fea- 
ture that  attracts  attention  varies  in  color  from  a  dark  brown  to  a  leaden  or 
bluish  black.  Dr.  Maude  Abbott's  case  was  known  as  Blue  Mary.  The  liver 
shows  cirrhosis  with  a  smooth  and  uniform  enlargement.  The  spleen  may 
be  enlarged  secondarily.  It  was  very  large  in  two  of  our  cases.  The  diabetes 
is  usually  severe,  and  runs  a  rapid  course.  Prior  to  the  onset  of  diabetes 
the  disease  may  last  for  years. 

There  is  no  special  treatment  beyond  measures  for  the  general  health;  in 
the  patients  with  diabetes  the  usual  treatment  should  be  carried  out. 

Vm.     OCHRONOSIS 

Definition. — A  rare  disorder  of  metabolism  associated  with  blackening  of 
the  cartilages  and  fibrous  tissues  and  pigmentation  of  the  skin,  and  the  pres- 
ence of  dark  urine  due  to  alcapton  or  to  derivatives  of  carbolic  acid. 


ACIDOSIS  445 

Etiology. — There  are  two  groups  of  cases : 

(ft)  There  is  a  congenital  life-long  chemical  malformation,  sometimes  a 
family  affection,  in  which  there  is  a  failure  to  complete  the  catabolism  of  cer- 
tain aromatic  compounds,  with  the  result  that  peculiar  bodies,  homogentisic 
acid  and  uroleucic  acid  are  excreted  in  the  urine,  which  blackens  on  exposure 
to  air — alcaptonuria.     The  anomaly  may  be  present  in  three  generations. 

(b)  In  the  other  gToup  the  dark  urine  and  the  blackening  of  the  tissues 
are  due  to  the  prolonged  use  of  carbolic  acid,  usually  the  application  of  strong 
solutions  externally  to  ulcers.     There  may  possibly  be  other  causes. 

Symptoms. — When  well  developed,  ochronosis  presents  a  very  striking  pic- 
ture. The  discoloration  of  the  fibrous  tissues  is  best  seen  about  the  knuckles, 
and  in  thin  persons  the  tendons  of  the  hands  and  feet  show  a  bluish-gray  ap- 
pearance. The  cartilage  of  the  ear  has  a  bluish  tint,  and  there  may  be  sym- 
metrical black  patches  on  the  sclerotics.  Widespread  pigmentation  of  the 
skin  has  been  observed.  In  one  patient  there  was  a  coal-black  discoloration 
of  the  skin  over  the  nose  and  cheeks,  and  the  same  was  beginning  in  the 
hands.  This  may  occur  also  in  the  carboluria  group,  as  well  shown  in  the 
colored  illustration  of  Dr.  Pope's  patient.  Several  of  the  reported  cases  had 
arthritis,  and  the  two  brothers  in  the  Maryland  family  had  a  curious  anterior 
inclination  of  the  trunk,  and  a  peculiar  waddling  gait.  There  are  few  symp- 
toms directly  due  to  the  chemical  malformation.  The  patients  enjoy  good 
health,  but  the  disfigurement  may  be  very  great.  Post  mortem,  the  appear- 
ance is  remarkable,  as  pictured  in  Virchow's  original  case;  the  cartilages,  liga- 
ments and  fibrous  structures  are  everywhere  of  a  brown-black  color. 


IX.    ACIDOSIS 

Definition. — ^Acidosis  may  be  defined  as  a  decrease  in  the  amount  of  fixed 
bases  in  the  blood  and  other  tissues  of  the  body  or  in  other  words  a  relative 
increase  in  the  acid  ions.  This  involves  a  decrease  in  the  alkali  reserve  of  the 
body  and  hence  a  disturbance  of  the  acid-base  equilibrium.  This  might  be 
described  better  as  a  decrease  in  the  alkalinity ;  an  actual  acid  condition  is  not 
present.  The  free  carbon  dioxide  in  the  body  converts  the  bases  not  bound 
by  other  acids  to  bicarbonate  and  hence  the  bicarbonate  represents  the  excess 
of  base  remaining  after  non-volatile  acids  have  been  neutralized.  Hence 
acidosis  involves  a  depletion  of  the  bicarbonate  in  the  blood  which  has  been 
termed  the  "first  line  of  defence"  against  acidosis.  A  definite  acid-base 
equilibrium  is  essential  to  life  and  any  marked  departure  from  it  results  in 
serious  difficulty.  This  equilibrium  is  kept  at  a  very  constant  level  and  any 
increase  of  acid  or  alkali  is  automatically  guarded  against.  Under  ordinary 
conditions  of  diet  there  is  production  of  acid  radicals.  These  are  disposed 
of  by  oxidation,  elimination,  excretion  and  neutralization. 

The  means  by  which  the  normal  ratio  is  maintained  are  as  follows:  (1) 
Elimination  of  carbon  dioxide  by  the  lungs,  in  which  sodium  bicarbonate 
plays  a  large  part  as  a  carrier;  (2)  elimination  of  acid  by  the  kidneys;  (3) 
neutralization  of  acid  by  ammonia,  and  (4)  intake  of  fixed  bases  with  the 
food.  It  is  evident  that  oxidation  plays  a  large  part  in  the  process.  In  dis- 
turbance of  the  usual  acid -base  relations  the  body  endeavors  to  protect  itself 


446  DISEASES  OF  METABOLISM 

by  an  increase  in  the  normal  processes.  One  important  means  is  increased 
neutralization  of  acid  by  ammonia.  The  ratio  of  this  to  the  total  N  of  the 
urine,  which  normally  is  2  to  5  per  cent.,  may  rise  to  25  or  even  40  per  cent. 
By  an  increased  respiration  rate  the  effort  is  made  to  excrete  more  carbon 
dioxide  by  the  lungs.  The  kidneys  may  excrete  more  acid  than  in  normal 
conditions.  The  reserve  of  alkali  is  used  so  far  as  it  is  available.  These 
means,  however,  may  not  be  sufficient  and  it  is  evident  that  a  decrease  in  the 
amount  of  sodium  bicarbonate  will  result  in  less  CO,  being  carried  from  the 
tissues  and  hence  an  accumulation  of  it  there.  From  this  dyspnoea  and  air 
hunger  result.  So  long  as  the  reduction  in  the  alkali  reserve  is  not  marked 
the  condition  is  not  serious,  but  if  this  does  result  many  changes  follow,  dis- 
turbance in  oxidation,  disturbed  renal  function,  altered  N  metabolism,  dysp- 
noea, etc. 

The  mechanism  of  this  decreased  alkalinity  is  various.  In  diabetes  melli- 
tus  there  is  excessive  formation  of  acetone  bodies.  In  certain  of  the  diarrhceal 
diseases  it  may  be  that  alkali  is  excreted  by  the  bowel;  this  probably  occurs 
in  cholera.  In  conditions  in  which  there  is  loss  of  fluids  it  may  be  that  there 
is  not  sufficient  fluid  available.  The  kidneys  may  not  excrete  the  normal 
amount  of  acid  phosphates  or  may  be  unable  to  increase  the  excretion  to  meet 
an  emergency. 

Occurrence. — Acidosis  may  occur  in  many  diseases,  in  some  of  which  it 
is  of  slight  significance  only,  in  others  of  extreme  gravity.  The  more  impor- 
tant are  as  follows : 

(1)  Starvation. — This  applies  particularly  to  the  absence  of  carbohy- 
drates from  the  diet.  It  is  probably  a  factor  in  the  production  of  acidosis  in 
acute  infections  in  which  there  is  difficulty  in  giving  sufficient  food,  and  may 
contribute  to  the  acidosis  after  anaesthesia,  especially  in  cases  in  which  little 
or  no  food  has  been  taken  for  sometime  beforehand. 

(2)  Anaesthesia. — Slight  grades  of  acidosis  are  common  and  in  the  ma- 
jority unimportant,  but  in  a  critical  case  the  incidence  of  acidosis  may  be 
enough  to  determine  a  fatal  outcome.  Hence  the  wisdom  of  taking  meas- 
ures to  prevent  it  so  far  as  possible. 

(3)  Pregnancy. — Here  the  acidosis  is  rarely  of  serious  moment. 

(4)  In  Children.— In  certain  of  the  diarrhoeal  diseases  of  children,  aci- 
dosis may  be  marked  and  be  sufficient  to  determine  a  fatal  result.  The  cyclic 
vomiting  of  children  is  often  associated  with  acidosis.  An  acid  intoxication 
may  be  due  to  a  disturbance  in  the  metabolism  of  the  fats  and  proteins.  The 
condition  may  come  on  in  a  perfectly  healthy  child,  with  gastro-intestinal 
symptoms,  vomiting,  diarrhoea  and  slight  fever.  On  the  second  or  third 
day  dyspnoea  appears  with  abdominal  distention,  the  child  begins  to  get  drowsy, 
and  on  the  fourth  or  fifth  day  or  even  earlier  there  is  coma.  The  urine  usu- 
ally contains  acetone  and  diacetic  acid. 

(5)  Infectious  Diseases. — Eheumatic  fever,  pneumonia,  astatic  cholera 
and  typhoid  fever  are  examples. 

(6)  Diabetes  Mellitus. — In  this  acidosis  is  a  serious  factor.  The  term 
ketosis  or  ketone  acidosis  has  been  suggested  as  a  designation. 

(7)  Eenal  and  Cardio-Eenal  Disease. — In  this  group  it  appears  that 
the  decrease  in  the  ability  of  the  kidney  to  excrete  acids  is  an  important  factor. 

Diagnosis. —  (1)   Increase  in  the  Respiration  Eate. — In  certain  forms, 


ACIDOSIS  447 

as  in  diabetes  mellitus,  this  suggests  the  diagnosis  at  once.  In  all  cases  of 
h3'perpnoea  for  which  no  other  cause  is  found,  the  possibility  of  acidosis  should 
be  considered.  If  the  ketone  bodies  are  responsible  there  is  usually  a  fruity 
odor  to  the  breath. 

(2)  Carbon  Dioxide  Tension  in  the  Alveolar  Air. — Marked  lower- 
ing of  this  is  evidence  of  acidosis  except  when  due  to  the  effect  of  high  alti- 
tudes or  conditions  interfering  with  the  exchange  of  gases  between  the  alveolar 
air  and  the  blood. 

(3)  Blood.^ — (a)  Lowering  of  the  COg  content.  (&)  Decreased  alkalin- 
ity,     (c)   Determination  of  the  oxygen-containing  power  of  the  haemoglobin. 

(4)  Urine. —  (a)  Increase  in  the  ammonia,  (h)  Excess  of  acid  or  the 
presence  of  abnormal  acids,     (c)   Change  in  the  fixed  bases. 

(5)  Tolerance. — Tolerance  to  alkalies,  especially  bicarbonate,  measured 
by  the  amount  of  sodium  bicarbonate  required  to  render  the  urine  alkaline. 

Prognosis.. — ^As  acidosis  is  not  a  disease  in  itself,  it  is  difficult  to  speak 
of  prognosis,  but  the  outcome  of  the  disease  which  it  complicates  may  depend 
on  the  acidosis,  as  for  example  in  the  diarrhoeal  diseases  of  children.  In 
diabetes  mellitus,  acidosis  is  often  the  terminal  event.  The  response  to  treat- 
ment may  be  regarded  as  an  important  element  in  estimating  the  outcome. 

Treatment. — Prevention  should  be  used  whenever  possible.  In  diabetes 
mellitus  this  is  essential  and  should  always  be  considered  in  the  treatment 
of  that  disease.  Before  anaesthesia  and  in  the  acute  infections  the  useful 
measures  are:  (1)  The  giving  of  large  amounts  of  water.  (2)  The  admin- 
istration of  carbohydrate.  This  may  be  by  mouth  or  by  bowel  as  by  the  use 
of  a  2  to  5  per  cent,  solution  of  glucose.  (3)  The  giving  of  soda  bicarbonate 
by  mouth,  bowel  or  intravenously  until  the  urine  is  alkaline.  This  is  im- 
portant in  the  early  stages,  as  for  instance  in  children.  In  some  cases  the 
giving  of  sodium,  calcium,  potassium  and  magnesium  salts  may  be  of  advan- 
tage. With  established  acidosis  the  treatment  must  depend  on  the  under- 
lying condition.  In  general  the  giving  of  sodium  bicarbonate  intravenously 
(2-5  per  cent,  solution)  even  up  to  100  grams  is  advisable  in  severe  cases. 
In  milder  ones  the  administration  may  be  by  mouth  or  by  tectum.  If  possi- 
ble large  amounts  of  water  should  be  given. 


SECTIOX  YI 

DISEASES  OF  THE  DIGESTIVE  SYSTEM 

A.    DISEASES  OF  THE  MOUTH 

STOMATITIS 

Acute  Stomatitis. — Simple  or  erythematous  stomatitis,  tlie  commonest 
form,  results  from  the  action  of  irritants  of  various  sorts.  Frequent  at  all 
ages,  in  children  it  is  usually  associated  with  dentition  and  with  gastro-intes- 
tinal  disturbance,  particularly  in  ill-nourished,  unhealthy  subjects:  in  adults 
it  may  follow  the  abuse  of  tobacco,  or  the  use  of  too  hot  or  too  highly  seasoned 
food;  it  is  a  concomitant  of  indigestion,  or  of  the  specific  fevers. 

The  aifection  may  be  limited  to  the  gums  and  lips  or  may  extend  over  the 
whole  surface  of  the  mouth  and  include  the  tongue.  There  are  at  first  super- 
ficial redness  and  dryness  of  the  membrane,  followed  by  increased  secretion  and 
swelling  of  the  tongue,  which  is  furred  and  indented  by  the  teeth.  There 
is  rarely  any  constitutional  disturbance,  but  in  children  there  may  be  slight 
fever.  The  condition  causes  discomfort,  sometimes  actual  distress  and  pain, 
particularly  in  mastication. 

In  infants  the  mouth  should  be  carefully  sponged  after  each  feeding.  A 
mouth-wash  of  borax  or  glycerin  and  borax  may  be  used,  and  in  severe  cases, 
which  tend  to  become  chronic,  a  one  per  cent,  solution  of  nitrate  of  silver 
may  be  applied. 

Aphthous  Stomatitis. — This  form,  also  known  as  follicular  or  vesicular 
stomatitis,  is  characterized  by  the  presence  of  small,  slightly  raised  spots, 
from  2  to  4  mm.  in  diameter,  surrounded  by  reddened  areolae.  The  spots 
appear  first  as  vesicles,  which  rupture,  leaving  small  ulcers  with  gra3dsh  bases 
and  bright-red  margins.  They  are  seen  most  frequently  on  the  inner  surfaces 
of  the  lips,  the  edges  of  the  tongue,  and  the  cheeks.  They  are  seldom  present 
on  the  mucous  membrane  of  the  i)har}Tix.  This  form  is  met  with  most  often 
in  children  under  three  years,  either  as  an  independent  affection  or  in  asso- 
ciation with  a  febrile  disease  or  with  an  attack  of  indigestion.  The  vesicles 
come  out  with  great  rapidity  and  the  little  ulcers  may  be  fully  formed  within 
twenty-four  hours.  The  child  complains  of  soreness  of  the  mouth  and  takes 
food  with  reluctance.  The  buccal  secretions  are  increased  and  the  breath  is 
heavy,  but  not  foul.  The  constitutional  symptoms  are  usually  those  of  the 
disease  with  which  the  aphtha  are  associated.  The  disease  must  not  be  con- 
founded with  thrush.  Xo  special  parasite  has  been  found  in  connection  with 
it.  It  is  not  a  serious  condition,  and  heals  rapidly  with  the  improvement  of 
the  constitutional  state.     In  severe  cases  it  may  extend  to  the  pillars  of  the 

448 


STOMATITIS  449 

fauces  and  to  the  pharynx,  and  produce  ulcers  which  are  irritating  and  difficult 
to  heal. 

Each  ulcer  should  be  touched  with  nitrate  of  silver  and  the  mouth  should 
be  thoroughly  cleansed  after  taking  food.  A  wash  of  chlorate  of  potassium,  or 
of  borax  and  glycerin,  may  be  used.  The  constitutional  symptoms  should  re- 
ceive careful  attention. 

A  curious  affection  occurs  in  southern  Italy  sometimes  in  epidemic  form, 
characterized  by  a  pearly-colored  membrane  with  induration,  immediately  be- 
neath the  tongue  on  the  frsenum  (Eiga's  disease).  There  may  be  much  indura- 
tion and  ultimately  ulceration.  It  occurs  in  both  healthy  and  cachectic  chil- 
dren, usually  about  the  time  of  the  eruption  of  the  first  teeth. 

Ulcerative  Stomatitis. — This  form,  which  is  also  known  by  the  names  of 
fetid  stomatitis,  or  putrid  sore  mouth,  occurs  particularly  in  children  after 
the  first  dentition.  It  may  prevail  as  a  widespread  epidemic  in  institutions 
in  which  the  sanitary  conditions  are  defective.  It  has  been  met  with  in  jails 
and  camps.  Insufficient  and  unwholesome  food,  improper  ventilatioii,  and 
prolonged  damp,  cold  weather  seem  to  be  special  predisposing  causes.  Lack 
of  cleanliness  of  the  mouth,  the  presence  of  carious  teeth,  and  the  collection 
of  tartar  around  them  favor  the  occurrence  of  the  disease.  The  affection 
spreads  like  a  specific  disease,  but  the  microbe  has  not  been  isolated.  It  has 
been  held  that  the  disease  is  the  same  as  the  foot-and-mouth  disease  and  that 
it  is  conveyed  by  milk,  but  there  is  no  positive  evidence  on  these  points. 

,  The  morbid  process  begins  at  the  margin  of  the  gums,  which  become 
swollen  and  red,  and  bleed  readily.  Ulcers  form,  the  bases  of  which  are 
covered  with  a  grayish-white,  firmly  adherent  membrane.  In  severe  cases  the 
teeth  may  become  loosened  and  necrosis  of  the  alveolar  process  may  occur. 
The  ulcers  extend  along  the  gum-line  of  the  upper  and  lower  jaws;  the  tongue, 
lips,  and  mucosa  of  the  cheeks  are  usually  swollen,  but  rarely  ulcerated.  There 
is  salivation,  the  breath  is  foul,  and  mastication  is  painful.  The  submaxillary 
lymph-glands  are  enlarged.  An  exanthem  may  appear  and  be  mistaken  for 
measles.  The  constitutional  symptoms  are  often  severe,  and  in  debilitated 
children  death  sometimes  occurs. 

In  the  treatment  chlorate  of  potassium  has  been  found  to  be  almost  specific. 
It  should  be  given  in  doses  of  5  grains  (0.3  gm.),  three  times  a  day,  to  a 
child,  and  to  an  adult  double  that  amount.  Locally  it  may  be  used  as  a 
mouth-wash,  or  the  powdered  salt  may  be  applied  directly  to  the  ulcerated 
surfaces.  When  there  is  much  fetor,  a  solution  of  potassium  permanganate 
may  be  used  as  a  wash,  and  silver  nitrate  applied  to  the  ulcers. 

A  variety  of  ulcerative  sore  mouth,  which  differs  entirely  from  this  form, 
is  common  in  nursing  women,  and  is  usually  seen  on  the  mucous  membrane 
of  the  lips  and  cheeks.  The  ulcers  arise  from  the  mucous  follicles,  and  are 
from  3  to  5  ■  mm.  in  diameter.  They  may  cause  little  or  no  inconvenience ; 
but  in  some  instances  they  are  very  painful  and  interfere  seriously  with  the 
taking  of  food  and  its  mastication.  As  a  rule  they  heal  readily  after  the 
application  of  nitrate  of  silver,  and  the  condition  is  an  indication  for  tonics, 
fresh  air,  and  a  better  diet. 

Recurring  outbreaks  of-  an  herpetic,  even  pemphigoid,  stomatitis  are  seen 
in  neurotic  individuals  {stomatitis  neurotica  chronica,  Jacobi).  It  may  pre- 
cede or  accompany  the  fatal  form  of  pemphigu^s  vegetans. 


450  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

Parrot  describes  the  occasional  appearance  in  new-born,  debilitated  chil- 
dren of  small  ulcers  symmetrically  placed  on  the  hard  palate  on  either  side 
of  the  middle  line.  They  rarely  heal,  but  tend  to  increase  in  size,  and  may 
involve  the  bone.  Bednar's  aphthae  consist  of  small  patches  and  ulcers  on  the 
hard  palate,  caused  as  a  rule  in  young  infants  by  the  artificial  nipple  or  the 
nurse's  finger. 

Parasitic  Stomatitis  (Thrush;  Soor;  Muguet). — This  affection,  most 
commonly  seen  in  children,  is  dependent  upon  a  fungus,  Saccharomyces  albi- 
cans^ called  by  Eobin  O'idium  albicans.  It  belongs  to  the  order  of  yeast 
fungi,  and  consists  of  branching  filaments,  from  the  ends  of  which  ovoid 
torula  cells  develop.  The  disease  apparently  does  not  arise  in  a  normal 
mucosa.  Improper  diet,  uncleanliness  of  the  mouth,  fermentation  of  rem- 
nants of  food,  or  the  occurrence,  from  any  cause,  of  catarrhal  stomatitis  pre- 
dispose to  the  growth.  In  institutions  it  is  frequently  transmitted  by  unclean 
feeding-bottles,  spoons,  etc.  It  is  not  confined  to  children,  but  is  met  with 
in  adults  in  the  final  stages  of  fever,  in  chronic  tuberculosis,  diabetes,  and  in 
cachectic  states.  The  parasite  grows  in  the  upper  layers  of  the  mucosa,  and 
the  filaments  form  a  dense  felt-work  among  the  epithelial  cells.  The  disease 
begins  on  the  tongue  and  is  seen  in  the  form  of  slightly,  raised,  pearly-white 
spots,  which  increase  in  size  and  gradually  coalesce.  The  membrane  thus 
formed  can  be  readily  scraped  off,  leaving  an  intact  mucosa,  or,  if  the  process 
extends  deeply,  a  bleeding,  slightly  ulcerated  surface.  The  disease  spreads 
to  the  cheeks,  lips,  and  hard  palate,  and  may  involve  the  tonsils  and  pharynx. 
In  very  severe  eases  the  entire  buccal  mucosa  is  covered  by  the  grayish-white 
membrane.  It  may  even  extend  into  the  oesophagus  and  to  the  stomach  and 
cgecum.  It  is  occasionally  met  with  on  the  vocal  cords.  Eobust,  well-nour- 
ished children  are  sometimes  affected,  but  it  is  usually  met  with  in  enfeebled, 
emaciated  infants  with  digestive  or  intestinal  troubles.  In  such  cases  the 
disease  may  persist  for  months. 

The  affection  is  readily  recognized,  and  must  not  be  confounded  with 
aphthous  stomatitis,  in  which  the  ulcers,  preceded  by  the  formation  of  vesi- 
cles, are  perfectly  distinctive.  In  thrush  the  microscopic  examination  shows 
the  presence  of  the  characteristic  fungus  throughout  the  membrane.  In  this 
condition,  too,  the  mouth  is  usually  dry — a  striking  contrast  to  the  salivation 
accompanying  aphthge. 

Thrush  is  more  readily  prevented  than  removed.  The  child's  mouth 
should  be  kept  scrupulously  clean,  and,  if  artificially  fed,  the  bottles  should 
be  thoroughly  sterilized.  Lime-water  or  any  other  alkaline  fluid,  such  as  the 
bicarbonate  of  soda  (a  drachm  to  a  tumbler  of  water),  may  be  employed. 
When  the  patches  are  present  these  alkaline  mouth-washes  may  be  continued 
after  each  feeding.  A  spray  of  borax  or  of  sulphite  of  soda  (a  drachm  to  the 
ounce)  or  the  black  wash  with  glycerine  may  be  employed.  The  perman- 
ganate of  potassium  is  also  useful.  The  constitutional  treatment  is  of  equal 
importance,  and  it  will  often  be  found  that  the  thrush  persists,  in  spite  of  all 
local  measures,  until  the  general  health  of  the  infant  is  improved  by  change 
of  air  or  the  relief  of  the  diarrhoea,  or,  in  obstinate  cases,  the  substitution  of 
a  natural  for  the  artificial  diet. 

Gangrenous  Stomatitis  (Cancrum  Oris;  Noma). — An  affection  character- 
ized by  a  rapidly  progressing  gangrene,  starting  on  the  gums  or  cheeks,  and 


STOMATITIS  451 

leading  to  extensive  sloughing  and  destruction.  This  terrible,  but  fortunately 
rare,  disease  is  seen  only  in  children  under  very  insanitary  conditions  or  dur- 
ing convalescence  from  the  acute  fevers.  It- is  more  common  in  girls  than  in 
boys.  It  is  met  with  between  the  ages  of  two  and  five  years.  In  at  least  one- 
half  of  the  cases  the  disease  occurs  during  convalescence  from  measles.  Cases 
have  been  seen  also  after  scarlet  fever  and  typhoid.  The  mucous  membrane 
is  first  affected,  usually  of  the  gums  or  of  one  cheek.  The  process  begins 
insidiously,  and  when  first  seen  there  is  a  sloughing  ulcer  of  the  mucous 
membrane,  which  spreads  rapidly  and  leads  to  brawny  induration  of  the  skin 
and  adjacent  parts.  The  sloughing  extends,  and  in  severe  cases  the  cheek  is 
perforated.  The  disease  may  spread  to  the  tongue  and  chin;  it  may  invade 
the  bones  of  the  jaws  and  even  involve  the  eyelids  and  ears.  In  mild  cases  an 
ulcer  forms  on  the  inner  surface  of  the  cheek,  which  heals  or  may  perforate 
and  leave  a  fistulous  opening.  Xaturally  in  such  a  severe  affection  the  con- 
stitutional disturbance  is  great,  the  pulse  rapid,  the  prostration  extreme, 
and  death  usually  takes  place  within  a  week  or  ten  days.  The  temperature 
may  reach  103°  or  104°  F.  Diarrhoea  is  usually  present,  and  aspiration 
pneumonia  is  a  common  complication.  No  specific  organism  has  been  found. 
Destruction  of  the  sore  by  the  Paquelin  cautery  or  fuming  nitric  acid  is  the 
most  effectual  treatment.  Antiseptic  applications  should  be  used  to  destroy 
the  fetor.  The  child  should  be  carefully  nourished  and  stimulants  given 
freely. 

Mercurial  Stomatitis  (Ptyalism) . — It  occurs  in  persons  with  a  special  sus- 
ceptibility, rarely  now  as  a  result  of  the  excessive  use  of  the  drug,  and  also 
in  those  whose  occupation  necessitates  the  constant  handling  of  mercury.  It 
may  follow  the  administration  of  repeated  small  doses.  Thus,  a  patient  with 
heart-disease  who  was  ordered  an  eighth  of  a  grain  of  calomel  every  three 
hours  for  diuretic  purposes  had,  after  taking  eight  or  ten  doses,  a  severe 
stomatitis,  which  persisted  for  several  weeks.  It  may  follow  the  adminis- 
tration of  small  doses  of  gray  powder.  The  patient  complains  first  of  a  me- 
tallic taste  in  the  mouth,  the  gums  become  swollen,  red,  and  sore,  mastication 
is  difficult,  the  salivary  glands  become  enlarged  and  painful,  and  there  is  a 
great  increase  in  their  secretion.  The  tongue  is  swollen,  the  breath  is  foul, 
and,  if  the  affection  progresses,  there  may  be  ulceration  of  the  mucosa,  and, 
in  rare  instances,  necrosis  of  the  jaw.  Although  troublesome  and  distressing, 
the  disease  is  rarely  serious,  and  recovery  usually  takes  place  in  a  couple  of 
weeks.  Instances  in  which  the  teeth  become  loosened  or  detached  or  in  which 
the  inflammation  extends  to  the  pharynx  and  Eustachian  tubes  are  rarely 
seen. 

The  administration  of  mercury  should  be  suspended  so  soon  as  the  gums 
are  "touched."  Mild  cases  of  the  affection  subside  within  a  few  days  and 
require  only  a  simple  mouth-wash.  In  severer  cases  the  chlorate  of  potassium 
may  be  given  internally,  and  used  to  rinse  the  mouth.  The  bowels  should  be 
freely  opened;  the  patient  should  take  a  hot  bath  every  evening  and  should 
drink  plentifully  of  alkaline  mineral  waters.  Atropine  is  sometimes  service- 
able, and  may  be  given  in  doses  of  1/100  of  a  grain  (0.00065  gm.)  twice  a  day. 
Iodine  is  also  recommended.  When  the  salivation  is  severe  and  protracted 
the  patient  becomes  much  debilitated  and  anemic,  so  that  a  supporting  treat- 
ment is  indicated.     The  diet  is  necessarily  liquid,  for  the  patient  finds  the 


452  DISEASES  OE  THE  DIGESTIVE  SYSTEM 

chief  difficulty  in  taking  food.  If  the  pain  is  severe  Dover's  powder  may  be 
given  at  night. 

Here  may  be  appropriately  mentioned  the  influence  of  stomatitis,  particu- 
larly the  mercurial  form,  upon  the  developing  teeth  of  children.  The  con- 
dition known  as  erosion,  in  which  the  teeth  are  honeycombed  or  pitted  owing 
to  defective  formation  of  enaniel,  is  indicative,  as  a  rule,  of  infantile  stoma- 
titis. Such  teeth  must  be  distinguished  carefully  from  those  of  congenita] 
syphilis,  which  may  coexist,  but  the  two  conditions  are  distinct.  The  honey^ 
combing  is  frequently  seen  on  the  incisors ;  but,  according  to  Jonathan  Hutch- 
inson, the  test  teeth  of  infantile  stomatitis  are  the  first  permanent  molars, 
then  the  incisors,  "which  are  almost  as  constantly  pitted,  eroded,  and  of  bad 
color,  often  showing  the  transverse  furrow  which  crosses  all  the  teeth  at  the 
same  level."  Magitot  regards  these  transverse  furrows  as  the  result  of  infan- 
tile convulsions  or  of  severe  illness  during  early  life,  analogous  to  the  furrows 
on  the  nails  which  may  follow  a  serious  disease. 

Geographical  Tong-ue  {Eczema  of  the  Tongue).— K  remarkable  desqua- 
mation of  the  superficial  epithelium  of  the  tongue  in  circinate  patches,  which 
i^pread  while  the  central  portions  heal.  Fusion  of  patches  leads  to  areas  with 
sinuous  outlines.  When  extensive  the  tongue  may  be  covered  with  these  areas, 
like  a  geographical  map.  The  affection  causes  a  good  deal  of  itching  and 
heat,  and  it  may  be  a  source  of  much  mental  worry  to  the  patients,  who  often 
dread  lest  it  may  be  a  commencing  cancer. 

The  etiology  is  unknown.  It  occurs  in  infants  and  children,  and  it  is 
not  very  infrequent  in  adults.  It  has  been  regarded  as  a  gouty  manifestation, 
and  transient  attacks  may  accompany  indigestion.  It  is  very  liable  to  relapse. 
In  adults  it  may  prove  very  obstinate  and  in  one  instance  the  disease  per- 
sisted in  spite  of  all  treatment  for  more  than  two  years.  Solutions  of  nitrate 
of  silver  give  the  most  satisfactory  results  in  relieving  the  intense  burning. 

There  is  a  superficial  glossitis,  limited  usually  to  the  border  and  point  of 
the  tongue,  which  presents  irregular  reddish  spots,  looking  as  if  the  epithelium 
was  removed,  and  the  papillae  are  reddened  and  swollen.  The  condition  is 
sometimes  known  as  Moller^s  glossitis.  Local  treatment  with  nitrate  of  silver 
as  a  rule  gives  relief. 

Leukoplakia  Buccalis. — Samuel  Plumbe  described  the  condition  as  ictliyo- 
sis  lingualis.  It  has  also  been  called  buccal  psoriasis  and  leuco-heratosis 
mucoscB  oris.  The  following  forms  occur :  (a)  Small  white  spots  upon  the 
tongue,  slightly  raised,  even  papillomatous — lingual  corns.  (6)  Diffuse  thick- 
ening of  the  epithelial  coating  of  the  tongue,  either  a  thin,  bluish-white  color 
or  opaque  white,  depending  upon  the  thickness.  It  is  patchy,  and  more  often 
upon  the  dorsum  and  sides,  (c)  Diffuse  oral  leukoplakia,  a  remarkable  con- 
dition in  which  the  roof  of  the  mouth,  the  gums,  lips,  and  cheeks  are  covered 
with  an  opaque  white,  sometimes  smooth,  sometimes  fissured,  rugose  layer. 
In  this  widespread  form  the  tongue  may  be  spared.  The  visible  mucosa  of 
the  lips,  occasionally  the  genital  mucosa,  and  the  pelves  of  the  kidneys  may  be 
involved. 

While  appearing  spontaneously,  the  condition  is  most  common  in  heavy 
smokers,  and  has  been  called  smoker's  tongue.  Epithelioma  occasionally 
starts  from  the  localized  patches.  A  majority  of  the  patients  have  had  syphi- 
lis, but  the  condition  does  not  yield,  as  a  rule,  to  specific  treatment. 


STOMATITIS  453 

Leukoplakia  is  a  very  obstinate  affection.  All  irritants,  such  as  smoke  and 
very  hot  food,  should  be  avoided.  Local  treatment  with  one-half-per-cent. 
corrosive  sublimate  or  a  one-per-cent.  chromic-acid  solution  has  been  recom- 
mended. The  propriety  of  active  local  treatment  is  doubtful.  Papillomatous 
outgrowths  should  be  cut  off.  The  X-rays  may  be  tried.  The  most  extensive 
form  may  disappear  spontaneously. 

The  glossy  fat  atrophy  of  the  posterior  part  of  the  tongue,  described  by 
Virchow,  is  in  a  majority  of  instances  of  syphilitic  origin.  Scars  may  give  an 
irregular  appearance  to  the  surface.  Symmers  found  this  smooth  atrophy  in 
55  of  75  post  mortems  in  syphilitic  subjects. 

Hyperesthesia  of  the  Tongue. — A  very  distressing  affection,  seen  chiefly 
in  women  at  or  beyond  the  menopause,  occurs  as  a  sensation  of  burning  felt 
at  the  top  over  the  dorsum,  along  the  edges  or  sometimes  over  the  entire  organ. 
On  examination  nothing  is  to  be  seen;  there  is  no  swelling,  and  there  may  be 
no  irritation  about  the  teeth.  It  is  a  very  obstinate  affection.  Painting  with 
iodine  or  in  some  cases  the  application  of  the  X-rays  may  give  relief. 

Fetor  Oris. — The  practitioner  is  frequently  consulted  for  foul  breath,  and 
is  daily  made  aware  of  its  prevalence.  All  unconscious,  he  is  himself  often  a 
subject  of  the  condition,  to  the  disgust  of  his  patients,  with  whom,  he  has  to 
come  into  such  close  contact.  It  is  impossible  to  give  even  a  list  of  all  the 
causes.  The  following  are  a  few  of  the  more  important :  {a)  In  connection 
Avith  indigestion  and  the  associated  catarrhal  disturbances  in  the  mouth, 
pharynx,  and  stomach.  The  breath  is  "heavy,"  as  the  mothers  say.  A  sim- 
ple mouth-wash  and  a  mercurial  purge  suffice  to  remove  it.  In  a  more  se- 
rious disease  of  the  stomach  the  breath  may  be  foul,  and  occasionally,  in 
sloughing  cancer,  horribly  stinking.  (&)  Local  conditions  in  the  mouth: 
(1)  All  the  forms  of  stomatitis.  Smokers  should  remember  that,  apart  alto- 
gether from  the  smell  of  tobacco,  their  breath  in  the  morning  is  usually,  to 
say  the  least,  "heavy."  (2)  Pyorrhoea  alveolaris.  This  is  the  most  common 
cause  of  foul  breath  in  adults,  and  is  almost  constantly  present  after  middle 
life,  causing  a  perfectly  distinctive  odor.  To  test  for  the  presence  draw  a  bit 
of  stout  thread  or  the  edge  of  a  sheet  of  paper  high  up  between  the  teeth  and 
the  gums  and  then  smell  it.  Scrupulous  treatment  by  a  dentist  is  needed, 
and  daily  scouring,  etc.  (c)  The  tonsillar  diseases.  In  the  crypts  of  the 
tonsils  the  epithelial  debris  accumulates,  and,  invaded  by  micro-organisms, 
gradually  forms  the  little  round  or  triangular  bodies,  which  can  be  squeezed  out 
of  the  lacunae,  and  when  pressed  between  the  fingers  smell  like  Limburger 
cheese.  The  fetor  oris  from  this  cause  is  quite  distinctive.  To  test  the  pres- 
ence in  child  or  adult,  smell  the  finger  after  it  has  been  rubbed  firmly  upon  the 
tonsil.  Local  treatment  is  needed,  {d)  Decayed  teeth,  the  foul  odor  of  which 
is  quite  distinct  from  that  of  pyorrhoea  or  chronic  tonsillitis,  (e)  Eespiratory. 
Many  diseases  of  the  nose,  larynx,  bronchi,  and  lungs  are  associated  with  foul 
breath.  (/)  Hsemic.  The  halitus — the  expired  air  from  the  lung — may  be 
impregnated  with  odors  from  the  blood.  Of  this  there  are  many  well-known 
instances.  For  practical  purposes  it  is  to  be  remembered  that  pyorrhoea  alveo- 
laris and  chronic  lacunar  tonsillitis  are  the  two  most  common  causes  of  foul 
breath. 

Oral  Sepsis. — To  William  Hunter,  of  Charing  Cross  Hospital,  is  due  the 
credit  of  insisting  upon  the  importance  of  the  mouth  as  the  chief  channel  of 


454  DISEASES  OE  THE  DIGESTIVE   SYSTEM 

entrance  of  the  pyogenic  organisms,  and  as  itself  the  seat  of  septic  processes. 
Necrosed  teeth,  pyorrhoea  alveolaris,  gingivitis,  alveolar  abscess,  etc.,  are  pres- 
ent in  a  great  many  people.  A  systemic  infection  may  follow  or  the  general 
health  may  be  lowered  by  the  continuous  production  of  pus.  In  extensive 
pyorrhoea  alveolaris  the  daily  amount  of  pus  must  be  considerable,  and  there 
can  be  no  question  that  it  has  a  debilitating  influence  on  the  general  health 
and  is  sometimes  associated  with  a  moderate  angemia  and  with  a  pasty  com- 
plexion. Hunter  describes  septic  gastritis  and  septic  enteritis  as  common 
sequences;  indeed,  he  regards  appendicular,  pleuritic,  gall-bladder  and  pyelitic 
inflammations  as  forms  of  "medical  sepsis"  due  largely  to  infection  from 
the  mouth.  One  form  of  pernicious  anaemia — infective  hemolytic  anaemia — 
he  believes  to  be  due  to  oral  sepsis,  or  an  infective  glossitis.  Certain  types  of 
nephritis  and  forms  of  arthritis  are  believed  to  be  due  to  oral  infection. 

There  is  no  question  of  the  importance  of  the  subject,  and  we  should  insist 
upon  scrupulous  cleanliness  of  the  mouth  and  teeth.  An  adult  should  have  his 
teeth  cleansed  by  a  dentist  once  a  month.  We  should,  too,  have  less  delicacy 
in  telling  our  friends  in  whom  the  odor  of  the  breath  reveals  the  presence 
of  pyorrhoea.  It  is  a  very  difficult  condition  to  cure.  Locally  much  may 
be  done  to  keep  it  under  control.  Vaccines  have  been  used,  sometimes,  but 
not  always,  with  success.  If  possible,  the  patient  should  be  referred  to  a 
dentist  who  is  specially  competent  to  deal  with  it.  The  tartar  should  be  re- 
moved and  antiseptic  mouth  washes,  such  as  carbolic  acid  (1  per  cent.),  used 
frequently.  Hydrogen  peroxide  or  equal  parts  of  tincture  of  iodine  and  al- 
cohol may  be  applied  locally.  A  saturated  solution  of  thymol  is  an  effective 
mouth  wash. 

Affections  of  the  mucous  glands  are  not  very  common.  In  catarrhal 
troubles  in  children  and  in  measles  they  may  be  swollen.  They  are  enlarged 
and  very  prominent  in  Mikulicz's  disease,  with  chronic  symmetrical  enlarge- 
ment of  the  salivary  and  lachrymal  glands.  There  is  a  singular  affection  of 
the  mucous  glands  of  the  lips,  chiefly  of  the  lower,  with  much  swelling  and 
infiltration.  It  was  described  by  A-^olkmann,  and  has  been  called  Balz's  dis- 
ease. The  mucous  glands  are  enlarged,  the  ducts  much  dilated,  and  on  pres- 
sure a  mucoid  or  muco-purulent  secretion  may  exude.  The  skin  over  the  lips 
may  be  reddened  and  swollen. 


B.    DISEASES  OF  THE  SALIVARY  GLANDS 

Supersecretion  {Ptyalism). — The  normal  amount  of  saliva  varies  from 
3  to  3  pints  in  the  twenty-four  hours.  The  secretion  is  increased  during  the 
taking  of  food  and  in  the  physiological  processes  of  dentition.  A  great  in- 
crease, to  which  the  term  ptyalism  is  applied,  is  met  with  (1)  occasionally  in 
mental  and  nervous  affections  and  in  rabies;  (2)  occasionally  in  the  acute 
fevers,  particularly  in  small-pox;  (3)  sometimes  with  disease  of  the  pancreas; 
(4)  during  gestation,  usually  early,  though  it  may  persist  through  the  entire 
course;  (5)  occasionally  at  each  menstrual  period;  and,,  lastly,  it  is  a  com- 
mon effect  of  certain  drugs — mercury,  the  iodine  compounds,  and  (among  vege- 
table remedies)   jaborandi,  mnscarin,  and  tobacco  excite  the  salivary  secre- 


DISEASES  OF  THE  SALIVARY  GLANDS  455 

tion.  Of  these  we  most  frequently  see  the  effect  of  mercury  iu  producing 
ptyalism.  The  salivation  may  be  present  without  any  inflammation  of  the 
mouth.  For  treatment  atropine  or  the  bromides  may  be  given  in  small  doses 
at  first  and  the  effect  watched  until  the  most  efficient  dosage  is  found. 

Xerostomia  {Arrest  of  the  Saliva/ry  and  Buccal  Secretions;  Dry  Mouth). — 
In  this  condition,  first  described  by  Jonathan  Hutchinson,  the  secretions  of 
the  mouth  and  salivary  glands  are  suppressed.  The  tongue  is  red,  sometimes 
cracked,  and  quite  dry ;  the  mucous  membrane  of  the  cheeks  and  of  the  palate 
is  smooth,  shining,  and  dry ;  and  mastication,  deglutition,  and  articulation  are 
very  difficult.  A  majority  of  the  cases  are  in  women,  and  in  several  instances 
have  been  associated  with  nervous  phenomena.  The  general  health,  as  a  rule, 
is  unimpaired.  It  may  be  due  to  involvement  of  some  centre  which  controls 
the  secretion  of  the  glands.  The  free  use  of  glycerin  locally  is  sometimes 
of  value  and  jaborandi  or  pilocarpine  can  be  given  cautiously. 

Inflammation  of  the  Salivary  Glands. —  (a)  Specific  Parotitis.  (See 
Mumps. ) 

(6)   Symptomatic  parotitis  or  parotid,  bubo  occurs: 

(1)  In  the  course  of  the  infectious  fevers — typhus,  typhoid,  pneumonia, 
pyaemia,  etc.  It  was  a  common  complication  of  the  fevers  during  the  recent 
war.  In  ordinary  practice  it  occurs  oftenest,  perhaps,  in  typhoid  fever.  It 
is  the  result  of  infection  through  the  blood  or  by  the  salivary  duct.  The 
process  is  usually  intense  and  leads  rapidly  to  suppuration.  It  is,  as  a  rule, 
an  unfavorable  indication  in  the  course  of  a  fever.  Parotitis  may  occur  in 
secondary  syphilis. 

(2)  In  connection  with  injury  or  disease  of  the  abdomen  or,  pelvis,  a 
condition  to  which  Stephen  Paget  has  called  special  attention.  Of  101  cases 
of  this  kind,  "10  followed  injury  or  disease  of  the  urinary  tract,  18  were  due 
to  injury  or  disease  of  the  alimentary  canal,  and  23  were  due  to  injury  or 
disease  of  the  abdominal  wall,  the  peritoneum,  or  the  pelvic  cellular  tissue. 
The  remaining  50  were  due  to  injury,  disease,  or  temporary  derangement  of 
the  genital  organs."  By  temporary  derangement  is  meant  slight  injuries  or 
natural  processes — a  slight  blow  on  the  testis,  the  introduction  of  a  pessary, 
menstruation,  or  pregnancy.  Bucknell  has  brought  forward  strong  evidence 
to  show  that  in  all  these  cases  infection  takes  place  through  the  duct, 

(3)  In  association  with  facial  paralysis,  as  in  a  case  of  fatal  peripheral 
neuritis  described  by  Gowers;  in  diabetes  and  chronic  metallic  poisoning. 

In  the  infectious  diseases  rigid  cleanliness  of  the  mouth  is  an  important 
preventive  measure.  For  the  parotitis  an  ice  bag  often  aids,  or  hot  fomenta- 
tions may  be  applied.  A  free  incision  should  be  made  early  if  there  are  signs 
of  suppuration. 

(c)  Chronic  parotitis,  a  condition  in  which  the  glands  are  enlarged,  rarely 
painful,  may  follow  inflammation  of  the  throat  or  mumps.  Salivation  may 
be  present.  It  may  be  due  to  lead,  mercury,  or  potassium  iodide.  It  occurs 
also  in  chronic  nephritis  and  in  syphilis.  Symmetrical  enlargement  of  the 
parotids  of  moderate  extent  is  not  very  uncommon  among  hospital  patients. 
The  cases  at  the  Johns  Hopkins  clinic  have  been  reported  by  C.  P,  Howard 
(Internat.  Clinics,  xix,  1).  It  may  be  associated  with  xerostomia.  The 
parotid  and  submaxillary  glands  are  affected  with  equal  frequency.  In  one 
case  the  swelling  recurred  over  a  period  of  20  years  (Greig), 


456  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

(d)  Mikulicz's  Disease. — In  this  remarkable  affection,  described  in  1888, 
there  is  a  chronic,  indolent,  painless,  symmetrical  enlargement  of  the  salivary 
and  lachrymal  glands.  The  condition  may  last  for  several  years.  In  some 
cases  the  process  is  tuberculous  or  luetic.  The  gland  substance  itself  may 
not  be  disturbed,  but  there  is  a  great  infiltration  of  the  interstitial  connective 
tissue.  In  one  case  the  lachrymal  glands  were  replaced  by  fibrous  tissue. 
In  America  the  disease  has  been  seen  chiefly  in  negroes.  The  enlargement 
may  subside  after  an  acute  fever.  Good  results  have  followed  the  use  of  arsenic, 
iodide  and  the  X-rays,     There  is  no  tendency  to  recurrence  after  removal. 

(e)  Gaseous  Tumors  of  Steno's  Duct  and  of  the  Parotid  Gland. — In  glass- 
blowers  and  musicians  Steno's  duct  may  become  inflated  with  air  and  form 
a  tumor  the  size  of  a  nut  or  of  an  egg.  Some  have  contained  a  mixture  of 
air,  saliva,  and  pus.  In  rare  cases  there  are  gaseous  tumors  of  the  glands, 
which  give  a  sensation  of  crepitation  on  palpation. 


C.    DISEASES  OF  THE  PHARYNX 

Circulatory  Disturbances. —  (a)  Htipercemia  is  common  in  acute  and 
chronic  affections  of  the'  throat,  and  is  frequently  seen  as  a  result  of  the  irri- 
tation of  tobacco  smoke,  and  from  the  constant  use  of  the  voice.  Venous 
stasis  is  seen  in  valvular  disease  of  the  heart,  and  in  mechanical  obstruction 
of  the  superior  vena  cava  by  tumor  or  aneurism.  In  aortic  insufficiency  the 
capillary  pulse  may  sometimes  be  seen,  and  the  intense  throbbing  of  the  in- 
ternal carotid  may  be  mistaken  for  aneurism. 

(b)  TIcemorrliage  is  found  in  association  with  bleeding  from  other  mucous 
surfaces,  or  it  is  due  to  local  causes— granulations,  varicosities,  or  vegetations. 
It  may  be  mistaken  for  haemorrhage  from  the  lungs  or  stomach.  Sometimes 
the  patient  finds  the  pillow  stained  in  the  morning  with  bloody  secretion.  The 
condition  is  rarely  serious,  and  requires  only  suitable  local  treatment.  Oc- 
casionally a  hemorrhage  takes  place  into  the  mucosa,  producing  a  pharyngeal 
hsematoma.  A  condition  of  the  uvula  resembling  hsemorrhagic  infarction  may 
occur. 

(c)  CEdema. — An  infiltrated  oedematous  condition  of  the  uvula  and  adja- 
cent parts  is  not  very  uncommon  in  conditions  of  debility,  in  profound  anaemia, . 
and  in  nephritis.  The  uvula  is  sometimes  enormously  enlarged  from  this 
cause,  whence  may  arise  difficulty  in  swallowing  or  in  breathing. 

Acute  Pharyngitis  {Sore  Throat;  Angina  Simplex). — The  entire  pharj-n- 
geal  structures,  often  with  the  tonsils,  are  involved.  The  condition  may  fol- 
low cold  or  exposure.  In  other  instances  it  is  associated  with  constitutional 
states,  such  as  gout,  or  with  digestive  disorders.  The  patient  complains  of 
uneasiness  and  soreness  in  swallowing,  of  a  feeling  of  tickling  and  dryness 
in  the  throat,  together  with  a  constant  desire  to  hawk  and  cough.  Frequently 
the  inflammation  extends  into  the  larynx  and  produces  hoarseness.  Not  un- 
commonly it  is  only  part  of  a  general  naso-pharyngeal  catarrh.  The  process 
may  pass  into  the  Eustachian  tubes  and  cause  slight  deafness.  Ther  _  is  stiff- 
ness of  the  neck,  the  lymph-glands  of  which  may  be  enlarged  and  painful. 
The  constitutional  symptoms  are  rarely  severe.     The  disease  sets  in  with  t. 


DISEASES  OF  THE  PHAEYNX  457 

chilly  feeling  and  slight  fever ;  the  pulse  is  increased  in  frequency.  Occasion- 
ally the  febrile  symptoms  are  more  severe,  particularly  if  the  tonsils  are 
specially  involved.  The  examination  of  the  throat  shows  general  congestion 
of  the  mucous  membrane,  which  is  dry  and  glistening,  and  in  places  covered 
with  sticky  secretion.    The  uvula  may  be  much  swollen. 

Acute  pharyngitis  lasts  only  a  few  days  and  requires  mild  measures.  Cold 
compresses  or  an  ice  bag  may  be  applied  to  the  neck.  If  the  tonsils  are  in- 
volved and  the  fever  is  high,  aconite  or  sodium  salicylate  may  be  given. 
Guaiacum  also  is  beneficial;  but  in  a  majority  of  the  cases  a  calomel  purge 
or  a  saline  aperient  and  simple  inhalations  meet  the  indications. 

Chronic  Pharyng^itis. — This  may  follow  repeated  acute  attacks.  It  is  very 
common  in  persons  who  smoke  or  drink  to  excess,  and  in  those  who  use 
the  voice  very  much,  such  as  clergymen,  hucksters,  and  others.  It  is  fre- 
quently associated  with  chronic  nasal  catarrh.  The  naso-pharynx  and  the 
posterior  wall  are  the  parts  most  frequently  affected.  The  mucous  membrane 
is  relaxed,  the  venules  are  dilated,  and  roundish  bodies,  from  2  to  4  mm. 
in  diameter,  reddish  in  color,  project  to  a  variable  distance  beyond  the  mucous 
membrane  and  represent  proliferation  of  lymph  tissue  about  the  mucous  glands. 
They  may  be  very  abundant,  forming  elongated  rows  in  the  lateral  walls 
of  the  pharynx.  There  may  be  a  dry  glistening  state  of  the  pharyngeal  mucosa, 
known  as  pharyngitis  sicca.  The  pillars  of  the  fauces  and  the  uvula  are  often 
much  relaxed.  The  secretion  forms  at  the  back  of  the  pharynx  and  the  pa- 
tient may  feel  it  drop  down  from  the  vault,  or  it  is  tenacious  and  adherent, 
and  is  removed  only  by  repeated  efforts  at  hawking. 

In  the  treatment  special  attention  must  be  paid  to  the  general  health.  If 
possible,  the  cause  should  be  ascertained.  The  condition  is  almost  constant 
in  smokers,  and  cannot  be  cured  without  stopping  the  use  of  tobacco.  The 
use  of  food  either  too  hot  or  too  much  spiced  should  be  forbidden.  When  it 
depends  upon  excessive  exercise  of  the  voice,  rest  should  be  enjoined.  In 
many  of  these  cases  change  of  air  and  tonics  help  very  much.  In  the  local 
treatment,  gargles,  washes,  and  pastilles  of  various  sorts  give  temporary  relief, 
but  when  the  hypertrophic  condition  is  marked  the  spots  should  be  thoroughly 
destroyed  by  the  galvano-cautery.  In  many  instances  this  affords  great  and 
permanent  relief,  but  in  others  the  condition  persists,  and,  as  it  is  not  un- 
bearable, the  patient  gives  up  hope  of  permanent  relief. 

Ulceration  of  the  Pharynx. —  (a)  Follicular. — The  ulcers  are  usually 
small,  superficial,  and  generally  associated  with  chronic  catarrh. 

(&)  Syphilitic. — Most  frequently  painless  and  situated  on  the  posterior 
wall  of  the  pharynx,  they  occur  in  the  secondary  stage  as  small,  shallow  ex- 
cavations with  the  mucous  patches.  In  the  tertiary  stage  they  are  due  to 
erosion  of  gummata,  and  in  healing  they  leave  whitish  cicatrices. 

(c)  Tuberculous. — Not  very  uncommon  in  advanced  cases  of  pulmonary 
tuberculosis,  if  extensive,  they  form  one  of  the  most  distressing  features  of 
the  disease.  The  ulcers  are  irregular,  with  ill-defined  edges  and  grayish-yel- 
low bases.  The  posterior  wall  of  the  pharynx  may  have  an  eroded,  worm- 
eaten  appearance.  These  ulcers  are,  as  a  rule,  intensely  painful.  Occasionally 
the  primary  disease  is  about  the  tonsils  and  the  pillars  of  the  fauces. 

(d)  Ulcers  occur  in  connection  with  pseudo-membranous  inflammation, 
particularly  the  diphtheritic.     In  cancer  and  in  lupus  ulcers  are  also  present. 


458  DISEASES  OF  THE  DIGESTIVE   SYSTEM 

(e)   Ulcers  are  met  with  in  certain  of  the  fevers,  particularly  in  typhoid. 

In  many  instances  the  diagnosis  of  the  nature  of  pharyngeal  ulcers  is  very 
difficult.  The  tuberculous  and  cancerous  varieties  are  readily  recognized,  but 
doubt  frequently  arises  as  to  the  syphilitic  character  of  an  ulcer.  In  many 
instances  the  local  conditions  may  be  uncertain.  Other  evidences  of  syphilis 
should  be  sought  for,  and  the  patient  placed  on  mercury  and  iodide  of  potas- 
sium, under  which  remedies  specific  ulcers  usually  heal  with  great  rapidity. 

Acute  Infectious  Phleg^mon  of  the  Pharynx. — Under  this  term  Senator 
has  described  cases  in  which,  along  with  difficulty  in  swallowing,  soreness  of 
the  throat,  and  sometimes  hoarseness,  the  neck  enlarges,  the  pharyngeal 
mucosa  becomes  swollen  and  injected,  the  fever  is  high,  the  constitutional 
symptoms  are  severe,  and  the  inflammation  passes  on  rapidly  to  suppuration. 
The  symptoms  are  very  intense.  The  swelling  of  the  pharyngeal  tissues  early 
reaches  such  a  grade  as  to  impede  respiration.  Similar  symptoms  may  be 
produced  by  foreign  bodies  in  the  pharynx. 

Retro-pharyugeal  abscess  occurs :  (a)  In  healthy  children  between  six 
months  and  two  years  of  age.  The  child  becomes  restless,  the  voice  changes; 
it  becomes  nasal  or  metallic  in  tone,  and  there  are  pain  and  difficulty  in  swal- 
lowing. Inspection  of  the  pharynx  reveals  a  projecting  tumor  in  the  middle 
line,  or,  if  not  visible,  it  is  felt,  on  palpation,  projecting  from  the  posterior 
wall.  (&)  As  a  not  infrequent  sequel  of  the  fevers,  particularly  scarlet  fever 
and  diphtheria,  (c)  In  caries  of  the  bodies  of  the  cervical  vertebrae.  The 
diagnosis  is  readily  made,  as  the  projecting  tumor  can  be  seen,  or  felt  with 
the  finger  on  the  posterior  wall  of  the  pharynx. 

Angina  Ludovici  [Ludwig's  Angina;  Cellulitis  of  the  Neck). — In  medical 
practice  this  is  seen  as  a  secondary  inflammation  in  the  specific  fevers,  par- 
ticularly diphtheria  and  scarlet  fever.  It  may  occur  idiopathically  or  result 
from  trauma.  It  is  probably  always  a  streptococcus  infection  which  spreads 
rapidly  from  the  glands.  The  swelling  at  first  is  most  marked  in  the  sub- 
maxillary region  of  one  side.  The  symptoms  are,  as  a  rule,  intense,  and, 
unless  early  and  thorough  surgical  measures  are  employed,  there  is  great  risk 
of  systemic  infection.  The  various  acute  septic  inflammations  of  the  throat 
— acute  oedema  of  the  larynx,  phlegmon  of  the  pharynx  and  larynx,  and  angina 
Ludovici — "represent  degrees  varying  in  virulence  of  one  and  the  same  proc- 
ess" (Semon).     The  treatment  is  surgical  and  free  incisions  should  be  made, 


D.    DISEASES  OF  THE  TONSILS 

I.     SUPPURATIVE  TONSILLITIS 

Etiology. — Acute  suppuration  of  the  tonsillar  tissues  is  met  with  most 
frequently  in  young  persons,  with  chronic  enlargement  of  the  glands,  some- 
times as  a  sequence  of  the  acute  follicular  form,  sometimes  as  a  result  of 
exposure  to  cold  or  wet. 

Symptoms. — The  constitutional  disturbance  is  very  great.  The  tempera- 
ture rises  to  104°  or  105°  F.,  and  the  pulse  ranges  from  110  to  130.  N^octurnal 
delirium  is  not  uncommon.     The  prostration  may  be  extreme.     There  is  no 


CHEOXIC  TONSILLITIS  459 

local  disease  of  similar  extent  which  so  rapidly  exhausts  the  strength  of  a 
patient.  Soreness  and  dryness  of  the  throat,  with  pain  in  swallowing,  are 
the  symptoms  of  which  the  patient  first  complains.  One  or  both  tonsils  may 
be  involved.  They  are  enlarged,  firm  to  the  touch,  dusky  red  and  edematous, 
and  the  contiguous  parts  are  also  much  swollen.  The  swelling  of  the  glands 
may  be  so  great  that  they  meet  in  the  middle  line,  or  one  tonsil  may  even 
push  the  uvula  aside  and  almost  touch  the  other  gland.  The  salivary  and 
buccal  secretions  are  increased.  The  glands  of  the  neck  enlarge,  the  lower  Jaw 
is  fixed,  and  the  patient  is  unable  to  open  his  mouth.  In  from  two  to  four 
days  the  enlarged  gland  becomes  softer,  and  fluctuation  can  be  distinctly  felt 
by  placing  one  finger  on  the  tonsil  and  the  other  at  the  angle  of  the  jaw.  The 
abscess  points  usually  toward  the  mouth,  but  in  some  cases  toward  the  pharynx. 
It  may  burst  spontaneously,  affording  instant  relief.  Suffocation  has  fol- 
lowed the  rupture  of  a  large  abscess  and  the  entrance  of  the  pus  into  the 
larynx.  When  the  suppuration  is  peritonsillar  and  extensive,  the  internal 
carotid  artery  may  be  opened;  but  these  are,  fortunately,  very  rare  accidents 

Occasionally  a  small  focus  of  deep-seated  suppuration  is  the  cause  of  a 
fever  lasting  for  weeks  ©r  months. 

Treatment. — Hot  applications  in  the  form  of  poultices  and  fomentations 
are  more  comfortable  than  the  ice-bag.  The  gland  should  be  felt — it  cannot 
always  be  seen — from  time  to  time,  and  opened  when  fluctuation  is  distinct. 
The  progress  may  be  shortened  and  the  patient  spared  several  days  of  great 
suffering  if  an  incision  is  made  early.  The  curved  bistoury,  guarded  nearly  to 
the  point  with  plaster  or  cotton,  is  the  most  satisfactory  instrument.  The  in- 
cision should  be  made  from  above  downward,  j^arallel  with  the  anterior  pillar. 
There  are  cases  in  which,  before  suppuration  takes  place,  the  swelling  is  so 
great  that  the  patient  is  threatened  with  suffocation.  In  such  instances  the 
tonsil  must  be  excised  or  tracheotomy  performed.  Delavan  refers  to  two  cases 
in  which  he  states  that  tracheotomy  would  have  saved  life.  Patients  with  this 
affection  require  a  nourishing  liquid  diet,  and  during  convalescence  iron  in 
full  doses. 

Early  removal  of  the  tonsils  should  be  practised  when  a  child  suffers  with 
recurring  attacks,  and  thorough  local  treatment  should  be  given  to  the  naso- 
pharynx.    Particular  care  should  be  taken  of  the  child's  mouth  and  throat. 


II.     CHRONIC  TONSILLITIS 

(Chronic  Naso-pliaryngeal  Obstruction;  Adenoids;  Mouth-hreafJting ; 

Aprosexia) 

Under  this  heading  will  be  considered  also  hypertrophy  of  the  adenoid 
tissue  in  the  vault  of  the  pharynx,  sometimes  known  as  the  pharyngeal  tonsil, 
as  the  affection  usually  involves  both  the  tonsils  proper  and  this  tissue,  and 
the  symptoms  are  not  to  be  differentiated. 

Chronic  enlargement  of  the  tissues  of  the  tonsillar  ring  is  an  affection  of 
great  importance,  and  may- influence  in  an  extraordinary  way  the  mental  and 
bodily  development  of  children. 

The  lacunae  are  really  nothing  but  culture  tubes  in  which  an  extraordinary 


460  DISEASES  OP  THE  DIGESTIVE   SYSTEM 

number  of  organisms  grow,  the  dominant  one  being  the  streptococcus.  Other 
frequent  organisms  are  the  staphylococcus,  pneumococcus,  and  Micrococcus 
catarrhalis.  Normally  these  forms  of  organisms  are  kept  at  bay  by  the 
epithelium  and  by  an  army  of  leucocytes  which  constantly  stream  out  from 
the  lymphoid  tissue.  But  in  catarrhal  conditions  or  by  abrasion,  the  or- 
ganisms may  spread  into  the  substance  of  the  tonsil  or  even  pass  the  capsule 
and  enter  the  system  through  the  lymphatics. 

Etiolog^y. — "Adenoids'^  have  become  recognized  as  one  of  the  most  com- 
mon and  important  affections  of  childhood,  occurring  most  frequently  between 
the  fifth  and  tenth  years.  The  introduction  of  the  systematic  inspection  of 
school  children  has  done  more  than  anything  else  to  force  upon  the  profession 
and  the  public  the  recognition  of  the  condition  as  one  influencing  seriously 
the  bodily  and  mental  growth,  disturbing  hearing  and  furnishing  a  focus  for 
the  development  of  pathogenic  organisms.  Few  children  escape  altogether. 
In  many  it  is  a  trifling  affair,  easily  remedied;  in  others  it  is  a  serious  and 
obstinate  trouble,  taxing  the  skill  and  judgment  of  the  specialist.  It  is 
not  easy  to  say  why  the  disease  has  become  so  prevalent.  In  the  United 
States  it  is  attributed  to  the  dry,  hot  air  of  the  houses,  in  England  to  the  cold, 
damp  climate.  In  winter  nearly  all  the  school  children  in  England  have  the 
"snuffles,"  and  a  considerable  proportion  of  them  adenoids.  American  chil- 
dren may  be  especially  prone,  but  the  disease  is  even  more  prevalent  in  Eng- 
land. 

Adenoids  may  be  associated  with  slight  enlargement  of  the  lymph-glands, 
thymus  and  spleen  in  the  condition  of  lymphatism. 

Morbid  Anatomy. — The  tonsils  are  enlarged,  due  to  multiplication  of  all 
the  constituents  of  the  glands.  The  lymphoid  elements  may  be  chiefly  in- 
volved without  much  development  of  the  stroma.  In  other  instances  the 
fibrous  matrix  is  increased,  and  the  organ  is  then  harder,  smaller,  firmer,  and 
is  cut  with  much  greater  difficulty. 

The  adenoids,  which  spring  from  the  vault  of  the  pharynx,  form  masses 
varying  in  size  from  a  small  pea  to  an  almond.  They  may  be  sessile,  with 
broad  bases,  or  pedunculated.  They  are  reddish  in  color,  of  moderate  firm- 
ness, and  contain  numerous  blood-vessels.  "Abundant,  as  a  rule,  over  the 
vault,  on  a  line  with  the  fossa  of  the  Eustachian  tube,  the  groAvths  may  lie 
posterior  to  the  fossa — ^namely,  in  the  depression  known  as  the  fossa  of  Eosen- 
mfiller,  or  upon  the  parts  which  are  parallel  to  the  posterior  wall  of  the 
pharynx.  The  growths  appear  to  spring  in  the  main  from  the  mucous  mem- 
brane, covering  the  localities  where  the  connective  tissue  fills  in  the  inequalities 
of  the  base  of  the  skull"  (Harrison  Allen).  The  growths  are  most  frequently 
papillomatous  with  a  lymphoid  parenchyma.  Hypertrophy  of  the  pharyngeal 
adenoid  tissue  may  be  present  without  great  enlargement  of  the  tonsils  proper. 
Chronic  catarrh  of  the  nose  usually  coexists. 

Symptoms. — The  direct  effect  of  adenoids  is  the  establishment  of  mouth- 
breathing.  The  indirect  effects  are  deformation  of  the  thorax,  changes  in  the 
facial  expression,  sometimes  marked  alteration  in  the  mental  condition,  in 
certain  cases  stunting  of  the  growth,  and  in  a  great  many  subjects  deafness. 
Woods  Hutchinson  has  suggested  that  the  embryological  relation  of  these 
structures  and  the  pituitary  body  may  account  for  the  interference  with  de- 
velopment.    The   establishment   of   mouth-hreathmg   is   the   symptom   which 


CHEONIC  TONSILLITIS  461 

first  attracts  the  attention.  It  is  not  so  noticeable  by  day,  although  the  child 
may  present  the  vacant  expression  characteristic  of  this  condition.  At  night 
the  child^s  sleep  is  greatly  disturbed;  the  respirations  are  loud  and  snorting, 
and  there  are  sometimes  prolonged  pauses,  followed  by  deep,  noisy  inspira- 
tions. The  pulse  may  vary  strangely  during  these  attacks,  and  in  the  pro- 
longed intervals  may  be  slow,  to  increase  greatly  with  the  forced  inspira- 
tions. The  alse  nasi  should  be  observed  during  the  sleep  of  the  child,  as  they 
are  sometimes  much  retracted  during  inspiration,  due  to  a  laxity  of  the  walls, 
a  condition  readily  remedied  by  the  use  of  a  soft  wire  dilator.  Night  terrors 
are  common.  The  child  may  wake  up  in  a  paroxysm  of  shortness  of  breath. 
Sometimes  these  attacks  are  of  great  severity  and  the  dyspnoea  may  suggest 
pressure  of  enlarged  glands  on  the  trachea.  Sometimes  there  is  a  nocturnal 
paroxysmal  cough  of  a  very  troublesome  character,  usually  excited  by  lying 
down.  Children  with  adenoids  are  specially  liable  to  bronchitis.  The  thin, 
ill-nourished  mouth-breathing  child  with  deformed  chest,  cough  and  scat- 
tered bronchial  rales  is  a  familiar  figure  in  tuberculosis  dispensaries. 

When  the  mouth-breathing  has  persisted  for  a  long  time  definite  changes 
result  in  the  face,  mouth,  and  chest.  The  facies  is  so  peculiar  and  distinc- 
tive that  the  condition  may  be  evident  at  a  glance.  The  expression  is  dull, 
heavy,  and  apathetic,  due  in  part  to  the  fact  that  the  mouth  is  habitually  open. 
In  long-standing  cases  the  child  is  stupid-looking,  responds  slowly  to  ques- 
tions, and  may  be  sullen  and  cross.  The  lips  are  thick,  the  nasal  orifices 
small  and  pinched-in,  the  superior  dental  arch  narrowed  and  the  roof  of  the 
mouth  considerably  raised.     Carious  teeth  are  common. 

The  remarkable  alterations  in  the  shape  of  the  chest  in  connection  with 
enlarged  tonsils  were  first  carefully  studied  by  Dupuytren  (1828),  who  evi- 
dently fully  appreciated  the  great  importance  of  the  condition.  He  noted 
*'&  lateral  depression  of  the  parietes  of  the  chest  consisting  of  a  depression, 
more  or  less  great,  of  the  ribs  on  each  side,  and  a  proportionate  protrusion  of 
the  sternum  in  front."  J.  Mason  Warren  (Medical  Examiner,  1839)  gave 
an  admirable  description  of  the  constitutional  symptoms  and  the  thoracic  de- 
formities induced  by  enlarged  tonsils.  These,  with  the  memoir  of  Lambron 
(1861),  constitute  the  most  important  contributions  to  our  knowledge  on  the 
subject.     Three  types  of  deformity  may  be  recognized: 

(a)  The  pigeon  or  chicken  breast  is  the  most  common  form,  in 
which  the  sternum  is  prominent  and  there  is  a  circular  depression  in  the  lat- 
eral zone  (Harrison's  groove),  corresponding  to  the  attachment  of  the  dia- 
phragm. The  ribs  are  prominent  anteriorly  and  the  sternum  is  angulated 
forward  at  the  manubrio-gladiolar  junction.  As  a  mouth-breather  is  watched 
during  sleep  one  can  see  the  lower  and  lateral  thoracic  regions  retracted  dur- 
ing inspiration  by  the  action  of  the  diaphragm. 

(b)  Barrel  Chest. — Some  children,  the  subject  of  chronic  naso-pharyn- 
geal  obstruction,  have  recurring  attacks  of  asthma,  and  the  chest  may  be 
gradually  deformed,  becoming  rounded  and  barrel-shaped,  the  neck  short,  and 
the  shoulders  and  back  bowed.  A  child  of  ten  or  eleven  may  have  the  thoracic 
conformation  of  an  old  man  with  emphysema. 

(o)  The  Funnel  Breast  (Trichterbrust). — This  remarkable  deformity, 
in  which  there  is  a  deep  depression  at  the  lower  sternum,  has  excited  much 
controversy  as  to  its  mode  of  origin.     In  some  instances,  at  least,  it  is  due  to 


462  DISEASES  OF  THE  DIGESTIVE   SYSTEM 

the  obstructed  breathing  in  connection  with  adenoid  vegetations.  In  two 
cases  in  children  seen  while  the  condition  was  in  process  of  formation  dur- 
ing inspiration  the  lower  sternum  was  forcibly  retracted,  so  much  so  that 
at  the  height  the  depression  corresponded  to  that  of  a  well-marked  "Tricliter- 
hrust."     While  in  repose,  the  lower  sternal  region  was  distinctly  excavated. 

The  voice  is  altered  and  acquires  a  nasal  quality.  The  pronunciation  of 
certain  letters  is  changed,  and  there  is  inability  to  pronounce  the  nasal  con- 
sonants n  and  m.  Bloch  lays  great  stress  upon  the  association  of  mouth- 
breathing  with  stuttering. 

The  hearing  is  impaired,  usually  owing  to  the  extension  of  inflammation 
along  the  Eustachian  tubes  and  the  obstruction  with  mucus  or  the  narrow- 
ing of  their  orifices  by  pressure  of  the  adenoid  vegetations.  In  some  instances 
it  may  be  due  to  retraction  of  the  drums,  as  the  upper  pharynx  is  insufficiently 
supplied  with  air.  Naturally  the  setises  of  taste  and  smell  are  much  impaired. 
There  may  be  little  or  no  nasal  catarrh  or  discharge,  but  the  pharyngeal  se- 
cretion of  mucus  is  increased.  Children  do  not  notice  this,  as  the  mucus 
is  usually  swallowed,  but  older  persons  expectorate  it  with  difficulty. 

Among  other  symptoms  are  headache,  which  is  by  no  means  uncommon,  gen- 
eral listlessness,  and  an  indisposition  for  physical  or  m'ental  exertion.  Habit- 
spasm  of  the  face  has  been  described  in  connection  with  it  and  permanent 
relief  has  been  afforded  by  the  removal  of  the  adenoid  vegetations.  Enuresis 
is  occasionally  an  associated  symptom.  The  influence  upon  the  mental  de- 
velopment is  striking.  Mouth-breathers  are  usually  dull,  stupid,  and  back- 
ward. It  is  impossible  for  them  to  fix  the  attention  for  long  at  a  time,  and 
to  this  impairm.ent  of  the  mental  function  Guye,  of  Amsterdam,  gave  the 
name  aprosexia.  Headaches,  forgetfulness,  inability  to  study  without  discom- 
fort are  frequent  symptoms  of  this  condition  in  students.  There  is  more 
than  a  grain  of  truth  in  the  aphorism  shut  your  mouth  and  save  your  life, 
which  is  found  on  the  title-page  of  Captain  Catlin's  celebrated  pamphlet  on 
mouth-breathing  (1861),  to  which  cause  he  attributed  all  the  ills  of  civili- 
zation. 

A  symptom  specially  associated  with  enlarged  tonsils  is  fetor  of  the  breath. 
The  inspissated  secretion  undergoes  decomposition  and  the  little  cheesy  masses 
may  sometimes  be  squeezed  from  the  crypts  of  the  tonsils.  In  some  cases  of 
chronic  enlargement  the  cheesy  masses  may  be  deep  in  the  tonsillar  crypts; 
and  if  chey  remain  for  a  prolonged  period  lime  salts  are  deposited  and  a  ton- 
sillar calculus  is  produced. 

Children  with  adenoids  are  especially  prone  to  take  cold  and  to  recurring 
attacks  of  follicular  disease.  They  are  also  more  liable  to  diphtheria,  and  in 
them  the  anginal  features  in  scarlet  fever  are  always  more  serious.  The  ulti- 
mate results  of  untreated  adenoid  hypertrophy  are  important.  In  some  cases 
the  vegetations  disappear,  leaving  an  atrophic  condition  of  the  vault  of  the 
pharynx.  Neglect  may  also  lead  to  the  so-called  Thornwaldt's  disease,  in 
which  there  is  a  cystic  condition  of  the  pharyngeal  tonsil  and  constant  secre- 
tion of  muco-pus. 

Diagnosis.— The  facial  aspect  is  usually  distinctive.  Enlarged  tonsils  are 
readily  seen  on  inspection  of  the  pharynx.  There  may  be  no  great  enlargement 
of  the  tonsils  and  nothing  apparent  at  the  back  of  the  throat  even  when  the 
naso-pharynx  is  completely  blocked  with  adenoid  vegetations.     In  children  the 


(ESOPHAGITIS  463 

rhinoscopic  examination  is  rarely  practicable.  Digital  examination  is  the  most 
satisfactory.  The  growths  can  then  be  felt  either  as  small,  flat  bodies  or,  if 
extensive,  as  velvety,  grape-like  papillomata. 

Treatment. — If  the  tonsils  are  large  and  the  general  state  is  evidently 
influenced  by  them  they  should  be  removed.  Important  complications  may 
follow  the  removal — haemorrhage,  hyperpyrexia,  infarction  and  abscess  of  the 
lungs,  general  sepsis,  cerebro-thrombosinusitis,  subcutaneous  emphysema,  death 
from  status  lymphaticus.  Applications  of  iodine  and  iron,  or  penciling  the 
crypts  with  nitrate  of  silver,  are  of  service  in  the  milder  grades,  but  it  is  waste 
of  time  to  apply  them  to  enlarged  glands.  There  is  a  condition  in  which  the 
tonsils  are  not  much  enlarged,  but  the  crypts  are  constantly  filled  with  cheesy 
secretions  and  give  a  foul  odor  to  the  breath.  In  such  instances  the  removal  of 
the  secretion  and  thorough  penciling  of  the  crypts  with  chromic  acid  may  be 
practised.  The  galvano-cautery  is  of  service  in  many  cases  of  enlarged  ton- 
sils when  there  is  objection  to  removal. 

The  treatment  of  the  adenoid  growths  should  be  thoroughly  carried  out. 
Parents  should  be  frankly  told  that  the  affection  is  serious,  one  which  im- 
pairs the  mental  not  less  than  the  bodily  development  of  the  child.  In  spite 
of  the  thorough  ventilation  of  this  subject  by  specialists,  practitioners  do  not 
appear  to  have  grasped  the  full  importance  of  this  disease.  They  are  far  too 
apt  to  temporize  and  unnecessarily  postpone  radical  measures.  The  child 
must  be  anesthetized.  Severe  haemorrhage  has  followed  in  a  few  cases.  Spe- 
cial examination  should  be  made  of  the  thymus  and  lymph  glands,  as  if  they 
are  enlarged  the  operation  should  be  postponed.  In  this  state  of  lymphatism 
death  during  anaesthesia  has  occurred.  The  good  effects  of  the  operation  are 
often  apparent  within  a  few  days,  and  the  child  begins  to  breathe  through 
the  nose.  In  some  instances  the  habit  of  mouth-breathing  persists.  As  soon 
as  the  child  goes  to  sleep  the  lower  jaw  drops  and  the  air  is  drawn  into  the 
mouth.  In  these  cases  a  chin  strap  can  be  readily  adjusted,  which  the  child 
may  wear  at  night.  In  severe  cases  it  may  take  months  of  careful  training 
before  the  child  can  speak  properly.  An  all-important  point  in  the  treat- 
ment of  lesions  of  the  naso-pharynx  (and,  indeed,  in  the  prevention  of  this 
imfortunate  condition)  is  to  increase  the  breathing  capacity  of  the  chest  by 
making  the  child  perform  systematic  exercises,  which  cause  the  air  to  be  driven 
freely  and  forcibly  in  and  out  through  the  naso-pharynx. 

Throughout  the  entire  treatment  attention  should  be  paid  to  hygiene  and 
diet,  and  cod-liver  oil  and  the  iodide  of  iron  may  be  administered  with  benefit. 


E.    DISEASES  OF  THE  CESOPHAGUS 

I.     ACUTE  (ESOPHAGITIS 

Etiology. — Acute  inflammation  occurs  (a)  in  the  catarrhal  processes  of 
the  specific  fevers;  more  rarely  as  an  extension  from  catarrh  of  the  pharynx. 
(b)  As  a  result  of  intense  mechanical  or  chemical  irritation,  produced  by 
foreign  bodies,  very  hot  liquids,  or  strong  corrosives,  (c)  In  the  form  of 
pseudo-membranous   inflammation  in  diphtheria,  and  occasionally  in  pneu- 


464  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

monia,  typhoid  fever,  and  pyaemia,  (d)  As  a  pustular  inflammation  in  small- 
pox, and,  according  to  Laennec,  as  a  result  of  a  prolonged  administration  of 
tartar  emetic,  (e)  In  connection  with  local  disease,  particularly  cancer  either 
of  the  tube  itself  or  extension  to  it  from  without.  And,  lastly,  acute  oesopha- 
gitis, occasionally  with  ulceration,  may  occur  spontaneously  in  sucklings. 

Morbid  Anatomy. — It  is  extremely  rare  to  see  redness  of  the  mucosa, 
except  when  chemical  irritants  have  been  swallowed.  More  commonly  the 
epithelium  is  thickened  and  has  desquamated,  so  that  the  surface  is  covered 
with  a  fine  granular  substance.  The  mucous  follicles  are  swollen  and  occa- 
sionally there  are  small  erosions.  In  the  pseudo-membranous  inflammation 
there  is  a  grayish  exudate,  usually  limited  in  extent,  at  the  upper  portion  of 
the  gullet.  In  the  phlegmonous  inflammation  the  mucous  membrane  is 
greatly  swollen,  and  there  is  purulent  infiltration  in  the  submucosa.  It  may 
extend  throughout  a  large  part  of  the  gullet.  Gangrene  occasionally  super- 
venes. There  is  a  remarkable  fibrinous  or  membranous  oesophagitis,  most 
frequently  met  with  in  the  fevers,  sometimes  also  in  hysteria,  in  which  long 
casts  of  the  tube  may  be  vomited. 

Symptoms. — Pain  in  deglutition  is  always  present  in  severe  inflammation 
of  the  oesophagus.  A  dull  pain  beneath  the  sternum  is  also  present.  In  the 
milder  forms  of  catarrhal  inflammation  there  are  usually  no  symptoms.  The 
presence  of  a  foreign  body  is  indicated  by  dysphagia  and  spasm  with  the 
regurgitation  of  portions  of  the  food.  Later,  blood  and  pus  may  be  ejected. 
It  is  surprising  how  extensive  the  disease  may  be  in  the  oesophagus  without 
producing  much  pain  or  great  discomfort,  except  in  swalloAving.  The  intense 
inflammation  which  follows  the  swallowing  of  corrosives,  when  not  fatal,  gradu- 
ally subsides,  and  often  leads  to  cicatricial  contraction  and  stricture.  In  the 
cases  in  which  there  is  danger  of  contraction  oesophageal  bougies  should  be 
passed  before  this  is  marked.  The  patient  should  swallow  some  oil  before  the 
passage  of  the  bougie,  the  size  of  which  should  be  gradually  increased.  Dila- 
tation should  be  done  every  few  days  at  first. 

Treatment. — This  is  unsatisfactory,  particularly  in  the  severer  forms. 
The  slight  catarrhal  cases  require  no  special  treatment.  When  the  dysphagia 
is  intense  it  is  best  not  to  give  food  by  the  mouth,  but  to  feed  entirely  by 
enema ta.  Fragments  of  ice  may  be  given,  and  as  the  pain  and  distress  sub- 
side, demulcent  drinks.     External  applications  of  cold  often  give  relief. 

A  chronic  form  of  oesophagitis  is  described,  but  this  results  usually  from 
the  prolonged  action  of  the  causes  which  produce  the  acute  form. 

Catarrhal  Ulceration-. — Follicular  ulcers  are  not  uncommon.  Tuberculous 
and  syphilitic  ulcers  are  rare.  Very  prominent  varicose  veins  and  small  ero- 
sions are  not  uncommon.  The  other  forms  are  the  carcinomatous,  the  erosion 
due  to  aneurism,  and  the  ulcerative  action  of  corrosive  substances.  There  are 
two  other  important  varieties — the  ulcers  in  acute  infectious  diseases,  diphthe- 
ria, scarlet  fever,  and  pneumonia;  and  the  peptic  ulcer,  first  described  by 
Albers  in  1839.  Tileston  has  collected  forty  cases  of  peptic  ulcer  in  the 
oesophagus.  The  pain,  dysphagia,  vomiting,  and  hgemorrhage  have  been  the 
most  important  symptoms.  Perforation  occurred  in  six  cases,  in  one  instance 
into  the  aorta.  Treatment  is  difficult;  in  severe  cases  gastrostomy  should  be 
done. 

(Esophageal  Varices. — Associated  with  chronic  heart-disease  and  more  fre- 


STRICTURE  OF  THE  (ESOPHAGUS  465 

quently  with  the  senile  and  the  cirrhotic  liver,  the  oesophageal  veins  may  be- 
come distended  and  varicose.  The  mucous  membrane  is  in  a  state  of  chronic 
catarrh,  and  the  patient  has  frequent  eructations  of  mucus.  Rupture  of  these 
varices  is  one  of  the  commonest  causes  of  hamatemesis  in  cirrhosis  of  the 
liver  and  in  enlarged  spleen.     The  blood  may  pass  per  rectum  alone. 


11.    SPASM  OF  THE  (ESOPHAGUS 

{(Esophagismus) 

This  is  met  with  in  nervous  patients  and  hypochondriacs,  also  in  chorea, 
epilepsy,  and  especially  hydrophobia.  It  is  sometimes  associated  also  with  the 
lodgment  of  foreign  bodies,  or  with  cases  in  which  a  patient  has  swallowed  a 
foreign  body  and  thinks  it  has  stuck.  For  weeks  there  may  be  spasm,  due 
perhaps  to  autosuggestion,  though  the  bougie  passes  freely.  The  idiopathic 
form  is  found  in  females  of  a  marked  neurotic  habit,  but  may  also  occur  in 
elderly  men.  It  may  be  present  only  during  pregnancy.  The  patient  com- 
plains of  inability  to  swallow  solid  food,  and  in  extreme  instances  even  liquids 
are  rejected.  The  attack  may  come  on  abruptly,  and  be  associated  with  emo- 
tional disturbances  and  with  substernal  pain.  The  bougie,  when  passed,  may 
be  arrested  temporarily  at  the  seat  of  the  spasm,  which  gradually  yields,  or 
it  may  slip  through  without  the  slightest  effort.  The  condition  is  rarely  se- 
rious^ though  it  may. persist  for  years.  Spasm  of  the  lower  end  of  the  gullet, 
associated  with  cardio-spasm,  may  be  the  cause  of  a  remarkable  fusiform  dila- 
tation of  the  oesophagus. 

The  diagnosis  is  not  difficult,  particularly  in  young  persons  with  marked 
nervous  manifestations.  In  elderly  persons  oesophagismus  often  occurs  with 
hypochondriasis,  but  great  care  must  be  taken  to  exclude  cancer. 

In  some  cases  a  cure  is  at  once  effected  by  the  passage  of  a  bougie.  The 
general  neurotic  condition  also  requires  special  attention.  Atropine  in  full 
doses  is  sometimes  helpful. 

Paralysis  of  the  oesophagus  is  a  very  rare  condition,  due  most  often  to 
central  disease,  particularly  bulbar  paralysis.  It  may  be  peripheral  in  origin, 
as  in  diphtheritic  paralysis.  Occasionally  it  occurs  in  hysteria.  The  essen- 
tial symptom  is  dysphagia. 


III.     STRICTURE  OF  THE  (ESOPHAGUS 

This  results  from:  {a)  Congenital  stenosis  of  the  oesophagus. — There  are 
two  groups  of  cases,  one  in  which  there  is  complete  occlusion,  and  the  middle 
of  the  tube  is  converted  into  a  fibrous  cord ;  the  other,  the  more  common,  in 
which  the  lowei  part  opens  into  the  trachea  or  one  of  the  bronchi.  There  are 
some  19  cases  on  record  (William  Thomas).  (6)  The  cicatricial  contraction 
of  healed  ulcers,  usually  due  to  corrosive  poisons,  occasionally  to  syphilis,  and 
in  rare  instances  after  the  fevers,  (c)  The  groA\i;h  of  tumors  in  the  walls, 
as  in  the  so-called  cancerous  stricture.     Eighty-five  per  cent,  of  the  cases  are 


466  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

of  this  nature,     (d)   External  pressure  by  aneurism,  enlarged  lymph-glands, 
enlarged  thyroid,  other  tumors,  and  sometimes  by  pericardial  effusion. 

The  cicatricial  stricture  may  occur  anywhere  in  the  gullet,  and  in  extreme 
cases  may  involve  the  whole  tube,  but  in  a  majority  of  instances  it  is  found 
either  high  up  near  the  pharynx  or  low  down  toward  the  stomach.  The  nar- 
rowing may  be  extreme,  so  that  only  smaU  quantities  of  food  can  trickle 
through,  or  the  obstruction  may  be  quite  slight.  When  the  stricture  is  low 
down  the  oesophagus  is  dilated  and  the  walls  are  usually  much  hypertrophied. 
When  the  obstruction  is  high  in  the  gullet,  the  food  is  usually  rejected  at  once, 
whereas,  if  it  is  low,  it  may  be  retained  and  a  considerable  quantity  collects 
before  it  is  regurgitated.  Any  doubt  as  to  its  having  reached  the  stomach  is 
removed  by  the  alkalinity  of  the  material  ejected  and  the  absence  of  the  char- 
acteristic gastric  odor.  Auscultation  of  the  oesophagus  may  be  practised  and 
is  sometimes  of  service.  The  patient  takes  a  mouthful  of  water  and  the  aus- 
cultator  listens  along  the  left  of  the  spine.  The  normal  oesophageal  bruit 
may  be  heard  later  than  seven  seconds,  the  normal  time,  or  there  may  be 
heard  a  loud  splashing,  gurgling  sound.  The  secondary  murmur,  heard  as  the 
fluid  enters  the  stomach,  may  be  absent.  The  bismuth  meal  and  the  fluoro- 
scope  make  the  diagnosis  very  easy.  The  passage  of  the  oesophageal  bougie  will 
determine  accurately  the  locality.  Conical  bougies  attached  to  a  flexible  whale- 
bone stem  are  the  most  satisfactory,  but  the  gum-elastic  stomach  tube  may 
be  used ;  a  large  one  should  be  tried  first.  The  patient  should  be  placed  on  a 
low  chair  with  the  head  well  thrown  back.  The  index  finger  of  the  left  hand 
is  passed  far  into  the  pharynx,  and  in  some  instances  this  procedure  alone 
may  determine  the  presence  of  a  new  growth.  The  bougie  is  passed  beside  the 
finger  u,ntil  it  touches  the  posterior  wall  of  the  pharynx,  then  along  it,  more 
to  one  side  than  in  the  middle  line,  and  so  gradually  pushed  into  the  gullet.  It 
is  to  be  borne  in  mind  that  in  passing  the  cricoid  cartilage  there  is  often  a  slight 
obstruction.  Great  gentleness  should  be  used,  as  the  bougie  has  been  passed 
through  a  cancerous  ulcer  into  the  mediastinum  or  through  a  diverticulum. 
It  is  well  always,  as  a  precautionary  measure,  to  examine  carefully  for  aneur- 
ism, which  may  produce  all  the  symptoms  of  organic  stricture.  In  cases  in 
which  the  narrowing  is  extreme  there  is  always  emaciation.  For  treatment, 
surgical  works  must  be  consulted. 


IV.     CANCER  OF  THE  (ESOPHAGUS 

This  is  usually  epithelioma.  It  is  not  a  common  disease ;  there  were  only 
38  cases  in  the  medical  wards  of  the  Johns  Hopkins  Hospital  in  twenty-three 
years.  It  may  occur  in  quite  young  persons,  and  is  more  frequent  in  males 
than  in  females.  The  middle  and  lower  thirds  are  most  often  affected.  At 
first  confined  to  the  mucous  membrane,  the  cancer  gradually  increases  and  soon 
ulcerates.  The  lumen  of  the  tube  is  narrowed,  but  when  ulceration  is  exten- 
sive in  the  later  stages  the  stricture  may  be  less  marked.  Dilatation  of  the 
tube  and  hypertrophy  of  the  walls  usually  take  place  above  the  cancer.  The 
ulcer  may  perforate  the  trachea  or  a  bronchus,  the  lung,  the  pleura,  the  me- 
diastinum, the  aorta  or  one  of  its  larger  branches,  the  pericardium,  or  erode 


DILATATIOXS  AND  DIVEETICULA  467 

the  vertebrae.  The  recurrent  laryngeal  nerves  are  not  infrequently  impli- 
cated.    Perforation  of  the  lung  produces,  as  a  rule,  local  gangrene. 

Symptoms. — Dysphagia  is  usually  an  early  symptom  but  may  be  absent 
throughout.  If  present  it  is  progressive  and  becomes  extreme,  so  that  the 
patient  emaciates  rapidly.  Kegurgitation  may  take  place  at  once;  or,  if  the 
cancer  is  situated  near  the  stomach,  it  may  be  deferred  for  ten  or  fifteen  min- 
utes, or  even  longer  if  the  tube  is  much  dilated.  The  rejected  materials  may 
be  mixed  with  blood  and  may  contain  cancerous  fragments.  Tickling  sensa- 
tions in  the  throat,  increased  secretion  and  cough  are  not  infrequent.  In  per- 
sons over  fifty  years  of  age  persistent  diiUculty  in  swallowing  accompanied  by 
rapid  emaciation  usually  indicates  oesophageal  cancer.  Sudden  transient  at- 
tacks of  difficulty  in  swallowing  may  occur.  The  cervical  lymph-glands  are 
frequently  enlarged  and  may  give  early  indication  of  the  nature  of  the  trouble. 
Pain  may  be  persistent  or  be  present  only  when  food  is  taken.  In  certain 
instances  the  pain  is  very  great.  The  latent- -cases  are  very  rare.  Bronchitis 
and  broncho-pneumonia  are  common  terminal  events. 

DiagTiosis. — It  is  important,  in  the  first  place,  to  exclude  pressure  from 
without,  as  by  aneurism  or  tumor.  The  history  enables  us  to  exclude  cicatricial 
stricture  and  foreign  bodies.  The  sound  may  be  passed  and  the  presence  of 
the  stricture  determined  but  great  care  should  be  exercised.  The  cesophago- 
scope  is  of  great  aid.  Fragments  of  carcinomatous  tissue  may  be  removed 
with  the  tube.  The  X-ray  examination  is  of  service  both  in  showing  the 
presence  of  a  growth  and  its  position. 

Treatment. — In  most  cases  milk  and  liquids  can  be  swallowed,  but  supple- 
mentary nourishment  should  be  given  by  the  rectum.  It  may  be  advisable 
to  pass  a  tube  into  the  stomach  and  introduce  food  in  this  way.  When  there 
is  difficulty  in  feeding  the  patient  it  is  much  better  to  have  gastrostomy  per- 
formed at  once,  as  it  gives  comfort  and  prolongs  the  patient's  life. 

V.     RUPTURE  OF  THE  (ESOPHAGUS 

(a)  Eupture  may  occur  as  a  result  of  violent  vomiting  after  a  full  meal, 
or  when  intoxicated.  In  1914  Walker  collected  22  cases,  20  of  which  were 
in  males.  In  every  case  the  rupture  was  at  the  lower  end.  Boerhaave  de- 
scribed the  first  case  in  Baron  Wassennar,  who  "broke  asunder  the  tube  of  the 
oesophagus  near  the  diaphragm,  so  that,  after  the  most  excruciating  pain,  the 
elements  which  he  swallowed  passed,  together  with  the  air,  into  the  cavity  of 
the  thorax,  and  he  expired  in  twenty-four  hours."  (h)  In  a  few  cases  the  rup- 
ture has  occurred  in  a  diseased  and  weakened  tube,  near  the  scar  of  an  ulcer, 
for  example,  (c)  Post  mortem  softening — oesophago-malacia — must  not  be 
mistaken  for  it.  In  spontaneous  rupture  the  rent  is  clean-cut;  in  malacia  it 
is  rounded  and  the  margins  are  softened.  The  contents  of  the  stomach  may 
be  in  the  left  pleura. 

VI.    DILATATIONS  AND  DIVERTICULA 

Stenosis  of  the  gullet  is  followed  by  secondary  dilatation  of  the  tube  above 
the  constriction  and  great  hypertrophy  of  the  walls.     Primary   dilatation, 


468  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

which  is  extremely  rare,  is  associated  with  spasm  of  the  lower  end  of  the  gullet 
and  of  the  cardiac  orifice  or  with  contraction  of  the  stomach  as  in  scirrhous 
cancer.  The  tube  may  attain  extraordinary  dimensions,  as  in  the  specimen 
presented  in  1904  to  the  Association  of  American  Physicians  by  Kinnicutt. 
Eegurgitation  of  food  is  the  most  common  symptom.  There  may  also  be  diffi- 
culty in  breathing  from  pressure. 

Diverticula  are  of  two  forms:  (a)  Pressure  diverticula,  which  are  most 
common  at  the  junction  of  the  pharynx  and  gullet,  on  the  posterior  wall. 
Owing  to  weakness  of  the  muscles  at  this  spot,  local  bulging  occurs,  which  is 
gradually  increased  by  the  pressure  of  food,  and  finally  forms  a  saccular 
pouch.  (h)  The  traction  diverticula  situated  on  the  anterior  wall  near 
the  bifurcation  of  the  trachea  result,  as  a  rule,  from  the  extension  of  inflam- 
mation from  the  lymph-glands  with  adhesion  and  subsequent  cicatricial  con- 
traction, by  which  the  wall  of  the  gullet  is  drawn  out.  The  diagnosis  of  these 
forms  is  readily  made  by  the  'X-rays.  Diverticula  have  been  successfully 
extirpated. 

A  rare  and  remarkable  condition,  of  which  a  case  has  been  recorded  by 
MacLachlan,  and  of  which  a  second  was  in  attendance  at  the  Hopkins  clinic, 
is  the  oesophago-pleuro-cutaneous  fistula.  In  this  patient  fluids  were  dis- 
charged at  intervals  through  a  fistula  in  the  right  infra-clavicular  region, 
which  communicated  with  a  cavity  in  the  upper  part  of  the  pleura  or  lung. 
The  condition  had  persisted  for  more  than  twenty-five  years. 


F.   DISEASES  OF  THE  STOMACH 

I.    ACUTE  GASTRITIS 

(Simple  Gastritis;  Acute  Gastric  Catarrh;  Acute  Dyspepsia) 

Etiolog-y. — Acute  gastritis  occurs  at  all  ages,  and  is  usually  traceable  to 
errors  in  diet.  It  may  follow  the  ingestion  of  more  food  than  the  stomach 
can  digest,  or  it  may  result  from  taking  unsuitable  articles,  which  either  them- 
selves irritate  the  mucosa  or,  remaining  undigested,  decompose,  and  so  excite 
an  acute  dyspepsia.  A  frequent  cause  is  the  taking  of  food  which  has  begun 
to  decompose,  particularly  in  hot  weather.  In  children  these  fermentative  proc- 
esses are  very  apt  to  excite  acute  catarrh  of  the  bowels  as  well.  Another  very 
common  cause  is  the  abuse  of  alcohol,  and  the  acute  gastritis  which  follows 
a  drinking-bout  is  one  of  the  most  typical  forms.  The  tendency  to  gastric 
disturbance  varies  very  much  in  difl'erent  individuals,  and,  indeed,  in  fam- 
ilies. We  recognize  this  in  using  the  expressions  a  /'delicate  stomach"  and  a 
"strong  stomach." 

Morbid  Anatomy.— Beaumont's  study  of  St.  Martin's  stomach  showed 
that  in  acute  catarrh  the  mucous  membrane  is  reddened  and  swollen,  less 
gastric  juice  is  secreted,  and  mucus  covers  the  surface.  Slight  hemorrhages 
may  occur  or  even  small  erosions.  The  submucosa  may  be  somewhat  cedema- 
tous.     Microscopically  the  changes  are  chiefly  noticeable  in  the  mucous  and 


ACUTE  GASTEITIS  469 

peptic  cells,  which  are  swollen  and  more  granular,  and  there  is  an  infiltration 
of  the  intertubular  tissue  with  leucocytes. 

Symptoms. — In  mild  cases  the  symptoms  are  those  of  slight  indigestion 
— an  uncomfortable  feeling  in  the  abdomen,  headache,  depression,  nausea, 
eructations,  and  vomiting,  which  usually  gives  relief.  The  tongue  is  heavily 
coated  and  the  saliva  is  increased.  In  children  there  are  intestinal  symptoms 
— diarrhoea  and  colicky  pains  and  often  slight  fever.  The  duration  is  rarely 
more  than  twenty-four  hours.  In  the  severer  forms  the  attack  may  set  in  with 
a  chill  and  febrile  reaction,  in  which  the  temperature  rises  to  102°  or  103°  F. 
The  tongue  is  furred,  the  breath  heavy,  and  vomiting  is  frequent.  The 
ejected  substances,  at  first  mixed  with  food,  subsequently  contain  nmch  mucus 
and  bile-stained  fluids.  There  may  be  constipation,  but  very  often  there  is 
diarrhoea.  The  urine  presents  the  usual  febrile  characteristics,  and  there  is 
a  heavy  deposit  of  urates.  The  abdomen  may  be  somewhat  distended  and 
slightly  tender  in  the  epigastric  region.  Herpes  may  appear  on  the  lips.  The 
attack  may  last  from  one  to  three  days,  and  occasionally  longer.  The  exam- 
ination of  the  vomitus  shows,  as  a  rule,  absence  of  hydrochloric  acid,  the  pres- 
ence of  lactic  and  fatty  acids,  and  marked  increase  in  the  mucus. 

Diagnosis. — The  ordinary  asfebrile  gastritis  is  readily  recognized.  The 
acute  febrile  form  is  so  similar  to  the  initial  symptoms  of  many  of  the  in- 
fectious diseases  that  it  is  impossible  for  a  day  or  two  to  make  a  diagnosis, 
particularly  in  the  cases  which  have  come  on,  so  to  speak,  spontaneously  and', 
independently  of  an  error  in  diet.  Some  of  these  resemble  closely  an  acute; 
infection;  the  symptoms  may  be  very  intense,  and  if,  as  sometimes  happens,, 
the  attack  sets  in  with  severe  headache  and  delirium,  the  case  may  be  mis- 
taken for  meningitis.  When  the  abdominal  pains  are  intense  the  attack  may 
be  confounded  with  gallstone  colic.  The  gastric  crises  in  tabes  have  been 
confounded  with  a  simple  acute  gastritis,  and  it  is  always  wise  in  adults  to 
test  the  knee-jerks  and  pupillary  reactions. 

Treatment.- — Mild  cases  recover  spontaneously  in  twenty-four  hours,  and 
require  no  treatment  other  than  a  dose  of  castor  oil  in  children  or  of  blue 
mass  in  adults.  In  the  severer  forms,  if  there  is  much  distress  in  the  region 
of  the  stomach,  the  vomiting  should  be  promoted  by  warm  water,  or  the 
stomach  tube  may  be  employed  for  some  patients.  A  dose  of  calomel,  2  to  3 
grains  (0.13  to  0.2  gm.),  should  be  given,  and  followed,  after  some  hours,  by  a 
saline  cathartic.  If  there  is  eructation  of  acid  fluid,  bicarbonate  of  soda  and 
bismuth  may  be  given.  The  stomach  should  have,  if  possible,  absolute  rest, 
and  it  is  a  good  plan  in  the  case  of  strong  persons,  particularly  in  those  ad- 
dicted to  alcohol,  to  cut  off  all  food  for  a  day  or  two.  The  patient  may  be 
allowed  soda  water  and  ice  freely.  It  is  well  not  to  attempt  to  check  the^ 
vomiting  unless  it  is  excessive  and  protracted.  Eecovery  is  usually  complete,, 
though  repeated  attacks  may  lead  to  subacute  or  chronic  gastritis. 

Phlegmonous  Gastritis;  Acute  Suppurative  Gastritis. — The  disease  is  due 
to  infection  of  the  submucosa,  probably  through  a  minute  abrasion.  Males, 
are  more  frequently  affected  than  females,  and  most  of  the  cases  are  in  com- 
paratively young  people.  In  a  majority  of  the  instances  in  which  the  examina- 
tion has  been  made  streptococci  have  been  present,  but  the  pneumococcus  has 
been  found  in  a  few  cases.  The  disease  is  rare ;  Leith  was  able  to  collect  only 
85  cases.     There  is  a  widespread  suppurative  infiltration  of  the  submucosa. 


470  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

with  great  thickening  of  the  walls.  Sometimes  there  is  a  localized  abscess 
formation^  with  tumor,  which  may  burst  into  the  stomach  or  into  the  peri- 
toneum. 

The  important  symptoms  are  pain,  high  fever,  vomiting,  dry  tongue,  all 
the  features  of  a  severe  infection,  and  sometimes  jaundice.  A  diagnosis  is 
rarely  made;  occasionally  there  is  a  large  tumor  mass  to  be  felt.  The  out- 
look is  very  serious.  In  the  case  reported  by  Bovee,  he  cut  down  and  opened 
an  acute  abscess,  the  size  of-  a  man's  fist,  in  the  anterior  wall  of  the  pyloric 
region. 

Toxic  G-astritis. — This  most  intense  form  of  inflammation  of  the  stomach 
is  excited  by  the  swallowing  of  concentrated  mineral  acids  or  strong  alkalies, 
or  by  such  poisons  as  phosphorus,  corrosive  sublimate,  ammonia,  arsenic,  etc. 
In  the  non-corrosive  poisons,  such  as  phosphorus,  arsenic,  and  antimony,  the 
process  consists  of  an  acute  degeneration  of  the  glandular  elements,  and  hgem- 
orrhage.  With  the  powerful  concentrated  poisons  the  mucous  membrane  is 
extensively  destroyed,  and  may  be  converted  into  a  brownish-black  eschar.  In 
the  less  severe  grades  there  may  be  areas  of  necrosis  surrounded  by  inflamma- 
tory reaction,  while  the  submucosa  is  hsemorrhagic  and  infiltrated.  The 
process  is  of  course  more  intense  at  the  fundus,  but  the  active  peristalsis  may 
drive  the  poison  through  the  pylorus  into  the  intestine. 

Symptoms.— The  symptoms  are  intense  pain  in  the  mouth,  throat,  and 
stomach,  salivation,  great  difficulty  in  swallowing,  and  constant  vomiting,  the 
vomited  materials  being  bloody  and  sometimes  containing  portions  of  the 
mucous  membrane.  The  abdomen  is  tender,  distended,  and  jDainful  on  pres- 
sure. In  the  most  acute  cases  symptoms  of  collapse  supervene;  the  pulse  is 
weak,  the  skin  pale  and  covered  with  sweat;  there  is  restlessness,  and  some- 
times convulsions.  There  may  be  albumin  or  blood  in  the  urine,  and  petechia 
may  occur  on  the  skin.  When  the  poison  is  less  intense,  the  sloughs  may 
separate,  leaving  ulcers,  which  too  often  lead,  in  the  oesophagus  to  stricture,  in 
the  stomach  ^o  chronic  atrophy,  and  finally  to  death  from  exhaustion. 

Diagnosis. — The  diagnosis  of  toxic  gastritis  is  usually  easy,  as  inspection 
of  the  mouth  and  pharynx  shows,  in  many  instances,  corrosive  effects,  while 
the  examination  of  the  vomit  may  indicate  the  nature  of  the  poison. 

In  poisoning  by  acids,  magnesia  should  be  administered  in  milk  or  with 
egg  albumen.  When  strong  alkalies  have  been  taken,  the  dilute  acids  should 
be  administered.  If  the  case  is  seen  early,  lavage  should  be  used.  For  the 
severe  inflammation  which  follows  the  swallowing  of  the  stronger  poisons 
palliative  treatment  is  alone  available,  and  morphia  may  be  freely  employed 
to  allay  the  pain. 

Diphtheritic  or  Membranous  Gastritis.— This  is  met  with  occasionally  in 
diphtheria,  but  more  commonly  as  a  secondary  process  in  typhus  or  typhoid 
fever,  pneumonia,  pygemia,  small-pox,  and  occasionally .  in  debilitated  chil- 
dren. The  exudation  may  be  extensive  and  uniform  or  in  patches.  The  con- 
dition is  not  recognizable  during  life,  unless  the  membranes  are  vomited. 

Mycotic  and  Parasitic  Gastritis.- — It  occasionally  happens  that  fungi  grow 
in  the  stomach  and  excite  inflammation.  One  of  the  most  remarkable  cases  of 
the  kind  is  that  reported  by  Kundrat,  in  which  the  favus' fungus  occurred  in 
the  stomach  and  intestine. 

In  cancer  and  in  dilatation  of  the  stomach  the  sarcinre  and  yeast  fungi 


CHRONIC  GASTEITIS  471 

probably  aid  in  maintaining  the  chronic  gastritis.  As  a  rule,  the  gastric 
juice  is  capable  of  killing  the  ordinary  bacteria.  Anthrax  bacilli  may  pro- 
duce swelling  of  the  mucosa  and  ulceration.  Acute  emphysematous  gastritis 
may  be  of  mycotic  origin.     The  larvse  of  certain  insects  may  excite  gastritis. 


II.     CHRONIC  GASTRITIS 

(Chronic  Catarrh  of  the  Stomach;  Chronic  Dyspepsia) 

Definition. — A  condition  of  disturbed  digestion  associated  with  increased 
mucous  formation,  qualitative  or  quantitative  changes  in  the  gastric  juice, 
enf eeblement  of  the  muscular  coats,  so  that  the  food  is  retained  for  an  ab- 
normal time  in  the  stomach;  and,  finally,  with  alterations  in  the  mucosa. 
The  term  chronic  gastritis  is  used  loosely  to  designate  a  variety  of  gastric  dis- 
orders, in  many  of  which  there  are  no  actual  changes  in  the  mucous  mem- 
brane. 

Etiology. — ^The  causes  may  be  classified  as  follows:  (a)  Dietetic.  Un- 
suitable or  improperly  prepared  food,  and  the  persistent  use  of  certain  articles 
of  diet,  such  as  very  fat  substances  or  foods  containing  too  much  of  the  carbo- 
hydrates. The  use  in  excessive  quantity  of  hot  bread,  hot  cakes,  and  pie  is 
a  fruitful  cause,  particularly  in  the  United  States.  The  use  in  excess  of  tea 
or  coffee,  and,  above  all,  of  alcohol  in  its  various  forms.  Under  this  head- 
ing, too,  may  be  mentioned  the  habits  of  eating  at  irregular  hours  or  too 
rapidly,  and  imperfectly  chewing  the  food.  "The  platter  kills  more  than  the 
sword."  A  common  cause  is  drinking  too  freely  of  ice-water  during  meals, 
a  practice  which  plays  no  small  part  in  the  prevalence  of  dyspepsia  in  Amer- 
ica. Another  frequent  cause  is  the  abuse  of  tobacco,  particularly  chewing. 
(&)  Constitutional  causes.  Angemia,  chlorosis,  chronic  tuberculosis,  gout,  dia- 
betes, and  nephritis  are  often  associated  with  chronic  gastric  catarrh,  (c) 
Local  conditions:  (1)  of  the  stomach,  as  in  cancer,  ulcer,  and  dilatation; 
(2)  conditions  of  the  portal  circulation,  causing  chronic  engorgement  of  the 
mucous  membrane,  as  in  cirrhosis,  chronic  heart-disease,  and  certain  chronic 
lung  affections,  {d)  Oral  sepsis,  particularly  pyorrhoea,  is  regarded  as  a 
common  cause  of  gastric  disturbance.  The  evidence  for  this  is  chiefly  of  the 
propter  hoc  kind — the  improvement  in  digestion  after  attention  to  the  mouth, 
(e)  The  association  of  chronic  appendicitis  with  gastric  disturbance  is  well 
recognized.  The  frequency  with  which  the  stomach  symptoms  recur  or  per- 
sist after  removal  of  the  appendix  suggests  that  both  conditions  are  sometimes 
due  to  another  common  cause. 

Morbid  Anatomy. — In  simple  chronic  gastritis  the  organ  is  usually  en- 
larged, the  mucous  membrane  pale  gray  in  color,  and  covered  with  closely 
adherent,  tenacious  mucus.  The  veins  are  large,  patches  of  ecchymosis  are 
not  infrequently  seen,  and  in  the  chronic  catarrh  of  portal  obstruction  and 
of  chronic  heart-disease  small  hsemorrhagic  erosions.  Toward  the  pylorus  the 
mucosa  is  not  infrequently  irregularly  pigmented,  and  presents  a  rough, 
wrinkled,  mammilated  surface,  which  may  be  so  prominent  that  writers  have 
described  it  as  gastritis  polyposa.  The  membrane  may  be  thinner  than  nor- 
.  mal,  and  much  firmer.     The  minute  anatomy  shows  the  picture  of  a  parenchy- 


472  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

matous  and  an  interstitial  inflammation.  The  mucous  membrane  may  undergo 
complete  atrophy  and  be  represented  by  a  smooth  cuticular  membrane  resem- 
bling that  of  the  cardiac  portion  of  the  horse's  stomach. 

Symptoms. — The  affection  persists  for  an  indefinite  period,  and,  as  is  the 
case  with  most  chronic  diseases,  changes  from  time  to  time.  Many  of  the 
symptoms  are  due  to  functional  disturbance.  The  disease  itself  probably 
does  not  cause  many  symptoms.  The  appetite  is  variable,  sometimes  greatly 
impaired,  at  others  very  good.  Among  early  symptoms  are  feelings  of  dis- 
tress or  oppression  after  eating,  which  may  become  aggravated  and  amount  to 
actual  pain.  When  the  stomach  is  empty  there  may  also  be  a  painful  feeling. 
The  pain  differs  in  different  cases,  and  may  be  trifling  or  of  extreme  sever- 
ity. When  localized  and  felt  beneath  the  sternimi  or  in  the  prgscordial  region 
■it  is  known  as  heart-burn  or  sometimes  cardialgia.  There  is  pain  on  pressure 
over  the  stomach,  usually  diffuse  and  not  severe.  The  tongue  is  coated,  and 
the  patient  complains  of  a  bad  taste  in  the  mouth.  The  tip  and  margin  of 
the  tongue  are  very  often  red.  Associated  with  this  catarrhal  stomatitis 
there  niay  be  an  increase  in  the  salivary  and  pharyngeal  secretions.  Nausea 
is  an  early  symptom,  and  is  particularly  apt  to  occur  in  the  morning  hours. 
It  is  not,  however,  nearly  so  constant  a  symptom  as  in  cancer  of  the  stomach, 
and  in  mild  grades  of  the  affection  it  may  not  occur  at  all.  Eructation  of 
gas,  which  may  continue  for  some  hours  after  taking  food,  is  a  very  prominent 
feature  in  cases  of  so-called  flatulent  dyspepsia,  and  there  may  be  marked 
distention  of  the  intestines.  With  the  gas,  bitter  fluids  may  be  brought  up. 
Tomiting^  which  is  not  very  frequent,  occurs  either  immediately  after  eating 
or  an  hour  or  two  later.  In  the  chronic  catarrh  of  old  topers  a  bout  of 
morning  vomiting  is  common,  in  which  a  slimy  mucus  is  brought  up.  The 
vomitus  consists  of  food  in  various  stages  of  digestion  and  slimy  mucus,  and 
the  chemical  examination  shows  the  presence  of  abnormal  acids,  such  as 
butyric,  or  even  acetic,  in  addition  to  lactic  acid,  while  the  hydrochloric  acid, 
if  present,  is  much  reduced  in  quantity.  The  digestion  may  be  delayed,  but 
usually  there  is  not  much  disturbance  of  motility. 

Constipation  is  usually  present,  but  in  some  instances  there  is  diarrhoea, 
and  undigested  food  passes  rapidly  through  the  bowels.  The  urine  is  often 
scanty,  high-colored,  and  deposits  a  heavy  sediment  of  urates. 

Of  other  symptoms  headache  is  common,  and  the  patient  feels  constantly 
out  of  sorts,  indisposed  for  exertion,  and  low-spirited.  In  aggravated  cases 
melancholia  may  occur.  Trousseau  called  attention  to  the  occurrence  of  ver- 
tigo, a  marked  feature  in  certain  cases.  The  pulse  is  small,  sometimes  slow, 
and  there  may  be  palpitation  of  the  heart.  Eever  does  not  occur.  Cough  is 
sometimes  present,  but  the  so-called  stomach  cough  of  chronic  dyspeptics  is  in 
all  probability  dependent  upon  pharyngeal  irritation.  J.  T.  Pilcher  has  called 
attention  to  the  frequency  with  which  absence  of  free  hydrochloric  acid  is 
found  with  the  presence  of  occult  blood.  In  many  of  these  the  stomach  con- 
dition appears  to  be  secondary  to  local  disease  elsewhere  in  the  abdomen,  par- 
ticularly the  appendix,  gall-bladder  or  the  pancreas.  The  bleeding  comes 
from  small  erosions,  and  is  always  of  the  so-called  occult  variety.  Many  va- 
rieties of  pathogenic  organisms  are  almost  constantly  found,  of  which  the 
streptococci  are  the  most  important. 

The  Gastric  Contents. — The  fasting  stomach  usually  contains  much  mucus. 


CHEOXIC  GASTEITIS  473 

The  study  of  the  gastric  contents  usually  shows  the  appearance  of  the  secretions 
to  be  much  delayed  but  they  gradually  appear.  The  HCl  is  usually  dimin- 
ished, though  it  may  be  normal.  In  some  cases  the  free  HCl  may  be  absent 
while  in  the  advanced  forms  of  atrophy  of  the  mucosa  there  may  be  neither 
acids  nor  ferments.     Mucus  is  not  present  in  atrophic  gastritis. 

The  symptoms  of  atrophy  of  the  mucous  membrane  of  the  stomach,  with- 
out contraction  of  the  organ,  are  very  complex,  and  cannot  be  said  to  present 
a  uniform  picture.  The  majority  of  the  cases  present  the  symptoms  of  an 
aggravated  chronic  dyspepsia,  often  of  such  severity  that  cancer  is  suspected. 
The  persistent  distress  after  eating,  the  vomiting,  and  the  gradual  loss  of  flesh 
and  strength  may  lead  to  the  diagnosis  of  cancer.  The  clinical  picture  may 
be  that  of  a  severe  ansemia.  As  early  as  1860  Flint  called  attention  to  this 
connection  between  atrophy  of  the  gastric  tubules  and  aneemia. 

Diagnosis. — It  is  well  in  any  patient  complaining  of  gastric  symptoms  to 
decide  first  whether  there  is  primary  organic  disease  of  the  stomach  or 
whether  the  condition  is  secondary  to  disease  elsewhere.  This  involves  a 
general  study  which  should  always  be  made  thoroughly.  It  is  easy  to  fix 
one's  attention  on  the  area  of  symptoms  and  fail  to  recognize  the  site  of  the 
cause.  The  organic  causes  of  chronic  stomach  disturbance  are  usually  read- 
ily recognized.  Carcinoma  may  give  the  greatest  difficulty,  but  a  careful 
study  of  the  gastric  contents  and  the  X-ray  findings  usually  removes  any 
doubt.  "With  this  excluded  the  problem  is  to  decide  whether  there  is  any 
other  organic  change  in  the  stomach  or  whether  the  symptoms  are  purely 
functional.  If  evidence  of  change  is  found  the  next  problem  is  whether  the 
condition  is  primary  or  secondary.  In  this  the  history  and  the  general  study 
of  the  patient  are  important.  The  causes  mentioned  before  give  an  idea  as 
to  how  varied  the  etiology  may  be. 

Ewald  distinguishes  three  forms  of  chronic  gastritis:  (1)  Simple  gas- 
tritis; (2)  mucous  gastritis;  (3).  atrophic  gastritis.  In  (1)  the  fasting 
stomach  contains  only  a  small  quantity  of  a  slimy  fluid,  while  after  the  test 
breakfast  the  HCl  is  diminished  in  quantity  or  may  be  absent.  Lactic  acid 
and  the  fatty  acids  may  be  present.  The  pepsin  and  rennin  are  always  pres- 
ent. In  (2)  the  acidity  is  always  slight  and  the  condition  is  distinguished 
from  (1)  chiefly  by  the  large  amount  of  mucus  present.  In  (3)  the  fasting 
stomach  is  generally  empty,  while  after  the  test  breakfast  HCl,  pepsin,  and 
rennin  are  wholly  wanting. 

The  diagnosis  of  cancer  of  the  stomach  from  chronic  gastritis  may  be  very 
difficult  when  a  tumor  is  not  present.  The  cases  require  most  careful  study, 
and  it  is  important  to  decide  whether  the  stomach  is  primarily  at  fault,  or 
whether  the  symptoms  are  due  to  disease  of  other  organs — liver,  gall-bhidder, 
appendix  or  pancreas. 

Treatment. — When  possible  the  cause  in  each  case  should  be  ascertained 
and  an  attempt  made  to  determine  the  special  form  of  indigestion.  In  the 
majority  of  cases  the  symptoms  are  secondary  to  disease  elsewhere  and  in 
them  the  treatment  is  largely  of  the  primary  condition.  Usually  there  is  no 
difficulty  in  differentiating  the  ordinary  catarrhal  and  the  nervous  varieties. 
A  careful  study  of  the  phenomena  of  digestion  should  be  made.  Two  im- 
portant questions  should  be  asked  of  every  dyspeptic — first,  as  to  the  time 
taken  at  his  meals ;  and,  second,  as  to  the  quantity  he  eats.    A  number  of  all. 


474  DISEASES  OF  THE  DIGESTIVE   SYSTEM 

cases  of  disturbed  digestion  come  from  hasty  and  imperfect  mastication  and 
from  overeating.  Especial  stress  should  be  laid  upon  the  former  point.  In 
some  instances  it  will  alone  suffice  to  cure  dyspepsia  if  the  patient  will  count 
a  certain  number  before  swallowing  each  mouthful.  The  second  point  is  of 
even  greater  importance.  People  habitually  eat  too  much,  and  it  is  probably 
true  that  a  greater  number  of  maladies  arise  from  excess  in  eating  than  from 
excess  in  drinking.  Chittenden's  researches  have  shown  that  we  require  much 
less  nitrogenous  food  to  maintain  a  standard  of  perfect  health — a  lesson  that 
the  Hindoos  and  Japanese  have  also  taught  us.  George  Cheyne's  thirteenth 
aphorism,  quoted  under  the  section  on  Obesity,  contains  a  volume  of  dietetic 
wisdom. 

(a)  General  and  Dietetic. — A  careful  and  systematically  arranged  diet- 
ary is  the  first,  sometimes  the  only,  essential  in  the  treatment  of  a  case  of 
chronic  dyspepsia.  It  is  impossible  to  lay  down  rules  applicable  to  all  cases 
but  in  general  the  diet  should  be  low  in  protein  and  largely  carbohydrate. 
Individuals  differ  extraordinarily  in  their  capability  of  digesting  different 
articles  of  food,  and  there  is  much  truth  in  the  old  adage,  "One  man's  food 
is  another  man's  poison."  The  individual  preferences  for  different  articles 
of  food  should  be  permitted  in  the  milder .  forms.  Physicians  have  probably 
been  too  arbitrary  in  this  direction,  and  have  not  yielded  sufficiently  to  the 
intimations  given  by  the  appetite  and  desires  of  the  patient. 

A  rigid  milk  diet  may  be  tried.  "Milk  and  sweet  sound  Blood  differ  in 
nothing  but  in  Color:  Milli  is  Blood"  (George  Cheyne).  In  the  forms  as- 
sociated with  nephritis  and  chronic  portal  congestion,  as  well  as  in  many  in- 
stances in  which  -the  dyspepsia  is  part  of  a  neurasthenic  or  hysterical  trouble, 
this  plan  in  conjunction  with  rest  is  most  efficacious.  If  milk  is  not  digested 
well  it  may  be  diluted  one-third  with  soda  water  or  Vich}'',  or  5  to  10  grains 
of  carbonate  of  soda,  or  a  pinch  of  salt  may  be  added  to  each  tumblerful. 
In  many  cases  the  milk  from  which  the  cream  has  been  taken  is  better  borne. 
Buttermilk  is  particularly  suitable,  but  can  rarely  be  taken  for  so  long  a  time 
alone,  as  patients  tire  of  it  much  more  quickly  than  they  do  of  ordinary  milk. 
Not  only  can  the  general  nutrition  be  maintained  on  this  diet,  but  patients 
sometimes  increase  in  weight,  and  the  gastric  symptoms  disappear  entirely. 
It  should  be  given  at  fixed  hours  and  in  definite  quantities.  A  patient  may 
take  6  or  8  ounces  every  three  hours.  The  amount  necessary  varies  a  good 
deal,  but  at  least  3  to  5  pints  should  be  given  in  the  twenty-four  hours.  This 
form  of  diet  is  not,  as  a  rule,  well  borne  when  there  is  a  tendency  to  dilatation 
of  the  stomach.  The  milk  may  be  previously  peptonized,  but  it  is  impossible 
to  feed  a  chronic  dyspeptic  in  this  way.  The  stools  should  be  carefully  watched, 
and  if  more  milk  is  taken  than  can  be  digested  it  is  well  to  supplement  the  diet 
with  eggs  and  dry  toast  or  biscuits. 

In  a  large  proportion  of  the  cases  it  is  not  necessary  to  annoy  the  patient 
with  strict  dietaries.  It  may  be  quite  sufficient  to  cut  off  certain  articles  of 
food.  Thus,  if  there  are  acid  eructations  or  flatulency  the  farinaceous  foods 
should  be  restricted,  particularly  potatoes  and  the  coarser  vegetables.  A 
fruitful  source  of  indigestion  is  the  hot  bread  and  this,  as  well  as  the  various 
forms  of  pancakes,  pies  and  tarts,  with  heavy  pastry,  and  fried  articles  of 
all  sorts,  should  be  strictly  forbidden.  As  a  rule,  white  bread,  toasted,  is  more 
readily  digested  than  bread  made  from  the  whole  meal.     Persons,  however, 


CHEOmC  GASTEITIS  475 

differ  very  much  in  this  respect,  and  the  Graham  or  brown  bread  is  most  di- 
gestible for  many  people.  Sugar  and  very  sweet  articles  of  food  should  be 
taken  in  great  moderation  or  avoided  altogether.  Many  instances  of  aggra- 
vated indigestion  are  due  to  the  prevalent  practice  of  eating  largely  of  ice- 
cream. One  of  the  most  powerful  enemies  of  the  American  stomach  is  the 
soda-water  fountain,  which  has  usurped  so  important  a  place  in  the  apothecary 
shop. 

Fats,  with  the  exception  of  a  moderate  amount  of  good  butter,  very  fat 
meats,  and  thick,  greasy  soups  should  be  avoided.  Ripe  fruit  in  moderation 
is  often  advantageous,  particularly  when  cooked.  Bananas  are  not,  as  a  rule, 
well  borne.  Strawberries  are  to  many  persons  a  cause  of  an  annual  attack  of 
indigestion  and  sore  throat. 

In  the  matter  of  special  articles  of  food  it  is  impossible  to  lay  down  rigid 
rules,  and  it  is  the  common  experience  that  one  patient  with  indigestion  will 
take  with  impunity  the  articles  which  cause  distress  to  another. 

Another  detail  of  importance  is  the  general  hygienic  management.  These 
patients  are  often  introspective,  dwelling  in  a  morbid  manner  on  their  symp- 
toms, and  much  inclined  to  take  a  despondent  view  of  their  condition.  Very 
little  progress  can  be  made  unless  the  physician  gains  their  confidence  from 
the  outset.  Their  fears  and  whims  should  not  be  made  too  light  of  or  ridi- 
culed. Systematic  exercise,  carefully  regulated,  particularly  when,  as  at  wa- 
tering places,  it  is  combined  with  a  restricted  diet,  is  of  special  service.  Change 
of  air  and  occupation,  a  prolonged  sea  voyage,  or  a  summer  m  the  mountains 
will  sometimes  cure  the  most  obstinate  dyspepsia. 

(&)  Medicinal. — The  special  measures  may  be  divided  into  those  which 
attempt  to  replace  elements  which  are  lacking  in  the  digestive  juices  and  those 
which  stimulate  the  organ.  In  the  first  group  come  the  hydrochloric  acid 
and  ferments,  which  are  so  freely  employed.  The  former  is  the  most  impor- 
tant. It  is  the  ingredient  in  the  gastric  juice  most  commonly  deficient.  It  is 
not  only  necessary  for  its  own  important  actions,  but  its  presence  is  intimately 
associated  with  that  of  the  pepsin,  as  it  is  only  in  the  presence  of  a  sufficient 
quantity  that  the  pepsinogen  is  converted  into  the  active  digestive  ferment. 
It  is  best  given  as  the  dilute  acid  taken  in  somewhat  larger  quantities  than  are 
usually  advised.  Ewald  recommends  large  doses — of  from  90  to  100  drops — 
at  intervals  of  fifteen  minutes  after  the  meals.  Leube  and  Riegel  advise 
smaller  doses.  Probably  from  15  to  20  drops  is  sufficient.  The  prolonged 
use  of  it  does  not  appear  to  be  hurtful.  Its  use  should  be  restricted  to  cases 
of  neurosis  and  atrophy  of  the  mucous  membrane.  In  actual  gastritis  its 
value  is  doubtful. 

iSTitrate  of  silver  is  a  good  remedy  in  some  cases,  used  in  solution  in  the 
lavage  (1  to  1,500  or  1  to  2,000),  or  in  pill  form,  one-eighth  to  one-fourth  of 
a  grain  three  times  a  day.     Argyria  has  resulted  after  its  protracted  use. 

The  digestive  ferments  are  extensively  employed.  The  use  of  pepsin  may 
be  limited  to  the  cases  of  advanced  mucous  catarrh  and  atrophy  of  the  stom- 
ach, in  which  it  should  be  given,  in  doses  of  from  10  to  15  grains,  with  dilute 
hydrochloric  acid  a  quarter  of  an  hour  after  meals.  Pancreatin  is  of  equal 
or  even  greater  value  and-  should  be  given  in  doses  of  from  15  to  20  grains,  in 
combination  with  bicarbonate  of  soda.  It  is  conveniently  administered  in 
.tablets,  each  of  which  contains  5  grains  of  the  pancreatin  and  the  soda,  and 


476  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

of  these  two  or  three  may  be  taken  fifteen  or  twenty  minutes  after  each  meal. 
Malt  diastase  is  sometimes  serviceable  given  with  alkalies. 

Of  measures  which  stimulate  the  glandular  activity  lavage  is  the  most 
important,  particularly  in  the  forms  characterized  by  the  secretion  of  a  large 
quantity  of  mucus.  Lukewarm  water  should  be  used,  or,  if  there  is  much 
mucus,  a  1-per-cent.  salt  solution,  or  a  3-  to  5-per-cent.  solution  of  bicarbonate 
of  soda.  If  there  is  much  fermentation  the  3-per-cent.  solution  of  boric  acid 
may  be  used.  It  is  best  employed  in  the  morning  on  an  empty  stomach,  or  in 
the  evening  some  hours  after  the  last  meal  in  those  cases  in  which  there  is 
much  nocturnal  distress  and  flatulency.  Once  a  day  is,  as  a  rule,  sufficient, 
or,  in  the  case  of  delicate  persons,  every  second  day.  The  irrigation  may  be 
continued  until  the  water  which  comes  away  is  quite  clear.  It  is  not  neces- 
sary to  remove  all  the  fluid  after  the  irrigation.  While  in  some  hands  this 
measure  has  been  carried  to  extremes,  it  is  one  of  value  in  certain  cases. 
When  there  is  an  insuperable  objection  to  lavage  a  substitute  may  be  used  in 
the  form  of  warm  alkaline  drinks,  taken  slowly  in  the  early  morning  or  the 
last  thing  at  night. 

Of  medicines  which  stimulate  the  gastric  secretion  the  most  important  are 
the  bitter  tonics,  such  as  nux  vomica,  gentian,  and  cardamom.  These  are 
probably  of  more  value  in  chronic  gastritis  than  the  hydrochloric  acid.  Of 
these'  nux  vomica  is  the  most  powerful,  though  none  of  them  have  probably 
any  very  great  stimulating  action  on  the  secretion,  and  influence  rather  the 
appetite  than  the  digestion.  If  a  patient  has  been  in  the  habit  of  taking  beer 
or  light  wines  or  stimulants  with  his  meals,  the  practice  may  be  continued  if 
moderate  quantities  are  taken.  Beer,  as  a  rule,  is  not  well  borne.  A  dry 
sherry  or  a  glass  of  claret  is  preferable. 

(c)  Treatment  of  Special  Conditions. — Flatulency. — For  this  condi- 
tion careful  dieting  may  suffice,  particularly  forbidding  such  articles  as  tea, 
pastr}^,  and  the  coarser  vegetables.  It  is  usually  combined  with  pyrosis,  in 
which  the  acid  fluids  are  brought  into  the  mouth.  Bismuth  and  bicarbonate 
of  soda  sometimes  suffice  to  relieve  the  condition.  For  acid  dyspepsia  Sir 
William  Eoberts  recommended  the  bismuth  lozenge  of  the  British  Pharma- 
copoeia, the  antacid  properties  of  which  depend  on  chalk  and  bicarbonate  of 
soda.  It  should  be  taken  an  hour  or  two  after  meals,  and  only  when  the  pain 
and  uneasiness  are  present.  The  burnt  magnesia  is  also  a  good  remedy.  Gly- 
cerin in  from  20-  to  60-minim  doses,  the  essential  oils,  animal  charcoal  alone 
or  in  combination  with  compound  cinnamon  powder  may  be  tried.  If  there  is 
much  pain,  chloroform  in  20-minim  doLes  or  a  teaspoonful  of  Hoffman's  ano- 
dyne may  be  used.  In  obstinate  cases  lavage  is  indicated  and  is  sometimes 
striking  in  its  effects.    Alkaline  solutions  may  be  used. 

Vomiting  is  not  a  feature  which  often  calls  for  treatment  in  chronic  dys- 
pepsia; sometimes  in  children  it  is  a  persistent  symptom.  Creosote  and  car- 
bolic acid  in  drop  doses,  a  few  drops  of  chloroform  or  of  dilute  hydrocyanic 
acid,  cocaine,  bismuth,  and  oxalate  of  cerium  may  be  used.  If  obstinate,  the 
stomach  should  be  washed  out  daily. 

Constipation  is  a  frequeut  and  troublesome  feature  of  most  forms  of  indi- 
gestion. Every  effort  should  be  made  to  remedy  this  without  the  use  of  pur- 
gatives. Eegularity  in  going  to  stool,  the  taking  of  sufficient  water  especially 
before  meals,  proper  exercise,  and  the  use  of  agar-agar  or  mineral  oil  may  be 


DILATATION  OF  THE  STOMACH  477 

enough.  If  drugs  are  needed  the  simpler  laxatives  should  be  used,  such  as 
senna,  cascara  and  phenolphthalein.  In  the  cases  secondary  to  other  diseases, 
such  as  renal  or  cardiac,  the  use  of  salines  is  indicated.  Glycerin  supposi- 
tories and  the  injection  of  from  half  a  teaspoonful  to  a  teaspoonful  of  g'ycerin 
may  be  efficacious. 

Many  cases  are  greatly  benefited  by  the  use  of  mineral  waters,  particularly 
a  residence  at  the  springs  with  a  careful  supervision  of  the  diet  and  systematic 
exercise. 

m.     CIRRHOSIS  VENTRICULI 

(Plastic  Linitis) 

Brinton  described  under  the  term  limtis  plastica  a  condition  of  diffuse 
sclerosis  of  the  stomach  with  thickening  of  the  walls  and  reduction  of  the 
lumen.  It  may  be  localized,  but  more  commonly  involves  the  whole  organ, 
and  a  similar  condition  has  been  found  in  the  colon,  small  bowel,  and  rectum. 
In  one  case,  a  patient  of  Dr.  Drake's,  Montreal,  the  stomach  was  no  bigger  than 
a  cucumber,  and  the  caecum  and  part  of  the  ascending  colon  showed  the  same 
thickening.  The  special  lesion  is  an  enormous  hypertrophy  of  the  submucosa, 
with  atrophy  of  the  gland  elements  and  hypertrophy  of  the  muscular  layers,  so 
that  the  wall  is  six  to  eight  times  the  normal  thickness;  but,  as  Brinton  re- 
marks, the  layers  remain  distinct.  There  are  two  forms,  benign  and  ma- 
lignant, which  are  not  easy  to  separate  without  the  most  careful  microscopic 
examination.  Lyle  collected  118  cases  from  the  literature,  more  than  half 
of  which  were  the  true  plastic  linitis  of  Brinton. 

The  symptoms  are  at  first  indefinite,  but  when  well  established  vomiting 
becomes  marked  and  there  is  inability  to  retain  even  small  amounts  of  food. 
The  presence  of  a  sausage-shaped  tumor  in  the  epigastrium  is  important. 
Hgemorrhage  may  be  present.  The  X-ray  picture  is  of  great  help.  The 
protracted  history,  the  restriction  in  capacity  of  the  stomach,  and  the  tumor 
may  give  a  characteristic  clinical  picture.  Gastro-enterostomy  is  helpful  if  it 
can  be  done  but  in  the  majority  it  is  impossible;  total  gastrectomy  has  been 
performed  in  some  cases. 


IV.    DILATATION  OF  THE  STOMACH 

{Gastredasis) 

Etiology. — Acute  dilatation  is  a  very  serious  condition,  described  by 
Hilton  Fagge,  characterized  by  sudden  onset,  vomiting  of  enormous  quantities 
of  fluid,  and  symptoms  of  collapse.  Of  102  cases  collected  by  Lewis  A.'  Con- 
ner 42  followed  operation  with  general  angesthesia.  The  next  largest  group 
occurs  in  the  course  of  severe  diseases,  or  during  convalescence.  Cases  have 
followed  injuries,  particularly  of  the  head  and  spine.  In  9  cases  the  symp- 
toms came  on  after  a  single  large  meal;  6  cases  were  associated  with  spinal 
disease,  in  3  while  the  patients  were  in  a  plaster  of  Paris  jacket,  and  in  a  few 
cases  it  has  come  on  in  persons  in  good  health.    There  were  74  deaths.    In  69 


478  DISEASES  OF  THE  DIGESTIVE   SYSTEM      ~ 

autopsies  the  duodenum  was  found  dilated  in  38  cases.  In  a  majority  of 
cases  it  is  due  to  a  constriction  of  the  lower  end  of  the  duodenum  by  traction 
on  the  mesenteric  root,  which  is  particularly  apt  to  occur  when  there  is  a 
long  mesentery  and  when  the  coil  of  small  bowel  is  empty  and  falls  into  the 
true  pelvis.  The  diagnosis  is  usually  easy — repeated  vomiting  of  large  quan- 
tities of  bilious  non-fsecal  fluid,  with  subnormal  temperature,  pain,  collapse 
symptoms,  and  distended  abdomen  are  the  common  features.  The  treatment 
consists  in  repeated  emptying  of  the  stomach  with  the  tube;  change  in  pos- 
ture from  the  dorsal  to  the  belly  position  or  the  knee-elbow  position  has  been 
followed  by  prompt  relief.     Operation  has  not  proved  very  satisfactory. 

Chronic  dilatation  results  from:  (a)  Pyloric  obstruction  due  to  nar- 
rowing of  the  orifice  or  of  the  duodenum  by  the  cicatrization  of  an  ulcer, 
hypertrophic  stenosis  of  the  pylorus  (whether  cancerous  or  simple),  congeni- 
tal stricture,  or  occasionally  by  pressure  from  without  of  a  tumor  or  of  a 
floating  kidney.  The  pylorus  may  be  tilted  up  by  adhesions  to  the  liver  or 
gall-bladder,  or  the  stomach  may  be  so  dilated  that  the  pylorus  is  dragged 
down  and  kinked.  Adhesions  about  the  gall-bladder  may  extend  along  the 
adjacent  parts  of  the  stomach  and  hitch  up  the  pylorus  into  the  hilus  of  the 
liver,  forming  a  very  acute  kink.  In  some  cases  there  is  an  intermittent  re- 
tention lasting  for  some  hours,  often  due  to  pyloric  spasm.  In  such  cases 
there  are  usually  hyperacidity  and  the  signs  of  vagotonia.  It  may  be  associ- 
ated with  disease  of  the  duodenum,  gall-bladder  or  appendix.  In  some  cases 
it  seems  as  if  pyloric  spasm  leads  to  definite  dilatation.  (6)  Relative  or  abso- 
lute insufficiency  of  the  muscular  poiver  of  the  stomach,  due  on  the  one  hand 
to  repeated  overfilling  of  the  organ  with  food  and  drink,  and  on  the  other  to 
atony  of  the  coats  induced  by  chronic  inflammation  or  the  degeneration  of 
impaired'  nutrition,  the  result  of  constitutional  affections. 

The  most  extreme  forms  are  met  with  as  a  sequence  of  the  cicatricial  con- 
traction of  an  ulcer.  There  may  be  considerable  stenosis  without  much  dila- 
tation, the  obstruction  being*  compensated  by  hypertrophy  of  the  muscular 
coats.  In  the  second  group,  due  to  atony  of  the  muscular  coats,  we  must  dis- 
tinguish between  instances  in  which  the  stomach  is  simply  enlarged  and  those 
with  actual  dilatation,  conditions  characterized  by  Ewald  as  megalogastria 
and  gastrectasis  respectively.  The  size  of  the  stomach  varies  greatly  and  the 
maximum  capacity  of  a  normal  organ  Ewald  places  at  about  1,600  c.  c. 
Measurements  above  this  point  indicate  absolute  dilatation. 

Atonic  dilatation  may  result  from  weakness  of  the  coats,  due  to  repeated 
overdistention,  to  chronic  catarrh  of  the  mucous  membrane,  or  to  the  general 
muscular  debility  associated  with  chronic  wasting  disorders  of  all  sorts.  The 
combination  of  chronic  gastric  catarrh  with  overfeeding  and  excessive  drink- 
ing is  a  common  cause  of  atonic  dilatation.  The  condition  is  frequently  seen  in 
diabetics,  in  the  insane,  and  in  beer-drinkers.  In  Germany  this  form  is  com- 
mon in  men  employed  in  breweries.  Possibly  muscular  weakness  of  the  coats 
may  result  in  some  cases  from  disturbed  innervation.  Dilatation  of  the  stom- 
ach is  most  frequent  in  middle-aged  or  elderly  persons,  but  the  condition  is 
not  uncommon  in  children,  especially  in  association  with  rickets. 

Symptoms. — In  atonic  dilatation  there  may  be  no  symptoms  whatever, 
even  with  a  very  greatly  enlarged  organ;  more  frequently  there  are  the  asso- 
ciated features  of  neurasthenia,  enteroptosis,  and  nervous  dyspepsia ;  while  in 


DILATATION  OF  THE  STOMACH  479 

a  third  group  there  may  be  all  the  symptoms  of  pyloric  obstruction — vomiting 
of  enormous  quantities,  etc.  There  is  no  limit  to  the  capacity  of  the  organ 
in  this  condition.  Gould  and  Pyle  mention  an  instance  in  which  the  stomach 
held  70  pints ! 

The  features  of  pyloric  obstruction,  from  whatever  cause,  are  usually  very 
evident.  Dyspepsia  is  present  in  nearly  all  cases,  and  there  are  feelings  of 
distress  and  uneasiness  in  the  region  of  the  stomach.  The  patient  may  com- 
plain much  of  hunger  and  thirst  and  eat  and  drink  freely.  The  most  charac- 
teristic symptom  is  the  vomiting  at  intervals  of  enormous  quantities  of  liquid 
and  of  food,  amounting  sometimes  to  four  or  more  litres.  The  material  is 
often  of  a  dark-grayish  color,  with  a  characteristic  sour  odor  due  to  the  or- 
ganic acids  present,  and  contains  mucus  and  remnants  of  food.  On  standing 
it  separates  into  three  layers,  the  lowest  consisting  of  food,  the  middle  of  a 
turbid,  dark-gray  fluid,  and  the  uppermost  of  a  brownish  froth.  The  micro- 
scopic examination  shows  a  large  variety  of  bacteria,  yeast  fungi,  and  the 
sarcina  ventriculi.  There  may  also  be  cherry  stones,  plum  stones,  and  grape 
seeds.  The  hydrochloric  acid  may  be  absent,  diminished,  normal,  or  in  excess, 
depending  upon  the  cause  of  the  dilatation.  The  fermentation  produces  lac- 
tic, butyric,  and,  possibly,  acetic  acid  and  various  gases.  In  the  intermittent 
forms  with  pyloric  spasm  there  is  retention  often  for  four  to  eight  hours, 
usually  with  hyperacidity.  Vagotonia  is  often  present  and  disease  of  the  gall- 
bladder, duodenum  or  appendix  should  be  considered. 

In  consequence  of  the  small  amount  of  fluid  which  passes  from  the  stom- 
ach or  is  absorbed  there  are  constipation,  scanty  urine,  and  extreme  dryness 
of  the  skin.  The  general  nutrition  of  the  patient  suffers  greatly ;  there  is  loss 
of  flesh  and  strength,  and  in  some  cases  the  most  extreme  emaciation.  The 
color  may  be  retained  and  if  there  is  much  vomiting,  there  may  be  marked 
polycythsemia.  The  gastric  tetany  will  be  considered  in  the  section  on  that 
disease. 

Physical  Signs. — Inspection. — The  abdomen  may  be  large  and  promi- 
nent, the  greatest  projection  occurring  below  the  navel  in  the  standing  pos- 
ture. In  some  instances  the  outline  of  the  distended  stomach  can  be  plainly 
seen,  the  small  curvature  a  couple  of  inches  below  the  ensiform  cartilage,  and 
the  greater  curvature  passing  obliquely  from  the"  tip  of  the  tenth  rib  on  the 
left  side,  toward  the  pubes,  and  then  curving  upward  to  the  right  costal  margin. 
Too  much  stress  can  not  be  laid  on  the  importance  of  inspection.  Very  often 
the  diagnosis  may  be  made  de  visu.  Active  peristalsis  may  be  seen  in  the 
dilated  organ,  the  waves  passing  from  left  to  right.  Occasionally  anti-peri- 
stalsis may  be  seen.  In  cases  of  stricture,  particularly  of  hypertrophic  steno- 
sis, as  the  peristaltic  wave  reaches  the  pylorus,  the  tumor-like  thickening  can 
sometimes  be  distinctly  seen  through  the  thin  abdominal  wall.  To  stimulate 
the  peristalsis  the  abdomen  may  be  flipped  with  a  wet  towel.  Inflation  may 
be  practiced  with  carbonic-acid  gas.  A  small  teaspoonful  of  tartaric  acid  dis- 
solved in  an  ounce  of  water  is  first  given,  then  a  rather  larger  quantity  of  bi- 
carbonate of  soda.  In  many  cases  the  outline  of  the  dilated  stomach  stands 
out  with  great  distinctness,  and  waves  of  peristalsis  are  seen  in  it. 

Palpation. — The  peristalsis  may  be  felt,  and  usually  in  stenosis  a  tumor 
is  evident  at  the  pylorus.  The  resistance  of  a  dilated  stomach  is  peculiar,  and 
has  been  aptly  compared  to  that  of  an  air  cushion.    Bimanual  palpation  elicits 


480  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

a  splashing  sound — clapotage — which  is,  of  course,  not  distinctive,  as  it  can 
be  obtained  whenever  there  are  much  liquid  and  air  in  the  organ.  The  splash- 
ing may  be  very  loud,  and  the  patient  may  produce  it  himself  by  suddenly 
depressing  the  diaphragm,  or  it  may  be  readily  obtained  by  shaking  him.  The 
gurgling  of  gas  through  the  pylorus  may  be  felt. 

Percussion. — The  note  is  tympanitic  over  the  greater  portion  of  a  dilated 
stomach;  in  the  dependent  part  the  note  is  flat.  In  the  upright  position  the 
percussion  should  be  made  from  above  downward,  in  the  left  parasternal  line, 
until  a  change  in  resonance  is  reached.  The  line  of  this  should  be  marked, 
and  the  patient  examined  in  the  recumbent  position,  when  it  will  be  found 
to  have  altered  its  level.  When  this  is  on  a  line  with  the  navel  or  below  it, 
dilatation  of  the  stomach  may  generally  be  assumed  to  exist.  The  fluid  may 
be  withdrawn  from  the  stomach  with  a  tube,  and  the  dulness  so  made  to  dis- 
appear, or  it  may  be  increased  by  pouring  in  more  fluid.  In  cases  of  doubt 
the  organ  should  be  distended  with  carbonic-acid  gas  or  inflated  through  a 
stomach-tube. 

Auscultation. — The  clupotage  or  succussion  can  be  obtained  readily.  Fre- 
quently a  curious  sizzling  sound  is  present,  not  unlike  that  heard  when  the 
ear  is  placed  over  a  soda-water  bottle  when  first  opened.  It  can  be  heard 
naturally,  and  is  usually  evident  when  the  artificial  gas  is  heing  generated. ' 
The  heart  sounds  may  sometimes  be  transmitted  with  great  clearness  and 
with  a  metallic  quality. 

Diagnosis. — This  can  usually  be  made  without  much  difficulty.  Emphasis 
should  be  placed  on  the  value  of  inspection,  particularly  in  combination  with 
inflation  of  the  stomach.  Curious  errors  are  on  record,  one  of  the  most  re- 
markable of  which  was  the  confounding  of  dilated  stomach  with  an  ovarian 
cyst;  even  after  tapping  and  the  removal  of  portions  of  food  and  fruit  seeds, 
abdominal  section  was  performed  and  the  dilated  stomach  opened.  The  diag- 
nosis of  ascites  has  been  made  and  the  abdomen  opened.  The  prognosis  de- 
pends upon  the  cause;  it  is  good  in  simple  atony,  bad  in  cancerous  stricture, 
fairly  good  in  simple  stricture,  from  whatever  cause. 

Treatment. — In  the  cases  due  to  atony  careful  regulation  of  the  diet  and 
proper  treatment  of  the  associated  catarrh  will  suffice  to  effect  a  cure.  Strych- 
nine, ergot,  and  iron  are  recommended.  Washing  out  the  stomach  is  of  great 
service,  though  we  do  not  see  such  striking  and  immediate  results  in  this 
form.  In  cases  of  mechanical  obstruction  the  stomach  should  be  emptied  and 
thoroughly  washed,  either  with  warm  water  or  with  an  antiseptic  solution. 
Three  important  things  are  accomplished:  The  weight  which  distends  the 
organ  is  removed;  the  fermenting  materials  which  irritate  and  inflame  the 
stomach  and  impede  digestion  are  washed  out;  and  we  cleanse  the  inner  sur- 
face of  the  organ.  The  patient  can  usually  be  taught  to  wash  out  his  own 
stomach,  and  in  a  case  of  dilatation  from  simple  stricture  the  practice  may 
be  followed  with  great  benefit.  The  rapid  reduction  in  the  size  of  the  stomach 
is  often  remarkable,  the  vomiting  ceases,  food  is  taken  readily,  and  in  many 
cases  the  general  nutrition  improves  rapidly.  As  a  rule,  once  a  day  is  suf- , 
ficient,  and  it  may  be  practised  either  the  first  thing  in  the  morning  or  before 
going  to  bed.  So  soon  as  the  fermentative  processes  have  been  checked  luke- 
warm water  alone  should  be  used.    In  the  inUrmitient  form  the  use  of  atro- 


THE  PEPTIC  ULCEE,  GASTEIC  AND  DUODENAL  481 

pine  with  small  closes  of  bromide  is  often  useful.  Any  lesion  elsewhere  in  the 
abdomen  should  be  properly  treated. 

The  food  should  be  taken  in  small  quantities  at  frequent  intervals,  and  as 
concentrated  as  possible.  Fatty  and  starchy  articles  of  diet  are  to  be  avoided. 
Liquids  should  be  taken  sparingly. 

Surgery  should  be  resorted  to  early  in  cases  of  organic  stricture ;  in  atonic 
dilatation  after  all  other  measures  have  been  given  a  thorough  trial,  gastro- 
enterostomy may  be  practised  but  the  results  are  not  satisfactory. 


V.     THE  PEPTIC  ULCER,  GASTRIC  AND  DUODENAL 

The  round,  perforating,  simple  or  peptic  ulcer  is  usually  single,  and  oc- 
curs in  the  stomach  and  in  the  duodenum  as  far  as  the  papilla.  Post  mortem 
statistics  show  a  great  preponderance  of  the  gastric  ulcer,  but  the  experience 
of  surgeons  has  taught  us  that  in  more  than  fifty  per  cent,  of  cases  which 
come  to  operation  the  ulcer  is  outside  the  pyloric  ring. 

Erosions. — Small  abrasions  of  the  mucosa — 2  to  4  mm. — usually  multiple, 
are  common,  extending  half  way  or  quite  through  the  layer.  They  are  often 
called  h^emorrhagic  erosions  from  their  blood-stained  appearance.  They  are 
met  with  in  the  new-born,  in  cachectic  states  in  children,  in  chronic  heart  and 
arterial  disease,  in  cirrhosis  of  the  liver,  etc.  Of  no  clinical  importance,  as  a 
rule,  occasionally  an  acute  hemorrhagic  erosion  of  quite  small  size  opens  a 
large  artery,  and  the  patient  bleeds  to  death.  There  is  no  difference  between 
this  condition  and  the  acute  form  of  the  gastric  ulcer. 

In  certain  acute  infections  with  the  pneumococcus  (Dieulafoy)  and  septic 
organisms  there  may  be  hgemorrhagic  erosions,  which  occasionally  prove  fatal 
by  hsematemesis.  It  is  probable  that  the  post-operative  hamatemesis,  slight 
or  grave,  may  be  due  to  these  erosions.  The  French  have  described  them  as  if 
peculiar  to  operations  for  appendicitis  but  cases  occur  after  all  sorts  of  ab- 
dominal operations.  It  is  probable  that  the  slight  gastric  haemorrhages  which 
occur  in  connection  with  the  throbbing  aorta  in  neurotic  women  are  due  to 
these  erosions. 

Etiology  of  Peptic  Ulcer. — Incidence. — The  disease  is  much  more  com- 
mon than  medical  and  pathological  statistics  indicate.  The  surgical  work  of 
many  men  has  taught  us  that  the  peptic  ulcer  exists  in  many  cases  which  we 
had  regarded  as  simple  hyperchlorhydria.  In  two  points  surgical  experience 
has  completely  changed  our  medical  standpoint,  viz. :  the  incidence  of  ulcer 
in  the  male  is  greater  than  in  the  female,  and  the  duodenal  is  more  common 
than  the  gastric  ulcer.  In  a  series  of  1725  proved  cases  more  than  two-thirds 
were  duodenal  (Smithies).  The  surgical  statistics  have  sent  our  medical 
figures  to  the  scrap  heap.  The  incidence  appears  to  vary  in  different  localities, 
and  post  mortem  figures  from  the  United  States  and  Canada  show  a  much 
lower  percentage  of  cases  (1.32)  than  on  the  continent  of  Europe  (5  per  cent.), 
and  in  London,  4.2  per  cent.   (C.  P.  Howard). 

Sex. — Of  1,699  cases  collected  from  hospital  statistics  by  W.  H.  Welch  and 
examined  post  mortem,  40  per  cent,  were  in  males  and  60  per  cent,  were  in 
females.     Surgical  statistics  show  an  enormous  preponderance  of  males. 

Age. — In  females  the  largest  number  of  cases  occurred  between  fifteen  and 


482  DISEASES   OF  THE  DIGESTIVE   SYSTEM 

twenty-five;  in  males  between  forty  and  fifty,  in  our  series.  It  may  occur  in 
old  people.  E.  G.  Cutler  studied  a  series  of  29  cases  in  children.  In  6  the 
symptoms  came  on  immediately  after  birth.  There  were  8  cases  under  seven 
years  of  age,  and  9  between  eight  and  thirteen. 

OccuPATiox. — It  was  impossible  in  our  series  to  say  that  occupation  had 
any  influence.  Among  women,  chlorotic,  dyspeptic  servant  girls  seem  very 
prone.  Shoemakers  are  thought  to  be  specially  liable.  It  appears  relatively 
more  common  in  the  hospital  classes. 

Trauma. — Ulcers  have  been  known  to  follow  a  blow  in  the  region  of  the 
stomach.     There  was  a  history  of  injury  in  7  cases  in  our  series. 

Associated  Diseases. — Anaemia  and  chlorosis  predispose  strongly  to  gas- 
tric ulcer,  particularly  in  women  and  in  association  with  menstrual  disorders. 
A  very  considerable  number  of  all  cases  of  gastric  ulcer  occur  in  chlorotic 
girls.  It  has  been  found  also  in  connection  with  disease  of  the  heart,  arterio- 
sclerosis, and  disease  of  the  liver.  The  tuberculous  and  syphilitic  ulcers  of  the 
stomach  have  been  considered. 

BuRXS. — The  duodenal  ulcer  may  follow  large  superficial  burns.  Perry 
and  Shaw  found  it  in  5  of  149  autopsies  in  cases  of  burns  of  the  skin. 

Infection. — This  is  the  most  important  factor.  Any  focal  infection  may 
be  responsible,  as  in  the  mouth.  In  cases  of  other  associated  abdominal  in- 
fections, as  in  the  appendix  or  gall-bladder,  both  may  have  come  from  a  com- 
mon source,  or  the  ulcer  may  be  secondary  to  the  other. 

Morbid  Anatomy  and  Pathology.— Xinety  per  cent,  of  gastric  ulcers  are 
to  be  found  at  the  pyloric  end;  nearly  all  duodenal  ulcers  are  in  the  first  or 
ascending  portion,  and  more  than  one-half  extend  up  to  or  within  three- 
fourths  of  an  inch  of  the  pylorus,  while  twenty  per  cent,  involve  the  margin 
of  the  pyloric  ring  (Mayo).  In  explanation  of  the  greater  frequency  of  the 
ulcer  just  outside  the  pyloric  sphincter  it  is  stated  that  this  part  of  the  duo- 
denal mucosa  is  deficient  in  blood  supply  in  comparison  with  the  other.  It  is 
thought  to  be  a  bacteriological  infection  of  the  mucosa,  the  source  being  some 
focus  in  the  territory  of  the  portal  vein,  particularly  the  appendix.  It  may 
not  be  easy  on  the  operating  table  to  distinguish  between  an  ulcer  of  the  duo- 
denum and  that  of  the  stomach,  but  Mayo  says  that  the  position  of  the  pyloric 
vein  gives  the  exact  location.  Multiple  ulcers  may  occur,  8.2  per  cent,  in  the 
Mayo  series.  From  5  to  34  have  been  found.  In  the  stomach,  post  mortem 
statistics  (Welch)  give,  in  793  cases,  288  on  the  lesser  curvature,  235  on  the 
posterior  wall,  69  on  the  anterior  wall,  95  at  the  pylorus,  50  at  the  cardia,  29 
at  the  fundus,  and  27  on  the  greater  curvature. 

The  acute  ulcer  is  usually  small,  punched  out,  the  edges  clean-cut,  the  floor 
smooth,  and  the  peritoneal  surface  not  thickened.  The  chronic  ulcer  is  of 
larger  size,  the  margins  are  no  longer  sharp,  the  edges  are  indurated,  and  the 
border  is  sinuous.  It  may  reach  an  enormous  size,  as  in  the  one  reported  by 
Peabody,  which  measured  19  by  10  cm.  and  involved  all  of  the  lesser  curva- 
ture and  spread  over  a  large  part  of  the  anterior  and  posterior  walls.  The 
sides  are  often  terraced.  The  floor  is  formed  either  by  the  submucosa,  by  the 
muscular  layers,  or,  not  infrequently,  by  the  neighboring  organs,  to  which  the 
stomach  has  become  attached.  In  the  healing  of  the  ulcer,  if  the  mucosa  is 
alone  involved,  the  granulation  tissue  grows  from  the  edges  and  the  floor  and 
the  newly  formed  tissue  gradually  contracts  and  unites  the  margins,  leaving 


THE  PEPTIC  ULCER,  GASTRIC  AND  DUODEXAL  483 

a  smooth  scar.  In  larger  ulcers  which  have  involved  the  muscular  coat  the 
cicatricial  contraction  may  cause  serious  changes,  the  most  important  of  which 
is  pyloric  narrowing  and  consequent  dilatation  of  the  stomach.  In  the  case  of 
a  girdle  ulcer  hour-glass  contraction  of  the  stomach  may  be  produced.  Large 
ulcers  persist  for  years  without  any  attempt  at  healing. 

Among  the  more  serious  changes  which  may  result  are  the  following : 

Perforation. — This  occurred  in  28.1  per  cent,  of  1,871  cases  collected  by 
Musser.  In  some  series  (Mayo's)  duodenal  perforation  is  the  more  common. 
Of  272  cases  of  duodenal  ulcer  in  Mayo's  series  (to  June  1,  1908),  perforation 
was  found  sixty-six  times,  16  acute,  13  subacute  with  abscess,  and  37  chronic 
and  protected.  Perforation  of  the  anterior  v/all  of  the  stomach  usually  excites 
an  acute  peritonitis.  On  the  posterior  wall  the  ulcer  penetrates  directly  into 
the  lesser  peritoneal  cavity,  in  which  case  it  may  produce  an  air-containing 
abscess  with  the  symptoms  of  the  condition  known  as  subphrenic  pyopneumo- 
thorax. In  rare  instances  adhesions  and  a  gastrocutaneous  fistula  form,  usu- 
ally in  the  umbilical  region.  Fistulous  communication  with  the  colon  may 
also  occur,  or  a  gastroduodenal  fistula.  The  pericardium  may  be  perforated, 
and  even  the  left  ventricle.  Perforation  into  the  pleura  may  also  occur.  It 
is  to  be  noted  that  general  emphysema  of  the  subcutaneous  tissues  occasion- 
ally follows  perforation  of  a  gastric  ulcer. 

Erosion  of  Blood-vessels. — In  both  forms  of  ulcer  haemorrhage  occurs, 
in  8.1  per  cent,  of  Musser's  series  of  1,871  cases.  In  Moynihan's  114  cases  of 
duodenal  ulcer,  hemorrhage  occurred  in  41.  It  is  more  common  in  the 
chronic  form.  Ulcers  on  the  posterior  wall  may  erode  the  splenic  artery,  but 
perhaps  more  frequently  the  bleeding  proceeds  from  the  artery  of  the  lesser 
curvature.  In  the  case  of  duodenal  ulcer  the  pancreaticoduodenal  artery  may 
be  eroded,  or  fatal  haemorrhage  may  result  from  the  opening  of  the  hepatic 
artery,  or  more  rarely  the  portal  vein.  Embolism  of  the  artery  supplying  the 
ulcerated  region  has  been  met  with  in  several  cases;  in  others  diffuse  endar- 
teritis. Small  aneurisms  have  been  found  in  the  floor  of  the  ulcers.  A  rare 
event  is  emphysema  of  the  sub-peritoneal  tissue,  which  may  be  extensive  and 
even  pass  on  to  the  posterior  mediastinum.  Jurgensen  ascribes  it  to  entrance 
of  air  into  the  veins,  but  Welch  thinks  it  represents  an  invasion  with  the  gas 
bacillus. 

Cicatrization. — Superficial  ulcers  often  heal  without  leaving  any  serious 
damage.  Stenosis  of  the  pyloric  orifice  not  infrequently  follows  the  healing  of 
an  ulcer  in  its  neighborhood.  In  other  instances  the  large  annular  ulcer 
may  cause  in  its  cicatrization  an  hour-glass  contraction  of  the  stomach.  The 
adhesion  of  the  ulcer  to  neighboring  parts  may  subsequently  be  the  cause  of 
much  pain.  The  parts  of  the  mucosa  in  the  neighborhood  of  the  ulcer  fre- 
quently show  signs  of  chronic  gastritis. 

Perigastric  Adhesions. — The  condition  is  common,  as  high  as  5  per 
cent,  of  post  mortem  records.  It  follows  ulcer,  lesions  of  the  gall-bladder, 
pancreatic  disease,  syphilitic  disease  of  the  liver,  and  chronic  tuberculosis. 
In  some  instances  the  lesions  are  quite  extensive,  and  the  condition  has  been 
called  plastic  perigastritis.  It  may  be  associated,  too,  with  hypertrophic  thick- 
ening of  the  coats  of  the  stomach  and  with  chronic  plastic  peritonitis.  In 
somie  instances  the  pylorus  may  be  narrowed  as  a  result  of  the  adhesions,  or 
a  sort  of  hour-glass  stomach  may  be  produced,  or  the  motility  of  the  organ 


484  DISEASES  OP  THE  DIGESTIVE  SYSTEM 

is  interfered  with.  Pain  is  the  most  constant  feature,  and  may  simulate  that 
of  gastric  ulcer  or  of  hyperacidity,  and  may  be  present  constantly  or  at  in- 
tervals. It  is  much  influenced  by  posture  and  usually  relieved  by  pressure. 
Local  tenderness  is  present  in  a  majority  of  instances.  The  cases  are  chronic, 
the  general  health  is  but  slightly  interfered  with,  and  there  are  not,  as  a  rule, 
signs  of  gastric  dilatation.  A  definite  tumor  may  be  present  about  the  region 
of  the  pylorus.  Chronic  appendicitis  and  lesions  of  the  gall-bladder  are  found 
in  many  cases. 

Mode  of  Origin. — The  mode  of  origin  is  unknown.  The  anatomical  basis 
is  an  interference  wit^  the  blood  supply  in  a  limited  area  of  the  mucosa,  at- 
tributed to  embolism,  thrombosis,  or  spasm  of  the  arteries.  As  they  are  not 
end  vessels,  simple  obstruction  can  not  account  for  it.  Trophic  influences, 
bacterial  necrosis  of  the  mucosa,  spasm  of  the  muscular  coat  in  limited  areas, 
etc.,  are  among  the  hypotheses  which  have  been  advanced.  The  present  tend- 
ency is  to  attach  much  importance  to  the  part  played  by  infection. 

Jejunal  Ulcer. — This  may  occur  after  gastrojejunostomy,  but  in  many 
cases  the  ulcer  involves  both  stomach  and  jejunum.  The  condition  is  rare, 
as  after  1,141  gastrojejunostomies  at  the  Mayo  clinic  not  one  developed  an 
ulcer. 

Carcinoma  AND  Ulcer. — There  has  been  much  difference  of  opinion  as  to 
the  number  of  cases  in  which  carcinoma  develops  in  an  ulcer.  There  is  no 
doubt  of  its  occurrence  but  the  percentage  is  probably  small. 

Symptoms. — The  condition  may  be  latent  and  only  met  with  accidentally, 
post  mortem.  The  first  symptoms  may  be  those  of  perforation.  In  other 
cases  the  patient  has  had  gastric  disturbance  for  years  and  the  ulcer  may  not 
have  been  suspected  until  the  occurrence  of  a  sudden  haemorrhage.  The 
history  is  almost  always  of  an  illness  of  long  duration,  usually  of  some  years, 
in  which  there  have  been  remissions  often  with  complete  relief  from  symptoms. 
The  periodicity  may  be  marked;  the  symptoms  are  rarely  continuoas.  Many 
of  the  symptoms  are  due  to  associated  conditions  of  which  vagotonia  is  im- 
portant.    The  ulcer  alone  may  give  few  symptoms  in  some  cases. 

Dyspepsia  may  be  slight  and  trifling  or  of  a  most  aggravated  character. 
Nausea  and  vomiting  occur  in  a  large  proportion  of  the  gastric  cases,  the 
latter  not  for  two  or  more  hours  after  eating.  It  is  probably  most  conxmnn 
when  the  ulcer  is  near  the  pylorus.  The  vomitus  usually  contains  a  large 
amount  of  hydrochloric  acid. 

Hemorrhage  is  present  in  at  least  one-third  of  all  cases.  A  patient  may 
feel  faint  and  turn  pale  and  sweat;  the  next  day  the  stools  may  be  tarry  from 
the  blood  that  has  passed  into  the  small  bowel.  The  bleeding  may  be  latent 
(occult).  These  concealed  hsemorrhages  are  often  small,  and  the  blood  is  not 
readily  seen  in  the  vomitus  or  stools.  These  latent  hsemorrhages  may  cause 
a  slowly  progressive  anaemia.  More  commonly  the  bleeding  is  profuse,  and 
the  blood  may  be  in  such  quantities  and  brought  up  so  quickly  that  it  is  fluid, 
bright  red  in  color,  and  quite  unaltered.  When  it  remains  for  some  time  in 
the  stomach  and  is  mixed  with  food  it  may  be  greatly  changed,  but  the  vomit- 
ing of  a  large  quantity  of  unaltered  blood  is  very  characteristic  of  ulcer.  As; 
a  rule,  there  are  only  one  or  two  attacks;  in  our  series  7  cases  had  one  hem- 
orrhage, 7  two,  11  three,  1  fou^r,  and  15  many  (Howard).    Profuse  bleedings 


THE  PEPTIC  ULCEK,  GASTRIC  AND  DUODEXAL  485 

may  occur  at  intervals  for  many  years.     Death  may  follow  directly.     From 
16  to  18  per  cent,  of  the  fatal  cases  are  due  to  it  (S.  and  W.  Fenwick). 

The  immediate  effect  of  the  haemorrhage  is  a  severe  anaemia,  from  which 
it  may  take  months  to  rally ;  slight  fever  is  common.  Pare  and  untoward  ef- 
fects are  convulsions,  sometimes  only  the  usual  convulsions  of  extreme  cere- 
bral anaemia  from  which  recovery  takes  place,  or  they  may  precede  a  hemi- 
plegia, due  probably  to  thrombosis.  Amaurosis  may  follow  the  haemorrhage 
and  unfortunately  may  be  permanent,  due  to  degeneration  of  the  retinal 
ganglion  cells,  or  to  a  thrombosis  of  the  cerebral  arteries  or  veins. 

Pain  is  perhaps  the  most  constant  and  distinctive  feature  of  ulcer.  It 
varies  greatly  in  character;  it  may  be  only  a  gnawing  or  burning  sensation, 
which  is  particularly  felt  when  the  stomach  is  empty,  and  is  relieved  by  taking 
food,  but  the  more  characteristic  form  comes  on  in  paroxysms,  in  which  the 
pain  is  not  only  felt  in  the  epigastrium,  but  radiates  to  the  back  and  to  the 
sides.  In  many  cases  the  two  points  of  epigastric  pain  and  dorsal  pain,  about 
the  level  of  the  tenth  dorsal  vertebra,  are  very  well  marked.  These  attacks 
are  most  frequently  induced  by  taking  food,  and  they  may  recur  at  a  variable 
period  after  eating,  sometimes  within  fifteen  or  twenty  minutes,  at  others  as 
late  as  two  or  three  hours.  The  pain  rarely  comes  on  more  than  four  hours 
after  taking  food.  It  is  usually  stated  that  when  the  ulcer  is  near  the  cardia 
the  pain  is  apt  to  set  in  earlier,  but  there  is  no  certainty  on  this  point.  In 
some  cases  it  comes  on  in  the  early  morning  hours.  The  attacks  may  occur 
at  intervals  with  great  intensity  for  weeks  or  months  at  a  time,  so  that  the 
patient  requires  morphia,  then  again  they  may  disappear  entirely  for  a  pro- 
longed period.  In  the  attack  the  patient  is  usually  bent  forward,  and  finds 
relief  from  pressure  over  the  epigastric  region;  one  patient  during  the  attack 
would  lean  over  the  back  of  a  chair;  another  would  lie  flat  on  the  floor,  with 
a  hard  pillow  under  the  abdomen. 

Tenderness  on  pressure  is  a  common  symptom  and  patients  wear  the 
waist-band  very  low.  Pressure  should  be  made  with  great  care,  as  rupture 
of  an  ulcer  is  said  to  have  been  induced  by  careless  manipulation. 

In  old  ulcers  with  thickened  bases  an  indurated  mass  may  be  felt  in  the 
neighborhood  of  the  pylorus. 

Gastric  Contents. — There  is  often  evidence  of  some  retention.  The  find- 
ings as  to  acidity  vary  and  too  much  importance  should  not  be  placed  on  them. 
Our  ideas  as  to  hyperacidity  have  had  to  be  revised;  high  figures  are  not  al- 
ways present  in  ulcer.  With  marked  retention  there  may  be  high  acidity 
figures.  If  neoplasm  has  developed  in  an  ulcer  the  HCl  is  reduced.  Careful 
search  should  always  be  made  for  blood,  either  fresh  or  occult,  both  in  the 
stomach  contents  and  stools. 

Of  general  symptoms,  loss  of  weight  results  from  the  prolonged  dyspepsia, 
but  it  rarely,  except  in  association  with  cicatricial  stenosis  of  the  pylorus, 
reaches  the  high  grade  met  with  in  cancer.  The  ancemia  may  be  extreme,  and 
in  one  case  of  duodenal  ulcer,  the  blood-count  was  as  low  as  700,000  per  c.  mm. 
Of  44  cases  in  the  wards  of  the  Hopkins  Hospital  in  which  blood-counts  were 
made,  the  lowest  was  1,902,000  per  c.  mm.  There  are  instances  in  which  the 
anaemia  can  not  be  explained  by  the  occurrence  of  haemorrhage.  In  a  few  in- 
stances polycythaemia  is  present,  even  after  a  haemorrhage,  due  to  concentration 


486  DISEASES  OE  THE  DIGESTIVE  SYSTEM 

of  the  blood  in  association  with  dilatation  of  the  stomach.  In  a  few  cases 
parotitis  occurs,  with  the  perforation  sometimes,  or  after  a  haemorrhage. 

Perforation. — The  acute,  perforating  form  is  much  more  common  in 
women  than  in  men.  The  symptoms  are  those  of  perforative  peritonitis. 
Particular  attention  must  be  given  to  this  accident,  since  it  has  come  so  suc- 
cessfully within  the  sphere  of  the  surgeon.  Perforation  may  take  place  either 
into  the  lesser  peritoneum  or  into  the  general  peritoneal  cavity,  in  both  of 
which  cases  operation  is  indicated;  in  rare  instances  the  ulcer  may  perforate 
the  pericardium.  This  was  the  case  in  10  of  28  cases  in  which  the  diaphragm 
was  perforated  (Pick).  Localized,  more  frequently  subphrenic,  abscess  may 
follow  perforation. 

Urine. — Albumin  is  occasionally  present;  in  14  of  our  series  with  dilata- 
tion of  the  stomach.  Indican  may  be  present.  Acetone  and  diacetic  acid 
(with  syncopal  attacks)  have  been  described  by  Dreschfeld. 

Hour-glass  stomach  most  frequently  results  from  the  cicatrization  of  an 
ulcer.  It  may  follow  perforation  of  an  ulcer  into  the  liver  or  pancreas.  In  a 
few  cases  it  is  congenital.  The  symptoms,  fairly  characteristic,  are  thus  given 
by  Moynihan : 

(a)  In  washing  out  the  stomach  part  of  the  fluid  is  lost,  (b)  If  the  stom- 
ach is  washed  clean,  a  sudden  reappearance  of  stomach  contents  may  take 
place,  (c)  "Paradoxical  dilatation" ;  when  the  stomach  has  apparently  been 
emptied,  a  splashing  sound  may  be  elicited  by  palpation  of  the  pyloric  seg- 
ment, (d)  After  distending  the  stomach,  a  change  in  the  position  of  the 
distention  tumor  may  be  seen  in  some  cases,  (e)  Gushing,  bubbling,  or 
sizzling  sounds  are  heard  on  dilatation  with  carbon  dioxide  at  a  point  distinct 
from  the  pylorus.  (/)  In  some  cases,  when  both  parts  are  dilated,  two  tumors 
with  a  notch  or  sulcus  between  are  apparent  to  sight  or  touch.  To  these  may 
be  added  (g)   a  most  characteristic  X-ray  picture. 

Prognosis. — -In  all  statistics  the  acute  and  chronic  ulcer  have  been  consid- 
ered together.  The  former  is  more  amenable  to  medical  treatment,  but  grave 
complications  may  occur  even  before  the  digestive  symptoms  have  been  very 
pronounced.  The  chronic  ulcer  may  last  for  years — twelve,  eighteen,  or  even 
twenty- — with  intervals  of  good  health.  Controversy  as  to  the  relative  results 
of  medical  and  surgical  treatment  is  futile.  Medical  treatment  is  indicated 
in  different  conditions  than  surgical.  In  the  early  stages  medical  treatment 
is  advisable  and  should  have  a  thorough  trial.  With  a  chronic  ulcer  it  may 
be  a  waste  of  time  to  attempt  it.  Many  cases  do  well  with  medical  treatment ; 
others  are  not  helped.  Surgery  is  not  always  successful,  for  gastro-enteros- 
tomy,  which  is  done  so  often,  can  not  be  regarded  as  a  physiological  operation. 
In  private  practice  many  series  of  cases  have  not  a  mortality  above  6  per  cent. 
The  mortality  of  the  chronic  peptic  ulcer  in  the  hangls  of  such  experts  as  the 
Mayos  and  Moynihan  is  very  low.  In  670  operations  for  ulcer  of  the  stomach 
the  mortality  was  3.5  per  cent.,  and  47  cases  required  a  secondary  operation 
(Balfour).  In  Moynihan's  cases  of  duodenal  ulcer,  114  in  number  (exclusive 
of  perforation),  there  were  only  two  deaths. 

Diagnosis. — The  acute  non-indurated  ulcer  may  cause  very  few  symptoms 
— nothing  beyond  gastric  discomfort  with  pain.  Hsematemesis  may  be  the 
first  symptom  of  moment.  This  group  of  cases  is  seen  chiefly  in  young  girls, 
and  appears  to  be  more  common  in  England  than  in  the  United  States.     A 


THE  PEPTIC  ULCEE,  GASTEIC  AND  DUODENAL  487 

condition  which  may  be  confounded  with  it  is  gastrostaxis,  described  by  Hale 
White.  The  stomach  symptoms  are  marked,  the  bleeding  may  be  profuse,  but 
post  mortem  or  at  operation  no  ulcer  is  found.  Careful  inspection  must  be 
made,  as  fatal  bleeding  may  come  from  a  very  small  erosion. 

In  the  chronic  cases  the  nutrition  at  first  may  remain  good,  and  the  pa- 
tient looks  well.  The  whole  complaint  is  of  the  stomach,  of  pain  and  distress, 
with  belching  and  nausea  or  vomiting  from  two  to  four  hours  after  meals. 
This  special  feature  of  the  recurrence  of  the  pain  some  hours  after  taking 
food,  its  extraordinary  regularity,  and  the  relief  afforded  by  taking  food 
clearly  separate  the  dyspeptic  features  of  ulcer  from  other  types.  In  the  early 
stages  there  is  usually  no  alteration  in  secretion  or  motility,  but  sooner  or 
later  both  are  altered.  The  rhythm  of  gastric  function  is  disturbed.  With 
disturbance  in  motility,  usually  delay,  the  secretion  is  altered.  The  secre- 
tory findings  depend  partly  on  the  extent  and  chronicity  of  the  ulcer  and  the 
impairment  of  motility.  The  post-digestion  secretion  increases.  The  X-ray 
examination  is  of  the  greatest  aid  and  may  be  the  only  means  by  which  we 
can  distinguish  gastric  from  duodenal  ulcer.  In  uncomplicated  duodenal  ulcer 
the  stomach  is  usually  hypertonic. 

The  presence  of  adhesions,  especially  between  the  gall-bladder  and  duode- 
num, may  cause  difficulty.  The  symptoms  are  long  continued,  present  a  great 
variety  and  may  suggest  gastric  ulcer  but  in  their  irregularity  are  more  like 
those  of  gall-stones.  The  taking  of  food  may  give  relief  which  may  suggest 
duodenal  or  gastric  ulcer  close  to  the  pylorus.  Blood  is  not  found  in  the 
gastric  contents  or  stools.  The  X-ray  study  may  suggest  duodenal  ulcer.  As 
operation  is  indicated  in  these  cases,  an  error  in  diagnosis  leading  to  operation 
is  not  serious. 

Treatment — The  main  principles  are  as  follows:  Eirst,  the  control  of 
foci  of  infection;  second,  the  obtaining  of  gastric  rest  so  far  as  possible,  and, 
third,  the  neutralization  of  acidity.  Unless  there  are  definite  indications  for 
operation,  it  seems  wise  to  try  the  efi^ect  of  medical  treatment,  but  this  should 
be  carried  out  systematically.  The  control  of  infection  demands  proper  treat- 
ment of  any  foci,  especially  in  the  mouth.  The  control  of  gastric  acidity 
means  that  there  should  not  be  free  HCl  in  the  stomach  either  while  food  is 
contained  there  or  during  the  night. 

The  patient  should  be  at  rest  in  bed  and  kept  there  for  several  weeks.  In 
the  method  advised  by  Sippy,  food  is  given  every  hour  from  7  a.  m.  to  7  p.  m. 
during  the  day.  At  first  three  ounces  of  a  mixture  of  equal  parts  of  milk  and 
cream  are  given.  After  a  few  days  soft  eggs  and  cooked  cereals  are  gradually 
added.  These  may  be  given  alternately  with  and  in  addition  to  the  milk  and 
cream.  The  total  bulk  at  one  feeding  should  not  exceed  six  ounces.  Later, 
cream  soups,  bread  and  butter,  and  soft  foods  may  be  added. 

To  control  the  acidity,  alkali  is  given  between  each  feeding.  This  is  done 
by  giving  a  powder  of  gr.  x  (0.6  gm.)  each  of  heavy  calcined  magnesia  and 
sodium  bicarbonate  alternating  with  a  powder  of  gr.  x  (0.6  gm.)  of  bismuth 
carbonate  and  gr.  xxx  (2  gm.)  of  sodium  bicarbonate.  In  addition,  after  the 
last  feeding  of  the  day,  the  powders  should  be  given  every  half  hour  for  four 
doses  or  until  the  stomach  is  empty.  The  powders  are  administered  in  about 
two  ounces  of  water.  It  is  well  to  aspirate  the  stomach  about  two  hours  after 
the  last  feeding  to  be  sure  that  it  is  empty.     If  this  amount  of  alkali  is  not 


488  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

sufficient,  more  sodium  bicarbonate  may  be  given.  By  examining  the  stomach 
contents  occasionally  it  oan  be  determined  whether  or  not  the  free  acidity  is 
being  controlled.  After  some  weeks  the  patient  may  be  given  light  meals, 
but  the  taking  of  equal  parts  of  milk  and  cream  each  hour  should  be  kept  up. 
When  the  hourly  feedings  between  meals  are  stopped,  the  alkaline  powder 
should  be  taken  every  hour  for  three  doses  after  each  meal.  It  is  usually  well  to 
continue  this  treatment  longer  than  may  seem  necessary. 

If  the  ulcer  has  caused  pyloric  obstruction,  as  a  rule  a  larger  amount  of 
alkali  is  required  and  it  is  well  to  empty  the  stomach  each  night  about  half 
an  hour  after  the  last  pow.der  is  taken.  The  important  thing  is  to  give  suf- 
ficient alkali  to  control  the  acidity.  A  careful  watch  over  the  progress  should 
be  kept  and  the  amount  of  retained  material  noted.  The  emptying  of  the 
stomach  the  last  thing  at  night  lessens  the  tendency  to  night  secretion.  Eegu- 
lar  examinations  of  the  stool  for  occult  blood  are  an  important  guide  as  to  the 
value  of  the  treatment.  In  all  cases  it  is  important  to  obtain  the  co-operation 
of  the  patient  so  that  after  he  passes  from  immediate  observation  he  will  be 
careful  to  follow  instructions. 

Medicinal  measures,  apart  from  the  alkaline  treatment,  are  of  little  value. 
Atropine  may  be  useful  in  the  dosage  suitable  for  each  patient.  For  the 
bowels  the  use  of  salines  in  the  morning  is  usually  best,  or  enemata  may  be 
given.  The  artificial  Carlsbad  salts  (sulphate  of  sodium,  50  parts;  bicarbo- 
nate of  sodium,  6;  chloride  of  sodium,  3)  may  be  given. 

The  pain,  if  severe,  requires  opium.  Unless  it  is  intense  morphia  should 
not  be  given,  as  there  is  a  very  serious  danger  of  establishing  the  morphia 
habit.  Doses  of  an  eighth  of  a  grain  (0.008  gm.),  with  bicarbonate  of  soda 
and  bismuth,  will  allay  the  mild  attacks,  but  the  very  severe  ones  require  the 
hypodermic  injection  of  a  quarter  (0.016  gm.)  or  often  half  (0.03  gm.)  a 
grain.  In  the  milder  attacks  Hoffman's  anodyne,  or  20  or  30  drops  of  spirit 
of  chloroform,  or  the  spirit  of  camphor,  will  give  relief.  Counter  irritation- 
over  the  stomach  with  mustard  or  cantharides  is  often  useful. 

When  the  stomach  is  irritable,  the  patient  should  be  fed  per  rectum.  He 
will  sometimes  retain  food  which  is  passed  into  the  duodenum  through  a  tube. 
Cracked  ice,  chloroform,  oxalate  of  cerium,  and  bismuth  may  be  tried.  When 
hcemorrhage  occurs  the  patient  should  be  put  under  the  influence  of  opium  as 
rapidly  as  possible.  Xo  attempt  should  be  made  to  check  the  haemorrhage  by 
administering  medicines  by  the  mouth;  as  the  profuse  bleeding  is  always  from 
an  eroded  artery,  frequently  from  one  of  considerable  size,  it  is  doubtful  if 
acetate  of  lead,  tannic  and  gallic  acids,  and  the  usual  remedies  have  the  slight- 
est influence.  The  essential  point  is  to  give  rest,  which  is  best  obtained  by 
opium.  Nothing  should  be  given  by  the  mouth  except  small  quantities  of  ice. 
Not  infrequently  the  loss  of  blood  is  so  great  that  the  patient  faints.  A  fatal 
result  is  not,  however,  very  common  from  hgemorrhage.  Blood  serum  (15  to 
30  c.  c.)  may  be  injected  intramuscularly.  Transfusion  is  advisable  in  severe 
conditions.  The  patients  usually  recover  rapidly  from  the  hemorrhage  and  re- 
quire iron  in  full  doses,  which  may,  if  necessary,  be  given  hypodermically. 

Surgical  interference  is  indicated:  (1)  For  perforation;  (2)  in  the 
chronic  indurated  ulcer.  Experience  has  shown  that  after  gastro-enterostomy 
the  ulcer  may  heal  rapidly,  and  in  some  cases  the  ulcer  itself  may  be  located; 
(3)  in  all  cases  when  the  ulcer  has  caused  persistent,  mechanical  interference; 


CAXCER  OF  THE  STOMACH  489 

(4)  in  all  cases  associated  with  recurring  hgemorrhages.  In  young  girls  the 
single  severe  attack  of  hamatemesis  may  be  a  simple  gastrorrhexis,  or  from 
a  simple  ulcer  that  heals  readily,  but  in  men  severe  hgematemesis  is  almost  al- 
ways from  the  chronic  ulcer;  (5)  in  the  perigastric  adhesions  after  chronic 
ulcer  operation  is  sometimes  helpful;  (6)  in  chronic  cases  in  which  medical 
treatment  fails  to  give  relief;  and  (7)  when  there  is  reason  to  suspect  the  de- 
velopment of  carcinoma. 

In  the  present  state  of  our  knowledge  it  is  not  easy  to  determine  the  lim- 
its of  medical  and  surgical  practice  in  the  treatment  of  peptic  ulcer.  The  old 
statistics  are  not  of  use,  since  it  is  quite  clear  that  scores  of  cases  have  been 
masquerading  under  the  names  of  hyperchlorhydria,  acid  dyspepsia,  and  so 
forth.  The  simple  non-indurated  ulcer  is,  in  the  majority  of  cases,  a  medical 
disease.    A  chronic  indurated  form  is  best  treated  surgically. 


VI.     CANCER  OF  THE  STOMACH 

Etiology. — Incidence. — In  an  analysis  of  30,000  cases  of  cancer,  W.  H. 
Welch  found  the  stomach  involved  in  21.4  per  cent.,  this  organ  thus  standing 
next  to  the  uterus  in  order  of  frequency.  Among  8,464  medical  cases  admitted 
to  the  Johns  Hopkins  Hospital,  there  were  150  cases  of  cancer  of  the  stomach 
and  39  cases  among  the  first  1,000  autopsies.  The  disease  is  more  common  in 
some  countries.  Figures  indicate  that  cancer  of  the  stomach  is  increasing  in 
frequency. 

Sex. — Of  the  150  cases  126  were  males  and  24  females.  Welch  gives  the 
ratio  as  5  to  4. 

Age. — Of  our  150  cases  the  ages  were  as  follows:  Between  twenty  and 
thirty,  6 ;  from  thirty  to  forty,  17 ;  forty  to  fifty,  38 ;  fifty  to  sixty,  49 ;  sixty 
to  seventy,  36 ;  seventy  to  eighty,,  4.  Fifty-eight  per  cent,  occurred  between 
the  ages  of  forty  and  sixty.  Of  the  6  cases  occurring  under  the  thirtieth 
year,  the  youngest  was  twenty-two.  Of  the  large  number  of  cases  analyzed  by 
Welch,  three-fourths  occurred  between  the  fortieth  and  seventieth  years.  Con- 
genital cancer  of  the  stomach  has  been  described,  and  cases  have  been  met 
with  in  children. 

Eace. — Among  our  150  cases,  131  were  white,  19  were  negroes. 

Previous  Diseases,  Habits,  Etc. — A  history  of  dyspepsia  was  present  in 
only  33  cases;  of  these,  17  had  had  attacks  at  intervals,  11  had  had  chronic 
stomach  trouble,  and  5  had  had  dyspepsia  for  one  or  two  years  before  the 
symptoms  of  cancer  developed.  ISTapoleon,  discussing  this  point  with  his 
physician  Antommarchi,  said  that  he  had  always  had  a  stomach  of  iron  and 
felt  no  inconvenience  until  the  onset  of  what  proved  to  be  his  fatal  illness. 

Gastric  Ulcer. — The  relation  to  this  condition  is  in  dispute — the  physi- 
cians are  against,  some  surgeons  are  in  favor.  In  only  4  cases  in  our  series 
was  there  a  history  pointing  to  ulcer. 

Morbid  Anatomy. — The  most  common  varieties  of  gastric  cancer  are  the 
cylindrical-celled  adeno-carcinoma  and  the  encephaloid  or  medullary  carci- 
noma ;  next  in  frequency  is  scirrhous,  and  then  colloid  cancer.  With  reference 
to  the  situation  of  the  tumor,  Welch  analyzed  1,300  cases,  in  which  the  dis- 
tribution was  as  follows:     Pyloric  region,  791;  lesser  curvature,  148;  cardia, 


490  DISEASES  OF  THE  DIGESTIVE   SYSTEM 

104;  posterior  wall,  68;  the  whole  or  greater  part  of  the  stomach,  61;  multiple 
tumors,  45;  greater  curvature,  34;  anterior  wall,  30;  fundus,  19. 

The  medullary  cancer  occurs  in  soft  masses,  which  involve  all  the  coats 
of  the  stomach  and  usually  ulcerate  early.  The  tumor  may  form  villous  pro- 
jections or  cauliflower-like  outgrowths.  It  is  soft,  grayish- white  in  color,  and 
contains  much  blood.  The  cylindrical-celled  epithelioma  may  also  form  large 
irregular  masses,  but  the  consistence  is  usually  firmer,  particularly  at  the  edges 
of  the  cancerous  ulcers.  Cysts  are  not  uncommon  in  this  form.  The  scirrhous 
variety  is  characterized  by  great  hardness,  due  to  the  abundance  of  the  stroma 
and  the  limited  amount  of  alveolar  structures.  It  is  seen  most  frequently  at 
the  pylorus,  where  it  is  a  common  cause  of  stenosis.  It  may  be  combined  with 
the  medullary  form.  It  may  be  diffuse,  involving  all  parts  of  the  organ,  and 
leading  to  a  condition  which  can  not  be  recognized  macroscopically  from  cir- 
rhosis. This  form  has  also  been  seen  in  the  stomach  secondary  to  cancer  of 
the  ovaries.  In  connection  with  the  diffuse  carcinomatosis  there  may  be  simul- 
taneous involvement  of  the  small  and  large  intestines.  The  colloid  cancer  is 
peculiar  in  its  widespread  invasion  of  all  the  coats.  It  also  spreads  with 
greater  frequency  to  the  neighboring  parts,  and  it  occasionally  causes  ex- 
tensive secondary  growths  of  the  same  nature  in  other  organs.  The  appear- 
ance on  section  is  very  distinctive,  and  even  with  the  naked  eye  large  alveoli 
can  be  seen  filled  with  the  translucent  colloid  material.  The  term  alveolar 
cancer  is  often  applied  to  this  form.  Ulceration  is  not  constantly  present, 
and  there  are  instances  in  which,  with  most  extensive  disease,  digestion  has 
been  but  slightly  disturbed. 

Secondary  Cancer  of  the  Stomach. — Of  37  cases  collected  by  Welch, 
17  were  secondary  to  cancer  of  the  breast.  Among  the  first  1,000  autopsies  at 
the  Johns  Hopkins  Hospital  there  were  3  cases  of  secondary  cancer. 

Changes  in  the  Stomach. — Cancer  at  the  cardia  is  usually  associated 
with  wasting  of  the  organ  and  reduction  in  its  size.  The  oesophagus  above 
the  obstruction  may  be  greatly  dilated.  On  the  other  hand,  annular  cancer 
at  the  pylorus  causes  stenosis  with  great  dilatation  of  the  organ.  In  a  few 
rare  instances  the  pylorus  has  been  extremely  narrowed  without  any  increase 
in  the  size  of  the  stomach.  In  diffuse  scirrhous  cancer  the-  stomach  may  be 
very  greatly  thickened  and  contracted.  It  may  be  displaced  or  altered  in 
shape  by  the  weight  of  the  tumor,  particularly  in  cancer  of  the  p3dorus;  in 
such  cases  it  has  been  found  in  every  region  of  the  abdomen,  and  even  in 
the  true  pelvis.  The  mobility  of  the  tumors  is  at  times  extraordinary  and 
very  deceptive,  and  they  may  be  pushed  into  the  right  hypochondrium  or  into 
the  splenic  region,  entirely  beneath  the  ribs.  Adhesions  very  frequently  occur, 
particularly  to  the  colon,  the  liver,  and  the  anterior  abdominal  wall. 

Secondary  cancerous  growths  in  other  organs  are  very  frequent,  as  shown 
by  the  following  analysis  by  Welch  of  1,574  cases:  Metastasis  occurred  in 
the  lymphatic  glands  in  551 ;  in  the  liver  in  475 ;  in  the  peritoneum,  omentum, 
and  intestine  in  357;  in  the  pancreas  in  122;  in  the  pleura  and  lung  in  98; 
in  the- spleen  in  26';  in  the  brain,  and  meninges  in  9  ;  in  other  parts  in  92.  The 
lymph  glands  affected  are  usually  those  of  the  abdomen,  but  the  cervical  and 
inguinal  glands  are  not  infrequently  attacked,  and  give  an  important  clue  in 
diagnosis.  Secondary  metastatic  growths  occur  subcutaneously,  either  at  the 
navel  or  beneath  the  skin  in  the  vicinity,  and  are  of  value  in  diagnosis. 


CANCER  OF  THE  STOMACH  491 

Perforation. — This  occurred  into  the  peritoneum  in  17  of  507  cases  of 
cancer  of  the  stomach  (Brinton).  In  our  series  perforation  occurred  in  4 
cases.  When  adhesions  form,  the  most  extensive  destruction  of  the  walls  may 
take  place  without  perforation  into  the  peritoneal  cavity.  In  one  instance 
a  large  portion  of  the  left  lobe  of  the  liver  lay  within  the  stomach.  Occa- 
sionally a  gastro-cutaneous  fistula  is  established.  Perforation  may  occur  into 
the  colon,  the  small  bowel,  the  pleura,  the  lung,  or  the  pericardium. 

Symptoms. — Latent  Carcinoma. — There  may  be  no  symptoms  pointing 
to  the  stomach,  and  the  tumor  may  be  discovered  accidentally  after  death.  In 
a  second  group  the  symptoms  of  carcinoma  are  present,  not  of  the  stomach, 
but  of  the  liver  or  some  other  organ,  or  there  are  subcutaneous  nodules,  or, 
as  in  one  of  our  cases,  secondary  masses  on  the  ribs  and  vertebrae.  In  a  third 
group,  seen  particularly  in  elderly  persons  in  institutions,  there  is  gradual 
asthenia,  sometimes  anasarca,  without  nausea,  vomiting,  or  other  local  symp- 
toms. 

Features  of  Onset. — Of  the  150  cases  in  our  series,  48  complained  of 
pain,  44  of  dyspepsia,  21  of  vomiting,  13  of  loss  in  weight,  3  of  difficulty  in 
swallowing,  1  of  tumor.  In  7  the  features  of  onset  suggested  pernicious  anse- 
mia.    In  37  cases  there  was  a  history  of  sudden  onset. 

General  Symptoms. — Loss  of  Weight. — Progressive  emaciation  is  one  of 
the  most  constant  features.  In  79  of  our  cases  in  which  exact  figures  were 
taken:  To  30  pounds,  32  cases;  30  to  50  pounds,  36  cases;  50  to  60  pounds, 
5  cases;  60  to  70  pounds,  4;  over  70  pounds,  1;  100  pounds,  a  case  of  cancer 
at  the  cardiac  end  with  obstruction  to  swallowing.  The  loss  in  weight  is  not 
always  progressive.  We  see  increase  in  weight  under  three  conditions :  (a) 
Proper  dieting,  with  treatment  of  the  associated  catarrh ;  ( 6 )  in  cancer  of  the 
pylorus  after  relief  of  the  dilatation  of  the  organ  by  lavage,  operation,  etc.; 
(c)  after  a  profound  mental  impression.  The  visit  of  an  optimistic  consult- 
ant may  be  followed  by  a  gain  in  weight.  In  Keen  and  D.  D.  Stewart's  case 
there  was  a  gain  of  seventy  pounds  after  an  exploratory  operation ! 

Loss  in  strength  is  usually  proportionate  to  the  loss  in  weight.  One  sees 
sometimes  remarkable  vigor  almost  to  the  close,  but  this  is  exceptional. 

Anosmia  is  present  in  a  large  proportion  of  all  cases,  and  with  the  emacia- 
tion gives  the  picture  of  cachexia.  There  is  often  a  yellow  or  lemon  tint  of 
the  skin.  In  59  cases  bloocl-counts  were  made;  in  3  the  red  corpuscles  were 
above  6,000,000  per  c.  mm.  This  occurs  in  the  concentrated  condition  of  the 
blood  in  certain  cases  of  cancer  of  the  pylorus  with  dilatation  of  the  stomach. 
The  average  count  in  the  59  cases  was  3,712,186  per  c.  mm.  In  only  8  cases 
was  the  count  below  2,000,000,  and  in  none  below  1,000,000.  The  average  of 
the  haemoglobin  was  44.9  per  cent.  In  only  9  was  it  below  30  per  cent.  In  62 
cases  in  which  the  leucocytes  were  counted  there  were  only  18  cases  in  which 
they  were  above  12,000  per  c.  mm.;  in  only  3  cases  were  they  above  20,000. 
The  features  of  onset  may  suggest  a  primary  ana?mia. 

Among  other  general  symptoms  may  he  mentioned  fever,  which  was  pres- 
ent at  some  time  in  74  of  our  150  cases.  In  only  13  of  these  did  the  tempera- 
ture rise  above  101°.  In  2  it  was  above  103°.  Fifteen  presented  fairly  con- 
stant elevation  of  temperature.  Eight  presented  sudden  rises.  Two  cases  had 
cliills,  with  elevation  to  103°  and  104°.  Chills  may  be  associated  with  sup- 
puration at  the  base  of  the  cancer. 


492  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

Urine. — There  may  be  no  changes  throughout  or  albumin  and  casts  may 
be  found.  Glycosuria^,  peptonuria^,  and  acetonuria  have  been  described.  In- 
dican  is  common. 

(Edema. — Swelling  of  the  ankles  is  of  frequent  occurrence  toward  the  close. 
With  an  early  general  anasarca  in  combination  with  extreme  anaemia,  the 
cancer  is  usually  overlooked. 

The  bowels  are  often  constipated.  In  only  13  cases  in  our  series  was 
diarrhoea  present.  In  2  cases  blood  was  passed  per  rectum.  There  are  no 
special  cardiac  symptoms;  the  pulse  becomes  progressively  weaker.  Throm- 
bosis of  one  femoral  vein  may  occur,  or,  as  in  one  of  our  cases,  widespread 
thrombosis  in  the  superficial  veins  of  the  body. 

Symptoms  on  the  part  of  the  nervous  system  are  rare;  consciousness  is 
often  retained  to  the  end.  Coma  may  occur  similar  to  that  seen  in  diabetes, 
and  is  believed  to  be  due  to  an  acid  intoxication. 

Functional  Disturbances. — Anorexia,  loss  of  desire  for  food,  is  a  fre- 
quent and  valuable  symptom,  more  constant  perhaps  than  any  other.  Nausea 
is  a  striking  feature  in  many  cases;  there  is  often  a  sudden  repulsion  at  the 
sight  of  food.    In  exceptional  cases  the  appetite  is  retained  throughout. 

Vomiting  may  come  on  early,  or  only  after  the  dyspepsia  has  persisted  for 
some  time.  It  occurred  in  128  cases  in  our  series.  At  first  it  is  at  long  inter- 
vals, but  subsequently  it  is  more  frequent,  and  may  recur  several  times  in  the 
day.  There  are  cases  in  which  it  comes  on  in  paroxysms  and  then  subsides; 
in  other  cases  it  sets  in  early,  persists  with  great  violence,  and  may  cause  a 
fatal  termination  within  a  few  weeks.  Vomiting  is  more  frequent  when  the 
cancer  involves  the  orifices,  particularly  the  pylorus,  in  which  case  it  is  usually 
delayed  for  an  hour  or  more  after  taking  the  food.  When  the  cardiac  orifice 
is  involved  it  may  follow  at  a  shorter  interval.  Extensive  disease  of  the  fundus 
or  of  the  anterior  or  posterior  wall  may  be  present  without  the  occurrence  of 
vomiting.  The  food  is  sometimes  very  little  changed,  even  after  it  has  re- 
mained in  the  stomach  for  twenty-four  hours. 

HcemorrJiage  occurred  in  36  of  our  150  cases;  in  32  the  blood  was  dark 
and  altered,  in  3  it  was  bright  red.  In  2  cases  vomiting  of  blood  was  the  first 
symptom.  The  bleeding  is  rarely  profuse;  more  commonly  there  is  slight 
oozing,  and  the  blood  is  mixed  with,  or  altered  by,  the  secretions,  and,  when 
vomited,  the  material  is  dark  brown  or  black,  the  so-called  "coffee-ground" 
vomit.  Occult  blood  is  almost  constantly  present  in  carcinoma;  in  ulcer  it 
is  intermittent. 

Pain,  an  early  and  important  symptom,  was  present  in  130  of  our  cases.  It 
is  very  variable  in  situation  and,  while  most  common  in  the  epigastrium,  it 
may  be  referred  to  the  shoulders,  the  back,  or  the  loins.  The  pain  is  described 
as  dragging,  burning,  or  gnawing  in  character,  and  very  rarely  occurs  in  se- 
vere paroxysms,  as  in  gastric  ulcer.  As  a  rule,  it  is  aggravated  by  taking  food. 
There  is  usually  marked  tenderness  on  pressure  in  the  epigastric  region.  The 
areas  of  skin  tenderness  are  referred,  as  Head  has  shown,  to  the  region  between 
the  nipple  and  the  umbilicus  in  front  and  behind  from  the  fifth  to  the  twelfth 
thoracic  spine. 

The  Stomach  Contents. — The  finding  of  pus  and  blood  in  the  empty 
stomach  and  pus,  blood  and  mucus  two  hours  after  the  test  meal  is  suggestive. 
Diminished  motility  may  be  an  early  finding  in  pyloric  cancer.    There  is  a  tend- 


CANCER  OF  THE  STOMACH  493 

ency  to  a  downward  trend  of  gastric  secretion,  the  opposite  of  the  findings  in 
gastric  ulcer.  The  results  of  secondary  infection  and  secondary  gastric  ca- 
tarrh are  added  to  the  picture.  The  protein  curve  often  shows  a  marked  di- 
vergence from  the  acid  curve  which  increases  as  digestion  goes  on  and  is  most 
marked  in  cases  of  subacidity  or  achylia.  The  test  for  soluble  albumin  (Wolff- 
Junghans)  is  of  value,  especially  two  hours  after  the  test  meal.  The  tryp- 
tophan test  and  ereptic  reaction  are  of  doubtful  value  owing  to  frequent  regur- 
gitation of  duodenal  contents.  Bacteria  in  large  numbers  occur,  one,  the  Op- 
pler-Boas  bacillus — an  unusually  long  non-motile  form — is  supposed  to  be  of 
diagnostic  value,  and  to  be  largely  responsible  for  the  formation  of  lactic  acid. 
Blood  is  a  most  important  ingredient;  the  persistent  presence  microscopically 
of  red  corpuscles  in  the  early  morning  washings  is  always  very  suspicious. 
Later,  when  coffee-ground  vomiting  takes  place,  the  macroscopic  evidence  is 
sufficient.  Fragments  of  the  new  gTowth  may  be  vomited  or  may  appear  in 
the  washings. 

Examination  of  the  Gastric  Contents. — As  an  outcome  of  the  enormous 
number  of  observations,  it  may  be  said  that  free  HCl  is  absent  in  a  large  pro- 
portion of  all  cases  of  cancer  of  the  stomach.  Of  94  cases  in  which  the  con- 
tents were  examined  in  84  free  HCl  was  absent.  In  5  undoubted  cases  the 
reaction  was  good;  in  2  of  these  the  history  suggested  previous  ulcer.  HCl 
may  be  absent  in  chronic  gastritis  and  in  atrophy  of  the  gastric  mucosa.  The 
presence  of  lactic  acid  is  regarded  as  a  valuable  sign. 

Physical  ExAMiNATiOiSr. — Inspection. — After  a  preliminary  survey,  em- 
bracing the  facies,  state  of  nutrition,  etc.,  particular  attention  is  given  to  the 
abdomen.  An  all-important  matter  is  to  have  the  patient  in  a  good  light. 
Fullness  in  the  epigastric  region,  inequality  in  the  infracostal  grooves,  the  ex- 
istence of  peristalsis,  a  wide  area  of  aortic  pulsation,  the  presence  of  subcu- 
taneous nodules  or  small  masses  about  the  navel,  and,  lastly,  a  well-defined 
tumor  mass — these,  together  or  singly,  may  be  seen  on  careful  inspection.  In 
62  of  the  150  cases  a  positive  tumor  could  be  seen.  In  52  the  tumor  descended 
with  inspiration;  in  36  peristalsis  was  visible;  in  3  cases  movements  were 
visible  in  the  tumor  itself.  In  10  cases  with  visible  peristalsis  no  tumor  was 
seen,  but  could  be  felt  on  palpation.  Inflation  may  be  tried,  except  when 
hemorrhage  has  been  profuse  or  the  cancer  is  very  extensive.  The  dilatation 
often  renders  evident  the  peristalsis  or  may  bring  a  tumor  into  view.  The 
presence  of  subcutaneous  and  umbilical  nodules  may  help.  They  were  found 
in  5  of  our  series. 

Palpation. — In  115  cases  a  tumor  could  be  felt;  in  48  in  the  epigastric  re- 
gion, in  25  in  the  umbilical,  in  18  in  the  left  hypochondriac,  in  17  in  the  right 
hypochondriac  region,  while  in  7  cases  a  mass  descended  in  deep  inspiration 
from  beneath  the  left  costal  margin.  These  figures  illustrate  in  how  large  a 
proportion  of  the  cases  the  tumor  is  in  evidence  when  the  patient  comes  under 
observation.  In  rare  cases  examination  in  the  knee-elbow  position  is  of 
value.  Mobility  in  gastric  tumor  is  a  point  of  much  importance.  First,  the 
change  with  respiration,  a  mass  may  descend  3  or  4  inches  in  deep  inspira- 
tion; secondly,  the  communicated  pulsation  from  the  aorta,  which  is  often 
suggestive  in  its  extent;  thirdly,  the  intrinsic  movements  in  the  hypertrophied 
muscularis.  This  may  give  a  remarkable  character  to  the  mass,  causing  it  to 
appear  and  disappear,  lifting  the  abdominal  wall  in  the  epigastric  region ;  and. 


494  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

fourthly,  mechanical  movements,  with  inflation,  with  change  of  posture,  or 
communicated  with  the  hand.  Tumors  of  the  pylorus  are  the  most  movable, 
and  in  extreme  cases  can  be  displaced  to  either  hypochondrium  or  pushed  far 
down  below  the  navel  (see  illustrative  cases  in  Osier's  Lectures  on  the  Diag- 
nosis of  Abdominal  Tumors).  Pain  on  palpation  is  common;  the  mass  is 
usually  hard,  sometimes  nodular.  Gas  can  at  times  be  felt  gurgling  through 
the  tumor  at  the  pyloric  region. 

Percussion  gives  less  important  indications — the  note  over  a  tumor  is 
rarely  flat,  more  often  a  flat  tympany.  Auscultation  may  reveal  the  gurgling 
through  the  pylorus;  sometimes  a  systolic  bruit  is  transmitted  from  the 
aorta,  and  when  a  local  peritonitis  exists  a  friction  may  be  heard. 

Complications. — Secondm'y  groivtlis  are  common.  In  44  autopsies  in  our 
series  there  were  metastases  in  38;  in  29  the  lymph-glands  were  involved;  in 
23  the  liver,  in  11  the  peritoneum,  in  8  the  pancreas,  in  8  the  bowel,  in  4 
the  lung,  in  3  the  pleura,  in  4  the  kidneys,  and  in  2  the  spleen.  In  8  no 
deposits  were  found. 

Perforation  may  lead  to  peritonitis,  but  in  3  of  our  4  cases  there  was  no 
general  involvement.  Cancerous  ascites  is  not  very  uncommon.  Dock  has 
called  attention  to  the  value  of  the  examination  of  the  fluid  in  such  cases 
as  a  help  to  diagnosis.  The  cells  show  mitoses  and  are  very  characteristic. 
Secondary  cancer  of  the  liver  is  very  common;  the  enlargement  may  be  very 
great,  and  such  cases  are  not  infrequently  mistaken  for  primary  cancer  of 
the  organ.  Involvement  of  the  lymph-glands  may  give  valuable  indications. 
There  may  be  early  enlargement  of  a  gland  at  the  posterior  border  of  the 
left  sterno-cleido-mastoid  muscle;  later  adjacent  glands  may  become  affected. 
This  occurs  also  in  uterine  cancer. 

A  remarkable  picture  is  presented  when  the  cancer  sloughs  or  becomes 
gangrenous ;  the  vomitus  has  a  foul  odor,  often  of  a  penetrating  nature,  to  be 
perceived  throughout  the  room.  In  cases  in  which  the  ulcer  perforates  the 
colon  the  vomiting  may  be  fscal.  The  fsecal  odor  with  incessant  vomiting 
was  present  in  a  case  in  which  there  was  no  perforation  of  the  colon  at  autopsy. 

Course. — While  usually  chronic  and  lasting  from  a  year  to  eighteen 
m.onths,  acute  cancer  of  the  stomach  is  by  no  means  infrequent.  Of  the  69 
cases  in  which  we  could  determine  accurately  the  duration,  15  lasted  under 
three  months,  16  from  three  to  six  months,  14  from  six  to  twelve  months — 
a  total  of  45  under  one  year.  Four  cases  lasted  for  two  years  or  over.  One 
patient  lived  for  at  least  two  years  and  a  half. 

Diagnosis. — Every  effort  should  be  made  to  recognize  carcinoma  before  a 
tumor  is  present.  Persistent  gastric  symptoms  in  an  individual  over  forty 
require  that  malignant  disease  be  excluded.  Eepeated  studies  of  the  gastric 
contents  with  comparison  of  the  findings  and  the  X-ray  examination  are  the 
greatest  aids.  The  X-ray  picture  is  modified,  the  peristaltic  waves  are  inter- 
fered with,  anti-peristalsis  and  shadows  varying  in  intensity  with  the  degree 
of  induration  of  the  carcinoma  may  be  seen.  In  a  doubtful  case  exploration 
should  be  advised  without  much  delay  if  the  findings  are  suspicious.  There 
are  cases  in  which  a  positive  diagnosis  can  be  reached  in  no  other  way. 

In  115  of  our  150  cases  a  tumor  existed,  and  with  this  the  recognition 
is  rarely  in  doubt.  The  chief  difficulty  is  in  cases  with  gastric  symptoms  or 
anaemia,  or  both,  without  the  presence  of  tumor.     In  the  one  a  chronic  gas- 


CANCER  OF  THE  STOMACH  495 

tritis  is  suspected;  in  the  other  a  primary  angemia.  In  chronic  gastritis  the 
history  of  long-standing  dyspepsia,  the  absence  of  cachexia,  the  absence  of 
lactic  acid  in  the  test  meal,  and  the  less  striking  blood  changes  are  the  im- 
portant points  for  consideration.  The  cases  with  grave  anoemia  without  tumor 
offer  the  greatest  difficulty.  The  blood-count  is  rarely  so  low  as  in  pernicious 
anaemia.  In  only  8  of  our  59  cases  with  careful  blood  examination  was  the 
number  below  2,000,000  per  c.  mm.  The  lower  color  index,  as  in  secondary 
anaemia,  the  absence  of  megaloblasts,  and  a  leucocytosis  speak  for  cancer. 
With  metastases  in  the  bone  marrow  the  blood  picture  may  be  that  of  per- 
nicious anemia  (Harrington  and  Teacher). 

From  ulcer  of  the  stomach  malignant  disease  is,  as  a  rule,  readily  recog- 
nized. The  ulcus  carcinomatosum  usually  presents  a  well-marked  history  of 
ulcer  for  years.  The  greatest  difficulty  is  offered  when  there  is  ulcer  with 
tumor  due  to  cicatricial  contraction  about  the  pylorus.  In  3  such  cases  we 
mistook  the  mass  for  cancer,  and  even  at  operation  it  may  (as  in  one  of  them) 
be  impossible  to  say  whether  a  neoplasm  is  present. 

Treatment. — In  early  surgical  treatment  lies  the  only  hope,  but  there  is 
great  difficulty  in  the  diagnosis.  Operated  upon  early,  complete  removal  is 
sometimes  possible.  In  a  majority  of  cases  the  operation  is  only  palliative. 
In  suitable  cases  early  exploration  should  be  advised;  the  operation  per  se 
is  sometimes  beneficial  and  the  patient  is  rarely  the  worse  for  it.  W.  J. 
Mayo  reports  651  resections  of  the  stomach  in  a  period  of  twenty  years.  Of 
one  series  of  239  patients  who  recovered  from  the  operation  and  were  traced, 
62  were  alive  five  years  or  more  afterwards. 

The  diet  should  consist  of  readily  digested  substances  of  all  sorts.  Many 
patients  do  best  on  milk  alone.  Washing  out  the  stomach,  which  may  be 
done,  with  a  soft  tube  without  any  risk,  is  particularly  advantageous  when 
there  is  obstruction  at  the  pylorus,  and  is  by  far  the  most  satisfactory  means 
of  combating  the  vomiting.  The  excessive  fermentation  is  also  best  treated  by 
lavage.  When  the  pain  becomes  severe,  particularly  if  it  disturbs  the  rest  at 
night,  morphia  must  be  given.  One-eighth  of  a  grain  (0.008  gm.),  combined 
with  bicarbonate  of  soda  (gr.  v,  0.3  gm.),  bismuth  (gr.  v-x,  0.3-0.6  gm.), 
usually  gives  prompt  relief,  and  the  dose  does  not  always  require  to  be  in- 
creased. Creosote  (nx  j-ij,  0.06-0.12  c.  c.)  and  carbolic  acid  are  useful.  The 
bleeding  in  gastric  cancer  is  rarely  amenable  to  treatment.  In  cases  which 
are  inoperable  the  use  of  radium  or  deep  X-ray  therapy  with  hard  tubes  is 
worthy  of  trial. 

Other  Forms  of  Tumor. — N' on-cancerous  tumors  of  the  stomach  rarely 
cause  inconvenience.  Polypi  (polyadenomata)  are  common  and  they  may  be 
numerous;  as  many  as  150  have  been  reported  in  one  case.  There  is  a  form 
in  which  the  adenoma  exists  as  an  ejrtensive  area  slightly  raised  above  the 
level  of  the  mucosa — polyadenome  en  nappe  of  the  French.  An  extraordinary 
multiple  adenoma  associated  with  multiple  tumors  throughout  the  intestines 
and  subcutaneous  haemangio-endotheliomata  Avas  described  by  Winternitz.  H, 
B.  Anderson  described  a  case  of  remarkable  multiple  cysts  in  the  walls  of  the 
stomach  and  small  intestine.  Sarcomata  are  very  rare.  In  an  analysis  of  61 
cases  Frazier  fouiul  23.  spindle-cell,  16  small  round  cell,  3  large  round  cell 
forms,  6  lymphosarcoma,  7  myosarcoma,  5  myxosarcoma,  and  1  cystic  sarcoma. 
Fibromata   and    lipnmata   have   been    descril)ed.     External    polypoid    tumors, 


496  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

myo-  or  fibro-sarcomata  may  grow  from  the  peritoneal  surface,  usually  the 
posterior,  of  which  Sherran  has  collected  18  cases. 

Foreign  bodies,  occasionally  produce  remarkable  tumors  of  the  stomach. 
The  most  extraordinary  is  the  Ixair  tumor  which  occurs  in  hysterical  women 
who  have  been  in  the  habit  of  eating  their  own  hair.  A  specimen  in  the  med- 
ical museum  of  McGill  University  is  in  two  sections,  which  form  an  exact 
mold  of  the  stomach.  The  tumors  are  large,  very  puzzling,  and  are  usually 
mistaken  for  cancer.  Of  7  cases  operated  upon,  6  recovered;  in  9  cases  the 
condition  was  found  post  mortem  (Schulten). 


VII.    HYPERTROPHIC  STENOSIS  OF  THE  PYLORUS 

In  Adults. — Microscopically,  the  condition  is  found  to  be  very  largely 
hypertrophy  of  the  muscularis  and  submucosa  of  the  pylorus.  It  was  well 
described  by  the  older  writers.  The  symptoms  are  those  of  dilatation  of  the 
stomach.  Some  of  these  cases  may  be  congenital,  as  there  have  been  in- 
stances reported  in  girls  as  early  as  the  twelfth  and  sixteenth  years. 

Congenital. — This  remarkable  affection,  first  recognized  by  Beardsley  of 
Connecticut,  has  been  thoroughly  studied  by  Hirschsprung,  John  Thomson, 
and  others. 

Etiology. — There  are  two  conditions,  congenital  hypertrophy  of  the 
pylorus  and  spasm.  The  hypertrophy  is  frequent  in  first  born  children  and 
in  80  per  cent,  is  in  boys.  Symptoms  are  rare  in  the  first  week  of  life  and 
usually  appear  from  the  second  to  the  fourth  week.  Spasm  is  probably  mainly 
responsible  for  the  symptoms,  as  the  tumor  may  persist  after  the  symptoms 
have  gone.  The  majority  of  the  children  are  breast  fed.  How  much  hyper- 
trophy of  the  pyloric  ring  may  be  caused  by  spasm  is  a  questioUo 

Symptoms.— Vomiting  of  food  and  wasting  are  constantly  present;  the 
former  begins,  as  a  rule,  during  the  second  or  third  week,  and  in  a  few  in- 
stances at  birth;  it  occurs  usually  soon  after  nursing.  It  is  often  of  the  ex- 
pulsive type;  the  wasting  becomes  extreme,  there  are  marked  constipation, 
great  weakness,  sometimes  terminal  diarrha3a,  or  a  sudden  fatal  syncope. 

Physical  Signs. — These  are  distinctive — visible  peristalsis  and  palpable 
tumor.  The  peristalsis  is  best  seen  after  feeding,  when  the  waves  pass  at 
intervals,  in  characteristic  form,  from  left  to  right  above  the  navel;  two  or 
three  waves  may  be  seen  at  once.  The  pyloric  tumor  may  be  felt  as  a  firm, 
hard,  freely  movable  body,  to  the  right  of  the  navel  and  a  little  above  it, 
which  varies  in  size  and  consistency,  and  through  which  gas  may  sometimes 
be  felt  to  gurgle.     The  X-ray  examination  adds  little. 

Treatment. — Medical  treatment  consists  in  feeding  with  breast  or  modi- 
fied milk,  1-3  ounces  every  3  or  4  hours.  Dextrose  solution  (200  c.  c,  4 
per  cent.)  can  be  given  by  the  bowel.  Lavage  of  the  stomach  should  be  done 
twice  a  day.  The  milder  cases  do  well  under  this  but  there  should  not  be  de- 
lay in  resorting  to  surgical  measures  if  improvement  does  not  occur.  The 
division  of  the  circular  muscular  layer  (Eammstedt's  operation)  is  a  suc- 
cessful procedure  (47  recoveries  in  61  cases).  The  after  care  is  important. 
The  child  should  be  kept  warm,  given  fluid  by  bowel  and  subcutaneously,  and 
fed  carefully  with  a  gradual  increase  in  the  amount. 


H^MOKEHAGE  FROM  THE  STOMACH  497 


VIII.    HiEMORRHAGE  FROM  THE  STOMACH 

{Hcematemesis) 

Etiolo^. — Hgematemesis  may  result  from  many  conditions,  local  or  gen- 
eral, (a)  In  local  disease:  (1)  cancer;  (2)  ulcer;  (3)  disease  of  the 
blood-vessels,  such  as  miliary  aneurisms  and  occasionally  varicose  veins;  (4) 
acute  congestion,  as  in  gastritis,  and  possibly  in  vicarious  haemorrhage;  (5) 
following  operations  in  the  abdomen,  particularly  when  the  omentum  is 
wounded,  erosions  of  the  gastric  mucosa  may  occur,  from  which  haemorrhage 
takes  place.  It  is  a  very  fatal  complication  after  appendicitis  and  is  usually 
associated  with  peritonitis. 

(&)  Passive  congestion  due  to  obstruction  in  the  portal  system.  This  may 
be  either  (1)  hepatic,  as  in  cirrhosis  of  the  liver,  thrombosis  of  the  portal 
vein,  or  pressure  upon  the  portal  vein  by  tumor,  and  secondarily  in  cases  of 
chronic  disease  of  the  heart  and  lungs.  (2)  Splenic.  Gastrorrhagia  is  by 
no  means  an  uncommon  symptom  in  enlarged  spleen,  and  is  explained  by  the 
intimate  relations  which  exist  between  the  vasa  brevia  and  the  splenic  cir- 
culation. 

(c)  Toxic:  (1)  The  poisons  of  the  specific  fevers,  small-pox,  measles,  yel- 
low fever;  (2)  poisons  of  unknown  origin,  as  in  acute  yellow  atrophy  and  in 
purpura;  (3)   phosphorus. 

{d)  Trauma:  (1)  Mechanical  injuries,  such  as  blows  and  wounds,  and 
occasionally  by  the  stomach-tube;  (2)  the  result  of  severe  corrosive  poisons. 

(e)  Certain  constitutional  diseases :  (1)  Haemophilia;  (2)  profound  anae- 
mias; (3)   cholsemia. 

(/)  In  certain  nervous  affections,  particularly  hysteria,  and  occasionally 
in  general  paresis  and  epilepsy, 

{g)  The  blood  may  not  always  come  primarily  from  the  stomach  but 
from  the  nose  or  pharynx.  In  haemoptysis  some  of  the  blood  may  find  its 
way  into  the  stomach.  Again,  in  bleeding  from  the  oesophagus  blood  may 
trickle  into  the  stomach,  from  which  it  is  ejected.  This  occurs  in  the  case 
of  rupture  of  aneurism  and  of  oesophageal  varices.  A  child  may  draw  blood 
with  the  milk  from  the  mother's  breast  in  considerable  quantities  and  then 
vomit  it. 

{h)  Gastrostaxis. — Under  this  name  Hale  White  describes  cases  of  haemor- 
rhage from  the  stomach  in  young  girls  without  any  lesion  of  the  mucosa. 
They  are  often  mistaken  for  ulcer.  Surgeons  have  taught  us  that  the  condi- 
tion is  by  no  means  uncommon.  At  operation  the  blood  has  been  seen  oozing 
from  points  in  the  mucosa.  There  may  be  no  pain  or  any  of  the  ordinary  fea- 
tures of  ulcer, 

{i)  Miscellaneous  causes:  Aneurism  of  the  aorta  or  of  its  branches  may 
rupture  into  the  stomach.  There  are  instances  in  which  a  patient  has  vom- 
ited blood  once  without  any  recurrence  or  without  developing  symptoms  point- 
ing to  disease  of  the  stomach.  In  new-born  infants  hasmatemesis  may  occur 
alone  or  in  connection  with  bleeding  from  other  mucous  membranes. 

In  medical  practice,  "hemorrhage  from  the  stomach  occurs  most  frequently 
in  connection  with  cirrhosis  of  the  liver  and  ulcer  of  the  stomach. 


49g  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

Morbid  Anatomy. — When  death  has  occurred  from  the  hsematemesis  there 
are  signs  of  intense  anaemia.  The  lesion  is  evident  in  cancer  and  in  ulcer  of 
the  stomach.  Eatal  haemorrhage  may  come  from  a  small  miliary  aneurism 
communicating  with  the  surface  by  a  pinhole  perforation,  or  the  bleeding  may 
be  due  to  the  rupture  of  a  submucous  vein  and  the  erosion  in  the  mucosa  may 
be  small  and  readily  overlooked.  It  may  require  a  careful  and  prolonged 
search  to  avoid  overlooking  such  lesions.  In  the  large  group  associated  with 
portal  obstruction,  whether  due  to  hepatic  or  splenic  disease,  the  mucosa  is 
usually  pale,  smooth,  and  shows  no  trace  of  any  lesion.  In  cirrhosis,  fatal 
by  hsemorrhage,  one  may  sometimes  search  in  vain  for  any  local  lesion  and 
we  must  conclude  that  it  is  possible  for  even  the  most  profuse  bleeding  to 
occur  by  diapedesis.  The  stomach  may  be  distended  with  blood  and  yet  the 
source  of  the  haemorrhage  be  not  apparent.  In  such  cases  the  oesophagus 
should  be  examined,  as  the  bleeding  may  come  from  that  source.  In  toxic 
cases  there  are  invariably  haemorrhages  in  the  mucous  membrane  itself. 

Symptoms. — In  rare  instances  fatal  syncope  may  occur  without  any  vom- 
iting. In  a  case  of  the  kind,  in  which  the  woman  had  fallen  over  and  died 
in  a  few  minutes,  the  stomach  contained  between  three  and  four  pounds  of 
blood.  The  sudden  profuse  bleedings  rapidly  lead  to  profound  anaemia. 
When  due  to  ulcer  or  cirrhosis  the  bleeding  usually  recurs  for  several  days. 
Fatal  haemorrhage  from  the  stomach  is  met  with  in  ulcer,  cirrhosis,  enlarge- 
ment of  the  spleen,  and  in  instances  in  which  an  aneurism  ruptures  into  the 
stomach  or  oesophagus.  Gastrorrhagia  may  occur  in  splenic  anaemia  or  in 
leukaemia  before  the  condition  has  aroused  attention. 

The  vomited  blood  may  be  fluid  or  clotted ;  it  is  usually  dark  in  color,  but 
in  the  basin  the  'outer  part  becomes  red  from  the  action  of  the  air.  The 
longer  blood  remains  in  the  stomach  the  more  altered  it  is  when  ejected. 

The  amount  of  blood  lost  is  very  variable,  and  in  the  course  of  a  day  the 
patient  may  bring  up  three  or  four  pounds,  or  even  more.  In  a  case  under 
the  care  of  George  Ross,  in  the  Montreal  General  Hospital,  the  patient  lost 
during  seven  days  ten  pounds,  by  weight,  of  blood.  The  usual  symptoms  of 
anaemia  develop  rapidly,  and  there  may  be  slight  fever,  and  subsequently 
oedema  may  occur.  Syncope,  convulsions,  and  occasionally  hemiplegia  occur 
after  very  profuse  haemorrhage.  Blindness  may  follow,  the  result  either  of 
thrombosis  of  the  retinal  arteries  or  veins,  or  an  acute  degeneration  of  the 
ganglion  cells  of  the  retina. 

Diagnosis. — In  a  majority  of  instances  there  is  no  question  as  to  the 
origin  of  the  blood.  Occasionally  it  is  difficult,  particularly  if  the  case  has 
not  been  seen  during  the  attack.  Examination  of  the  vomit  readily  deter- 
mines whether  blood  is  present  or  not.  The  materials  vomited  may  be  stained 
by  wine,  the  juice  of  strawberries,  raspberries,  or  cranberries,  which  give  a 
color  very  closely  resembling  that  of  fresh  blood,  while  iron  and  bismuth 
and  bile  may  produce  the  blackish  color  of  altered  blood.  In  such  cases  the 
microscope  will  show  the  shadowy  outlines  of  the  red  blood-corpuscles,  and, 
if  necessary,  spectroscopic  and  chemical  tests  may  be  applied. 

Deception  is  sometimes  practised  by  hysterical  patients,  who  swallow 
and  then  vomit  blood  or  colored  liquids.  With  a  little  care  such  cases  can 
usually  be  detected.  The  cases  must  be  excluded  in  which  the  blood  passes 
from  the  nose  or  pharynx,  or  in  which  infants  swallow  it  with  the  milk. 


NEUEOSES  OF  THE  STOMACH  499 

There  is  not  often  difficulty  in  distinguishing  between  haemoptysis  and 
h^ematemesis,  though  the  coughing  and  the  vomiting  are  not  infrequently 
combined.     The  following  are  points  to  be  borne  in  mind  in  the  diagnosis : 

H.EMATEMESIS  HAEMOPTYSIS 

1.  Previous  history  points  to  gas-  1.  Cough  or  signs  of  some  pulmon- 
tric,  hepatic,  or  splenic  disease.  ary   or   cardiac    disease   precedes,    in 

many  cases,  the  haemorrhage. 

2.  The  blood  is  brought  up  by  2,  The  blood  is  coughed  up,  and 
vomiting,  prior  to  which  the  patient  is  usually  preceded  by  a  sensation  of 
may  experience  a  feeling  of  giddiness  tickling  in  the  throat.  If  vomiting 
or  faintness.  occurs,  it  follows  the  coughing. 

3.  The  blood  is  usually  clotted,  3.  The  blood  is  frothy,  bright  red 
mixed  with  particles  of  food,  and  has  in  color,  alkaline  in  reaction.  If 
an  acid  reaction.  It  may  be  dark,  clotted,  rarely  in  such  large  coagula, 
grumous,  and  fluid.  and  muco-pus  may  be  mixed  with  it. 

4.  Subsequent  to  the  attack  the  4.  The  cough  persists,  physical 
patient  passes  tarry  stools,  and  signs  signs  of  local  disease  in  the  chest  may 
of  disease  of  the  abdominal  viscera  usually  be  detected,  and  the  sputum 
may  be  detected.  may  be  blood-stained  for  many  da^^ 

Prognosis. — Except  in  the  case  of  rupture  of  an  aneurism  or  of  large 
veins,  ha^matemesis  rarely  proves  fatal.  In  our  experience  death  has  followed 
more  frequently  in  cases  of  cirrhosis  and  splenic  enlargement  than  in  ulcer 
or  cancer.  In  ulcer  it  is  to  be  remembered  that  in  the  chronic  hemorrhagic 
form  the  bleeding  may  recur  for  years.  The  treatment  of  haematemesis  is 
considered  under  gastric  ulcer. 


IX.     NEUROSES  OF  THE  STOMACH 

(Nervous  Dyspepsia) 

Serious  functional  disturbances  of  the  stomach  may  occur  without  any 
discoverable  anatomical  basis.  The  cases  are  most  frequent  in  those  who 
have  either  inherited  a  nervous  constitution  or  who  have  gradually,  through 
indiscretions,  brought  about  a  condition  of  nervous  prostration.  Not  infre- 
quently, the  gastric  symptoms  stand  so  far  in  the  foreground  that  the  general 
neuropathic  character  of  the  patient  quite  escapes  notice.  Sometimes  the 
gastric  manifestations  have  a  reflex  origin  depending  on  organic  disturbances 
in  other  parts,  such  as  the  gall-bladder,  appendix  or  colon. 

In  all  disturbance  of  the  digestive  tract,  attention  must  be  given  to  the 
whole  and  not  to  one  part  only.  The  digestive  tube  is  a  complicated  mechan- 
ism which  requires  perfect  coordination  for  proper  function.  Disease  of  one 
part  may  disturb  the  Avorking  elsewhere  as.  for  example,  disease  of  the  appen- 
dix may  cause  gastric  symptoms.  Creat  importance  attaches  to  proper  motor 
function  and  many  disturbances  are  due  to  this  being  disturbed.  Motility 
may  be  increased,  slowed,  reversed  or  stopped,  and  any  of  these  may  result 
in  symptoms.  Contraction  of  a  segment  causes  inhibition  of  the  segment  distal 
to  it  and  tliis  is  particularly  important  in  special  zones,  c.  g..  the  pylorus  and 


500  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

duodenum.  Irregularities  and  blocks  may  occur  as  in  the  heart,  especially 
where  one  zone  passes  into  another,  e.  g.,  at  the  pylorus  and  ileo-csecal  valve. 
The  nervous  control  plays  a  large  part  and  the  importance  of  vagotonia  must 
always  be  kept  in  mind.  Keith  divides  the  digestive  tract  into  neuro-muscu- 
lar  sections,  each  separated  from  the  adjoining  one  by  a  sphincter  which 
blocks  the  passage  of  waves  of  contraction.  He  compares  these  to  the  blocks 
on  a  railroad,  in  which  if  one  is  blocked,  the  others  are  also. 

Alvarez  has  drawn  attention  to  the  part  played  by  reversed  peristalsis  in 
causing  symptoms.  Eor  example,  regurgitation  may  be  due  to  a  distended  and 
over-active  colon  or  irritation  from  a  diseased  appendix.  Vomiting  may  be 
due  to  increased  tone  and  activity  in  the  jejunum  for  which  an  irritable  colon 
may  be  responsible.  Belching  of  gas  may  represent  reversed  peristalsis  set 
up  by  some  organic  lesion.  Nausea  is  due  more  often  to  intestinal 
lesions,  e.  g.,  in  the  colon  with  reversed  peristalsis,  than  to  disease  of  the 
oesophagus  and  stomach.  As  to  the  cause  of  a  coated  tongue  there  is  no 
proof  that  it  is  always  due  to  gastric  disease.  It  may  be  due  to  regurgitation, 
as  particles  of  material  from  the  colon  may  easily  reach  the  tongue.  The  con- 
dition termed  "biliousness"  is  often  a  result  of  reversed  intestinal  activity 
originating  in  the  colon  and  when  this  is  emptied  relief  is  obtained. 

The  sufferer  from  nervous  dyspepsia  presents  a  varying  picture.  All 
grades  occur,  from  the  emaciated  skeleton-like  patient  with  anorexia  nervosa 
to  the  well-nourished,  healthy-looking,  fresh-complexioned  individual  whose 
only  complaint  is  distress  and  uneasiness  after  eating. 

Motor  Neuroses. —  (a)  Hypermotility. — An  increase  in  the  normal  motor 
activity  of  the  stomach  results  in  disturbance  if  there  is  pyloric  spasm.  It  is 
more  commonly  a  secondary  neurosis  but  it  may  occur  primarily,  possibly  from 
reflex  causes.  The  diagnosis  is  made  by  the  stomach-tube  or  X-ray  examina- 
tion.    It  gives  rise  to  no  characteristic  clinical  symptoms. 

(h)  Peristaltic  Unrest. — This  is  a  common  and  distressing  symptom. 
Shortly  after  eating,  the  peristaltic  movements  of  the  stomach  are  increased, 
and  borborygmi  and  gurgling  may  be  heard,  even  at  a  distance.  The  subjec- 
tive sensations  are  most  annoying,  and  it  appears  as  if  in  the  hypergesthetic 
condition  of  the  nervous  system  the  patient  felt  normal  peristalsis,  just  as  in 
these  states  the  usual  beating  of  the  heart  may  be  perceptible  to  him.  A 
further  analogy  is  afforded  by  the  fact  that  emotion  increases  this  peristalsis. 
It  may  extend  to  the  intestines,  particularly  to  the  duodenum,  and  on  palpa- 
tion over  this  region  the  gurgling  is  marked.  The  cause  is  usually  reversed 
peristalsis  due  sometimes  to  disease  elsewhere. 

(c)  Eructations. — Aerophagia. — In  this  condition  severe  attacks  of 
noisy  eructations,  following  one  another  often  in  rapid  succession,  occur. 
When  violent  they  last  for  hours  or  days.  At  other  times  they  occur  in  par- 
oxysms, depending  often  upon  mental  excitement.  They  are  more  commonly 
observed  in  hysterical  women  and  neurasthenics,  but  also,  not  infrequently, 
in  children.  The  hysterical  nature  of  the  affection  is  sometimes  testified  to 
by  the  occurrence,  especially  in  children,  of  several  instances  in  one  house- 
hold. The  expelled  gas  in  these  cases  is  atmospheric  air,  which  is  swallowed 
or  aspirated  from  without.  Sometimee  the  whole  process  may  be  clearly 
observed,  but  in  other  instances  the  act  of  swallowing  may  be  almost  or  quite 
imperceptible. 


NEUEOSES  OF  THE  STOMACH  501 

(d)  Nervous  Vomiting. — In  some  cases  this  is  not  associated  with  ana- 
tomical changes  in  the  stomach  or  with  any  state  of  the  contents,  but  is  due 
to  nervous  influences  acting  either  directly  or  indirectly  upon  the  vomiting 
centres.  The  patients  are,  as  a  rule,  women  and  the  subject  of  more  or  less 
marked  nervous  manifestations.  A  special  feature  of  this  form  is  the  absence 
of  preliminary  nausea  and  of  the  straining  efforts  of  the  ordinary  act  of  vom- 
iting. It  is  rather  a  regurgitation,  and  without  visible  effort  and  without 
gagging  the  mouth  is  filled  with  the  contents  of  the  stomach,  which  are  then 
spat  out.  It  comes  on,  as  a  rule,  after  eating,  but  may  occur  at  irregular  in- 
tervals. In  some  cases  the  nutrition  is  not  impaired,  a  feature  which  may  give 
a  clue  to  the  true  nature  of  the  disease,  as  there  may  be  no  other  hysterical 
manifestation  present.  It  may  occur  in  children  but  in  many  cases  this  re- 
curring vomiting  is  associated  with  acidosis.  Nervous  vomiting  may  be  a  very 
serious  condition.  We  have  had  at  least  two  fatal  cases.  In  some  instances, 
after  persisting  for  weeks  or  months  at  home,  the  patient  gets  well  in  a  few 
days  in  hospital.  In  other  instances  the  course  is  protracted,  and  the  cases 
are  among  the  most  trying  we  are  called  upon  to  treat. 

One  type  of  vomiting  is  associated  with  certain  diseases  of  the  nervous 
system — particularly  tabes — forming  part  of  the  gastric  crises.  Leyden  re- 
ported cases  of  primary  periodic  vomiting,  which  he  regarded  as  a  neurosis. 

(e)  EuMiNATiON ;  Merycismus. — In  this  remarkable  condition  the  pa- 
tients regurgitate  and  chew  the  cud  like  ruminants.  It  occurs  in  neurasthenic 
or  hysterical  persons,  epileptics,  and  idiots.  In  some  patients  it  is  hereditary. 
In  one  instance  a  governess  taught  it  to  two  children.  The  habit  may  persist 
for  years,  and  does  not  necessarily  impair  the  health. 

(/)  Cardiospasm. — Spasmodic,  usually  painful,  contraction  of  the  circular 
muscle  fibres  at  the  cardiac  orifice  may  follow  the  introduction  of  a  sound, 
hasty  eating,  or  the  taking  of  too  hot  or  too  cold  food.  It  may  occur  in 
tetanus  and  also  in  hysterical  and  neurasthenic  individuals,  especially  in  air 
swallowers,  in  whom,  if  it  be  combined  with  pyloric  spasm,  it  may  result  in 
painful  gastric  distention — "pneumatosis."  Here  the  spasm  may  be  of  con- 
siderable duration.  Vagotonia  is  often  responsible.  Some  cases  represent 
failure  of  the  sphincter  to  relax,  rather  than  actual  spasm. 

(g)  Pyloric  Spasm. — This  is  usually  a  secondary  occurrence,  following 
superacidity,  supersecretion,  ulcer,  or  the  introduction  of  irritating  substances. 
The  spasm  often  causes  pain  in  the  region  of  the  pylorus  and  increased  gastric 
peristalsis.  In  cases  in  which  the  spasm  is  combined  with  superacidity  and 
supersecretion  marked  dilatation  with  atony  may  follow.  Sometimes  the 
pylorus  may  be  felt  as  an  oval,  hard  tumor,  which  relaxes  under  the  fingers 
as  gas  passes  through  it.  It  is  not  easy  to  distinguish  organic  stricture  and 
pylorospasm,  but  the  duodenal  tube  will  pass  the  latter.  Atropine  usually 
has  a  relaxing  effect  on  pylorospasm,  especially  if  vagotonia  is  present. 

(/i)  Atony. — Motor  insufficiency  is  generally  due  to  injudicious  feeding, 
to  organic  disease  of  the  stomach  itself,  or  to  general  wasting  processes.  In 
some  otherwise  normal  individuals  of  neurotic  temperaments  an  atony  may, 
however,  occur  which  possibly  deserves  to  be  classed  among  the  neuroses.  The 
symptoms  are  usually  those  of  a  moderate  dilatation,  and  are  often  associated 
with  marked  sensory  disturbances — feelings  of  weight  and  pressure,  distention. 


502  DISEASES   OF  THE  DTGESTR'E   SYSTE^^I 

eructations,  and  so  forth.     Great  care  must  be  taken  in  the  diagnosis  to  rule 
out  all  other  possible  causes. 

(i)  IxsuFFiciEycY  OR  IxcoyiiyEycE  OF  THE  Pyloeus. — This  condition 
was  described  first  by  de  Sere  and  later  by  Ebstein.  It  may  be  recognized  by 
the  rapid  passing  of  gas  from  the  stomach  into  the  bowel  on  attempts  at 
inflation  of  the  former,  as  well  as  by  the  presence  of  intestinal  contents  in  the 
stomach.     There  are  no  distinctive  clinical  symptoms. 

(;')  Insufficiency  of  the  Capjdia. — This  condition  is  only  recognized  by 
the  occurrence  of  eructations  or  in  rumination. 

Secretory  Neuroses. —  (a)  Hyperacidity:  Hyperchlorhydria.  —  The 
work  of  Hawk  and  Eehfuss  and  their  co-workers  has  altered  materially  our 
views  as  to  hyperacidity.  They  have  shown  that  grades  of  acidity  which  we 
thought  abnormal  are  normal  in  certain  healthy  individuals.  Each  of  us  has 
his  own  figure  of  gastric  acidity  and  no  general  standard  can  be  given.  It  is 
a  question  what  symptoms  are  due  to  hyperacidity.  Other  disturbances,  as  in 
the  motor  function  and  pyloric  spasm,  have  to  be  taken  into  account.  Organic 
disease,  especially  ulcer  and  reflex  causes  lower  in  the  digestive  tract,  should 
always  be  considered.  Yet  there  are  some  symptoms  apparently  associated 
with  hyperacidity  especially  in  nervous  individuals.  They  do  not,  as  a  rule, 
immediately  follow  the  ingestion  of  food,  but  occur  one  to  three  hours  later, 
at  the  height  of  digestion.  There  is  a  sense  of  weight  and  pressure,  some- 
times of  burning  in  the  epigastrium,  commonly  associated  with  acid  eructa- 
tions. If  vomiting  occurs,  the  pain  is  relieved.  The  patient  is  usually  rela- 
tively well  nourished,  and  the  appetite  is  often  good,  though  the  sufferer  may 
be  afraid  to  eat  on  account  of  the  anticipated  pain.  There  is  commonly  con- 
stipation. 

(h)  Supeeseceetiox,  Ixtermittent  and  Continuous. — This  is  a  form 
long  recognized,  but  specially  studied  by  Eeichmann  and  others.  The  in- 
creased flow  of  the  gastric  juice  may  be  intermittent  or  continuous.  The  se- 
cretion under  such  circumstances  is  usually  superacid,  though  this  is  not  al- 
ways the  case.  The  periodical  form — the  gasiroxynsis  of  Eossbach — may  be 
quite  independent  of  the  time  of  digestion.  Great  quantities  of  highly  acid 
gastric  juice  may  be  secreted  in  a  very  small  space  of  time.  Such  cases  are 
rare,  and  are  especially  associated  either  with  profound  neurasthenia  or  with 
tabes.  The  attack  may  last  for  several  days.  It  usually  sets  in  with  a  gnaw- 
ing, unpleasant  sensation  in  the  stomach,  severe  headache,  and  shortly  after 
the  patient  vomits  a  clear,  watery  secretion  of  such  acidity  that  the  throat  is 
irritated  and  made  raw  and  sore.  The  attacks  may  be  quite  independent  of 
food.  Continuous  superseoretion  is  more  common.  The  constant  presence  of 
fluid  in  the  stomach,  together  with  the  pyloric  spasm,  which  commonly  results 
from  the  irritation  of  the  overacid  gastric  juice,  is  followed  by  more  or  less 
dilatation.  Digestion  of  the  starches  is  retarded,  and  there  are  eructations 
of  acid  fluid  and  gastric  distress.  This  secretion  of  highly  acid  gastric  juice 
may  continue  when  the  stomach  is  free  from  food.  In  these  cases  pain,  burn- 
ing acid  eructations,  and  even  vomiting,  occur  during  the  night  and  early  in 
the  morning, 

(c)  Subacidity  or  Anacidity;  Achylia  GrAsxRicA  Xervosa. — Lack  of 
the  normal  amount  of  acid  is  found  in  chronic  catarrh,  and  particularly  in 
cancer.     A  reduction  in  the  normal  amount  of  acid  mav  exist  witli  the  most 


NEUEOSES  OF  THE  STOMACH  503 

pronounced  symptoms  of  nervous  dyspepsia  and  yet  the  stomach  will  be  free 
from  food  within  the  regular  time.  A  condition  in  which  free  acid  is  absent 
in  the  gastric  juice  may  occur  in  cancer,  in  extreme  sclerosis  of  the  mucous 
membrane,  as  a  nervous  manifestation,  and  occasionally  in  tabes.  In  most 
of  these  cases,  though  there  be  no  free  acid,  yet  the  digestive  ferments  are 
present.  There  may  be  a  complete  absence  of  the  gastric  secretion.  To  these 
cases  Einhorn  has  given  the  name  of  acliylia  gastrica.  In  the  true  form  the 
enzymes  are  absent.  This  condition  was  at  first  thought  to  occur  only  in  cases 
of  total  atrophy  of  the  gastric  mucosa,  but  recent  observations  have  shown 
that  it  may  occur  as  a  neurosis.  In  a  case  of  Einhorn's  the  gastric  secre- 
tions returned  after  five  years  of  total  acliylia  gastrica. 

The  symptoms  of  subacidity,  or  even  of  acliylia  gastrica,  vary  greatly  in 
intensity;  they  may  be  almost  or  quite  absent  in  cases  of  advanced  atrophy  of 
the  mucosa,  and,  as  a  rule,  are  not  marked  so  long  as  the  motor  activity  of 
the  stomach  remains  good.  If  atony,  however,  occurs  and  abnormal  fermen- 
tative processes  arise,  severe  gastric  and  intestinal  symptoms  may  follow. 
In  the  cases  associated  with  hysteria  and  neurasthenia,  even  though  the  food 
may  be  well  taken  care  of  by  the  intestines,  there  are  very  commonly  grave 
sensory  disturbances  in  the  region  of  the  stomach,  in  addition  to  the  general 
nervous  symptoms. 

Sensory  Neuroses. —  {a)  Hypee^sthesia. — In  this  condition  the  patients 
complain  of  fullness,  pressure,  weight,  burning,  and  so  forth,  during  diges- 
tion, just  such  symptoms  as  accompany  a  variety  of  organic  diseases  of  the 
stomach,  and  yet  in  all  other  respects  the  gastric  functions  appear  quite  nor- 
mal. Sometimes  these  distressing  sensations  are  present  even  when  the 
stomach  is  empty.  These  symptoms  are  usually  associated  with  other  manifes- 
tations of  hysteria  and  neurasthenia.  The  pain  often  follows  particular  ar- 
ticles of  food.  An  hysterical  patient  may  apparently  suffer  excruciating  pain 
after  taking  the  smallest  amount  of  food  of  any  sort,  while  anything  prescribed 
as  a  medicine  may  be  well  borne.  In  severe  cases  the  patient  may  be  reduced 
to  an  extreme  degree  by  starvation. 

(&)  Gastralgia. — Severe  pains  in  the  epigastrium,  paroxysmal  in  char- 
acter, occur  (1)  as  a  manifestation  of  a  functional  neurosis,  independent  of 
organic  disease,  and  usually  associated  with  other  nervous  symptoms  (it  is 
this  form  which  will  here  be  described)  ;  (2)  in  chronic  disease  of  the  nervous 
system,  forming  the  so-called  gastric  crises;  and  (3)  in  organic  disease  of  the 
stomach,  such  as  ulcer  or  cancer. 

The  functional  neurosis  occurs  chiefly  in  women,  very  commonly  in  con- 
nection with  disturbed  menstrual  function  or  with  pronounced  nervous  symp- 
toms. The  affection  may  set  in  as  early  as  puberty,  but  it  is  more  common 
at  the  menopause.  Anaemic,  constipated  women  who  have  worries  and  anxie- 
ties at  home  are  most  prone  to  the  affection.  Attacks  of  it  sometimes  occur 
in  robust,  healthy  men.  More  often  it  is  only  one  feature  in  a  condition  of 
general  neurasthenia  or  a  manifestation  of  that  form  of  nervous  dyspepsia  in 
which  the  gastric  juice  or  hydrochloric  acid  is  secreted  in  excess. 

The  symptoms  are  very  characteristic;  the  patient  is  suddenly  seized  with 
severe  pains  in  the  epigastrium,  which  pass  toward  the  back  and  around 
the  lower  ribs.  The  attack  is  usually  independent  of  the  taking  of  food,  and 
may  recur  at  definite  intervals,  a  periodicity  which  lias  given  rise  to  the  sup- 


504  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

position  in  some  cases  that  the  affection  is  due  to  malaria.  The  most  marked 
periodicity,  however,  may  be  in  the  gastralgic  attacks  of  ulcer.  They  fre- 
quently come  on  at  night.  Vomiting  is  rare;  more  commonly  the  taking  of 
food  relieves  the  pain.  To  this,  however,  there  are  striking  exceptions.  Pres- 
sure upon  the  epigastrium  commonly  gives  relief,  but  deep  pressure  may  be 
painful.  Stress  has  been  laid  upon  the  occurrence  of  painful  points,  but  they 
are  so  common  in  neurasthenia  that  little  importance  can  be  attributed  to 
them. 

The  diagnosis  offers  many  difficulties.  Organic  disease  either  of  the  stom- 
ach or  of  the  nervous  system,  particularly  the  gastric  crises  of  tabes,  must  be 
excluded.  In  the  case  of  ulcer  or  cancer  this  is  not  always  easy.  Disease 
elsewhere,  such  as  in  the  gall-bladder  or  appendix,  may  be  the  etiological  fac- 
tor and  search  should  be  made  for  such  lesions.  The  prolonged  intervals  be- 
tween the  attacks  and  their  independence  of  diet  are  important  features  in 
simple  gastralgia;  but  in  many  instances  it  is  less  the  local  than  the  general 
symptoms  of  the  case  which  enable  us  to  make  the  diagnosis.  In  gall-stone 
colic  jaundice  is  frequently  absent,  and  in  any  long-standing  case  of  gastralgia 
the  question  of  cholelithiasis  should  be  considered.  There  may  be  hyperacid- 
ity associated  with  gastric  atony.  Such  a  case  may  be  treated  for  months  as 
one  of  nervous  dyspepsia  until  a  more  severe  attack  than  usual  is  followed 
by  jaundice. 

(c)  Anomalies  of  the  Sense  op  Hunger  and  Eepletion;  Bulimia. — 
Abnormally  excessive  hunger  coming  on  often  in  paroxysmal  attacks,  which 
cause  the  patient  to  commit  extraordinary  excesses  in  eating.  This  condition 
may  occur  in  diabetes  mellitus  and  sometimes  in  gastric  disorders,  particu- 
larly those  associated  with  supersecretion.  It  is,  however,  more  commonly 
seen  in  hysteria  and  in  psychoses.  It  may  occur  in  cerebral  tumors,  in 
Graves'  disease,  and  in  epilepsy. 

The  attacks  often  begin  suddenly  at  night,  the  patient  waking  with  a  feel- 
ing of  faintness  and  pain,  and  an  uncontrollable  desire  for  food.  Some- 
times such  attacks  occur  immediately  after  a  large  meal.  The  attack  may 
be  relieved  by  a  small  amount  of  food,  while  at  other  times  enormous  quan- 
tities may  be  taken.  In  obstinate  cases  gastritis,  atony,  and  dilatation  fre- 
quently result  from  the  abuse  of  the  stomach. 

Aloria. — An  absence  of  the  sense  of  satiety.  This  condition  is  commonly 
associated  with  bulimia  and  polyphagia,  but  not  always.  The  patient  always 
feels  "empty."  There  are  usually  other  well-marked  manifestations  of  hys- 
teria or  neurasthenia. 

Anorexia  Nervosa. — This  condition,  which  is  a  manifestation  of  a  neurotic 
temperament,  is  discussed  under  the  general  heading  of  Hysteria. 

Treatment  of  Neuroses  of  the  Stomach. — The  most  important  part  of  the 
treatment  of  nervous  dyspepsia  is  often  that  directed  toward  the  improve- 
ment of  the  general  physical  and  mental  condition  of  the  patient.  The  pos- 
sibility that  the  symptoms  may  be  of  reflex  origin  should  be  borne  in  mind. 
The  possibility  of  eye-strain,  cholelithiasis,  or  chronic  appendicitis  should  be 
considered.  A  large  proportion  of  cases  of  nervous  dyspepsia  are  dependent 
upon  mental  and  physical  exhaustion  or  worry,  and  a  vacation  or  a  change 
of  scene  will  often  accomplish  what  treatment  at  home  has  failed  to  do. 
The  manner  of  life  should  be  investigated  and  a  proper  amount  of  physical 


NEUROSES  OF  THE  STOMACH  505 

exercise  in  the  open  air  and  systematic  hydrotherapy  insisted  upon.  This 
alone  will  in  some  cases  be  sufficient  to  cause  the  disappearance  of  the 
symptoms. 

Many  cases  of  nervous  dyspepsia  with  marked  neurasthenic  or  hysterical 
symptoms  do  well  on  the  Weir  Mitchell  treatment,  and  in  obstinate  forms 
it  should  be  given  a  thorough  trial.  The  most  striking  results  are  perhaps 
seen  in  the  case  of  anorexia  nervosa.     It  is  also  of  value  in  nervous  vomiting. 

In  cardiospasm  care  should  be  taken  to  eat  slowly,  to  avoid  swallowing 
too  large  morsels  or  irritating  substances.  The  methodical  introduction  of 
thick  sounds  may  be  of  value. 

The  treatment  in  atony  of  the  stomach  should  be  similar  to  that  adopted 
in  moderate  dilatation — the  administration  of  small  quantities  of  food  at 
frequent  intervals;  the  limitation  of  fluids,  which  should  be  taken  in  small 
amounts  at  a  time;  lavage.     Strychnine  in  full  doses  may  be  of  value. 

In  the  distressing  cases  of  hyperacidity,  in  addition  to  the  treatment  of 
the  general  neurotic  condition,  alkalies  must  be  employed  either  in  the  form 
of  magnesia  or  bicarbonate  of  soda.  These  should  be  given  in  large  doses 
and  at  the  height  of  digestion.  The  burning  acid  eructations  may  be  re- 
lieved in  this  way.  In  hyperacidity  and  hypersecretion  the  use  of  atropine 
frequently  gives  relief.  It  should  be  given  before  food  and  in  small  doses 
at  first,  beginning  with  1/150  grain  (0.0004  gm.)  and  gradually  increas- 
ing. The  combination  of  bromide  and  belladonna  is  sometimes  useful.  The 
diet  should  be  mainly  albuminous.  Stimulating  condiments  and  alcohol 
should  be  avoided.  Starches  should  be  sparingly  allowed,  and  only  in  most 
digestible  forms.     Fats  are  fairly  well  borne. 

Limiting  the  patient  to  a  strictly  meat  diet  is  a  valuable  procedure  in 
many  cases  of  dyspepsia  associated  with  hyperacidity.  The  meat  should  be 
taken  either  raw  or,  if  an  insuperable  objection  exists  to  this,  very  slightly 
cooked.  It  is  best  given  finely  minced  or  grated  on  stale  bread.  An  ample 
dietary  is  314  ounces  (100  grams)  of  meat,  two  medium  slices  of  stale  bread, 
and  an  ounce  (30  grams)  of  butter.  This  may  be  taken  three  times  a  day 
with  a  glass  of  water  or  soda  water.  The  fluid  should  not  be  taken  too  cold. 
The  use  of  fats,  as  cream,  butter,  and  olive  oil,  is  often  of  value.  Special 
care  should  be  taken  in  the  examination  of  the  meat  to  guard  against  tape- 
worm infection.  Many  obstinate  cases  yield  satisfactorily  to  a  month  or  six 
weeks  of  this  treatment,  after  which  time  the  less  readily  digested  articles  of 
food  may  be  gradually  added  to  the  dietary. 

In  supersecretion  the  use  of  the  stomach-tube  is  of  the  greatest  value.  In 
the  periodical  form  it  should  be  used  as  soon  as  the  attack  begins.  The 
stomach  may  be  waslied  with  alkaline  solutions  or  solutions  of  nitrate  of 
silver,  1  to  1,000,  may  be  used.  Where  this  is  impracticable  the  taking  of 
albuminous  food  may  give  relief.  Alkalies  in  large  doses  are  indicated.  In 
cases  of  continued  supersecretion  there  are  usually  atony  and  dilatation.  The 
diet  here  should  be  much  as  in  superacidity,  but  should  be  administered  in 
smaller  quantities  at  frequent  intervals.  Lavage  with  alkaline  solutions  or 
with  nitrate  of  silver  is  of  great  value.  To  relieve  pain  large  quantities  of 
bicarbonate  of  soda  or  magnesia  should  be  given  at  the  height  of  digestion. 

In  suhacidity  a  carefully  regulated,  easily  digestible  mixed  diet,  not  too 
rich  in  protein,  is  advisable.     Bitter  tonics  before  meals  are  sometimes  of 


506  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

value.  .  In  acJiylia  gastrica  the  use  of  predigested  foods  and  of  hj^drochloric 
acid  in  full  doses  may  be  of  assistance. 

In  marked  hypercp.sthesia,  besides  the  treatment  of  the  general  condition, 
nitrate  of  silver  in  doses  of  gr.  14-%  (0.016  to  0.032  gm.),  taken  in  three 
or  four  ounces  of  water  on  an  empty  stomach,  is  advised  by  Eosenheim.  In 
some  instances  rectal  feeding  may  have  to  be  used. 

For  pain  large  doses  of  alkalies  should  be  given,  of  which  the  light  mag- 
nesia and  bicarbonate  of  soda  are  the  best.  A  teaspoonful  of  either  or  of  a 
mixture  of  equal  parts  may  be  given  after  food  and  when  required.  A  com- 
bination of  potassium  bromide  (gr.  xv,  1  gm.)  with  codein  (gr.  1/3,  0.02  gm.) 
or  atropine  (gr.  1/100,  0.00065  gm.)  is  sometimes  useful.  Chloroform  in 
small  doses  or  Hoffman's  anodyne  will  sometimes  allay  the  severe  pains.  The 
general  condition  should  receive  careful  attention,  and  in  many  cases  the  at- 
tacks recur  until  the  health  is  restored  by  change  of  air  with  the  prolonged 
use  of  arsenic.     If  there  is  anaemia  iron  may  be  given  freely. 

There  are  forms  of  nervous  dyspepsia  occurring  in  women  who  are  often 
well  nourished  and  with  a  good  color,  yet  who  suffer — particularly  at  night — 
with  flatulency  and  abdominal  distress.  The  sleep  may  be  quiet  and  undis- 
turbed for  two  or  three  hours,  after  which  they  are  aroused  with  painful 
sensations  in  the  abdomen  and  eructations.  The  appetite  and  digestion  may 
appear  to  be  normal.  Constipation  is.  however,  usually  present.  In  many 
of  these  patients  the  condition  seems  rather  intestinal  and  the  distress  is  due 
to  the  accumulation  of  gases  and  reversed  peristalsis.  The  fats,  starches,  and 
sugars  should  be  restricted.  Some  of  these  cases  obtain  relief  from  thorough' 
irrigation  of  the  colon  at  bedtime.  The  state  of  the  nervous  system  should 
be  carefully  studied. 

In  all  forms  of  gastric  neurosis  special  care  should  be  taken  to  prevent 
constipation. 


G.    DISEASES  OF  THE  INTESTINES 

I.     DISEASES  OF  THE  INTESTINES  ASSOCIATED 
WITH  DIAERHCEA 

CATARRHAL  ENTERITIS;  DIARRHCEA 

In  the  classification  of  catarrhal  enteritis  the  anatomical  divisions  of  the 
bowel  have  been  too  closely  followed,  and  a  duodenitis,  jejunitis,  ileitis,  typhli- 
tis, colitis,  and  proctitis  have  been  recognized;  whereas  in  a  majority  of  cases 
the  entire  intestinal  tract,  to  a  greater  or  lesser  extent,  is  involved,  some- 
times the  small  most  intensely,  sometimes  the  large  bowel;  but  during  life 
it  may  be  quite  impossible  to  say  which  portion  is  specially  affected. 

Etiology. — The  causes  may  be  either  primary  or  secondary.  Among  the 
causes  of  primary  catarrhal  enteritis  are:  (a)  Improper  food,  one  of  the  most 
frequent,  especially  in  children,  in  whom  it  follows  overeating,  or  the  in- 
gestion of  unripe  fruit.  In  some  individuals  special  articles  of  diet  will 
always  produce  a  slight  diarrhoea,  which  may  not  be  due  to  a  catarrh  of  the 
mucosa,  but  to  increased  peristalsis  induced  by  the  offending  material,     (b) 


DISEASES  OF  THE  IXTESTINES  507 

Various  toxic  substances.  Many  of  the  organic  poisons,  such  as  those  pro- 
duced in  the  decomposition  of  milk  and  articles  of  food,  excite  the  most 
intense  intestinal  catarrh.  Certain  inorganic  eubfetaxices,  as  arsenic  and 
mercury,  act  in  the  same  Avay.  (c)  Gastrogenous  diarrhoea.  This  is  secondary 
to  the  absence  of  free  hydrochloric  acid  in  the  stomach,  (d)  Changes  in  the 
weather.  A  fall  in  the  temperature  of  from  twenty  to  thirty  degrees,  par- 
ticularly in  the  spring  or  autumn,  may  induce — how,  it  is  difficult  to  say — an 
acute  diarrhoea.  We  speak  of  this  as  a  catarrhal  process,  the  result  of  cold 
or  of  chill.  On  the  other  hand,  the  diarrhoeal  diseases  of  children  are  associ- 
ated in  a  very  special  way  with  the  excessive  heat  of  summer  months,  (e) 
Changes  in  the  constitution  of  the  intestinal  secretions.  We  know  too  little 
about  the  succus  entericus  to  be  able  to  speak  of  influences  induced  by  change 
in  its  quantity  or  quality.  It  has  long  been  held  that  an  increase  in  the 
amount  of  bile  poured  into  the  bowel  might  excite  a  diarrhoea;  hence  the 
term  bilious  diarrhoea,  so  frequently  used  by  the  older  writers.  Possibly  there 
are  conditions  in  which  an  excessive  amount  of  bile  is  poured  into  the  intes- 
tine, increasing  the  peristalsis,  and  hurrying  on  the  contents;  but  the  oppo- 
site state,  a  scanty  secretion,  by  favoring  the  natural  fermentative  processes, 
much  more  commonly  causes  an  intestinal  catarrh.  Absence  of  the  pancre- 
atic secretion  from  the  intestine  is  associated  in  certain  cases  with  a  fatty 
diarrhoea.  (/)  Xervous  influences.  Mental  states  may  profoundly  affect  the 
intestinal  canal.  These  probably  act  through  the  autonomic  •  system.  As  a 
result  of  stimulation  of  the  vagus,  peristalsis  is  increased.  These  influences 
should  not  properly  be  considered  under  catarrhal  processes,  as  they  result 
from  disturbed  peristalsis  and  are  usually  described  under  the  heading  nervous 
diarrhcea.  In  children  it  frequently  follows  fright.  It  is  common,  too,  in 
adults  as  a  result  of  emotional  disturbances.  Canstatt  mentions  a  surgeon 
who  always,  before  an  important  operation,  had  watery  diarrhoea.  In  hys- 
terical women  it  is  an  occasional  occurrence,  due  to  excitement,  or  a  chronic, 
protracted  diarrhoea,  which  may  last  for  months  or  years. 

Among  the  secondary  causes  of  intestinal  catarrh  may  be  mentioned:  (a) 
Infectious  diseases.  Dysentery,  cholera,  typhoid  fever,  pygemia,  septicaemia, 
tuberculosis,  and  pneumonia  are  occasionally  associated  with  intestinal  ca- 
tarrh. In  dysentery  and  typhoid  fever  the  ulceration  is  in  part  responsible 
but  in  cholera  it  is  probably  a  direct  influence  of  the  bacilli  or  of  the  toxic 
materials  produced  by  them,  (b)  The  extension  of  inflammatory  processes 
from  adjacent  parts.  Thus,  in  peritonitis,  catarrhal  swelling  and  increased 
secretion  are  always  .present  in  the  mucosa.  In  cases  of  invagination,  hernia, 
tuberculosis,  or  cancerous  ulceration  catarrhal  processes  are  common,  (c) 
Circulatory  disturbances  cause  a  catarrhal  enteritis,  usually  of  a  very  chronic 
character.  This  is  common  in  diseases  of  the  liver,  such  as  cirrhosis,  and  in 
chronic  affections  of  the  heart  and  lungs — all  conditions,  in  fact,  which  pro- 
duce engorgement  of  the  terminal  branches  of  the  portal  vessels,  (d)  In  the 
cachectic  conditions  in  cancer,  profound  antemia,  Addison's  disease,  and 
nephritis  intestinal  catarrh  may  occur  as  a  terminal  event. 

Morbid  Anatomy. — It  is  rare  to  see  the  mucous  membrane  injected ;  more 

commonly  it  is  pale  and  covered  with  mucus.     In  the  upper  part  of  the  small 

intestine  the  tips  of  the  valvulge  conniventes  may  be  deeply  injected.     Even  in 

■  extreme  grades  of  portal  obstruction  intense  hypergemia  is  not  often  seen. 


508  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

The  entire  mucosa  may  be  softened  and  infiltrated,  the  lining  epithelium 
swollen,  or  even  shed,  and  appearing  as  large  flakes  among  the  intestinal 
contents.  This  is,  no  doubt,  a  post  mortem  change.  The  lymph  follicles  are 
almost  always  swollen,  particularly  in  children.  The  Peyer's  patches  may 
be  prominent  and  the  solitary  follicles  may  stand  out  with  distinctness  and 
present  erosions,  the  so-called  follicular  ulcers.  This  may  be  a  striking 
feature  in  the  intestine  in  all  forms  of  catarrhal  enteritis  in  children,  irrespec- 
tive of  the  intensity  of  the  diarrhcea.  When  the  process  is  more  chronic  the 
mucosa  is  firmer,  in  some  instances  thickened,  in  others  distinctly  thinned,  and 
the  villi  and  follicles  present  a  slaty  pigmentation. 

Symptoms. — Acute  and  chronic  forms  may  be  recognized.  The  important 
symptom  of  both  is  diarrhcea,  which,  in  the  majority  of  instances,  is  the  sole 
indication  of  this  condition.  It  is  not  to  be  supposed  that  diarrhcea  is  in- 
variably caused  by,  or  associated  with,  catarrhal  enteritis,  as  it  may  be  pro- 
duced by  nervous  and  other  influences.  It  is  probable  that  catarrh  of  the 
jejunum  may  exist  without  any  diarrhoea;  indeed,  it  is  common  to  find  post 
mortem  a  catarrhal  state  of  the  small  bowel  in  persons  who  have  not  had 
diarrhcea  during  life.  The  stools  vary  extremely  in  character.  The  color 
depends  upon  the  amount  of  bile  with  which  they  are  mixed,  and  they  may 
be  of  a  dark  or  blackish  brown,  or  of  a  light  yellow,  or  even  of  a  grayish- 
white  tint.  The  consistence  is  usually  very  thin  and  watery,  but  in  some 
instances  the  stools  are  pultaceous  like  thin  gruel.  Portions  of  undigested 
food  can  often  be  seen  (lienteric  diarrhoea),  and  flakes  of  yellowish-brown 
mucus.  Microscopically  there  are  innumerable  micro-organisms,  epithelium 
and  mucous  cells,  crystals  of  phosphate  of  lime,  oxalate  of  lime,  and  occasion- 
ally cholesterin  and  Charcot's  crystals.  In  enteritis  there  is  unchanged  bile, 
the  stools  may  be  green,  cellulose  is  not  digested  and  the  mucus  is  intimately 
mixed  with  the  stool.  In  colitis  the  stool  is  usually  browner,  cellulose  is 
largely  digested  and  the  mucus  is  on  the  outside  of  the  fseces  and  may  be  in 
large  masses. 

Pain  in  the  abdomen  is  usually  present  in  acute  enteritis,  particularly 
when  due  to  food.  It  is  of  a  colicky  character,  and  when  the  colon  is  in- 
volved there  may  be  tenesmus.  More  or  less  tympanites  exists,  and  there 
are  gurgling  noises  due  to  the  rapid  passage  of  fluid  and  gas  from  one  part 
to  another.  In  the  very  acute  attacks  there  may  be  vomiting.  Fever  is  not, 
as  a  rule,  present,  but  there  may  be  a  slight  elevation  of  one  or  two  degrees. 
The  appetite  is  lost,  there  is  intense  thirst,  and  the  tongue  is  dry  and  coated. 
In  very  acute  cases,  when  the  quantity  of  fluid  lost  is  great  and  the  pain 
excessive,  there  may  be  collapse  symptoms.  The  number  of  evacuations 
varies  from  four  or  five  to  twenty  or  more  in  the  course  of  the  day.  The  at- 
tack lasts  for  two  or  three  days,  or  may  be  prolonged  for  a  week  or  ten  days. 

Chronic  catarrh  may  follow  the  acute  form,  or  may  come  on  gradually  as 
an  independent  affection  or  as  a  sequence,  of  obstruction  in  the  portal  circula- 
tion. It  is  characterized  by  diarrhoea,  with  or  without  colic.  The  dejections 
vary;  when  the  small  bowel  is  chiefly  involved  the  diarrhoea  is  of  a  lienteric 
character,  and  when  the  colon  is  affected  the  stools  are  thin  and  mixed  with 
much  mucus.  A  special  form  of  mucous  diarrhoea  will  be  subsequently  de- 
scribed.    The  general  nutrition  in  these  chronic  cases  is  greatly  disturbed; 


DISEASES  OF  THE  INTESTINES  509 

there  may  be  much  loss  of  flesh  and  great  pallor.    The  patients  are  inclined  to 
suffer  from  depression  or  hypochondriasis. 

Carbohydrate  Indigestion. — This  may  involve  both  the  stomach  and  bow- 
els. The  main  symptom  is  distention  from  gas.  The  stools  are  acid  and 
contain  much  undigested  starch.  If  there  is  much  fermentation  the  stools 
in  addition  are  mushy  and  contain  bubbles  of  gas.  The  result  of  a  protein- 
fat  diet  is  an  important  point  in  the  diagnosis. 

Diagnosis. — It  is  important,  in  the  first  place,  to  determine,  if  possible, 
whether  the  large  or  small  bowel  is  chiefly  affected.  In  catarrh  of  the  small 
bowel  the  diarrhoea  is  less  marked,  the  pains  are  of  a  colicky  character,  bor- 
borygmi  are  not  so  frequent,  the  faeces  usually  contain  portions  of  food, 
and  are  more  yellowish-green  or  grayish-yellow  and  flocculent  and  do  not  con- 
tain much  mucus.  When  the  large  intestine  is  at  fault  there  may  be  no  pain 
whatever,  as  in  the  catarrh  of  the  large  intestine  associated  with  tubercu- 
losis and  nephritis.  When  present,  the  pains  are  most  intense,  and,  if  the 
lower  portion  of  the  bowel  is  involved,  there  may  be  marked  tenesmus.  The 
stools  have  a  uniform  soupy  consistence ;  they  are  grayish  in  color  and  granu- 
lar throughout,  with  here  and  there  flakes  of  mucus,  or  they  may  contain 
very  large  quantities  of  mucus. 

Duodenitis  is  usually  associated  with  acute  gastritis  and,  if  the  process 
extends  into  the  bile-duct,  with  jaundice.  The  study  of  the  duodenal  con- 
tents aids  in  the  diagnosis.  Neither  jejunitis  nor  ileitis  can  be  separated 
from  general  intestinal  catarrh. 

The  Coeliac  Affection. — Under  this  heading  Gee  described  an  intestinal 
disorder,  most  common  in  children  between  the  ages  of  one  and  five,  character- 
ized by  the  occurrence  of  pale,  loose  stools,  not  unlike  gruel  or  oatmeal  por- 
ridge. They  are  bulky,  not  watery,  yeasty,  frothy,  and  extremely  offensive. 
The  affection  has  received  various  names,  such  as  diarrlicea  alba  or  diairhosa 
chylosa.  It  is  not  associated  with  tuberculosis  or  other  hereditary  disease.  It 
begins  insidiously  and  there  are  progressive  wasting,  weakness,  and  pallor. 
The  belly  becomes  doughy  and  inelastic.  There  is  often  flatulency.  Fever  is 
usually  absent.  The  disease  is  lingering  and  a  fatal  termination  is  common. 
So  far  nothing  is  known  of  the  pathology  of  the  disease.  Ulceration  of  the 
intestines  has  been  met  with,  but  it  is  not  constant. 

Sprue  or  Psilosia. — It  is  difficult  to  decide  where  this  disease  should  be 
placed.  Various  theories  of  etiology  are  held — disease  of  the  pancreas,  bac- 
terial, infection  by  a  mould  (Monilia),  or  a  fat  deficiency  disease.  It  occurs 
especially  in  the  tropics  (India,  China  and  Java)  but  is  not  infrequent  in  the 
United  States,  a  point  which  Wood  has  emphasized. 

The  chief  features  are:  (1)  Diarrlicea.  The  stools  are  very  large,  acid, 
light  in  color  and  contain  a  large  amount  of  fat.  It  is  a  fatty  diarrhoea,  with- 
out pain  or  tenesmus,  and  the  stools  are  like  those  of  pancreatic  insufficiency. 
The  stools  are  usually  passed  between  midnight  and  10  a.  m.  The  loss  of 
fat  may  vary  from  30  to  50  per  cent.  There  is  also  marked  nitrogen  loss  in 
the  stools.  (2)  Tong.ue.  This  may  be  inflamed  and  show  eroded  patches 
or  superficial  cracks.  (3)  Ancemia,  The  color  index  may  be  high  and  the 
picture  resemble  that  of  pernicious  anaemia.  (4)  The  disease  is  chronic  and 
remissions  are  common.     There  is  often  marked  emaciation.     The  diagnosis 


510  DISEASES  OF  THE  DIGESTIVE   SYSTEM 

from  pellagra  has  given  difficulty  but  the  study  of  the  stools  should  prevent 
this. 

In  treatment,  absolute  rest  in  bed;,  a  diet  of  finely  chopped  beef,  cooked 
lightly  and  given  four  times  a  day,  and  at  least  four  pints  of  hot  water, 
have  been  found  useful.  The  giving  of  pancreatic  ferments  and  the  use  of 
autogenous  streptococcus  vaccine  should  be  tried. 

DIPHTHEROID    OR    CROUPOUS   ENTERITIS 

A  croupous  or  diphtheroid  inflammation  of  the  mucosa  of  the  small  and 
large  intestines  occurs  (a)  most  frequently  as  a  secondary  process  in  the 
infectious  diseases — pneumonia,  pyaemia  in  its  various  forms,  and  typhoid 
fever;  (&)  as  a  terminal  process  in  many  chronic  affections,  such  as  nephritis, 
cirrhosis  of  the  liver,  or  cancer;  and  (c)  as  an  effect  of  certain  poisons — 
mercury,  lead,  and  arsenic.  The  ulcerative  colitis  of  chronic  disease  may  be 
only  a  terminal  event  in  these  diphtheroid  processes. 

There  are  three  different  anatomical  pictures.  In  one  group  of  cases  the 
mucosa  presents  on  the  top  of  the  folds  a  thin  grayish-yellow  diphtheroid 
exudate  situated  upon  a  deeply  congested  base.  In  some  cases  all  grades  may 
be  seen  between  the  thinnest  film  of  superficial  necrosis  and  involvement  of 
the  entire  thickness  of  the  mucosa.  In  the  colon  similar  transversely  ar- 
ranged areas  of  necrosis  are  seen  situated  upon  hypersemic  patches,  and  it 
may  be  here  much  more  extensive  and  involve  a  large  portion  of  the  membrane. 
There  may  be  most  extensive  inflammation  without  any  involvement  of  the 
solitary  follicles  of  the  large  or  small  bowel. 

In  a  second  group  the  membrane  has  rather  a  croupous  character.  It  is 
grayish-white  in  color,  more  flake-like  and  extensive,  limited,  perhaps,  to 
the  csecum  or  to  a  portion  of  the  colon ;  thus,  in  pneumonia  this  flaky  adher- 
ent false  membrane  may  be  found  sometimes  forming  patches  1  to  2  cm.  in 
diameter,  in  form  not  unlike  rupia  crusts. 

In  a  third  group  the  affection  is  really  a  follicular  enteritis,  involving 
the  solitary  glands,  which  are  swollen  and  capped  with  an  area  of  diphtheroid 
necrosis  or  are  in  a  state  of  suppuration.  Follicular  ulcers  are  common  in 
this  form.  The  disease  may  run  its  course  without  any  symptoms,  and  the 
condition  is  unexpectedly  met  with  post  mortem.  In  other  instances  there 
are  diarrhoea,  pain,  but  not  often  tenesmus  or  the  passage  of  blood-stained 
mucus.  '  In  the  toxic  cases  the  intestinal  symptoms  may  be  very  marked,  but 
in  the  terminal  colitis  of  the  fevers  and  of  constitutional  affections  the  symp- 
toms are  often  trifling. 

PHLEGMONOUS  ENTERITIS 

As  an  independent  affection  this  is  excessively  rare,  even  less  frequent 
than  its  counterpart  in  the  stomach.  It  is  seen  occasionally  in  connection 
with  intussusception,  strangulated  hernia,  and  chronic  obstruction.  Apart 
Irom  these  conditions  it  occurs  most  frequently  in  the  duodenum,  and  leads 
to  suppuration  in  the  submucosa  and  abscess  formation.  Except  when  asso- 
ciated with  lienua  or  intussusception  the  affection  can  not  be  diagnosed.  The 
symptoms  Usually  resemble  those  of  peritonitis, 


DISEASES  OF  THE  INTESTINES  511 


ULCERATIVE    ENTERITIS 

In  addition  to  the  specific  ulcers  of  tuberculosis,  syphilis,  and  tjrphoid 
fever,  the  following  forms  of  ulceration  occur  in  the  bowels : 

Follicular  Ulceration. — As  mentioned,  this  is  very  conunon  in  the  diar- 
rhoeal  diseases  of  children,  and  also  in  the  secondary  or  terminal  inflamma- 
tions in  many  fevers  and  constitutional  disorders.  The  ulcers  are  small, 
punched  out,  with  sharply  cut  edges,  and  are  usually  limited  to  the  follicles. 
With  this  form  may  be  placed  the  catarrhal  ulcers  of  some  writers. 

Stercoral  ulcers,  which  occur  in  long-standing  cases  of  constipation.  Very 
remarkable  indeed  are  the  cases  in  which  the  sacculi  of  the  colon  become 
filled  with  rounded  small  scybala,  some  of  which  produce  distinct  ulcers  in 
the  mucous  membrane.  The  fsecal  masses  may  have  lime  salts  deposited  in 
them,  and  thus  form  little  enteroliths. 

Simple  Ulcerative  Colitis. — Apart  from  dysentery  of  the  Shiga  type,  the 
amoebic  and  terminal  forms,  there  is  a  variety  of  ulcerative  colitis,  some- 
times of  great  severity,  not  uncommon  in  England  and  the  United  States. 
It  is  a  disease  of  adults,  of  unknown  origin.  The  sexes  are  equally  affected; 
of  177  cases  collected  by  Eric  Smith,  89  were  in  males.  Some  patients  have 
had  previous  bowel  trouble;  sometimes  there  have  been  intermittent  attacks 
of  diarrhoea  and  constipation.  Post  mortem,  the  colon  is  dilated,  often  with- 
out hypertrophied  walls;  the  ulceration,  as  a  rule,  limited  to  it  and  very  ex- 
tensive, the  ulcers  ranging  in  size  from  a  pin's  head  to  large  areas,  with  in- 
filtrated, rarely  undermined,  edges.  The  Shiga  bacillus  is  not  present; 
colon  bacilli  are  found  but  no  one  organism  has  apparently  any  definite  rela- 
tion to  the  disease. 

When  established,  the  main  features  are : 

(a)  Diarrhoea:  the  motions  very  frequent  in  the  day,  up  to  20  or  30,  usu- 
ally small,  bile-stained,  with  mucus,  pus,  and  blood,  sometimes  mixed  with  the 
motion  or  separate.  There  may  be  clotted  lumps  of  blood,  or  the  blood  is 
uniformly  mixed,  and  the  motions  look  like  anchovy  sauce.  The  pain,  while 
severe,  is  usually  diffuse,  abdominal,  and  colicky,  and,  not  so  frequently,  in 
the  rectum.     Many  of  the  motions  pass  without  pain. 

(&)  Fever,  which  occurs  in  the  majority  of  the  cases,  though  severe 
forms  may  be  free  throughout. 

"  (c)   Wasting,  debility,  and  progressive  ansemia. 

(d)  With  the  proctoscope  the  mucous  membrane  is  seen  to  be  red  and 
cedematous.     Later  the  oedema  subsides  and  ulceration  appears. 

The  disease  may  run  a  very  acute  course,  but  most  frequently  it  is  chronic, 
lasting  from  eight  weeks  to  three  or  four  months.  Transient  improvement 
may  follow,  and  a  relapse.  Death  is  most  commonly  from  exhaustion,  occa- 
sionally from  haemorrhage,  and  in  a  few  instances  from  perforation. 

Ulceration  from  External  Perforation. — This  may  result  from  the  ero^ 
sion  of  new  growths  or,  more  commonly,  from  localized  peritonitis  with  ab- 
scess formation  and  perforation  of  the  bowel.  This  is  met  with  most  fre- 
quently in  tuberculous'  peritonitis,  but  it  may  occur  in  the  abscess  which 
follows  perforation  of  the  appendix  or  suppurative  or  gangrenous  pancreatitis, 
.Fatal  haemorrhage  may  result  from  the  perforation. 


512  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

Cancerous  Ulcers. — In  very  rare  instances  of  multiple  cancer  or  sar- 
coma the  submucous  nodules  break  down  and  ulcerate.  In  one  case  the  ileum 
contained  eight  or  ten  sarcomatous  ulcers  secondary  to  an  extensive  sarcoma 
in  the  neighborhood  of  the  shoulder- joint. 

Solitary  Ulcer. — Occasionally  a  solitary  ulcer  is  met  with  in  the  caecum  or 
colon,  which  may  lead  to  perforation.  Two  instances  of  ulcer  of  the  caecum, 
both  with  perforation,  have  come  under  our  observation,  and  in  one  instance 
a  simple  ulcer  of  the  colon  perforated  and  led  to  fatal  peritonitis. 

Diagnosis  of  Intestinal  Ulcers. — As  a  rule,  diarrhoea  is  present  in  all 
cases,  but  exceptionally  there  may  be  extensive  ulceration,  particularly  in  the 
small  bowel,  without  diarrhoea.  Very  limited  ulceration  in  the  colon  may 
be  associated  with  frequent  stools.  The  character  of  the  dejections  is  of  great 
importance.  Pus,  shreds  of  tissue,  and  blood  are  the  most  valuable  indica- 
tions. Pus  occurs  most  frequently  in  connection  with  ulcers  in  the  large 
intestine,  but  when  the  bowel  alone  is  involved  the  amount  is  rarely  great, 
and  the  passage  of  any  quantity  of  pure  pus  is  an  indication  that  it  has  come 
from  without,  most  commonly  from  the  rupture  of  a  pericgecal  abscess,  or 
in  women  of  an  abscess  of  the  broad  ligament.  Pus  may  also  be  present  in 
cancer  of  the  bowel  or  it  may  be  due  to  local  disease  in  the  rectum.  A 
purulent  mucus  may  be  present  in  the  stools  in  cases  of  ulcer,  but  it  has  not 
the  same  diagnostic  value.  The  swollen,  sago-like  masses  of  mucus  which 
are  believed  by  some  to  indicate  follicular  ulceration  are  met  with  also  in 
mucous  colitis.  Hcemorrhage  is  an  important  and  valuable  symptom  of  ulcer 
in  the  bowel,  particularly  if  profuse.  It  occurs  under  so  many  conditions 
that  taken  alone  it  may  not  be  specially  significant,  but  with  other  coexist- 
ing circumstances  it  may  be  the  most  important  indication  of  all. 

Fragments  of  tissue  are  occasionally  found  in  the  stools  in  ulcer,  particu- 
larly in  the  extensive  and  rapid  sloughing  in  dysenteric  processes.  Definite 
portions  of  mucosa,  shreds  of  connective  tissue,  and  even  bits  of  the  muscu- 
lar coat  may  be  found.  Pain  occurs  in  many  cases,  either  of  a  diffuse,  colicky 
character,  or  sometimes,  in  the  ulcer  of  the  colon,  very  limited  and  well 
defined.  Examination  by  means  of  tubes  should  always  be  done,  as  by 
them  ulcers  in  the  lower  bowel  may  be  viewed  directly. 

Perforation  is  an  accident  liable  to  happen  when  the  ulcer  extends  deeply. 
In  the  small  bowel  it  leads  to  a  localized  or  general  peritonitis.  In  the  large 
intestine,  too,  a  fatal  peritonitis  may  result,  or,  if  perforation  takes  place  in 
the  posterior  wall  of  the  ascending  or  descending  colon,  the  production  of  a 
large  abscess  cavity  in  the  retro-peritoneum. 

Treatment  of  the  Previous  Conditions 

Acute  Dyspeptic  Diarrhoea. — The  patient  should  be  in  bed  and  in  acute 
cases  no  food  should  be  allowed  for  twenty-four  hours.  If  there  is  vomiting 
the  stomach  should  be  washed  with  an  -alkaline  solution.  If  the  attack  has 
followed  the  eating  of  large  quantities  of  indigestible  material,  castor  oil  or 
calomel  is  advisable,  but  is  not  necessary  if  the  patient  has  been  freely  purged. 
If  the  pain  is  severe,  20  drops  (1.3  c.  c.)  of  laudanum  and  a  drachm  (4  c.  c.) 
of  spirit  of  chloroform  may  be  given,  or,  if  the  colic  is  very  intense,  a  hypo- 
dermic of  a  quarter  of  a  grain  (0.016  gm.)   of  morphia.     It  is  not  well  to 


DISEASES  OF  THE  INTESTINES  513 

check  the  diarrhoea  unless  it  is  profuse,  as  it  usually  stops  spontaneously 
within  forty-eight  hours.  If  persistent,  the  aromatic  chalk  powder  or  large 
doses  of  bismuth  (30  to  40  grains,  2  gm.)  may  be  given.  A  small  enema  of 
starch  (2  ounces,  60  c.  c),  with  20  drops  (1.3  c.  c.)  of  laudanum,  every  six 
hours,  is  a  most  valuable  remedy.  The  diet  should  be  increased  very  gradu- 
ally during  convalescence. 

Chronic  diarrhoea,  including  chronic  catarrh  and  ulcerative  enteritis.  It 
is  important,  in  the  first  place,  to  ascertain,  if  possible,  the  cause  and  whether 
ulceration  is  present  or  not.  So  much  in  treatment  depends  upon  the  careful 
examination  of  the  stools — as  to  the  amount  of  mucus,  the  presence  of  pus, 
the  occurrence  of  parasites,  and,  above  all,  the  state  of  digestion  of  the  food — 
that  the  practitioner  should  pay  special  attention  to  them.  Many  patients 
simply  require  rest  in  bed  and  a  restricted  diet.  Chronic  diarrhoea  of  many 
months'  or  even  of  several  years'  duration  may  be  sometimes  cured  by  strict 
confinement  to  bed  and  a  diet  of  boiled  milk  and  albumen  water. 

The  gasU'ogenous  diarrhoea  may  be  promptly  relieved  by  giving  dilute  hy- 
drochloric acid  in  full  doses.  Calcium  lactate  (gr.  xv,  1  gm.)  and  pancreatin 
are  also  useful. 

In  that  form  in  which  immediately  after  eating  there  is  a  tendency  to 
loose  evacuations  it  may  be  that  some  one  article  of  diet  is  at  fault.  The 
patient  should  rest  for  an  hour  or  more  after  meals.  Sometimes  this  alone 
is  sufficient  to  prevent  the  occurrence  of  the  diarrhoea.  Arsenic  in  moderate 
doses  taken  at  the  end  of  the  meal  is  sometimes  helpful.  In  those  forms 
which  depend  upon  abnormal  conditions  in  the  small  intestine,  bismuth  is 
indicated.  It  must  be  given  in  large  doses — from  half  a  dram  to  a  dram  (2 
to  4  gm.)  three  times  a  day.  The  smaller  doses  are  of  little  use.  Salol  and 
the  salicylate  of  bismuth  may  be  tried. 

In  the  form  due  to  carbohydrate  indigestion,  the  carbohydrate  should  be 
greatly  reduced  or  a  protein-fat  diet  given.  If  the  diarrhoea  lessens,  vege- 
tables with  a  low  carbohydrate  content  (see  page  433)  should  be  added 
gradually. 

An  extremely  obstinate  and  intractable  form  is  the  diarrhoea  of  hysterical 
and  nervous  women.  A  systematic  rest  cure  will  be  found  most  advantageous, 
and  if  a  milk  diet  is  not  well  borne  the  patient  may  be  fed  on  egg  albumen. 
The  condition  seems  to  be  associated  in  some  cases  with  increased  peristalsis, 
and  in  such  the  bromides  may  do  good,  or  preparations  of  opium  may  be 
necessary.  There  are  instances  which  prove  most  obstinate  and  resist  all 
forms  of  treatment,  and  the  patient  may  be  greatly  reduced.  A  change  of 
air  and  surroundings  may  do  more  than  medicines. 

In  a  large  group  of  the  chronic  diarrhoeas  the  mischief  is  seated  in  the 
colon  and  is  due  to  ulceration.  Medicines  by  the  mouth  are  here  of  little 
value.  The  stools  should  be  carefully  watched  and  a  diet  arranged  which 
shall  leave  the  smallest  possible  residue.  Boiled  or  peptonized  milk  may  be 
given,  but  the  stools  should  be  examined  to  see  whether  there  is  an  excess  of 
food  or  of  curds.  Meat  is,  as  a  rule,  badly  borne  in  these  cases.  The  diar- 
rhoea is  best  treated  by  enemata.  The  starch  and  laudanum  should  be  tried, 
but  when  ulceration  is  present  it  is  better  to  use  astringent  injections.  From 
2  to  4  pints  of  warm  water,  containing  from  half  a  dram  to  a  dram  (2  to  4 
gm.)  of  nitrate  of  silver,  may  be  used.     In  the  chronic  diarrhoea  which  fol- 


514  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

lows  dysentery  this  is  particularly  advantageous.  In  giving  large  injections 
the  patient  should  be  in  the  dorsal  position,  with  the  hips  elevated,  and  it 
is  best  to  allow  the  injection  to  flow  in  gradually  from  a  siphon  bag.  In  this 
way  the  entire  colon  can  be  irrigated  and  the  patient  can  retain  the  injection 
for  some  time.  The  silver  injections  may  be  very  painful,  but  they  are  in- 
valuable in  all  forms  of  ulcerative  colitis.  Acetate  of  lead,  boracic  acid, 
sulphate  of  copper,  suphate  of  zinc,  and  salicylic  acid  may  be  used  in  1  per 
cent,  solutions.  Any  ulcers  which  can  be  reached  should  be  treated  by  local 
applications,  of  which  the  silver  salts  are  particularly  useful.  In  obstinate 
cases  appendicostomy  or  cfficostomy  should  be  done  and  the  bowel  irrigated 
through  the  opening. 

In  the  intense  forms  of  choleraic  diarrhoea  in  adults  associated  with  constant 
vomiting  and  frequent  watery  discharges  the  patient  should  be  given  at  once  a 
hypodermic  of  a  quarter  of  a  grain  (0.016  gm.)  of  morphia,  which  should  be 
repeated  in  an  hour  if  the  pains  return  or  the  purging  persists.  This  gives 
prompt  relief,  and  is  often  the  only  medicine  needed  in  the  attack.  The 
patient  should  be  given  stimulants,  and,  when  the  vomiting  is  allayed  by 
suitable  remedies,  small  quantities  of  milk  and  lime  water. 


II.     DIARRHCEAL  DISEASES  IN  CHILDREN 

Children  are  particularly  susceptible  to  disorders  of  the  alimentary  tract. 
Although  several  forms  are  recognized,  they  so  often  merge  the  one  into  the 
other  that  a  sharp  differentiation  is  impossible. 

General  Etiology. — Certain  factors  predispose  to  diarrhoea.  Age. — The 
largest  number  of  cases  occur  just  after  the  nursing  period ;  the  highest  mor- 
tality is  in  the  second  half  of  the  first  year,  when  this  period  falls  in  the  hot 
weather;  hence  the  dread  of  the  "second  summer." 

Diet. — Diarrhoea  is  most  frequent  in  artificially  fed  babies.  Of  1,943 
fatal  cases  collected  by  Holt,  only  3  per  cent,  were  breast-fed.  The  agitation 
for  pure  milk  in  the  large  cities  has  decreased  materially  the  number  of  diar- 
rhoea cases  among  bottle-fed  infants. 

Among  the  poor  the  bowel  complaint  comes  with  artificial  feeding,  and  is 
due  either  to  milk  ill-suited  in  quantity  or  poor  in  quality,  or  to  indigestible 
articles  of  diet.  Many  of  the  fatal  cases  have  been  fed  upon  condensed  milk. 
In  some  cases  the  absorption  of  partially  digested  food  protein  may  be  re- 
sponsible, or  protein  from  bacteria  in  the  milk. 

Temperature. — The  relation  of  the  atmospheric  temperature  to  the  preva- 
lence of  the  disease  in  children  has  long  been  recognized.  The  mortality 
curve  begins  to  rise  in  May,  increases  in  June,  reaching  the  maximum  in 
July,  and  gradually  sinks  through  August  and  September.  The  maximum 
corresponds  closely  with  the  highest  mean  temperature,  yet  we  can  not  re- 
gard the  heat  itself  as  the  direct  agent,  but  only  as  one  of  several  factors. 
Thus  the  mean  temperature  of  June  is  only  four  or  five  degrees  lower  than 
that  of  July,  and  yet  the  mortality  is  not  more  than '  one-third.  Seibert, 
who  analyzed  the  mortality  and  the  temperature  month  by  month  in  ISTew 
York  for  ten  years,  fails  to  find  a  constant  relation  between  the  degrees  of 


DIAERHCEAL  DISEASES  IN  CHILDREN  515 

heat  and  the  number  of  cases  of  diarrhoea.  Neither  barometric  pressure 
nor  humidity  appears  to  have  any  influence. 

Bacteriology. — The  discovery  by  Duvall  and  Bassett  of  a  bacillus  appar- 
ently identical  with  the  Shiga  bacillus  in  the  dejecta  of  children  sufEering 
from  summer  diarrhcea  awakened  renewed  interest  in  the  relation  of  bacteria 
to  these  disorders  in  children.  The  Rockefeller  Institute  research  showed  that 
this  organism  was  present  in  a  large  number  of  cases  of  so-called  "summer 
diarrhoea."  The  studies  of  Martini  and  Lentz,  Flexner,  Hiss,  Parke,  and 
others  indicate  that  there  is  a  group  of  closely  allied  forms  of  bacilli  differing 
slightly  from  the  original  Shiga  bacillus  in  their  action  on  certain  sugars 
and  in  agglutinating  properties.  The  type  of  organisms  most  frequently  asso- 
ciated with  the  diarrhoeas  of  children  belongs  to  the  so-called  "acid  type,"  and, 
unlike  the  Shiga  cultures,  ferments  mannite  with  acid  production. 

The  causal  connection  of  this  group  of  bacteria  with  all  the  diarrhoea] 
diseases  of  children  has  not  been  proved.  In  the  hands  of  some  workers  they 
have  been  found  in  the  faeces  of  a  large  proportion  of  all  cases  examined, 
and  also  less  frequently  in  the  sporadic  diarrhoeas  occurring  throughout  the 
year.  These  organisms  are  often  found  in  comparatively  small  numbers, 
and  are  more  easily  isolated  from  mucus  or  blood-stained  stools.  They  occur 
in  the  acute  primary  intestinal  infection  in  children,  in  subacute  infection 
without  previous  symptoms  coincident  with  or  following  other  acute  dis- 
eases such  as  measles,  pneumonia,  etc.,  and  in  the  terminal  intestinal  infec- 
tion following  malnutrition  or  marasmus.  They  have  been  found  in  breast- 
fed infants  as  well  as  bottle-babies. 

The  mode  of  entrance  of  the  organism  has  not  been  determined.  Simul- 
taneous outbreaks  of  many  cases  in  remote  parts  of  a  community  where  there 
can  be  no  common  milk  supply,  and  occurrence  of  the  disease  in  breast-  and 
condensed-milk-fed  babies,  indicate  that  cow's  milk  is  not  the  only  conveyor 
of  the  infection,  and  point  to  some  common  cause,  possibly  to  the 'water,  as 
a  means  of  contamination. 

The  importance  of  other  organisms  must  not  be  overlooked.  The*  observa- 
tions of  Escherich  showed  the  remarkable  simplicity  of  bacterial  flora  in  the 
intestines  of  healthy  milk-fed  children,  Bacterium  lactis  aerogenes  being  pres- 
ent in  the  upper  portion  of  the  bowel  and  Bacterium  coU  commune  in  the 
lower  bowel,  each  almost  in  pure  culture. 

When  diarrhoea  is  set  up  the  number  and  varieties  of  bacteria  are  greatly 
increased,  although  heretofore  no  forms  had  been  found  to  bear  a  constant 
or  specific  relationship  to  the  diarrhoeal  fasces.  Certain  diarrhoeas  in  chil- 
dren are  apparently  induced  by  the  lactic  acid  organisms  in  milk,  others  by 
colon  or  proteus  bacilli,  and  others,  again,  by  the  pyogenic  cocci  and  other 
forms ;  all  these  bacteria  may  be  associated  with  the  dysentery  bacilli.  There 
is  considerable  evidence  to  support  the  view  that  the  destructive  lesions  of  the 
intestines  may  be  produced  by  the  Streptococcus  pyogenes  after  an  initial  in- 
fection with  a  member  of  the  dysentery  group. 

Morbid  Anatomy. — In  mild  cases  there  may  be  only  a  slight  catarrhal 
swelling  of  the  mucosa  of  both  small  and  large  bowel,  with  enlargement  of 
the  lymph  follicles.  The  mucous  membrane  may  be  irregularly  congested; 
often  this  is  most  marked  at  the  summit  of  the  folds.  The  submucosa  is 
usually  infiltrated  with  serum  and  small  round  cells.     In  more  severe  cases 


516  DISEASES  OP  THE  DIGESTIVE  SYSTEM 

ulceration  may  take  place.  The  loss  of  substance  begins,  usually,  in  the 
mucosa,  over  swollen  lymph  follicles.  About  the  ulcer  there  is  a  more  or  less 
distinctly  marked  inflammatory  zone.  The  destruction  of  the  tissue  is  lim- 
ited to  the  region  of  the  follicles  and  becomes  progressive  by  the  union  of 
several  adjoining  ulcers.  This  process  is  usually  confined  to  the  lower  bowel, 
and  may  be  so  extensive  as  to  leave  only  ribbons  of  intact  mucosa.  The  ulcers 
never  perforate.  Earely  there  is  a  croupous  or  pseudo-membranous  enteritis 
affecting  the  lower  ileum,  colon,  aia,d  rectum.  The  constant  features  are 
the  increased  secretion  of  mucus  and  the  lymphoid  hyperplasia.  The  mesen- 
teric glands  are  enlarged. 

The  changes  in  the  other  organs  are  neither  numerous  nor  characteristic. 
Broncho-pneumonia  occurs  in  many  cases.  The  liver  is  often  fatty,  the  spleen 
may  be  swollen.  Brain  lesions  are  rare;  the  membranes  and  substance  are 
often  anaemic,  but  meningitis  or  thrombosis  is  very  uncommon. 

Clinical  rorms. — Acute  Intestinal  Indigestion. — This  form  occurs  in 
children  of  all  ages,  and  is  associated  with  improper  food.  The  symptoms 
often  begin  abruptly  with  nausea  and  vomiting,  or,  especially  in  stronger 
children,  several  hours  or  a  day  or  two  after  the  disturbing  diet.  The  local 
symptoms  are  colicky  pains,  moderate  tympanites,  and  diarrhoea.  The  stools 
are  four  to  ten  in  twenty-four  hours;  at  first  faecal,  then  fluid,  with  more 
or  less  mucus  and  particles  from  undigested  material.  There  is  no  blood. 
The  usual  intestinal  bacteria  are  found.  Occasionally,  when  there  is  mucus, 
dysentery  bacilli  are  present.  There  is  always  fever.  It  is  rarely  very  high, 
and  never  continues.  The  pulse  may  be  rapid  and  the  prostration  marked  in 
very  young  or  weak  children.  These  symptoms  usually  subside  shortly  after 
the  emptying  of  the  bowel. 

In  weakened  infants,  or  when  the  treatment  has  been  delayed  or  the  diet 
remains  unchanged,  this  disturbance  may  lead  to  more  serious  conditions. 
Attacks  of  intestinal  indigestion  tend  to  recur. 

Fermentative  Diarrhcea. — This  form  is  characterized  by  more  severe 
constitutional  symptoms.  It  may  begin  after  an  intestinal  indigestion  of  sev- 
eral days  in  which  the  stools  are  fluid  and  offensive,  and  contain  undigested 
food  and  curds.  In  other  cases  the  disease  sets  in  abruptly  with  vomiting, 
griping  pains,  and  fever,  which  may  rapidly  reach  104°-105°  F. 

Nervous  symptoms  are  usually  prominent.  The  child  is  irritable  and  sleeps 
poorly.  Convulsions  may  usher  in  the  acute  symptoms  or  occur  later.  An  in- 
creasing drowsiness,  ending  in  coma,  has  been  noted  in  many  cases.  The 
stools,  which  vary  from  four  to  twenty  in  twenty-four  hours,  soon  lose 
their  faecal  character  and  become  fluid.  Later  they  consist  largely  of  green  or 
translucent  mucus.  An  occasional  fleck  of  blood  is  noticed  in  the  mucus,  but 
this  is  never  present  in  large  amounts.  Microscopically,  besides  the  food  resi- 
due and  mucous  strands  are  a  moderate  number  of  leucocytes  and  red  blood- 
corpuscles.     Epithelial  cells  are  found  with  numerous  bacteria. 

The  acute  symptoms  generally  pas&  away  in  a  few  days  with  judicious 
treatment.  Eel  apses  are  frequent,  following  any  indiscretion.  The  attack 
may  be  the  beginning  of  severe  ileo-colitis.  These  gastro-intestinal  intoxica- 
tions are  largely  confined  to  the  summer  months  and  form  an  important  group 
of  the  summer  diarrhoeas  of  children. 

Cholera  Infantum. — This  term  should  be  reserved  for  the  fulminating 


DIAEEHCEAL  DISEASES  IN  CHILDEEN  517 

form  of  gastro-intestinal  intoxication.  The  typical  cases  are  rare  and  form 
only  a  very  small  proportion  of  the  diarrhoeal  diseases  of  infants.  The  disease 
sets  in  with  vomiting,  which  is  incessant  and  is  excited  by  an  attempt  to  take 
food  or  drink.  The  stools  are  profuse  and  frequent ;  at  first  f gecal  in  character, 
brown  or  yellow  in  color,  and  finally  thin,  serous,  and  watery.  The  stools 
first  passed  are  very  ofi^ensive;  subsequently  they  are  odorless.  The  thin, 
serous  stools  are  alkaline.  There  is  fever,  but  the  axillary  temperature  may 
register  three  or  more  degrees  below  that  of  the  rectum.  From  the  outset  there 
is  marked  prostration;  the  eyes  are  sunken,  the  features  pinched,  the  fon- 
tanelles  depressed,  and  the  skin  has  a  peculiar  ashy  pallor.  At  first  restless 
and  excited,  the  child  subsequently  becomes  heavy,  dull,  and  listless.  The 
tongue  is  coated  at  the  onset,  but  subsequently  becomes  red  and  dry.  As  in 
all  choleraic  conditions,  the  thirst  is  insatiable;  the  pulse  is  rapid  and  feeble, 
and  toward  the  end  becomes  irregular  and  imperceptible.  Death  may  occur 
within  twenty-four  hours,  with  symptoms  of  collapse  and  great  elevation  of 
the  internal  temperature.  Before  the  end  the  diarrhoea  and  vomiting  may 
cease.  In  other  instances  the  intense  symptoms  subside,  but  the  child  remains 
torpid  and  semi-comatose,  with  fingers  clutched,  and  there  may  be  convul- 
sions. The  head  may  be  retracted  and  the  respirations  interrupted,  irregular, 
and  of  the  Cheyne-Stokes  type.  The  child  may  remain  in  this  condition  for 
some  days  without  any  signs  of  improvement.  It  was  to  this  group  of  symp- 
toms in  infantile  diarrhoea  that  Marshall  Hall  gave  the  term  "hydrencepha- 
loid,"  or  spurious  hydrocephalus.  As  a  rule,  no  changes  in  the  brain  or  other 
organs  are  found.  The  condition  of  sclerema  is  described  as  a  sequel  of  cholera 
infantum.  The  skin  and  subcutaneous  tissue  becomes  hard  and  firm,  and  the 
appearance  has  been  compared  to  that  of  a  half-frozen  cadaver. 

No  constant  organism  has  been  found  in  these  cases.  Baginsky  considers 
the  disease  the  result  of  the  action  on  the  system  of  the  poisonous  products 
of  decomposition  encouraged  by  the  various  bacteria  present — a  Fduhiiss  dis- 
ease. The  clinical  picture  is  that  produced  by  an  acute  bacterial  infection,  as 
in  Asiatic  cholera. 

Diagnosis. — The  diagnosis  is  readily  made.  There  is  no  other  intestinal 
affection  in  children  for  which  it  can  be  mistaken.  The  constant  vomiting, 
the  frequent  watery  discharges,  the  collapse  symptoms,  and  the  elevated  tem- 
perature make  an  unmistakable  clinical  picture.  The  outlook  in  the  majority 
of  cases  is  bad,  particularly  in  children  artificially  fed.  Hyperpyrexia,  ex- 
treme collapse,  and  incessant  vomiting  are  the  most  serious  symptoms. 

IleO-colitis  {E'rutero-colitis,  Inflammatory  DiarrJicea). — In  this  form 
there  is  evidence  of  an  inflammatory  alteration  of  the  intestinal  wall,  usually 
of  the  lower  ileum  and  large  intestine.  Several  sub-varieties  are  recognized  ac- 
cording to  the  nature  and  site  of  the  lesions.  Many  of  the  cases  are  grafted 
on  the  simple  forms  above  described.  The  mucous  discharges  continue,  mingled 
with  food  residue  and  often  streaked  with  blood.  Pus  cells  are  numerous 
under  the  microscope.  The  temperature  remains  elevated  or  may  be  remit- 
tent. After  two  or  three  weeks  the  symptoms  gradually  subside,  the  stools 
become  fewer  in  number,  and  the  faecal  character  returns. 

In  other  instances  the  severe  involvement  of  the  intestines  seems  evident 
within  a  few  hours  of  the  onset,  with  abdominal  pain,  vomiting,  and  fever. 
Blood  and  pus  may  bo  present  in  nearly  every  stool.     Tenesmus  is  frequent 


518  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

and  prolapsus  ani  is  not  -uncommon.  In  severe  attacks  the  prostration  is 
marked,  the  tongue  is  dry,  the  mouth  covered  with  sordes,  and  death  may 
ensue  in  a  few  days  from  profound  sepsis,  or  the  jDatient  may  continue  des- 
perately ill  for  weeks  and  gradually  recover  or  die  from  asthenia. 

Hcemorrhage  of  large  amount  is  extremely  rare.  The  appearance  of  bright 
red  stains  on  the  napkin  indicates,  usually,  ulceration  of  the  lower  bowel  or 
rectum.  When  the  blood  is  dark  brown  the  lesion  is  in  the  ileum  or  near  the 
valve.  The  extent  of  the  ulceration  can  not  be  accurately  determined  by  the 
quantity  of  the  blood  passed. 

Membranous-colitis  is  usually  only  to  be  distinguished  by  the  discovery 
of  the  membrane  in  the  rectum  through  a  speculum  or  in  prolapsus,  or  by 
the  passage  of  a  fragment  of  the  membrane  in  the  stools. 

Inflammation  of  the  colon  often  occurs  in  marantic  infants.  It  may  con- 
sist of  a  catarrhal  or  follicular  inflammation  of  the  lower  bowel  without  de- 
structive lesion,  and  is  frequently  a  terminal  infection. 

Ileo-coUtis  may  become  chroaiic  and  persist  for  months.  The  signs  of 
active  inflammation  subside;  there  is  little  pain  or  fever,  but  more  or  less 
mucus  remains  in  the  stools.  The  general  condition  suffers.  There  is  a  con- 
tinuous loss  in  weight;  the  skin  is  dry  and  hangs  in  folds;  nervous  symptoms 
are  always  present.  There  may  be  stiffness  and  contraction  of  the  extremities, 
with  opisthotonos.  The  progress  is  irregular,  marked  by  short  periods  of  im- 
provement. Death  is  often  due  to  a  relapse,  to  asthenia,  or  to  broncho-pneu- 
monia. In  many  of  these  cases,  both  acute  and  chronic,  the  dysentery  bacilli 
have  been  found  in  association  with  other  organisms.  In  all  these  forms  aci- 
dosis may  occur  and  should  always  be  kept  in  mind.  Increase  in  the  respira- 
tion rate,  for  which  no  other  explanation  is  found,  should  excite  suspicion  of 
acidosis. 

Prevention. — Unquestionably,  most  of  the  intestinal  disorders  of  children 
can  be  prevented.  In  many  large  cities  the  mortality  from  the  summer  diar- 
rhoeas has  been  greatly  reduced  by  prophylactic  measures.  The  infant  should 
have  abundance  of  air-space  in  the  home,  with  plenty  of  sunlight  and  fresh 
air.  In  hot  weather  it  may  be  well  for  him  to  sleep  out  of  doors,  day  and 
night.  The  clothing  must  not  be  too  heavy  in  midsummer;  often  only  a 
binder  and  thin  dress.  This  clothing  should  be  altered  with  every  change  of 
the  temperature.  The  gTeatest  cleanliness  should  surround  the  life  of  the 
baby,  and  the  nursing-bottles  and  nipples  are  to  be  boiled  each  day  and  kept 
scrupulously  clean.     Breast-feeding  is  continued  whenever  possible. 

With  bottle-babies,  in  warm  weather,  the  diet  should  be  reduced  in  strength 
— i.  e.,  weaker  milk  mixtures  used  and  more  water  given.  In  all  crowded  com- 
munities the  milk  should  be  sterilized  or  pasteurized  during  the  summer 
months,  and  all  the  water  given  the  baby,  either  with  or  between  the  nourish- 
ment, boiled.  It  is  better  that  a  child  should  be  in  the  country  during  the 
hot  weather,  but  when  this  is  impossible  the  parks  in  the  large  cities  afford 
much  relief. 

Treatment. — Hygienic  Management. — Even  after  the  illness  has  begun, 
much  can  be  done  by  hygienic  measures  to  diminish  the  severity.  Change  of 
air  to  seashore  or  mountain  is  often  followed  by  a  marked  improvement  in 
the  child's  condition.  The  patient  must  not  be  too  warmly  clad.  The  tem- 
perature may  ])e  lowered  and  iiervong  symptoms  allayed  by  hydrotherapy. 


DIAREHCEAL  DISEASES  IN  CHILDREN"  519 

Baths,  warm  and  cool,  are  helpful.  Colon  irrigations  serve  the  double  purpose 
of  flushing  the  bowel  and  stimulating  the  nervous  system.  They  should  be 
given  cool  when  there  is  much  fever. 

Diet. — The  dietetic  management  is  of  the  utmost  importance.  In  acute 
cases  with  fever  the  milk,  whether  breast  or  cow's  milk,  and  all  its  modifica- 
tions, must  be  stopped  at  once.  It  is  best  to  give  the  infant  nothing  but 
water  for  several  hours,  it  may  be  for  two  or  three  days,  or  until  the  acute 
symptoms  subside;  a  cereal  water  may  then  be  substituted,  to  which  may  be 
added  egg  albumen,  broth,  or  beef  juice.  The  time  at  which  it  is  safe  to^ 
return  to  a  milk  diet  varies  with  each  case,  and  no  definite  rules  can  be  laid 
down.    It  is  usuall}'  better  to  defer  milk  until  the  temperature  is  nearly  normal. 

If  the  stools  are  alkaline  from  protein  decomposition,  a  diet  consisting 
largely  of  carbohydrates — i.  e.,  barley  water — is  indicated;  whereas  protein 
diet,  such  as  beef  juice  and  egg  albumen,  is  more  helpful  when  the  stools  are 
strongly  acid. 

Experience  has  shown  that  the  ingredient  in  the  milk  that  is  not  well 
borne  is  the  fat;  hence  skimmed  milk,  diluted  or  partially  digested,  can  often 
be  safely  given  before  diluted  whole  milk.  Whey  is  often  helpful.  In  Ger- 
many buttermilk  has  been  widely  used  in  convalescence  from  intestinal  dis- 
turbances. The  various  proprietary  foods,  or  condensed  milk  mixed  with 
water,  although  not  to  be  given  over  long  periods,  may  be  found  serviceable  in 
the  gradual  return  of  the  child  to  a  normal  diet. 

In  children  from  three  to  seven  years  of  age  these  acute  derangements  are 
rarely  serious,  and  usually  respond  promptly  after  purgation  and  restricted 
diet,  consisting  largely  of  boiled  milk. 

It  must  be  borne  in  mind  that  injudicious  treatment,  either  in  diet  or 
medication,  may  interrupt  what  otherwise  would  be  a  prompt  recovery  and 
bring  on  the  most  serious  intestinal  lesions.  The  chronic  cases,  both  in  in- 
fants and  old  children,  especially  those  with  ileo-colitis  and  ulceration,  pre- 
sent unusual  difficulties.  Each  case  must  be  studied  by  itself.  Food  which 
is  digested  in  the  upper  portion  of  the  intestinal  tract  is  preferable.  Milk, 
properly  modified  with  cereal  water  or  predigested,  if  intelligently  prescribed, 
offers  the  best  chance  of  success.  The  percentage  system  of  milk  modifica- 
tion, which  enables  the  physician  to  alter  the  proportion  of  fat  or  carbohy- 
drate in  the  milk  mixture,  is  of  great  service  in  feeding  these  long-standing 
cases. 

Care  must  be  taken  not  to  over-feed,  although  occasionally,  when  there  is 
persistent  anorexia,  gavage  may  be  necessary.  This  is  best  accomplished 
through  a  nasal  tube.  Some  infants  will  retain  food  given  through  a  catheter 
when  they  will  vomit  the  same  mixture  taken  from  a  bottle.  Beef  juice  is 
frequently  useful.     It  should  always  be  given  with  considerable  fluid. 

Medicinal. — In  all  cases  of  diarrhoea  there  are  more  or  less  congestion  of 
the  intestinal  mucosa,  hypersecretion  of  mucus,  and  increased  peristalsis  due 
in  part  to  the  irritant  action  of  improper  food.  In  certain  forms  toxic  symp- 
toms are  noticed  early.  In  other  instances  inflammatory  lesions  in  the  wall 
of  the  bowel  are  present.  The  keynote,  then,  of  the  treatment  is  promptness. 
Nature's  effort  to  remove  the  disturbing  cause  should  be  assisted,  not  checked. 

Castor  oil  and  calomel  are  to  be  preferred  as  purgatives,  especially  for 
infants.     A  dram  (4  c.  c.)  of  the  former,  repeated,  if  necessary,  will  usually 


520  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

sweep  the  intestinal  tract  and  relieve  the  irritation.  Where  there  is  much 
nausea  or  intestinal  fermentation,  calomel  is  indicated.  It  may  be  given  in 
divided  doses  at  short  intervals  until  one  or  two  grains  (0.065  or  O.iy  gm.) 
have  been  taken,  or  until  the  characteristic  green  stools  appear.  Very  early 
in  the  attack,  if  nausea  is  marked,  nothing  relieves  so  quickly  as  gastric  lav- 
age Avith  warm  water  or  a  weak  soda  solution.  In  older  children  a  large 
draught  of  boiled  water  may  be  substituted.  In  many  cases  irrigation  of  the 
lower  bowel  with  large  quantities  of  salt  solution  flushes  the  colon,  removing 
the  irritating  material,  and  diminishes  the  absorption  of  toxins.  It  also  re- 
duces the  temperature  and  allays  nervous  symptoms.  The  irrigating  fluid 
should  be  cool  when  there  is  much  fever.  The  infant  is  placed  in  the  dorsal 
position  or  turned  a  little  to  the  left,  with  hips  elevated,  and  the  fluid  from 
a  fountain  syringe,  about  three  feet  above  the  patient,  is  allowed  to  flow  into 
the  rectum  through  a  large  soft  rubber  catheter.  Usually  about  a  pint  can  be 
retained  before  expulsion.  If  desired,  the  catheter  can  be  gently  pushed  into 
the  bowel  as  it  becomes  distended  with  fluid.  Two  or  three  quarts  should  be 
used  at  one  irrigation,  which  may  be  repeated  several  times  in  twenty-four 
hours  if  it  is  beneficial. 

Where  there  is  ulceration  of  the  lower  bowel  various  astringents,  such  as 
alum,  witch  hazel  (one  or  two  teaspoonfuls  to  one  quart),  silver  nitrate, 
1-4,000,  or  a  weak  solution  of  permanganate  of  potassium,  may  be  used  as 
the  irrigating  fluid.  In  great  local  irritation  and  tenesmus,  enemata  {2 
ounces,  60  c.  c.)  of  flaxseed  or  starch,  with  2  to  5  drops  (0.12  to  0.3  c.  c.)  of 
laudanum,  are  soothing  and  beneficial. 

Water  should  be  given  freely  by  whichever  method  is  indicated.  With 
signs  of  acidosis,  as  much  water  as  possible  should  be  given  and  sodium  bi- 
carbonate in  full  doses,  gr.  xv-lx  (1-4  gm.)  by  mouth  or  by  the  bowel  every 
two  hours,  until  the  urine  is  alkaline.  When  there  is  much  loss  of  fluid  from 
the  body  or  when  toxic  symptoms  are  marked  infusion  of  normal  salt  solution 
under  the  skin  may  be  tried.  One  to  three  hundred  c.  c.  can  be  readily  in- 
troduced. This  procedure  is  not  so  permanently  helpful  as  it  was  thought  to 
be  some  years  ago.  There  is  rarely  any  necessity  to  transfuse  unless  in  severe 
acidosis. 

Of  the  many  drugs  vaunted  as  intestinal  astringents  and  antiseptics,  bis- 
muth, either  as  subgallate  or  subnitrate,  has  proved  most  serviceable.  It 
should  not  be  given  until  the  disturbing  material  has  been  removed  and  the 
temperature  is  falling;  then  it  should  be  administered  in  large  doses,  5  to  10 
grains  (0.3  to  0.6  gm.)  every  hour,  until  there  is  discoloration  of  the  stools. 
In  some  cases  this  may  be  hastened  by  lac  sulphur  in  grain  doses.  Opium 
should  be  very  sparingly  used,  and  then  only  for  a  specific  puipose,  to  check 
excessive  peristalsis,  violent  colic,  or  very  numerous  passages.  It  may  be 
given  to  an  infant  as  Dover's  powder,  14-I  grain  (0.016  to  0.065  gm.)  ;  or 
paregoric,  5-10  minims  (0.3  to  0.6  c.  c.)  every  four  hours;  or  morphia,  hypo- 
dermically,  1/200-1/50  grain  (0.00032  to  0.0013  gm.),  when  prompt  action 
is  desired.  Occasionally  it  is  well  to  combine  it  with  atropine,  1/1,000-1/250 
grain  (0.000065-0.00026  gm.)  The  bowels  should  not  be  locked  when  the' 
stools  are  foul  or  the  temperature  is  high.  When  there  is  prostration  stimu- 
lants, such  as  camphor  or  strychnine  (gr.  1/200-1/100,  0.0003-0.0006  gm.), 
are  indicated. 


APPENDICITIS  531 

Seeum  Theeapy. — Thus  far  the  results  of  serum  therapy  have  been  dis- 
appointing. It  is  only  in  the  very  early  cases  that  any  improvement  results. 
The  marked  reduction  in  the  mortality  in  adult  dysentery  in  Japan,  reported 
by  Shiga,  should  encourage  the  further  trial  of  this  treatment  in  the  epidemic 
diarrhoea,  as  no  ill  effects  have  been  ascribed  to  its  use.  It  is  given  in  10-40 
c.  c.  doses,  hypodermically. 

Teeatment  of  Choleea  Infantum. — In  cholera  infantum  serious  symp- 
toms may  occur  with  great  rapidity,  and  here  the  incessant  vomiting  and  fre- 
quent purging  render  the  administration  of  remedies  extremely  difficult.  Ir- 
rigation of  the  stomach  and  large  bowel  is  of  great  service,  and  when  the 
fever  is  high  ice-water  injections  may  be  used,  or  a  graduated  bath.  As  in 
the  acute  choleraic  diarrhoea  of  adults,  morphia  hypodermically  is  the  remedy 
which  gives  greatest  relief,  and  in  the  conditions  of  extreme  vomiting  and 
purging,  with  restlessness  and  collapse  symptoms^  this  drug  alone  commands 
the  situation.  A  child  of  one  year  may  be  given  from  1/100  to  1/80  of  a  grain 
(0.00065  to  0.0008  gm.)  to  be  repeated  in  an  hour,  and  again  if  not  better. 

In  all  cases  of  diarrhoea  convalescence  requires  very  careful  management. 
An  infant  which  has  suffered  from  a  severe  attack  should  be  especially  watched 
throughout  the  remainder  of  the  hot  weather.  During  this  time  it  is  rarely 
safe  to  return  to  a  full  diet. 


in.    APPENDICITIS 

Inflammation  of  the  vermiform  appendix  is  the  most  important  of  acute 
intestinal  disorders.  Formerly  the  "iliac  phlegmon"  was  thought  to  be  due 
to  disease  of  the  caecum — typhlitis — or  of  the  peritoneum  covering  it — peri- 
typhlitis; but  we  now  know  that  with  rare  exceptions  the  caecum  itself  is  not 
affected,  and  even  the  condition  formerly  described  as  stercoral  typhlitis  is  in 
reality  appendicitis.  The  contribution  of  Fitz  in  1886  served  to  put  the 
whole  question  on  a  rational  basis.  For  historical  and  special  details  the 
reader  is  referred  to  the  monograph  of  Kelly  and  Hurdon. 

Etiology. — The  exciting  causes  of  appendicitis  are  not  always  evident.  An 
infection  is  the  essential  factor.  The  lumen  of  the  appendix  forms  a  sort  of 
test-tube,  in  which  the  faeces  lodge  and  are  with  difficulty  discharged,  so  that 
the  mucosa  is  liable  to  injury  from  retention  of  the  secretions  or  from  the 
presence  of  inspissated  faeces  or  occasionally  foreign  bodies.  The  anatomical 
features  of  the  appendix  render  it  liable  to  ulceration,  strangulation  and  per- 
foration. In  some  instances  the  appendicitis  is  a  local  expression  of  a  general 
infection.  The  causes  of  the  undoubted  increase  of  the  disease  are  not  known ; 
some  have  attributed  it  to  the  prevalence  of  influenza.  The  acute  catarrhal 
form  may  be  associated  with  pneumonia  or  typhoid  fever  or  any  of  the  acute 
infections.  Direct  injury,  as  in  straining  and  heavy  lifting,  is  an  occasional 
exciting  cause.  Other  conditions,  tuberculosis  and  actinomycosis,  may  pre- 
sent the  features  of  acute  appendicitis.  Cancer  was  found  in  23  of  5,000  ap- 
pendices removed  at  the  Mayo  Clinic  and  in  4  among  7,000  cases  reported  by 
Adams. 

The  BACTEEIOLOGY  is  most  varied.  The  Bacillus  coli  is  present  in  a  large 
number  of  cases,  and  the  pyogenic  organisms,  particularly  the  Streptococcus 


522  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

pyogenes.  A  fresh  conception  of  the  etiology  is  suggested  by  the  work  of 
Eosenow.  As  is  well  known,  the  dominant  parasite  in  appendicitis  is  the  colon 
bacillus,  either  in  pure  culture  or  with  streptococci  and  staphylococci;  the 
former  chiefly  in  the  lumen,  the  latter  in  the  walls  of  the  tube.  Eosenow 
claims  that  in  most  cases  appendicitis  is  a  blood  infection  secondary  to  a  dis- 
tant focus  such  as  the  tonsil :  and  it  would  appear  that  streptococci  circulat- 
ing in  the  blood  have  an  elective  affinity  for  the  appendix.  In  19  of  39  ani- 
mals appendicitis  was  produced  by  injection  of  human  tonsillar  strains  of 
organisms. 

Age. — Appendicitis  is  a  disease  of  young  persons,  50  per  cent,  of  the  cases 
occurring  before  the  twentieth  year.  It  has  been  met  with  as  early  as  the 
seventh  week,  but  it  is  rarely  seen  prior  to  the  fifth  year.  Of  1,223  cases  at 
the  Johns  Hopkins  Hospital  only  9  cases  were  under  5  years,  59  in  children 
under  10,  140  between  11  and  15,  199  between  16  and  20,  and  255  between  21 
and  25  (Churchman). 

Sex. — It  is  about  equally  common  in  males  and  in  females. 

In  England  since  1901  the  mortality  has  increased  from  38  per  million  to 
75  in  1911,  and  68  in  1913.  There  is  an  increase  in  the  years  of  high  diar- 
rhoeal  mortality.  The  figures  do  not  bear  out  any  belief  that  the  increased 
frequency  is  a  result  of  changes  in  diet.  There  were  9,374  deaths  in  the  regis- 
tration area  of  the  United  States  in  1917. 

Indiscretions  in  diet  are  very  prone  to  bring  on  an  attack,  particularly  in 
the  recurring  form  of  the  disease,  in  which  pain  in  the  appendix  region  not 
infrequently  follows  the  eating  of  indigestible  articles  of  food. 

Varieties. — McCarty  from  a  study  of  5,000  appendices  removed  at  the 
Mayo  clinic  makes  the  following  classification : 

(a)  Appendicitis  cataerhalis  acuta,  a  condition  in  which  the  mucosa 
is  infiltrated  with  leucocytes  and  congested  with  inflammatory  reaction  in  the 
lymph  follicles  and  lymphatic  tissues  of  the  submucosa. 

(&)  Appendicitis  cataerhalis  chronica,  following  repeated  mild  or 
severe  acute  catarrh,  marked  by  increase  of  scar  tissue,  and  distortion  of  the 
normal  regularity  of  the  structure.     Blood  pigment  is  often  present. 

(c)  Appendicitis  purulenta  necrotic  a,  an  advanced  stage  of  the  acute 
catarrhal  condition,  plus  the  formation  of  intramural  abscesses,  necrosis,  and 
perforation. 

{d)  Peri-appendicitis  acuta,  an  extension  to  the  peritoneum  of  the  con- 
ditions just  described. 

{e)  Obliteration,  a  condition  of  the  lumen,  the  result  of  destruction  of 
the  mucosa  and  the  formation  of  scar  tissue,  occurring  in  about  24  per  cent, 
of  all  cases,  and  an  inflammatory,  not  an  involutionary,  process. 

There  are  cases,  too,  in  which  the  appendix  becomes  sphacelated  en  masse, 
and  may  slough  off. 

Faecal  Concretions.— The  lumen  of  the  appendix  may  contain  a  mould  of 
faeces,  which  can  readily  be  squeezed  out.  Even  while  soft  the  contents  of  the 
tube  may  be  moulded  in  two  or  three  sections  with  rounded  ends.  Concretions 
—enteroliths,  coproliths — are  also  common.  Of  700  cases  of  foreign  bodies 
there  were  45  per  cent,  of  faecal  concretions  (J.  F.  Mitchell).  The  entero- 
liths often  resemble  date  stones  in  shape.     The  importance  of  these  concre- 


APPENDICITIS  523 

tions  is  shown  by  the  great  frequency  with  which  they  are  found  in  all  acute 
inflammations  of  the  appendix. 

Foreign  Bodies. — Of  1,400  cases  of  appendicitis  collected  by  J.  F.  Mitchell 
these  were  present  in  7  per  cent. ;  in  28  cases  pins  were  found.  It  is  well  to 
bear  in  mind  that  some  of  the  concretions  bear  a  very  striking  resemblance  to 
cherry  and  date  stones. 

Symptoms. — In  a  large  proportion  of  all  cases  of  acute  appendicitis  the 
following  symptoms  are  present:  (a)  Sudden  pain  in  the  abdomen,  usually 
referred  to  the  right  iliac  fossa;  (h)  fever,  often  of  moderate  grade;  (c) 
gastro-intestinal  disturbance — nausea,  vomiting,  and  frequently  constipation; 
(d)  tenderness  or  pain  on  pressure  in  the  appendix  region. 

Pain. — A  sudden,  violent  pain  in  the  abdomen  is  the  most  constant,  first, 
decided  symptom  of  perforating  inflammation  of  the  appendix,  and  occurred 
in  84  per  cent,  of  the  cases  analyzed  by  Fitz.  In  fully  half  of  the  cases 
it  is  localized  in  the  right  iliac  fossa,  but  it  may  be  central,  diffuse,  but  usually 
in  the  right  half  of  the  abdomen.  Even  in  the  eases  in  which  the  pain  is  at 
first  not  in  the  appendix  region  it  is  usually  felt  here  within  thirty-six  or  forty- 
eight  hours.  It  may  extend  toward  the  perineum  or  testicle.  It  is  sometimes 
very  sharp  and  colic-like,  and  cases  have  been  mistaken  for  nephritic  or  for 
biliary  colic.  Some  patients  speak  of  it  as  a  sharp,  intense  pain — serous- 
membrane  pain;  others  as  a  dull  ache — connective-tissue  pain.  While  a  very 
valuable  symptom,  pain  is  at  the  same  time  one  of  the  most  misleading.  Some 
of  the  forms  of  recurring  pain  in  the  appendix  region  Talamon  called  ap- 
pendicular colic.  The  condition  is  believed  to  be  due  to  partial  occlusion  of 
the  lumen,  leading  to  violent  and  irregular  peristaltic  action  of  the  circular  and 
longitudinal  muscles. 

Fevee. — Fever  is  always  present  in  the  early  stage,  even  in  the  mildest 
forms,  and  is  a  most  important  feature.  J.  B.  Murphy  stated  that  he  would 
not  operate  on  a  case  in  which  he  was  confident  that  no  fever  had  been  present 
in  the  first  thirty-six  hours  of  the  disease.  An  initial  chill  is  very  rare.  The 
fever  may  be  moderate,  from  100°  to  102°;  sometimes  in  children  at  the 
very  outset  the  thermometer  may  register  above  103.5°.  The  thermometer  is 
one  of  the  most  trustworthy  guides  in  the  diagnosis  of  acute  appendicitis.  Ap- 
pendicular colic  of  great  severity  may  occur  without  fever.  When  a  localized 
abscess  has  formed,  and  in  some  very  virulent  cases  of  general  peritonitis, 
the  temperature  may  be  normal,  but  at  this  stage  there  are  other  symptoms 
which  indicate  the  gravity  of  the  situation.  The  pulse  is  quickened  in  pro- 
portion to  the  fever. 

Gasteo-intestinal  Distuebance. — The  tongue  is  usually  furred  and 
moist,  seldom  dry.  Nausea  and  vomiting  may  be  absent,  but  are  commonly 
present  in  the  acute  perforative  cases.  The  vomiting  rarely  persists  beyond 
the  second  day  in  favorable  cases.  Constipation  is  the  rule,  but  the  attack 
may  set  in  with  diarrhoea,  particularly  in  children. 

Lymphoid  hyperplasia.  This  occurs  in  children  or  young  adults,  subjects 
of  status  lymphaticus,  and  is  marked  by  repeated  attacks  of  colic  without  any 
marked  change  in  temperature  or  pulse  rate,  or  leucocytosis  (Symmers). 

Local  Signs. — Inspection  of  the  abdomen  is  at  first  negative;  there  is 
no  distention,  and  the  iliac  fossae  look  alike.  On  palpation  there  are  usually 
from  the  outset  rigidity  or  must;le  spasm  of  tlie  right  rectus  muscle,  and  ten- 


534  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

derness  or  actual  pain  on  deep  pressure.  The  muscular  rigidity  may  be  so 
great  that  a  satisfactory  examination  can  not  be  made  without  an  auassthetic. 
McBurney  called  attention  to  a  localized  point  of  tenderness  on  deep  pressure, 
situated  at  the  intersection  of  a  line  drawn  from  the  navel  to  the  anterior- 
superior  spine  of  the  ilium,  with  a  second,  vertically  placed,  corresponding  to 
the  outer  edge  of  the  right  rectus  muscle.  Eirm,  deep,  continuous  pressure 
with  one  finger  at  this  spot  causes  pain,  often  of  the  most  exquisite  character. 
In  addition  to  the  tenderness,  rigidity,  and  actual  pain  on  deep  pressure,  there 
is  to  be  felt,  in  some  cases,  an  induration  or  swelling.  This  may  be  a  boggy, 
ill-defined  mass  in  the  situation  of  the  csecum;  more  commonly  the  swelling 
is  circumscribed  and  definite,  situated  in  the  iliac  fossa,  two  or  three  fingers' 
breadth  above  Poupart's  ligament.  Some  have  been  able  to  feel  and  roll  be- 
neath the  fingers  the  thickened  appendix.  The  later  the  case  comes  under 
observation  the  greater  the  probability  of  the  existence  of  a  well-marked  tumor 
mass.  It  is  not  to  be  forgotten  that  there  may  be  neither  tumor  mass  nor  in- 
duration to  be  felt  in  some  of  the  most  intensely  virulent  cases  of  perforative 
appendicitis.     The  pain  may  be  mistaken  for  that  of  hip  Joint  disease. 

In  addition  may  be  mentioned  marked  frequency  of  micturition,  especially 
in  children,  which  may  be  an  early  symptom.  The  urine  is  scanty  and  often 
contains  albumin  and  indican.  The  attitude  is  somewhat  suggestive,  the  de- 
cubitus is  dorsal,  and  the  right  leg  is  semi-flexed.  Pulling  on  the  right  sper- 
matic cord  may  cause  pain.  Examination  per  rectum  in  the  early  stages  rarely 
gives  any  information  of  value.  The  symptoms  may  be  entirely  pelvic  when 
the  appendix  dips  over  the  brim  and  the  inflamed  area  is  in  direct  contact 
with  the  uterine  adnexa. 

Leucocytosis. — The  blood  picture  is  of  value  equal  to  the  pulse  and  tem- 
perature. As  a  rule,  in  acute  attacks  there  is  a  leucocytosis  of  12,000  to  15,000, 
chiefly  of  the  polynuclears.  In  mild  catarrhal  cases  there  may  be  no  increase. 
Usually  the  degree  is  an  expression  of  the  peritoneal  irritation.  A  low  leu- 
cocytosis or  a  leucopenia  is  an  indication  of  a  virulent  infection. 

Albuminuria  is  common.  Sometimes  there  is  an  acute  nephritis,  and  Dieu- 
lafoy  described  an  acute  toxic  form.  He  thinks  that  the  kidneys  are  not  in- 
frequently damaged  in  the  disease. 

There  are  three  possibilities  in  any  case:  (1)  Gradual  recovery,  (2)  the 
formation  of  a  local  abscess,  and  (3)  general  peritonitis. 

Recovery  is  the  rule  in  the  mild  catarrhal  cases.  The  pain  lessens  at  the 
end  of  the  second  or  third  day,  the  temperature  falls,  the  tongue  becomes 
cleaner,  the  vomiting  ceases,  the  local  tenderness  is  less  marked,  and  the  bowels 
are  moved.  By  the  end  of  a  week  the  acute  symptoms  have  subsided.  So 
liable  is  the  attack  to  recur  that  relapsing  appendicitis  is  spoken  of. 

Local  Abscess  Formation. — As  a  result  of  ulceration  and  perforation, 
sometimes  following  the  necrosis,  by  the  end  of  the  fourth  or  fifth  day  there 
is  an  extensive  area  of  induration  in  the  right  iliac  fossa,  with  great  tender- 
ness, and  operations  have  shown  that  -even  at  this  very  early  date  an  abscess 
cavity  may  have  formed.  Though  as  a  rule  the  fever  becomes  aggravated  with 
the  onset  of  suppuration,  this  is  not  always  the  case.  The  two  most  important 
elements  in  the  diagnosis  of  abscess  formation  are  the  gradual  increase  of  the 
local  tumor  and  the  aggravation  of  the  general  s}miptoms.  N'owadays,  when 
operation  is  so  frequent,  we  have  opportunities  of  seeing  the  abscess  in  various 


APPENDICITIS  525 

stages  of  development.  Quite  early  the  pus  may  lie  between  the  csecum  and 
the  coils  of  the  ileum,  with  the  general  peritoneum  shut  off  by  fibrin,  or  there 
is  a  sero-fibrinous  exudate  with  a  slight  amount  of  pus  between  the  lower  coils 
of  the  ileum.  The  abscess  cavity  may  be  small  and  lie  on  the  psoas  muscle, 
or  at  the  edge  of  the  promontory  of  the  sacrum,  and  never  reach  a  palpable 
size.  The  sac,  when  larger,  may  be  roofed  in  by  the  small  bowel  and  present 
irregular  processes  and  pockets  leading  in  different  directions.  In  larger  col- 
lections in  the  iliac  fossa  the  roof  is  generally  formed  by  the  abdominal  wall. 
Some  of  the  most  important  of  the  localized  abscesses  are  those  which  are 
situated  entirely  within  the  pelvis.  The  various  directions  and  positions  into 
which  the  abscess  may  pass  or  perforate  are  many  and  left  alone,  it  may  dis- 
charge externally,  burrow  in  various  directions,  or  be  emptied  through  the 
rectum,  vagina,  or  bladder.  Death  may  be  caused  by  septicemia,  by  perfora- 
tion into  an  artery  or  vein,  or  by  pylephlebitis. 

General  Peritonitis. — This  may  be  caused  by  direct  perforation  of  the 
appendix  and  general  infection  of  the  peritoneum  before  any  delimiting  in- 
flammation is  excited.  In  a  second  group  of  cases  there  has  been  an  attempt 
at  localizing  the  infective  process,  but  it  fails,  and  the  general  peritoneum  be- 
comes involved.  In  a  third  group  of  cases  a  localized  focus  of  suppuration 
exists  about  an  inflamed  appendix,  and  from  this  perforation  takes  place. 

Death  in  appendicitis  is  due  usually  to  general  peritonitis. 

The  gravity  of  appendix  disease  lies  in  the  fact  that  from  the  very  onset 
the  peritoneum  may  he  infected;  the  initial  symptoms  of  pain,  tvith  nausea 
and  vomiting,  fever,  and  local  tenderness,  present  in  all  cases,  may  indicate 
a  ivide-spread  infection  of  this  membrane.  The  onset  is  usually  sudden,  the 
pain  diffuse,  not  always  localized  in  the  right  iliac  fossa,  but  it  is  not  so  much 
the  character  as  the  greater  intensity  of  the  symptoms  from  the  outset  that 
makes  one  suspicious  of  a  general  peritonitis.  Abdominal  distention,  diffuse 
tenderness,  and  absence  of  abdominal  movements  are  the  most  trustworthy 
local  signs,  but  they  are  not  really  so  trustworthy  as  the  general  symptoms. 
The  initial  nausea  and  vomiting  persist,  the  pulse  becomes  more  rapid,  the 
tongue  is  dry,  the  urine  scanty.  In  very  acute  cases,  by  the  end  of  twenty-four 
hours  the  abdomen  may  be  distended.  By  the  third  and  fourth  days  the  classi- 
cal picture  of  a  general  peritonitis  is  well  established — a  distended  and  motion- 
less abdomen,  a  rapid  pulse,  a  dry  tongue,  dorsal  decubitus  with  the  knees 
drawn  up,  and  an  anxious,  pinched,  Hippocratic  facies.  The  picture  may  be 
that  of  septicopygemia  or  saprasmia ;  high  fever,  chills,  sweats,  without  local 
reaction.  These  are  generally  acute,  gangrenous  cases  with  anomalous  posi- 
tion of  the  appendix,  behind  the  colon,  or  deep  in  the  pelvis.  Even  when  looked 
for  carefully  there  may  be  no  local  indications.  Sometimes  there  have  been 
gastro-intestinal  symptoms  for  a  few  days  before,  to  which  no  attention  has 
been  paid.  In  one  case,  seen  by  tlie  family  physician  at  2  p.  m.  for  the  flrst 
time,  by  the  senior  author  at  4.30  p.  m.,  at  7  p.  m.  by  a  surgeon  who  refused 
to  operate,  death  occurred  within  12  hours  after  the  physician  was  first  called. 

Remote  Effects. — The  remote  effects  of  perforative  appendicitis  are  inter- 
esting. Haemorrhage  may  occur.  In  one  of  our  cases  the  appendix  was  ad- 
herent to  the  promontory  of  the  sacrum,  and  the  abscess  cavity  had  perforated 
in  two  places  into  the  ileum.  Death  resulted  from  profuse  haemorrhage. 
Cases  are  on  record  in  which  the  internal  iliac  artery  or  the  deep  circumflex 


526  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

iliac  artery  has  been  opened.  Suppurative  pylephlebitis  may  result  from  in- 
flammation of  the  mesenteric  veins  near  the  perforated  appendix.  The  appen- 
dix may  perforate  in  a  hernial  sac.  Distant  disorders  attributed  to  disease 
of  the  appendix  are  various  types  of  gastric  dyspepsia,  ulcer,  spasm  of  the 
pylorus,  pancreatitis,  bile  tract  infection  and  cirrhosis  of  the  liver. 

After  operation,  thrombosis  •  of  the  iliac  or  femoral,  veins  is  not  uncom- 
mon, and  sudden  death  from  pulmonary  embolism  has  followed.  The  leg  may 
be  permanently  enlarged.  Hernia  may  occur  in  the  wound.  Strangulation  of 
the  bowel  is  an  occasional  sequence.  Eecurrence  of  the  symptoms  after  opera- 
tion has  been  noted,  due  in  some  cases  to  incomplete  removal. 

Diagnosis. — Appendicitis  is  by  far  the  most  common  inflammatory  con- 
dition, not  only  in  the  cgecal  region,  but  in  the  abdomen  generally  in  persons 
under  thirty.  The  surgeons  have  taught  us  that,  almost  without  exception, 
sudden  pain  in  the  right  iliac  fossa,  with  fever  and  localized  tenderness,  with 
or  without  tumor,  means  appendix  disease.  There  are  certain  diseases  of  the 
abdominal  organs  characterized  by  pain  which  are  apt  to  be  confounded  with 
appendicitis.  Biliary  colic,  kidney  colic,  and  the  colicky  pains  at  the  menstrual 
period  in  women  have  to  be  carefully  considered. 

Diseases  of  the  tubes  and  pelvic  peritonitis  may  simulate  appendicitis  very 
closely,  but  the  history  and  the  local  examination  under  ether  should  in  most 
cases  enable  the  practitioner  to  reach  a  diagnosis.  Some  cases  supposed  to  be 
recurring  appendicitis  prove  to  be  tubo-ovarian  disease. 

The  Dietl's  crises  in  floating  kidney  have  been  mistaken  for  appendicitis. 

Acute  hsemorrhagic  pancreatitis  may  produce  symptoms  very  like  those  of 
appendicitis  with  general  peritonitis.  The  relation  of  typhoid  fever  and  ap- 
pendicitis is  interesting.  The  gastro-intestinal  symptoms,  particularly  the  pain 
and  the  fever,  may  at  the  onset  suggest  appendicitis.  Operations  have  been 
comparatively  frequent.  In  the  second  and  third  weeks  of  typhoid  fever  per- 
foration of  the  appendix  may  occur,  and  occasionally  late  in  the  convalescence 
perforation  of  an  unhealed  ulcer  of  the  appendix. 

In  a  great  many  patients  with  clironic  appendicitis  stomach  symptoms 
predominate,  and  an  appendicular  dyspepsia  has  been  recognized  particularly 
by  the  French  writers  and  by  surgeons.  Many  of  the  patients  are  neurotic. 
The  dyspeptic  symptoms  are  irregular,  and  food  rarely  gives  relief,  as  in 
ulcer.  Pain  is  the  prevailing  symptom,  often  caused  by  food,  and  more  ab- 
dominal than  epigastric,  without  radiation,  and  there  are  frequently  pain  and 
tenderness  at  McBurney's  point.  Vomiting  is  rare,  but  there  is  usually  much 
flatulency.  Without  being  seriously  ill,  the  patient's  condition  is  constantly 
below  par,  and  he  may  go  the  rounds  of  physicians  for  years.  In  an  analysis 
of  100  cases  of  this  type  at  the  Mayo  clinic  by  Graham  and  Guthrie,  reported 
on  a  year  after  operation,  77  per  cent,  were  cured  by  the  removal  of  the  ap- 
pendix. As  a  majority  of  these  patients  are  neurotic,  it  is  not  easy  to  say 
how  far  the  good  results  have  been  due  directly  to  the  removal  of  the  appendix, 
the  pathological  condition  of  which,  as  reported  upon  by  Graham  and  Guthrie, 
did  not  seem  to  differ  much  from  that  which  is  met  with,  according  to  Aschoff, 
in  a  majority  of  individuals  in  the  fourth  decade.  In  a  certain  number  of 
these  patients  the  relief  after  removal  of  the  appendix  is  not  permanent. 

There  is  a  well-marked  appendicular  hypochondriasis.  Through  the  per- 
nicious influence  of  the  daily  press,  appendicitis  has  become  a  sort  of  fad,  and 


APPENDICITIS  527 

the  physician  has  often  to  deal  with  patients  who  have  almost  a  fixed  idea 
that  they  have  the  disease.  Hysteria  may  simulate  appendicitis  very  closely, 
and  it  may  require  a  very  keen  judgment  to  make  a  diagnosis.  Mucous  colitis 
'wdth  enteralgia  in  nervous  women  is  sometimes  mistaken  for  appendicitis. 

Perinephritic  and  pericsecal  abscess  from  perforation  of  ulcer,  either  sim- 
ple or  cancerous,  and  circumscribed  peritonitis  in  this  region  from  othei 
causes,  can  rarely  be  differentiated  until  an  exploratory  incision  is  made. 

Chronic  obliterative  appendicitis  can  not  always  be  differentiated  from  the 
perforative  form,  and  in  intensity  of  pain,  severity  of  symptoms,  and,  in  rare 
instances,  even  in  the  production  of  peritonitis,  the  two  may  be  identical. 

Briefly  stated,  localized  pain  in  the  right  iliac  fossa,  with  or  without  in- 
duration or  tumor,  the  existence  of  McBurney's  tender  point,  fever,  furred 
tongue,  vomiting,  with  constipation  or  diarrhoea,  indicate  appendicitis.  The 
occurrence  of  general  peritonitis  is  suggested  by  increase  and  diffusion  of  the 
abdominal  pain,  tympanites  (as  a  rule),  marked  aggravation  of  the  constitu- 
tional symptoms,  particularly  elevation  of  fever  and  increased  rapidity  of  the 
pulse.  Obliteration  of  hepatic  dulness  is  rarely  present,  as  the  peritoneum  in 
these  cases  does  not  often  contain  gas. 

Appendicitis  and  Pregnancy. — The  association  is  not  uncommon.  Of  103 
perforative  or  gangrenous  cases  89  were  operated  upon,  with  36  deaths.  Of 
14  cases  not  operated  upon  all  died.  Of  the  103  cases  80  aborted  before  or 
after  operation.  Of  104  non-perforative  cases  50  were  operated  upon  with  1 
death;  of  the  remaining  54,  4  died;  13  of  these  non-perforative  cases  aborted 
(Babler).  Mild  cases  recover;  in  the  severer  forms  it  is  safer  to  operate  at 
once. 

Prognosis. — There  would  he  no  percentage  of  deaths  from  appendicitis 
if  every  case  convmencing  with  acute  pain  and  developing  tenderness  and 
rigidity  of  the  abdomen  and  quickening  of  the  pulse  were  operated  upon  with- 
in twelve  hours  (Eutherford  Morison). 

The  mortality  from  the  operative  cases  is  steadily  diminishing.  At  the 
London  Hospital,  the  mortality  in  the  1,000  cases  operated  upon  between 
January,  1900,  and  August,  1904,  was  17.3  per  cent.,  whilst  in  the  1,000  con- 
secutive cases  operated  upon  between  1912  and  the  first  six  weeks  of  1913 
the  mortality  was  3.2  per  cent.,  and  only  4  per  cent  for  the  698  cases  operated 
upon  during  the  attack  (Lett).  The  earlier  the  operation  the  lower  the 
mortality.  It  would  be  interesting  to  know  how  many  of  the  9,374  fatal  cases 
in  1917  in  the  United  States  had  been  operated  upon  and  at  what  period. 

Treatment. — Gradually  the  profession  has  learned  to  recognize  that  ap- 
pendicitis is  a  surgical  disease."  In  hospital  practice  the  cases  should  be  ad- 
mitted directly  to  the  surgical  wards.  Many  lives  are  lost  by  temporizing. 
The  general  practitioner  does  well  to  remember — whether  his  leanings  be 
toward  conservative  or  radical  methods  of  treatment — that  the  surgeon  is  often 
called  too  late,  never  too  early. 

There  is  no  medicinal  treatment  of  appendicitis.  There  are  remedies  which 
will  allay  the  pain,  but  there  are  none  capable  in  any  way  of  controlling  the 
course  of  the  disease.  Eest  in  bed,  no  food,  no  purgation,  the  use-  of  an  enema 
if  necessary,  gastric  lavage  if  there  is  vomiting,  are  the  wisest  measures  till  a 
decision  as  to  operation  is  reached.  The  practice  of  giving  opium  in  some  form 
in  appendicitis  and  peritonitis  is  decreasing,  but  is  still  too  common.     The 


528  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

persistent  use  of  ice  locally  may  be  employed  to  relieve  the  pain.  General 
opinion  is  opposed  to  the  iise  of  purges. 

Operation  is  indicated  in  all  cases  of  acute  inflammatory  trouble  in  the 
csecal  region,  whether  tumor  is  present  or  not,  when  the  general  symptoms  are 
severe,  and  when  at  the  end  of  twelve  hours,  or  even  earlier,  the  features  of 
the  case  poinf  to  a  progressive  lesion.  The  mortality  from  early  operation 
under  these  circumstances  is  very  slight. 

In  recurring  appendicitis,  when  the  attacks  are  of  such  severity  and  fre- 
quency as  seriously  to  interrupt  the  patient's  occupation,  the  mortality  in  the 
hands  of  capable  operators  is  very  small. 


IV.     INTESTINAL  OBSTRUCTION 

Intestinal  obstruction  may  be  caused  by  strangulation,  intussusception, 
twists  and  knots,  strictures  and  tumors,  by  abnormal  contents,  and  by  par- 
alysis of  the  muscular  coat  of  the  bowel. 

Etiology  and  Pathology. — (a)  Strangulation. — This  is  the  most  fre- 
quent cause  of  acute  obstruction,  and  occurred  in  34  per  cent,  of  the  295  cases 
analyzed  by  Eitz,  and  in  35  per  cent,  of  the  1,134  cases  of  Leichtenstern.  Of 
the  101  cases  of  strangulation  in  Fitz's  table,  which  has  the  special  value  of 
having  been  carefully  selected  from  the  literature  since  1880,  the  following 
were  the  causes:  Adhesions,  63;  vitelline  remains,  21;  adherent  appendix,  6; 
mesenteric  and  omental  slits,  6;  peritoneal  pouches  and  openings,  3;  adher- 
ent tube,  1 ;  peduncular  tumor,  1.  The  bands  and  adhesions  result,  in  a  ma- 
jority of  cases,  from  former  peritonitis.  A  number  of  instances  have  been 
reported  following  operations  upon  the  pelvic  organs  in  women.  The  strangu- 
lation may  be  recent  and  due  to  adhesion  of  the  bowel  to  the  abdominal  wound 
or  a  coil  may  be  caught  between  the  pedicle  of  a  tumor  and  the  pelvic  wall. 
Such  cases  are  only  too  common.  Late  occlusion  after  recovery  from  the  opera- 
tion is  due  to  bands  and  adhesions. 

The  vitelline  remains  are  represented  by  Meckel's  diverticulum,  which 
forms  a  finger-like  projection  from  the  ileum,  usually  within  eighteen  inches 
of  the  ileo-csecal  valve.  The  coils  of  the  intestine  may  be  strangulated  about 
the  diverticulum  when  its  end  is  attached  to  the  abdominal  wall,  to  the  mesen- 
tery, or  to  another  portion  of  the  intestine,  or  a  long  diverticulum  unattached 
may  be  twisted,  or  there  may  be  inversion  of  the  diverticulum  into  the  lumen 
of  the  bowel  causing  obstruction  or  leading  to  intussusception. 

Seventy  per  cent,  of  the  cases  of  obstruction  from  strangulation  occur  in 
males ;  40  per  cent,  of  all  the  cases  occur  between  the  ages  of  fifteen  and  thirty 
years.  In  90  per  cent,  of  the  cases  of  obstruction  from  these  causes  the  site 
of  the  trouble  is  in  the  small  bowel ;  the  position  of  the  strangulated  portion 
was  in  the  right  iliac  fossa  in  67  per  cent,  of  the  cases,  and  in  the  lower  ab- 
domen in  83  per  cent. 

( b )  Intussusception. — In  this  condition  one  portion  of  the  intestine  slips 
into  an  adjacent  portion,  forming  an  invagination  or  intussusception.  The  two 
portions  make  a  cylindrical  tumor,  which  varies  in  length  from  a  half  inch  to 
a  foot  or  more.  The  condition  is  alwa3^s  a  descending  intussusception,  and, 
as  the  process  proceeds,  the  middle  and  inner  layers  increase  at  the  expense  of 


INTESTINAL  OBSTEUCTION  539 

the  outer  layer.  An  intussusception  consists  of  three  layers  of  bowel:  the 
outermost,  known  as  the  intussuscipiens,  or  receiving  layer;  a  middle  or  re- 
turning layer;  and  the  innermost  or  entering  layer.  The  student  can  obtain 
a  clear  idea  of  the  arrangement  by  making  the  end  of  a  glove-finger  pass  into 
the  lower  portion.  The  actual  condition  can  be  very  clearly  studied  in  the 
post  mortem  invaginations  which  are  so  common  in  the  small  bowel  of  chil- 
dren. In  the  statistics  of  Fitz,  93  of  295  cases  of  acute  intestinal  obstruction 
were  due  to  this  cause.  Of  these,  52  were  in  males  and  27  in  females.  The 
cases  are  most  common  in  early  life,  34  per  cent,  under  one  year  and  56  per 
cent,  under  the  tenth  year.  Of  103  cases  in  children,  nearly  50  per  cent,  oc- 
curred in  the  fourth,  fifth,  and  sixth  months  (Wiggin).  No  definite  causes 
could  be  assigned  in  42  of  the  cases;  in  the  others  diarrhoea  or  habitual  con- 
stipation had  existed. 

The  site  of  the  invagination  varies.  We  may  recognize  (1)  an  ileo-cmcal, 
when  the  ileo-csecal  valve  descends  into  the  colon.  There  are  cases  in  which 
this  is  so  extensive  that  the  valve  has  been  felt  per  rectum.  This  form  oc- 
curred in  75  per  cent,  of  the  cases ;  in  89  per  cent,  of  Wiggin's  collected  cases. 
In  the  ileo-colic  the  loM^er  part  of  the  ileum  passes  through  the  ileo-csecal  valve. 
(2)  The  ileal,  in  which  the  ileum  is  alone  involved.  (3)  The  colic,  in  which 
it  is  confined  to  the  large  intestine.  (4)  Colico-rectal,  in  which  the  colon  and 
rectum  are  involved.  (5)  Intussusception  of  the  appendix  is  rare,  but  there 
are  cases  on  record,  most  of  them  in  children. 

Irregular  peristalsis  is  the  essential  cause  of  intussusception.  Nothnagel 
found  in  the  localized  peristalsis  caused  by  the  faradic  current  that  it  was  not 
the  descent  of  one  portion  into  the  other,  but  the  drawing  up  of  the  receiving 
layer  by  contraction  of  the  longitudinal  coat.  Invagination  may  follow  any 
limited,  sudden,  and  severe  peristalsis. 

In  the  post  mortem  examination,  in  a  case  of  death  from  intussuscep- 
tion, the  condition  is  very  characteristic.  Peritonitis  may  be  present  or  an 
acute  injection  of  the  serous  membrane.  When  death  occurs  early,  as  it  may 
do  from  shock,  there  is  little  to  be  seen.  The  portion  of  bowel  affected  is 
large  and  thick,  and  forms  an  elongated  tumor  with  a  curved  outline.  The 
parts  are  swollen  and  congested,  owing  to  the  constriction  of  the  mesentery 
between  the  layers.  The  entire  mass  may  be  of  a  deep  livid-red  color.  In  very 
recent  processes  there  is  only  congestion,  and  perhaps  a  thin  layer  of  lymph, 
and  the  intussusception  can  be  reduced,  but  when  it  has  lasted  for  a  few  days, 
lymph  is  thrown  out,  the'  layers  are  glued  together,  and  the  entering  portion 
of  the  gut  can  not  be  withdrawn. 

The  anatomical  condition  accounts  for  the  presence  of  the  tumor,  which 
exists  in  two-thirds  of  all  cases;  and  the  engorgement,  which  results  from  the 
compression  of  the  mesenteric  vessels,  explains  the  frequent  occurrence  of 
blood  in  the  discharges,  which  has  so  important  a  diagnostic  value.  If  the 
patient  survives,  necrosis  and  sloughing  of  the  invaginated  portion  may  oc- 
cur, and,  if  union  has  taken  place  between  the  inner  and  outer  layers,  the 
calibre  of  the  gut  may  be  restored  and  a  cure  in  this  way  effected.  Many 
cases  of  the  kind  are  on  record.  In  the  Museum  of  McGill  University  are  17 
inches  of  small  intestine,  which  were  passed  by  a  lad  who  had  symptoms  of 
internal  strangulation,  and  who  made  a  complete  recovery. 

(c)   Tv^fiSTS,  Knots,  and  Traction  Kinks. — ^Volvulus  or  twist  occurred 


530  DISEASES  OP  THE  DIGESTIVE  SYSTEM 

in  42  of  the  295  cases  (Eitz).  Sixty-eight  per  cent,  were  in  males.  It  is 
most  frequent  between  the  ages  of  thirty  and  forty.  In  the  great  majority 
of  all  cases  the  twist  is  axial  and  associated  with  an  iinnsually  long  mesen- 
tery. In  50  per  cent,  of  the  cases  it  was  in  the  sigmoid  flexure.  The  next 
most  common  situation  is  about  the  caecum,  which  may  be  twisted  upon  its 
axis  or  bent  upon  itself.  As  a  rule,  in  volvulus  the  loop  of  bowel  is  simply 
twisted  upon  its  long  axis,  and  the  portions  at  the  end  of  the  loop  cross  each 
other  and  so  cause  the  strangulation.  It  occasionally  happens  that  one  por- 
tion of  the  bowel  is  twisted  about  another. 

Traction  hinks  occur  at  three  regions — the  third  portion  of  the  duodenum, 
the  last  part  of  the  ileum,  and  the  sigmoid  flexure.  What  is  known  as  gastro- 
mesenteric  ileus  is  caused  by  compression  of  the  lower  portion  of  the  duo- 
denum by  the  root  of  the  mesentery  with  its  contained  blood-vessels.  The  con- 
dition has  been  described  under  acute  dilatation  of  the  stomach. 

The  ileum  IcinTc  occurs  within  a  few  inches  of  the  caecum.  This  portion 
has  a  short  tight  mesentery  and  a  large  loose  caecum  sags  over  the  brim  of  the 
pelvis  and  may  cause  a  definite  kink  of  the  ileum  with  constipation,  pain  in 
the  right  iliac  fossa,  and  symptoms  which  simulate  appendicitis. 

Traction  of  a  very  full  sigmoid  flexure  may,  without  any  special  twist, 
compress  and  obstruct  a  neighboring  coil  of  the  colon. 

{d)  Strictures  and  Tumors. — These  are  very  much  less  important  causes 
of  acute  obstruction,  as  may  be  judged  by  the  fact  that  there  are  only  15  in- 
stances out  of  the  295  cases,  in  14  of  which  the  obstruction  occurred  in  the 
large  intestine  (Fitz).  On  the  other  hand,  they  are  common  causes  of  chronic 
obstruction.  Lipoma  may  occur,  growing  from  the  submucosa,  and  cause  in- 
tussusception. In  a  number  of  cases  the  tumor  has  been  passed  per  rectum. 
S.  B.  Ward  collected  9  cases. 

The  obstruction  may  result  from:  (1)  Congenital  stricture.  These  are 
exceedingly  rare.  Much  more  commonly  the  condition  is  that  of  complete 
occlusion,  either  forming  the  imperforate  anus  or  the  congenital  defect  by 
which  the  duodenum  is  not  united  to  the  pylorus.  (2)  Simple  cicatricial 
stenosis,  which  results  from  ulceration,  tuberculous  or  syphilitic,  more  rarely 
from  dysentery,  and  most  rarely  of  all  from  typhoid  ulceration.  (3)  NeiC 
growths.  The  malignant  strictures  are  due  chiefly  to  cylindrical  epithelioma, 
which  forms  an  annular  tumor,  most  commonly  met  with  in  the  large  bowel, 
about  the  sigmoid  flexure,  or  the  descending  colon.  Of  benign  growths,  papil- 
lomata,  adenomata,  lipomata,  and  flbromata  occasionally  induce  obstruction. 
(4)  Compression  and  traction.  Tumors  of  neighboring  organs,  particularly 
of  the  pelvic  viscera,  may  cause  obstruction  by  adhesion  and  traction.  In  the 
healing  of  tuberculous  peritonitis  the  contraction  of  the  thick  exudate  may 
cause  compression  and  narrowing  of  the  coils. 

(e)  Abkormal  Contents. — Foreign  bodies,  such  as  fruit  stones,  coins, 
pins,  needles,  or  false  teeth,  are  occasionally  swallowed.  Eound  worms  may 
become  rolled  into  a  tangled  mass  and  cause  obstruction.  In  reality,  how- 
ever, ihe  majority  of  foreign  bodies,  such  as  coins,  buttons,  and  pins,  swal- 
lowed by  children,  cause  no  inconvenience  whatever,  but  in  a  day  or  two  are 
found  in  the  stools.  Occasionally  such  a  foreign  body  as  a  pin  will  pass 
through  the  oesophagus  and  will  be  found  lodged  in  some  adjacent  organ,  as 
in  the  heart  (Peabody),  or  a  barley  ear  may  reach  the  liver  (Dock). 


INTESTINAL  OBSTEUCTION  531 

Medicines,  such  as  magnesia  or  bismuth,  have  been  known  to  accumulate 
in  the  bowels  and  produce  obstruction,  but  in  the  great  majority  of  the  cases 
the  condition  is  caused  by  fseces,  gall-stones,  or  enteroliths.  Of  44  cases,  in 
23  the  obstruction  was  by  gall-stones,  in  19  by  faeces,  and  in  2  by  enteroliths. 
Obstruction  by  faeces  may  happen  at  any  period  of  life.  As  mentioned  when 
speaking  of  the  dilatation  of  the  colon,  it  may  occur  in  young  children  and  per- 
sist for  weeks.  In  fgecal  accumulation  the  large  bowel  may  reach  an  enor- 
mous size  and  the  contents  become  very  hard.  The  retained  masses  may  be 
channeled,  and  small  quantities  of  faecal  matter  are  passed  until  a  mass  too 
large  enters  the  lumen  and  causes  obstruction.  There  may  be  very  few  symp- 
toms, as  the  condition  may  be  borne  for  weeks  or  even  for  months. 

Obstruction  by  gall-stones  is  not  very  infrequent,  as  may  be  gathered  from 
the  fact  that  23  cases  were  reported  in  the  literature  in  eight  years.  Eighteen 
of  these  were  in  women  and  5  in  men.  In  six-sevenths  of  the  cases  it  occurred 
about  the  fiftieth  year.  The  obstruction  is  usually  in  the  ileo-caecal  regioa, 
but  it  may  be  in  the  duodenum.  These  large  solitary  gall-stones  ulcerate 
through  the  gall-bladder,  usually  into  the  small  intestine,  occasionally  into 
the  colon.  In  the  latter  case  they  rarely  cause  obstruction.  Courvoisier  has 
collected  131  cases  in  the  literature. 

Enteroliths  may  be  formed  of  masses  of  hair,  more  commonly  of  the  phos- 
phates of  lime  and  magnesia,  with  a  nucleus  formed  of  a  foreign  body  or  of 
hardened  faeces.  Nearly  every  museum  possesses  specimens  of  this  kind.  They 
are  not  so  common  in  men  as  in  ruminants,  and,  as  indicated  in  Fitz's  statistics, 
are  very  rare  causes  of  obstruction. 

(/)  Paralytic  Ileus. — Without  any  obstruction  in  the  lumen,  in  a  local- 
ized area  or  in  a  wide  section  of  the  bowel,  the  muscular  walls  may  be  so 
paralyzed  that  no  movement  of  the  contents  occurs,  causing  a  condition  which 
virtually  amounts  to  obstruction.  The  best  illustrations  of  local  paralytic 
ileus  are  seen  in  the  embolic  and 'thrombotic  processes  in  the  mesenteric  ar- 
teries, when  the  corresponding  portions  of  the  intestinal  wall  are  in  a  state  of 
infarct.  This  occurs  in  the  verminous  aneurism  in  a  horse,  and  is  associated 
with  the  common  intestinal  colic.  It  is  more  common  in  the  small  than  in  the 
large  bowel,  but  in  one  instance  of  paralytic  ileus  due  to  localized  involvement 
of  about  eight  inches  of  the  wall  of  the  transverse  colon  there  was  not,  so  far 
as  one  could  discover,  any  affection  of  the  blood-vessels;  the  symptoms  were 
those  of  acute  obstruction. 

Following  operations,  particularly  on  the  abdomen,  after  injuries,  follow- 
ing paracentesis  in  ascites,  in  pneumonia,  pleurisy,  and  occasionally  in  heart 
disease,  a  paralytic  state  of  the  bowel  may  occur,  with  cessation  of  peristalsis, 
distention  of  the  abdomen,  vomiting,  and  other  signs  of  obstruction.  There 
are  remarkable  cases  of  hysteria  with  symptoms  of  chronic  obstruction  of  the 
bowels  and  fsecal  vomiting — the  so-called  ileus  hystericus. 

Symptoms. —  (a)  Acute  Obstructions'. — Constipation,  pain  in  the  abdomen 
and  vomiting  are  the  three  important  symptoms.  Pain  sets  in  early  and  may 
come  on  abruptly  while  the  patient  is  walking,  or,  more  commonly,  during  the 
performance  of  some  action.  It  is  at  first  colicky  in  character,  but  subse- 
quently it  becomes  continuous  and  very  intense.  Vomiting  follows  quickly 
and  is  a  constant  and  most  distressing  symptom.  At  first  the  contents  of  the 
stomach  are  voided,  and  then  greenish,  bile-stained  material,  and  soon,  in 


532  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

cases  of  acute  and  permanent  obstruction,  the  material  vomited  is  a  brownisH- 
black  liquid,  with  a  distinctly  faecal  odor.  This  sequence  of  gastric,  bilious, 
and,  finally,  stercoraceous  vomiting  is  perhaps  the  most  important  diagnostic 
feature  of  acute  obstruction.  The  constipation  may  be  absolute,  without  the 
discharge  of  either  fseces  or  gas.  Very  often  the  contents  of  the  bowel  below 
the  stricture  are  discharged.  Distention  of  the  abdomen  usually  occurs,  and, 
when  the  large  bowel  is  involved,  it  is  extreme.  On  the  other  hand,  if  the 
obstruction  is  high  up  in  the  small  intestine,  there  may  be  very  slight  tjan"- 
pany.  At  first  the  abdomen  is  not  painful,  but  subsequently  it  may  become 
acutely  tender. 

The  constitutional  symptoms  from  the  outset  are  severe.  The  face  is 
pallid  and  anxious,  and  finally  collapse  symptoms  supervene.  The  eyes  be- 
come sunken,  the  features  pinched,  and  the  skin  is  covered  with  a  cold,  clammy 
sweat.  The  pulse  becomes  rapid  and  feeble.  There  may  be  no  fever;  the 
axillary  temperature  is  often  subnormal.  The  tongue  is  dry  and  parched  and 
the  thirst  is  incessant.  The  urine  is  high-colored,  scanty,  and  there  may  be 
suppression,  particularly  when  the  obstruction  is  high  up  in  the  bowel.  This 
is  probably  due  to  the  constant  vomiting  and  the  small  amount  of  liquid  which 
is  absorbed.  The  case  terminates,  as  a  rule,  in  from  three  to  sis  days.  In 
some  instances  the  patient  dies  from  shock  or  sinks  into  coma.  A  leucocytosis 
of  75,000  or  80,000  may  be  present. 

(6)  Symptoms  of  Cheonic  Obstruction-. — ^When  due  to  faecal  impac- 
tion, there  is  a  history  of  long-standing  constipation.  There  may  have  been 
discharge  of  mucus,  or,  in  some  instances,  the  faecal  masses  have  been  chan- 
neled, and  so  have  allowed  the  contents  of  the  upper  portion  of  the  boTvel  to 
pass  through.  In  elderly  persons  this  is  not  infrequent;  but  examination, 
either  per  rectum  or  externally,  in  the  course  of  the  colon,  will  reveal  the 
presence  of  hard  scybalous  masses.  There  may  be  retention  of  faeces  for  weeks 
without  exciting  serious  symptoms.  In  other  instances  there  are  vomiting, 
pain  in  the  abdomen,  gradual  distention,  and  finally  the  ejecta  become  fjecal. 
The  hardened  masses  may  excite  an  intense  colitis  or  even  peritonitis. 

In  stricture,  whether  cicatricial  or  cancerous,  the  sjTtnptoms  of  obstruc- 
tion are  very  diverse.  Constipation  gradually  comes  on,  is  extremely  variable. 
and  it  may  be  months  or  even  years  before  there  is  complete  obstruction. 
There  are  transient  attacks,  in  which  from  some  cause  the  faeces  accumulate 
above  the  stricture,  the  intestine  becomes  greatly  distended,  and  in  the  swollen 
abdomen  the  coils  can  be  seen  in  active  peristalsis.  In  such  attacks  there  may 
be  vomiting,  but  it  is  very  rarely  of  a  fgecal  character.  In  the  majority  of 
these  cases  the  general  health  is  seriously  impaired;  the  patient  gradually 
becomes  anaemic  and  emaciated,  and,  finally,  in  an  attack  in  which  the  ob- 
struction is  complete,  death  occurs  with  all  the  features  of  acute  occlusion, 
or  the  case  may  be  prolonged  for  ten  or  twelve  days. 

Diagnosis. —  {a)  Tpie  Situatiox  of  the  Obstructiox. — Hernia  must  be 
excluded,  which  is  by  no  means  always  easy,  as  fatal  obstruction  may  occur 
from  the  involvement  of  a  very  limited  portion  of  the  gut  in  the  external  ring 
or  in  the  obturator  foramen.  A  thorough  rectal  and,  in  women,  a  vaginal  ex- 
amination should  be  made,  which  will  give  important  information  as  to  the 
condition  of  the  pelvic  and  rectal  contents,  particularly  in  cases  of  intussuscep- 
tion, in  which  tbe  descending  bowel  can  sometimes  be  felt.     In  eases  of  ob- 


IXTESTIXAL  OBSTRUCTION  533 

struction  high  up  the  empty  coils  sink  into  the  pelvis  and  can  there  be  de- 
tected. In  the  inspection  of  the  abdomen  there  are  important  indications,  as 
the  special  prominence  in  certain  regions,  the  occurrence  of  well-defined 
masses,  and  the  presence  of  hypertrophied  coils  in  active  peristalsis.  John 
WyUie  called  attention  to  the  great  value  in  diagnosis  of  the  "patterns  of  ab- 
dominal tumidity."  In  obstruction  of  the  lower  end  of  the  large  intestine 
not  only  may  the  horseshoe  of  the  colon  stand  out  plainly,  when  the  bowel  is 
in  rigid  spasm,-  but  even  the  pouches  of  the  gut  may  be  seen.  When  the  cae- 
cum or  lower  end  of  the  ileum  is  obstructed  the  tumidity  is  in  the  lower  central 
region,  and  during  spasm  the  coils  of  the  small  bowel  may  stand  out  promi- 
nently, one  above  the  other,  either  obliquely  or  transversely  placed — the  so- 
called  "ladder  pattern."  In  obstruction  of  the  duodenum  or  jejunum  there 
may  only  be  slight  distention  of  the  upper  part  of  the  abdomen,  associated 
usually  with  rapid  collapse  and  anuria.  The  acute  toxaemia  may  be  due  to 
proteose  intoxication. 

In  the  ileum  and  cacum  the  distention  is  more  in  the  central  portion  of  the 
abdomen ;  the  vomiting  is  distinctly  f ^cal  and  occurs  early.  In  o1)struction  of 
the  colon  tjnipanites  is  much  more  extensive  and  general.  Tenesmus  is  more 
common,  with  the  passage  of  mucus  and  blood.  The  course  is  not  so  quick, 
the  collapse  does  not  supervene  so  rapidly,  and  the  urinary  secretion  is  not  so 
much  reduced. 

In  obstruction  from  stricture  or  tumor  the  situation  can  in  some  cases  be 
accurately  localized,  but  in  others  it  is  very  uncertain.  Digital  examination 
of  the  rectum  should  first  be  made.  The  rectal  tube  may  then  be  passed, 
but  it  is  impossible  to  get  beyond  the  sigmoid  flexure.  In  the  use  of  the  rigid 
tube  there  is  danger  of  perforation  of  the  bowel  in  the  neighborhood  of  a  stric- 
ture. The  quantity  of  fluid  which  can  be  passed  into  the  large  intestine  should 
be  estimated.  The  capacity  of  the  large  bowel  is  about  six  quarts.  Wiggin 
advises  about  a  pint  and  a  half  from  a  height  of  three  feet  for  an  infant.  For 
diagnostic  purposes  the  rectum  may  be  inflated  with  air.  In  certain  cases  these 
measures  give  important  indications  as  to  the  situation  of  the  obstruction  in 
the  large  bowel.     Whenever  possible  an  X-ray  examination  should  be  made. 

(&)  Nature  of  the  Obstruction. — This  is  often  difficult,  not  infre- 
quently impossible,  to  determine.  Strangulation  is  not  common  in  very  early 
life.  In  many  instances  there  have  been  previous  attacks  of  abdominal  pain, 
or  there  are  etiological  factors  which  give  a  clue,  such  as  old  peritonitis  or 
operation  on  the  pelvic  viscera.  Neither  the  onset  nor  the  character  of  the 
pain  gives  us  any  information.  In  rare  instances  nausea  and  vomiting  may 
be  absent.  The  vomiting  usually  becomes  faecal  from  the  third  to  the  fifth 
day.  A  tumor  is  not  common  in  strangulation,  and  was  present  in  only  one- 
fifth  of  the  cases.     Fever  is  not  of  diagnostic  value. 

Intussusception  is  an  affection  of  childhood,  and  is  of  all  forms  of  internal 
obstruction  the  one  most  readily  diagnosed.  The  onset  is  acute  with  pain  and 
signs  of  shock  after  which  the  symptoms  may  decrease  for  a  time.  Vomiting 
is  not  constant.  The  presence  of  tumor,  bloody  stools,  and  tenesmus  are  the 
important  factors.  The  tumor  is  usually  sausage-shaped  and  felt  in  the  re- 
gion of  the  transverse  colon.  It  existed  in  &&  of  93  cases.  It  became  evident 
the  first  day  in  more  than  one-third  of  the  cases,  on  the  second  day  in  more 
than  one-fourth,  and  on  the  third  day  in  more  than  one-fifth.     Blood  in  the 


534  DISEASES  OF  THE  DIGESTIVE  SYSTEM  ' 

stools  occurs  in  at  least  three-fifths  of  the  cases,  either  spontaneously  or  fol- 
lowing the  use  of  an  enema.  The  blood  may  be  mixed  with  mucus.  Tenesmus 
is  present  in  one-third  of  the  cases.  Fffical  vomiting  is  not  very  common  and 
was  present  in  only  13  of  the  93  instances.  Abdominal  tympany  is  a  symptom 
of  slight  importance,  occurring  in  only  one-third  of  the  cases. 

Volvulus  can  rarely  be  diagnosed.  The  frequency  with  which  it  involves 
the  sigmoid  flexure  is  to  be  borne  in  mind.  The  passage  of  a  flexible  tube 
or  injecting  fluids  might  in  these  cases  give  valuable  indications. 

In  fcBcal  obstruction  the  condition  is  usually  clear,  as  the  faeces  can  be 
felt  per  rectum  and  also  in  the  distended  colon.  Fgecal  vomiting,  tympany, 
abdominal  pain,  nausea,  and  vomiting  are  late  and  are  not  so  constant.  In 
obstruction  by  gall-stone  a  few  of  the  patients  gave  a  previous  history  of  gall- 
stone colic.  Jaundice  was  present  in  only  3  of  the  23  cases.  Pain  and  vomit- 
ing, as  a  rule,  occur  early  and  are  severe,  and  faecal  vomiting  is  present  in  two- 
thirds  of  the  cases.     A  tumor  is  rarely  evident. 

(c)  Diagnosis  from  Other  Conditions. — ^Acute  enteritis  with  great  re- 
laxation of  the  intestinal  coils,  vomiting,  and  pain  may  be  mistaken  for  ob- 
struction. Instances  have  been  reported  in  which  peritonitis  following  disease 
of  the  appendix  has  been  mistaken  for  acute  obstruction.  The  intense  vomit- 
ing, the  general  tympany  and  abdominal  tenderness,  and,  in  some  instances, 
the  suddenness  of  the  onset  are  very  deceptive.  In  appendix  disease  the  tem- 
perature is  more  frequently  elevated,  the  vomiting  is  never  faecal,  and  in  many 
cases  there  is  a  history  of  previous  attacks  in  the  caecal  region.  Acute  haemor- 
rhagic  pancreatitis  may  produce  symptoms  which  simulate  closely  intestinal 
obstruction. 

Treatment. — Purgatives  should  not  be  given.  For  the  pain  hypodermic 
injections  of  morphia  are  indicated.  To  allay  the  distressing  vomiting,  the 
stomach  should  be  washed  out.  Not  only  is  this  directly  beneficial,  but  Kuss- 
maul  claimed  that  abdominal  distention  is  relieved,  pressure  in  the  bowel 
above  the  seat  of  obstruction  lessened,  and  the  violent  peristalsis  diminished. 
It  may  be  practised  three  or  four  times  a  day,  and  in  some  instances  has 
proved  beneficial ;  in  others  curative.  Thorough  irrigation  of  the  large  bowel 
with  injections  should  be  done,  the  warm  fluid  being  allowed  to  flow  in  slowly 
and  the  amount  carefully  estimated. 

Inflation  may  also  be  tried,  by  forcing  the  air  into  the  rectum,  but  this  is 
not  without  risk,  as  instances  of  rupture  of  the  bowel  have  been  reported.  Of 
39  cases  in  children  treated  by  inflation  or  enemata  16  recovered  ( Wiggin) .  In 
cases  of  acute  obstruction  surgical  measures  should  be  resorted  to  early. 

For  the  tympanites  turpentine  stupes  and  hot  applications  may  be  ap- 
plied. In  cases  of  chronic  obstruction  the  diet  must  be  carefully  regulated, 
and  opium  and  belladonna  are  useful  for  the  paroxysmal  pains.  Enemata 
should  be  employed,  and,  if  the  obstruction  becomes  complete,  resort  must  be 
had  to  surgical  measures. 


CONSTIPATION  535 


V.    CONSTIPATION 

(Costiveness) 

Definition. — Eetention  of  faeces  from  any  cause. 

Constipation  in  Adults. — The  causes  are  varied  and  may  be  classed  as 
general  and  local. 

General  Causes.' — (a)  Constitutional  peculiarities:  Torpidity  of  the  bow- 
els is  often  a  family  complaint  and  is  found  more  often  in  dark  than  in  fair 
persons.  (&)  Sedentary  habits,  particularly  in  persons  who  eat  too  much 
and  neglect  the  calls  of  nature,  (c)  Certain  diseases,  such  as  anaemia,  neuras- 
thenia, and  hysteria,  chrpnic  affections  of  the  liver,  stomach,  and  intestines, 
and  the  acute  fevers.  Under  this  heading  may  appropriately  be  placed  that 
most  injurious  of  all  habits,  drug-taking,  (d)  Either  a  coarse  diet,  which 
leaves  too  much  residue,  or  a  diet  which  leaves  too  little. 

Local  Causes. — Weakness  of  the  abdominal  muscles  in  obesity  or  from 
overdistention  in  repeated  pregnancies.  Atony  of  the  large  bowel  from  chronic 
disease  of  the  mucosa;  the  presence  of  tumors,  physiological  or  pathological, 
pressing  upon  the  bowel;  enteritis;  foreign  bodies,  large  masses  of  scybala, 
and  strictures  of  all  kinds.  An  important  local  cause  is  atony  of  the  colon, 
particularly  of  the  muscles  of  the  sigmoid  flexure  by  which  the  fseces  are 
propelled  into  the  rectum.  An  obstinate  form  is  that  associated  with  a  con- 
tracted state  of  the  bowel,  sometimes  spoken  of  as  spasmodic  constipation. 
This  is  met  with — first,  as  a  sequence  of  chronic  dysentery  or  ulcerative  co- 
litis; secondly,  in  cases  of  hysteria  and  neurasthenia,  usually  with  vagotonia; 
and,  thirdly,  in  very  old  persons  often  without  any  definite  cause.  It  may  be 
that  the  sigmoid  flexure  and  lower  colon  are  in  a  condition  of  contraction  and 
spasm,  while  the  transverse  and  ascending  parts  are  in  a  state  of  atony  and 
dilatation.  The  most  characteristic  sign  of  this  variety  is  the  presence  of  hard, 
globular  masses,  or,  more  rarely,  small  and  sausage-like  faeces. 

Eadiography  has  taught  us  much  of  the  conditions  favoring  intestinal  stasis. 
The  upward  position  in  man  favors  visceroptosis,  with  which  we  find  asso- 
ciated many  of  the  most  obstinate  cases  of  constipation.  Arbuthnot  Lane  has 
emphasized  the  fact  of  this  dropping  or  dragging  of  the  intestines,  particu- 
larly at  certain  points — e.  g.,  the  third  part  of  the  duodenum,  at  the  end  of 
which  there  may  be  an  abrupt  kink  associated  with  a  considerable  dilatation 
of  the  duodenum  itself.  This  is  of  course  relieved  immediately  when  the  pa- 
tient lies  down.  The  second  is  the  ileal  kink,  caused  by  a  dropping  of  the 
caecum,  and  the  lower  coil  of  the  ileum  itself.  The  obstruction  may  result  in 
considerable  dilatation  of  the  end  of  the  ileum,  with  delay  in  the  passage  of 
the  fluid  faeces.  A  third  point  is  the  fixed  splenic  flexure  of  the  colon,  and  the 
X-ray  may  show  an  ascending  colon  as  low  as  the  level  of  the  iliac  crest,  and 
the  transverse  in  the  pelvis,  necessarily  causing  delay  in  the  passage  of  the 
faeces  past  this  angle.  The  sigmoid  loop  seems  specially  designed  to  promote 
stasis;  the  rectum  may  also  present  an  elongated  S-shaped  loop,  and,  finally, 
there  is  the  sharp  pelyi-rectal  flexure,  above  which  the  faeces  accumulate. 

The  rate  of  the  passage  of  the  faeces  through  the  large  bowel  may  be  esti- 
mated accurately  with  the  X-rays.    After  a  bismuth  meal  the  caecum  is  reached 


536  DISEASES  OF  THE  DiaESTIVE  SYSTEM 

in  about  four  hours,  the  hepatic  flexure  two  hours  later,  the  splenic  flexure  three 
hours  after  that,  and  the  beginning  of  the.  pelvic  colon  twelve  hours  after  the 
commencement  of  the  meal.  The  faeces  do  not  pass  beyond  the  pelvi-rectal 
flexure  until  just  before  defaecation. 

Hurst  divides  all  cases  of  constipation  into  two  main  groups.  In  one  the 
delay  occurs  in  the  passage  through  the  colon,  particularly  in  the  distal  half; 
in  the  other  the  passage  as  far  as  the  pelvic  colon  is  normal,  but  defaecation  is 
not  properly  performed.  Every  case  of  chronic  constipation  ought  to  be  care- 
fully studied  with  the  X-rays. 

Symptoms. — The  most  persistent  constipation  for  weeks  or  even  months 
may  exist  with  fair  health.  Debility,  lassitude,  and  a  mental  depression  are 
frequent  symptoms  in  constipation,  particularly  in  persons  of  a  nervous  tem- 
perament. Headache,  loss  of  appetite,  a  furred  toQgue,  and  foul  breath  may 
also  occur.  In  girls  the  skin  is  "muddy,^'  acne  is  common,  chlorosis  may 
follow,  and  there  is  a  flabby  state  of  the  system  generally. 

When  persistent,  the  accumulation  of  faeces  leads  to  unpleasant,  sometimes 
serious,  local  symptoms,  such  as  piles,  ulceration  of  the  colon,  distention  of  the 
sacculi,  perforation,  enteritis,  and  occlusion.  In  women  pressure  may  cause 
pain  at  the  time  of  menstruation  and  a  sensation  of  fullness  and  distention  in 
the  pelvic  organs.  Neuralgia  of  the  sacral  nerves  may  be  caused  by  an  over- 
loaded sigmoid  flexure.  The  faeces  collect  chiefly  in  the  colon.  Even  in  ex- 
treme grades  of  constipation  it  is  rare  to  find  dry  f^ces  in  the  cacum.  The 
faeces  may  form  large  tumors  at  the  hepatic  or  splenic  flexures,  or  a  sausage- 
like, doughy  mass  above  the  navel,  or  an  irregular  lumpy  tumor  in  the  left 
inguinal  region.  In  old  persons  the  sacculi  of  the  colon  become  distended  and 
the  scybala  may  remain  in  them  and  undergo  calcification,  forming  enteroliths. 

In  cases  with  prolonged  retention  the  faecal  masses  become  channeled  and 
diarrhoja  may  occur  for  days  before  the  true  condition  is  discovered  by  rec- 
tal or  external  examination.  In  Avomen  who  have  been  habitually  constipated 
attacks  of  diarrhoea  with  nausea  and  vomiting  should  excite  suspicion  and 
lead  to  a  thorough  examination  of  the  large  bowel.  Fever  may  occur  and 
Meigs  reported  an  instance  in  which  the  condition  simulated  typhoid  fever. 

Captivated  by  the  theories  of  Metchnikoff  we  have  been  for  some  years  on 
the  crest  of  a  colonic  wave,  and  "intestinal  toxemia"  has  been  held  responsible 
for  many  of  the  worst  of  the  ills  that  flesh  is  heir  to,  more  particularly  ar- 
terio-sclerosis  and  old  age.  The  seniles  and  preseniles  of  two  continents  have 
been  taking  sour  milk  and  lacto-bacillary  compounds,  to  the  great  benefit  of 
the  manufacturing  chemists !  Much  of  what  is  regarded  as  intestinal  tox- 
aemia is  really  intestinal  infection. 

Constipation  in  infants  is  a  common  and  troublesome  disorder.  The 
causes  are  congenital,  dietetic,  and  local.  There  are  instances  in  which  the 
child  is  constipated  from  birth  and  may  not  have  a  natural  movement  for 
years,  and  yet  thrive  and  develop.  There  are  cases  of  enormous  dilatation  of 
the  large  bowel  with  persistent  constipation.  The  condition  appears  some- 
times to  be  a  congenital  defect.  In  some  of  these  patients  there  may  be  con- 
stricting bands,  or,  as  in  a  case  of  Cheever's,  a  congenital  stricture. 

Dietetic  causes  are  more  common.  In  sucklings  it  often  arises  from  an 
unnatural  dryness  of  the  small  residue  which  passes  into  the  colon,  and  it 
may  be  very  difficult  to  decide  whether  the  fault  is  in  the  mother's  milk  or 


COIsrSTIPATIOF  537 

in  the  digestion  of  the  child.  Most  probably  it  is  in  the  latter,  as  some  babies 
may  be  persistently  costive  on  natural  or  artificial  foods.  Deficiency  of  fat 
in  the  milk  is  believed  by  some  writers  to  be  the  cause.  In  older  children  it 
is  of  the  greatest  importance  that  regular  habits  should  be  enjoined.  Careless- 
ness on  the  part  of  the  mother  in  this  matter  often  lays  the  foundation  of 
troublesome  constipation  in  after  life.  Impairment  of  the  contractility  of 
the  intestinal  wall  in  consequence  of  inflammation,  disturbance  in  the  normal 
intestinal  secretions,  and  mechanical  obstruction  by  tumors,  twists,  and  intus- 
susception are  the  chief  local  causes. 

Treatment. — Much  may  be  done  by  systematic  habits,  particularly  in  the 
young.  The  patient  should  go  to  stool  at  a  fixed  hour  every  day,  whether 
there  is  desire  or  not,  and  the  desire  should  always  be  granted.  Exercise  in 
moderation  is  helpful.  In  stout  persons  and  in  women  with  pendulous  ab- 
domens the  muscles  should  have  the  support  of  a  bandage.  Friction  or  reg- 
ularly applied  massage  is  useful  in  the  more  chronic  cases.  A  good  substitute 
is  a  metal  ball  weighing  from  four  to  six  pounds,  which  may  be  rolled  over 
the  abdomen  every  morning  for  five  or  ten  minutes.  The  function  of  the 
stomach  should  be  thoroughly  studied  and  any  disturbance  properly  treated. 
The  diet  should  be  low  in  protein,  with  plenty  of  fruit  and  vegetables,  par- 
ticularly salads  and  tomatoes.  It  is  often  advisable  to  cut  meat  from  the  diet 
and  substitute  cereals,  milk  and  milk  foods.  Oatmeal  is  usually  laxative, 
though  not  to  all;  brown  or  bran  bread  is  better  than  that  made  from  fine 
white  flour.  Of  liquids,  water  and  aerated  mineral  waters  may  be  taken  freely. 
A-  tumblerful  of  hot  or  cold  water  on  rising,  taken  slowly,  is  efficacious  in  many 
cases.  A  glass  of  hot  water  at  night  may  also  be  tried  alone.  A  pipe  or  a 
cigar  after  breakfast  is  with  many  men  an  infallible  remedy. 

AVhen  the  condition  is  not  very  obstinate  it  is  w^ell  to  try  to  relieve  it  by 
hygienic  and  dietetic  measures.  If  drugs  must  be  used  they  should  be  the 
milder  saline  laxatives  or  the  compound  liquorice  powder.  Enemata  are  often 
necessary,  and  it  is  much  preferable  to  employ  them  early  than  to  constantly 
use  purgative  pills.  Glycerine  either  in  the  form  of  suppository  or  as  a  small 
injection  is  very  valuable.  Injections  of  tepid  water,  with  or  without  soap, 
may  be  used  for  a  prolonged  period  with  good  effect  and  without  damage. 
The  patient  should  be  in  the  dorsal  position  with  the  hips  elevated,  and  it  is 
best  to  let  the  fluid  flow  in  slowly  from  a  fountain  syringe. 

The  usual  remedies  employed  are  often  useless  in  spastic  constipation.  A 
very  satisfactory  measure  is  the  olive  or  cotton  seed  oil  injection.  The  patient 
lies  on  the  back  with  the  hips  elevated,  and  from  15  to  20  ounces  of  oil  are 
allowed  to  flow  slowly  (or  are  injected)  into  the  Ijowel.  The  operation  should 
take  at  least  fifteen  minutes.  This  may  be  repeated  every  day  until  the  in- 
testine is  cleared,  and  subsequently  a  smaller  injection  every  few  davs  will 
suffice.  In  the  cases  with  a  spastic  colon  the  injection  of  oil  at  bedtime,  which 
is  retained  during  the  night,  is  often  effectual. 

There  are  various  drugs  which  are  of  special  service,  particularly  the  com- 
bination of  ipecacuanha,  nux  vomica,  or  belladonna,  with  aloes,  or  podophyllin. 
Cascara  sagrada,  phenolphthalein,  and  agar  agar  are  useful.  Persistent  effort 
should  be  made  to  reduce  the  dosage  by  attention  to  hygienic  measures.  At 
present  petroleum  oil  in  some  form  is  much  in  vogue.  It  was  introduced  in 
1885  by  Randolph.     It  is  given  in  doses  from  half  an  ounce  to  one  ounce  one 


538  DISEASES  OF  THE  DIGESTIVE   SYSTEM 

to  three  times  a  day.  It  is  harmless,  sometimes  effective,  very  often  without 
any  inflnence  whatever.  In  aneemia  and  chlorosis,  a  sulphur  confection  taken 
in  the  morning,  and  a  pill  of  iron,  rhubarb,  and  aloes  throughout  the  day,  are 
very  serviceable.  Certain  very  severe  cases  are  benefited  by  "short-circuiting," 
the  lower  end  of  the  ileum  being  joined  to  the  lower  end  of  the  colon. 

In  children  the  indications  should  be  met,  as  far  as  possible,  by  hygienic 
and  dietetic  measures.  In  the  constipation  of  sucklings  a  change  in  the  diet 
of  the  mother  may  be  tried,  or  from  one  to  three  teaspoonfuls  of  cream  may 
be  given  before  each  nursing.  In  artificially  fed  children  the  top  milk  with 
the  cream  should  be  used.  Drinking  of  water,  barley  water,  or  oatmeal  water 
will  sometimes  obviate  the  difficulty.  If  laxatives  are  required,  simple  syrup, 
manna,  or  olive  oil  may  be  sufficient.  The  conical  piece  of  soap,  so  often  seen 
in  nurseries,  is  sometimes  efficacious.  Massage  along  the  colon  may  be  tried. 
Small  injections  of  cold  water  may  be  used.  Large  injections  should  be 
avoided,  if  possible.  If  it  is  necessary  to  give  a  laxative  by  the  mouth,  castor 
oil  or  fluid  magnesia  is  the  best.  The  saline  purgatives  appear  to  act  by 
increasing  the  muscular  and  glandular  activity  of  the  bowel.  If  there  are 
signs  of  gastro-intestinal  irritation,  rhubarb  and  soda  or  gray  powder  may 
be  given.    In  older  children  the  diet  should  be  carefully  regulated. 

VI.    ENTEROPTOSIS 

{GUnard's  Disease) 

Definition. — "Dropping  of  the  viscera,"  visceroptosis,  is  not  a  disease,  but 
a  sympton  group  characterized  by  looseness  of  the  mesenteric  and  peritoneal 
attachments,  so  that  the  stomach,  the  intestines,  particularly  the  transverse 
colon,  the  liver,  the  kidneys,  and  the  spleen  occupy  an  abnormally  low  posi- 
tion in  the  abdominal  cavity. 

Symptoms  and  Physical  Signs. — There  are  two  varieties:  in  one,  which 
may  be  called  constitutional  or  congenital,  it  is  an  expression  of  an  anomaly 
of  development,  a  narrow  upper  abdominal  opening,  low  diaphragm  and 
elongated  visceral  ligaments,  all  of  which  combined  lead  to  a  greater  or  less 
degree  of  prolapse  of  the  abdominal  viscera.  The  second  group,  or  the  ac- 
quired enteroptosis,  is  largely  due  to  relaxation  of  the  abdominal  wall.  The 
support  of  the  viscera  is  due  to  the  integrity  of  the  reflex  arc  and  abdominal 
muscles,  the  tonic  action  of  which,  as  shown  by  the  studies  of  Keith  and  of 
Sherrington,  is  brought  into  play  by  a  reflex,  the  afferent  end  organs  of  which 
are  the  peritoneal  nerves  and  Pacinian  bodies. 

In  the  first  group  is  embraced  a  somewhat  motley  series  of  cases,  in  which, 
with  a  pronounced  nervous  or,  as  we  call  it  now,  neurasthenic  basis,  there  are 
displacements  of  the  viscera  with  sijmptoms.  The  patients  are  usually  young, 
more  frequently  women  than  men,  and  of  spare  habit.  The  condition  may 
follow  an  acute  illness  with  wasting.  Tliey  complain,  as  a  rule,  of  dyspepsia, 
throbbing  in  the  abdomen,  and  dragging  pains  or  weakness  in  the  back,  and 
inability  to  perform  the  usual  duties  of  life.  A  very  considerable  proportion 
of  all  the  cases  of  neurasthenia  present  the  local  features  of  enteroptosis. 
When  preparing  for  the  examination  one  notices  usually  an  erythematous 
flushing  of  the  skin ;  the  scratch  of  the  nail  is  followed  instantly  by  a  line  of 


ENTEROPTOSIS  539 

hyperaeniia,  less  often  of  marked  pallor.  The  pulsation  of  the  abdominal 
aorta  is  readily  seen. 

In  the  second  group  inspection  of  the  abdomen  shows  a  very  relaxed  abdom- 
inal wall,  and,  as  a  rule,  the  linese  albicantes  of  recurring  pregnancies.  Per- 
istalsis of  the  intestines  may  be  seen,  and  in  extreme  cases  the  outlines  of  the 
stomach  itself  with  its  waves  of  peristalsis.  On  inflating  the  stomach  the 
organ  stands  out  with  great  prominence,  and  the  lesser  and  greater  curvatures 
are  seen,  the  latter  extending  perhaps  a  hand's  breadth  below  the  level  of  the 
navel.  The  waves  of  peristalsis  are  feeble  and  without  the  vigor  and  force  of 
those  seen  in  the  stomach  dilated  from  stricture  of  the  pylorus.  The  condi- 
tion of  descensus  ventriculi  with  atony  is  best  studied  in  this  group  of  cases. 
An  important  point  to  remember  is  that  it  may  exist  in  an  extreme  grade 
without  symptoms. 

Eadiography  has  given  much  information  of  the  position  of  the  viscera. 
The  stomach  is  vertically  placed  and  reaches  far  below  the  navel;  its  motility 
may  be  normal,  but  there  may  be  stasis  from  associated  pyloric  spasm  or  from 
kinking  of  the  duodenum.    Clapotage  or  splashing  is  usually  distinct. 

Nephroptosis,  or  displacement  of  the  kidney,  is  one  of  the  most  constant 
phenomena  in  enteroptosis.  It  is  well,  perhaps,  to  distinguish  between  the 
kidney  which  one  can  just  touch  on  deep  inspiration — palpable  kidney — one 
which  is  freely  movable,  and  which  on  deep  inspiration  descends  so  that  one 
can  put  the  fingers  of  the  palpating  hand  above  it  and  hold  it  down,  and, 
thirdly,  a  floating  kidney,  which  is  entirely  outside  the  costal  arch,  is  easily 
grasped  in  the  hand,  readily  moved  to  the  middle  line,  and  low  down  toward 
the  right  iliac  fossa.  It  is  held  by  some  that  the  designation  floating  kidney 
should  be  restricted  to  the  cases  in  which  there  is  a  meso-nephron,  but  this 
is  excessively  rare,  while  extreme  grades  of  renal  mobility  are  common.  Some 
of  the  more  serious  sequences  of  movable  kidney,  namely,  Dietl's  crises  and 
intermittent  hydronephrosis,  will  be  considered  with  diseases  of  the  kidney. 

Displacement  of  the  liver  is  very  much  less  common.  In  thin  women  who 
have  laced,  the  organ  is  often  tilted  forward,  so  that  a  very  large  surface  of 
the  lobes  comes  in  contact  with  the  abdominal  wall ;  it  is  a  very  common  mis- 
take under  these  circumstances  to  think  that  the  organ  is  enlarged.  Disloca- 
tion of  the  liver  itself  will  be  considered  later. 

Mobility  of  the  spleen  is  sometimes  very  marked  in  enteroptosis.  In  an 
extreme  grade  it  may  be  found  in  almost  any  region  of  the  abdomen.  It  is 
very  frequently  mistaken  for  a  fibroid  or  ovarian  tumor.  A  considerable  pro- 
portion of  the  cases  come  first  under  the  care  of  the  gynaecologist. 

There  is  usually  much  relaxation  of  the  mesentery  and  of  the  peritoneal 
folds  which  support  the  intestines.  The  colon  is  displaced  downward  (colop- 
tosis),  with  consequent  kinking  at  the  flexures.  The  descent  may  be  so  low 
that  the  transverse  colon  is  at  the  brim  of  or  even  in  the  pelvis.  It  may  indeed 
be  fixed  or  bent  in  the  form  of  a  Y.  It  is  frequently  to  be  felt,  as  Glenard 
states,  as  a  firm  cord  crossing  the  abdomen  at  or  below  the  level  of  the  navel. 
This  kinking  may  take  place  not  only  in  the  colon,  but  at  the  pylorus,  where 
the  duodenum  passes  into  the  jejunum,  and  where  the  ileum  enters  the  ca?cum. 

The  ccecum  may  be  very  movable  and  with  this  there  may  be  pain,  attacks 
of  colic  and  constipation.  There  may  be  fullness  in  the  c^ecal  region  and  on 
palpation  the  distended  caecum  is  easily  felt.    The  mass  may  be  very  movable. 


540  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

The  explanation  of  the  phenomena  accompanying  enteroptosis  is  by  no 
means  easy.  It  has  been  suggested  by  Glenard  and  others  that  overfilling  of 
the  splanchnic  vessels  in  consequence  of  displacements  and  kinking  accounts 
for  the  feelings  of  exhaustion  and  general  nervousness.  In  a  large  proportion 
of  the  cases,  however,  no  symptoms  occur  until  after  an  illness  or  some  pro- 
tracted nervous  strain. 

Treatment. — In  a  majority  of  all  cases  four  indications  are  present:  To 
treat  the  existing  neurasthenia,  to  relieve  the  nervous  dyspepsia,  to  overcome 
the  constipation,  and  to  afford  mechanical  support  to  the  organs.  Three  of 
these  are  considered  under  their  appropriate  sections.  In  cases  in  which  the 
enteroptosis  has  followed  loss  in  weight  after  an  acute  illness  or  worries  and 
cares  an  important  indication  is  to  fatten  the  patient. 

A  well-adapted  abdominal  bandage  is  one  of  the  most  important  measures 
in  enteroptosis.  In  many  of  the  milder  grades  it  alone  suffices.  There  is  no 
single  simple  measure  which  affords  relief  to  distressing  symptoms  in  so  many 
cases  as  the  abdominal  bandage.  It  is  best  made  of  linen,  should  fit  snugly, 
and  should  be  arranged  with  straps  so  that  it  can  not  ride  up  over  the  hips. 
A  special  form  must  be  used  for  movable  kidney.  In  some  cases  support  may 
be  given  by  the  use  of  adhesive  strapping.  Exercises  to  strengthen  the  abdomi- 
nal muscles  and  proper  abdominal  breathing  are  aids.  General  "setting-up" 
exercises  are  often  helpful.  Some  of  the  more  aggravated  types  of  enteroptosis 
are  combined  with  such  features  of  neurasthenia  that  a  rigid  Weir  Mitchell 
treatment  is  indicated.  In  a  few  very  refractory  cases  surgical  interference 
may  be  called  for. 

And,  lastly,  the  physician  must  be  careful  in  dealing  with  the  subjects  of 
enteroptosis  not  to  lay  too  much  stress  on  the  disorder.  It  is  well  never  to 
tell  the  patient  that  a  kidney  is  movable;  the  symptoms  may  date  from  a 
knowledge  of  the  existence  of  the  condition. 

VII.     MISCELLANEOUS  AFFECTIONS 

I.    MUCOUS  COLITIS 

Known  by  various  names,  such  as  membranous  enteritis,  tubular  diarrhoea, 
mucous  colic,  and  myxoneurosis  intestinalis,  this  remarkable  disease  has  been 
recognized  for  several  centuries.  An  exhaustive  description  of  it  is  given  by 
Woodward  in  vol.  ii  of  the  Medical  and  Surgical  Eeports  of  the  Civil  War. 
The  passage  of  mucus  in  large  quantities  from  the  bowel  is  met  with,  first, 
in  catarrh  of  the  intestine,  due  to  various  causes.  It  is  not  uncommon  in 
children,  and  may  be  associated  with  disturbances  of  digestion  and  slight 
colic.  Becondly,  in  local  disease  or  irritation  of  the  bowel,  in  cancer  of  the 
colon  and  of  the  rectum.  In  tubo-ovarian  disease  much  mucus  and  slime 
may  be  passed.  Thirdly,  true  mucous  colitis,  a  secretion  neurosis  of  the  large 
intestine  met  with  particularly  in  nervous  and  hysterical  patients.  It  is 
more  common  in  women  than  in  men.  It  has  increased  greatly  of  late  years, 
and  has  become  the  fashionable  complaint,  displacing  neuritis  to  a  great  ex- 
tent. There  is  an  abnormal  secretion  of  a  tenacious  mucus,  which  may  be 
slimy  and  gelatinous,  like  frog-spawn,  or  it  is  passed  in  strings  or  strips, 
more  rarely  as  a  continuous  tubular  membrane.    The  membrane  in  dtu  adheres 


MISCELLANEOUS  AFFECTIONS  541 

closely  to  the  mucosa,  but  is  capable  of  separation  without  any  lesion  of  the  sur- 
face. Microscopically  the  casts  are  mucoid,  of  a  imiform  granular  ground 
substance  through  which  there  are  remnants  of  cells,  some  of  which  have 
undergone  a  definite  hyaline  transformation.  Triple  phosphate,  cholesterin, 
and  fatty  crystals  are  present,  and  occasionally  fine,  sand-like  concretions. 
The  epithelium  of  the  mucosa  seems  to  be  intact. 

Symptoms. — In  a  large  proportion  of  all  the  cases  the  subjects  are  nervous 
in  greater  or  less  degree.  Some  cases  have  had  hysterical  outbreaks,  and 
there  may  be  hypochondriasis  or  melancholia.  The  patients  are  self-centred 
and  often  much  worried  about  the  mucous  stools.  Some  of  the  cases  are 
among  the  most  distressing  with  which  we  have  to  deal,  invalids  of  many 
years'  standing,  neurasthenic  to  an  extreme  degree,  with  recui^ring  attacks  of 
pain  and  the  passage  of  large  quantities  of  mucus  or  even  intestinal  casts. 

In  many  cases  the  attacks  may  come  on  in  paroxysms,  associated  with 
colicky  pains,  or  occasionally  crises  of  the  greatest  severity,  so  that  appen- 
dicitis may  be  suspected.  Emotional  disturbances,  worry  of  all  sorts,  or  an 
error  in  diet  may  bring  on  an  attack.  Constipation  is  a  special  feature  in 
many  cases.  Sometimes  there  are  attacks  of  nervous  diarrhoea.  Some  patients 
have  a  movement  after  each  meal.  This  is  due  to  an  active  gastro-colic  reflex, 
so  that  faeces  reach  the  rectum  after  each  meal. 

While  the  disease  is  obstinate  and  distressing,  it  is  rarely  serious,  though 
Herringham  states  that  he  knew  of  three  cases  of  mucous  colitis  in  which 
death  occurred  suddenly,  in  all  with  great  pain  in  the  left  side  of  the  abdo- 
men. The  abdomen  itself  is  rarely  distended.  There  is  often  a  painful  spot 
between  the  navel  and  the  left  costal  border,  tender  on  pressure,  and  sometimes 
the  paroxysms  of  pain  seem  centred  in  this  region.  A  spastic  condition  of  the 
colon  frequently  exists  and  is  easily  recognized  by  palpation. 

Diagnosis. — This  is  rarely  doubtful,  but  it  is  important  not  to  mistake  the 
membranes  for  other  substances;  thus,  the  external  cuticle  of  asparagus  and 
undigested  portions  of  meat  or  sausage-skins  sometimes  assume  forms  not 
unlike  mucous  casts,  but  microscopic  examination  will  quickly  differentiate 
them.  The  presence  of  ulcers,  and  polypi  should  be  excluded.  Mucous  colitis 
with  severe  pain  may  be  mistaken  for  appendicitis. 

Treatment. — Drugs  are  of  little  value.  It  is  quite  useless  to  give  bismuth 
and  so-called  intestinal  remedies.  First  the  basic  neurasthenic  state  is  to 
be  dealt  with,  and  this  may  suffice  for  a  cure.  Secondly,  daily  irrigations 
of  the  colon  through  a  long  tube — one  to  two  pints  of  warm  alkaline  fluid. 
At  Plombieres,  Harrogate,  and  other  spas  this  treatment  is  most  successfully 
carried  out.  The  injection  of  olive  oil  at  bedtime  is  sometimes  helpful.  It 
should  be  retained  during  the  night.  Thirdly,  the  coarser  sorts  of  food  which 
leave  a  large  residue  should  be  eaten,  and,  should  these  measures  fail,  the 
question  of  irrigating  through  the  appendix  or  caecum  may  be  considered. 

II.     DILATATION  OF  THE  COLON 

There  are  four  groups  of  cases.  In  the  first  the  distention  is  entirely 
gaseous,  and  occurs  not  infrequently  as  a  transient  condition.  In  many  cases 
it  has  an  important  influence,  inasmuch  as  it  may  be  extreme,  pushing  up  tlio 
diaphragm  and  seriously  impairing  the  action  of  the  heart  and  lungs.     It  is 


542  DISEASES  OF  THE  DIGESTIVE   SYSTEM 

an  occasional  cause  of  sudden  heart-failure.  In  pneumonia  and  other  acute 
diseases  this  inflation  of  the  colon  may  he  extreme. 

In  the  second  group  are  the  cases  in  which  the  distention  of  the  colon 
is  caused  by  solid  substances,  as  feecal  matter,  occasionally  by  foreign  bodies 
introduced  from  without,  and  more  rarely  by  gall-stones.  In  institutions, 
particularly  in  insane  asylums,  it  is  not  infrequent  to  find  the  aged  with 
great  distention  of  the  colon. 

When,  thirdly,  the  dilatation  is  due  to  an  organic  obstruction  in  front 
of  the  dilated  gut,  the  colon  may  reach  a  very  large  size.  These  cases  are 
common  enough  in  malignant  tumors  and  sometimes  in  volvulus.  Dilatation 
of  the  sigmoid  flexure  occurs  particularly  when  this  portion  of  the  bowel  is 
congenitally  very  long.  In  such  cases  the  bowel  may  be  so  distended  that  it 
occupies  the  greater  part  of  the  abdomen,  pushing  up  the  Kver  and  the  dia- 
phragm. An  acute  condition  is  sometimes  caused  by  a  twist  in  the  meso-colon. 
And,  fourthly — 

Idiopathic  Dilatation. — Hirschsprung's  disease.  The  cases  are  not  un- 
common, occurring  in  children  and  in  young  adults.  The  sigmoid  flexure 
alone  or  the  entire  colon  is  involved,  and  the  size  may  be  colossal.  In  For- 
ma d's  case  the  circumference  of  the  colon  was  from  fifteen  to  thirty  inches, 
and  the  weight  of  the  contents  forty-seven  pounds.  The  origin  is  obscure.  In 
some  the  condition  is  congenital,  and  the  dilatation  and  hypertrophy  increase 
progressively:  in  others  there  is  an  unusually  long  sigmoid  flexure;  in  others 
again  narrowing  of  the  terminal  portion  of  the  descending  colon  or  a  valve- 
like structure  has  been  found.  The  symptoms  are  very  definite — constipa- 
tion, an  enlarged  abdomen,  attacks  of  pain  with  increasing  distention,  and 
then  diarrhoea,  either  natural  or  induced,  with  relief.  Such  attacks  may 
occur  from  birth  and  continue  to  the  twentieth  or  thirtieth  year.  The  ab- 
dominal picture  is  distinctive — the  great  enlargement  of  the  upper  half  of 
the  abdomen,  the  spreading  of  the  costal  arch,  the  remarkable  length  from 
the  ensiform  cartilage  to  the  navel,  and  in  the  attacks  the  coils  of  the  colon 
stand  out  prominently,  and  even  the  longitudinal  bands  may  be  seen. 

The  outlook  is  uncertain.  Medical  treatment  is  of  little  avail.  Scrupulous 
care  of  the  bowels  may  check  the  progress ;  but,  as  a  rule,  it  is  a  progressive 
malady  for  which  surgery  alone  ofl'ers  complete  relief.  Eesection  of  the  en- 
larged colon  has  been  done  in  a  good  many  cases.  Colotomy  gives  relief; 
colostomy  has  also  been  successful.  Of  -i-t  cases  treated  surgically,  15  were 
completely  cured  and  7  were  improved    (Finney). 

III.     IXTESTIXAL  SAXD 

"Sable  Intestinal." — There  are  two  gToups  of  eases  in  which  sand-like 
material  is  passed  with  the  stools.  The  false,  in  which  it  is  made  up  of  the 
remains  of  vegetable  food  and  fruits  which  have  resisted  digestion  or  which 
have  become  encrusted  with  earthy  salts.  True  intestinal  sand  of  animal 
origin,  gritty  fine  particles,  usually  gray,  black  or  brovm,  is  formed  in  the 
bowel  and  is  made  up  largely  of  lime  salts.  In  mucous  colitis  this  material 
may  be  passed  at  intervals  for  months. 


MISCELLANEOUS  AFFECTIONS  543 


IV.  DIVERTICULITIS— PERISIGMOIDITIS 

Congenital  diverticula,  of  which  Meckel's  is  the  type,  may  cause  strangula- 
tion or  obstruction. 

Acquired  diverticula,  commonly  hernial  protrusion  of  the  mucous  and 
serous  coats,  occur  anywhere  in  the  intestinal  tract.  In  the  small  bowel  they 
rarely  cause  symptoms,  though  in  a  case  reported  by  one  of  us  with  scores  of 
hernias  ranging  in  size  from  a  marble  to  an  orange,  there  were  distressing 
audible  borborygmi,  and  Gardinier  and  Sampson  met  with  an  instance  of 
obstruction.  The  site  of  election  of  the  common  form  is  the  sigmoid  flexure 
near  the  junction  with  the  rectum  and  the  clinical  interest  in  the  frequency 
with  which  they  are  the  seat  of  inflammation — diverticulitis,  perisigmoiditis. 
Teller  and  Gruner  analyzed  324  cases.  The  evaginations  of  the  mucosa  are 
usually  the  result  of  high  intra-colic  pressure  with  gas  or  faeces  in  the  aged. 
Sixty-eight  per  cent,  of  the  cases  were  males. 

The  secondary  pathological  processes  are  mechanical,  as  torsion,  formation 
of  concretions  and  lodgment  of  foreign  bodies;  and  inflammatory,  acute 
diverticulitis,  which  may  rapidly  become  gangrenous;  chronic  inflammation 
leading  to  thickening,  and  tumor  formation  and  narrowing ;  perforation,  caus- 
ing local  abscess,  general  peritonitis  or  fistula.  Other  changes  are  chronic 
local  peritonitis  with  adhesions,  metastatic  suppuration,  and  in  late  stages 
cancer  may  develop. 

The  symptoms  rarely  permit  of  more  than  a  tentative  diagnosis.  Pain  in- 
the  left  lower  quadrant  with  tenderness,  rigidity  and  a  mass  in  a  person  over 
sixty,  who  has  been  constipated,  should  suggest  diverticulitis  as  well  as  cancer. 
The  absence  of  blood  in  the  stools,  the  long  history  of  pain,  negative  sigmoidos- 
copy, slight  fever  and  good  nutrition  or  even  obesity  are  in  favor  of  the 
former.  Unless  specially  contra -indicated,  the  condition  calls  for  operation. 
W.  J.  Mayo  reports  (1917)  resection  in  42  cases.  An  important  point  is  that 
carcinoma  coexisted  in  13.  The  mortality  was  high  in  the  series,  14  per 
cent. 

V.  AFFECTIONS  OF  THE  MESENTERY 

Haemorrhage  (Hwmatoma) . — Instances  in  which  the  bleeding  is  confined 
to  the  mesenteric  tissues  are  rare;  more  commonly  the  condition  is  associated 
with  hsemorrhagic  infiltration  of  the  pancreas  and  with  retroperitoneal  hasmor- 
ihage.  It  occurs  in  rupture  of  aneurisms,  either  of  the  abdominal  aorta  or  of 
the  superior  mesenteric  artery,  in  malignant  forms  of  the  infectious  fevers, 
small-pox,  and  in  individuals  in  whom  no  predisposing  conditions  exist. 

Affections  of  the  Mesenteric  Vessels. —  (a)  Aneurism  (see  page  853). 

(6)  Embolism  and  Thrombosis.' — Infarction  of  the  Bowel. — When  the 
mesenteric  vessels  are  blocked  by  emboli  or  thrombi  the  condition  of  infarc- 
tion follows  in  the  territory  supplied,  which  may  pass  on  to  gangrene  or  to 
perforation  and  peritonitis.  If  the  superior  mesenteric  artery  is  blocked  the 
result  is  fatal.  In  the  veins  the  thrombosis  may  be  primary,  following  in- 
fective processes  in  the  intestines,  particularly  about  the  appendix,  or  it  occurs 
in  cachectic  states.  Secondary  thrombosis  is  met  with  in  cirrhosis  of  the 
liver,  syphilis,  and  pylephlebitis,  or  may  result  from  the  stasis  caused  by 


544  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

arterial  emboli.  Jackson,  Porter,  and  Quimby  made  an  exhaustive  study  of 
30  Boston  cases,  and  collected  214  cases.  They  recognize  two  groups — acute 
and  chronic.  In  the  former  the  onset  is  sudden,  with  colic,  nausea,  vomiting, 
and  a  bloody  diarrhoea,  so  that  the  picture  is  one  of  acute  obstruction.  The 
abdomen  becomes  distended  and  death  occurs  in  collapse  within  a  few  days. 
In  the  chronic  cases  the  onset  is  insidious,  and  there  may  be  no  symptoms 
referable  to  the  abdomen.  Of  the  214  cases,  64  per  cent,  were  in  men.  The 
diagnosis  is  extremely  difficult,  and  the  acute  cases  are  usually  regarded  as 
obstruction.  Exploratory  operation  has  been  made  in  47  case's,  4  of  which  have 
recovered.  In  J.  W.  Elliot's  successful  case  48  inches  of  the  bowel  were  re- 
sected. In  the  horse,  infarction  of  the  intestine,  commonly  in  connection  with 
the  verminous  aneurisms  of  the  mesenteric  arteries,  is  the  usual  cause  of  colic. 

Diseases  of  the  Mesenteric  Veins. — Dilatation  and  sclerosis  occur  in  cir- 
rhosis of  the  liver.  In  instances  of  prolonged  obstruction  there  may  be  large 
saccular  dilatations  with  calcification  of  the  intima,  as  in  a  case  of  oblitera- 
tion of  the  venae  porta  described  by  the  senior  author.  Suppuration  of  the 
mesenteric  veins  is  not  rare,  and  occurs  usually  in  connection  with  pylephlebi- 
tis. The  mesentery  may  be  much  swollen  and  is  like  a  bag  of  pus,  and  it  is 
only  on  careful  dissection  that  one  sees  that  the  pus  is  really  within  channels 
representing  extremely  dilated  mesenteric  veins. 

Disorders  of  the  Chyle  Vessels. — Varicose,  cavernous,  and  cystic  chy- 
langiomata  are  met  with  in  the  mucosa  and  submucosa  of  the  small  intes- 
tine, occasionally  of  the  stomach.  Extravasation  of  chyle  into  the  mesenteric 
tissue  is  sometimes  seen.  Chylous  cysts  may  occur  at  the  root  of  the  mesentery. 
Bramann  records  a  case  in  a  man  aged  sixty-three,  in  which  a  cyst  of  this 
kind  the  size  of  a  child's  head  was  healed  by  operation.  There  is  an  instance 
on  record  of  a  congenital  malformation  of  the  thoracic  duct,  in  which  the 
receptaculum  formed  a  flattened  cyst  which  discharged  into  the  peritoneum, 
and  a  chylous  ascitic  fluid  was  withdrawn  on  several  occasions.  Homans  re- 
ported the  case  of  a  girl  who,  from  the  third  to  the  thirteenth  year,  had  an 
enlarged  abdomen.  Laparotomy  showed  a  series  of  cysts  containing  clear 
fluid.  They  were  supposed  to  be  dilated  lymph  vessels  connected  with  the 
intestines. 

Cysts  of  the  Mesentery. — They  may  be  either  dermoid,  hydatid,  serous, 
sanguineous,  or  chylous.  They  occur  at  any  portion  of  the  mesentery,  and 
range  from  a  few  inches  in  diameter  to  large  masses  occupying  the  entire 
abdomen.  They  are  frequently  adherent  to  the  neighboring  organs,  to  the 
liver,  spleen,  uterus,  and  sigmoid  flexure. 

The  symptoms  usually  are  those  of  a  progressively  enlarging  tumor  in 
the  abdomen.  Sometimes  a  mass  develops  rapidly,  particularly  in  the  hasmor- 
rhagic  forms.  Colic  and  constipation  or  acute  obstruction  are  present  in 
some  cases.  The  general  health,  as  a  rule,  is  well  maintained  in  spite  of  the 
progressive  enlargement  of  the  abdomen,  which  is  most  prominent  in  the  um- 
bilical region.  Mesenteric  cysts  may  persist  for  many  years,  even  ten  or 
twenty. 

The  diagnosis  is  extremely  uncertain,  and  no  single  feature  is  in  any  way 
distinctive.  The  important  signs  are :  the  great  mobility,  the  situation  in  the 
middle  line,  and  the  zone  of  tympany  in  front  of  the  tumor.  Of  these,  the 
second  is  the  only  one  which  is  at  all  constant,  as  when  the  tumors  are  large 


JAUNDICE  545 

the  mobility  disappears,  and  at  this  stage  the  intestines,  too,  are  pushed  to  one 
side.  It  is  most  frequently  mistaken  for  ovarian  tumor.  Movable  kidney, 
hydronephrosis,  and  cysts  of  the  omentum  have  also  been  confused  with  it. 
The  only  treatment  is  surgical. 

VI.     DILATATION  OF   THE  DUODENUM 

This  is  often  associated  with  visceroptosis  and  compression  of  the  terminal 
portion  of  the  duodenum  by  the  root  of  the  mesentery.  Adhesions  from  local 
peritonitis  are  responsible  in  some  cases.  The  symptoms  are  (1)  pain  in  the 
upper  abdomen,  sometimes  described  as  a  pulling  or  dragging  sensation,  some- 
times more  severe,  and  suggesting  ulcer  or  gall-bladder  disease;  (3)  vomiting 
which  is  frequent  and  sometimes  persistent ;  (3)  constipation;  and  (4)  marked 
vagotonic  features.  The  X-ray  study  is  an  important  aid  in  the  diagnosis. 
In  treatment,  position  may  be  useful,  the  patient  lying  on  the  face  with  the 
feet  elevated,  or  on  the  left  side,  or  taking  the  knee-chest  position.  Correction 
of  the  visceroptosis  by  an  abdominal  support  or  by  gaining  weight  may  give 
relief.    In  severe  cases  surgical  intervention  is  advisable. 


H.    DISEASES  OF  THE  LIVER 
I.    JAUNDICE 

(Icterus) 

Definition. — Jaundice  or  icterus  is  a  condition  characterized  by  coloration 
of  the  skin,  mucous  membranes,  and  fluids  of  the  body  by  bile-pigment. 

Like  albuminuria.  Jaundice  is  a  symptom  and  not  a  disease,  and  is  met 
with  in  a  variety  of  conditions.  Bile  pigment  and  bile  salts  may  be  in  the  blood 
and  not  appear  in  the  urine  or  be  in  the  tissues.  In  dissociated  jaundice  the 
bile  pigments  and  salts  reach  the  plasma  independently;  the  kidneys  may  ex- 
crete one  and  not  the  other. 

I.     OBSTEUCTIVE  JAUNDICE 

The  chief  causes  of  obstructive  jaundice  are:  (1)  Obstruction  by  foreign 
bodies  within  the  ducts,  as  gall-stones  and  parasites;  (2)  by  inflammatory 
tumefaction  of  the  duodenum  or  of  the  lining  membrane  of  the  duct;  (3)  by 
stricture  or  obliteration  of  the  duct;  (4)  by  tumors  closing  the  orifice  of  the 
duct  or  growing  in  its  interior;  (5)  by  pressure  on  the  duct  from  without,  as 
by  tumors  of  the  liver  itself,  of  the  stomach,  pancreas,  kidney,  or  omentum; 
by  pressure  of  enlarged  glands  in  the  fissures  of  the  liver,  and,  more  rarely,  of 
abdominal  aneurism,  fsecal  accumulation,  or  the  pregnant  uterus. 

In  these  cases  of  extra-hepatic  or  obstructive  jaundice  the  pressure  within 
the  biliary  capillaries,  usually  low,  becomes  increased  and  the  bile  is  absorbed 
by  the  lymphatics  of  the  liver  and  not  by  the  blood  capillaries.  To  these 
causes  some  add  lowering  of  the  blood  pressure  in  the  portal  system  so  that  the 


546  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

tension  in  the  smaller  bile-ducts  is  greater  than  in  the  blood-vessels.  For  this 
view  there  is  no  positive  evidence.  In  this  class  may  perhaps  be  placed  the 
cases  of  jaundice  from  mental  shock  or  depressed  emotions,  which  "may  con- 
ceivably cause  spasm  and  reversed  peristalsis  of  the  bile-duct"  (W.  Hunter). 

General  Symptoms  of  Obstructive  Jaundice. — (a)  Icterus,  or  tinting  of 
the  skin  and  conjundivce.  The  color  ranges  from  a  lemon-yellow  in  catarrhal 
jaundice  to  a  deep  olive-green  or  bronzed  hue  in  permanent  obstruction.  In 
some  instances  the  color  of  the  skin  is  greenish  black,  the  so-called  "black 
jaundice."    Except  the  central  nervous  system,  all  of  the  tissues  are  stained. 

(&)  In  the  more  chronic  forms  pruritus  is  a  most  distressing  symptom. 
There  is  a  curious  pre-icteric  itching,  which  Eiesman  thinks  is  suggestive  of 
cancer,  but  it  is  often  marked  in  gall-stone  cases.  Sweating  is  common,  and 
may  be  curiously  localized  to  the  abdomen  or  to  the  palms  of  the  hands. 
Lichen,  urticaria,  and  boils  may  occur.  Xantlioma  multiplex  is  rare.  Usually 
in  the  flat  form,  rarely  nodular,  they  ire  most  common  in  the  eyelids  and  on 
the  hands  and  feet.  They  may  be  very  numerous  over  the  whole  body.  Oc- 
casionally the  tumors  are  found  in  the  bile  duct.  After  persisting  for  years 
they  may  disappear.  In  very  chronic  cases  telangiectases  develop  in  the  skin, 
sometimes  in  large  numbers  over  the  body  and  face,  occasionally  on  the  mu- 
cous membrane  of  the  tongue  and  lips,  forming  patches  of  a  bright  red  color 
from  1  to  2  cm.  in  breadth. 

(c)  The  blood  serum  is  tinged  with  bilirubin.  By  this  an  early  diagnosis 
may  be  made. 

(d)  The  secretions  are  colored  with  bile-pigment.  The  sweat  tinges  the 
linen ;  the  tears  and  saliva  and  milk  are  rarely  stained.  The  expectoration  is 
not  often  tinted  unless  there  is  inflammation,  as  when  pneumonia  coexists  with 
jaundice.  The  urine  may  contain  the  pigment  before  it  is  apparent  in  the 
skin  or  conjunctiva.  The  color  varies  from  light  greenish  yellow  to  a  deep 
black-green.  In  cases  of  jaundice  of  long  standing  or  great  intensity  the 
urine  usually  contains  albumin  and  always  bile-stained  tubecasts. 

(e)  No  bile  passes  into  the  intestine.  The  stools  therefore  are  of  a  pale 
drab  or  slate-gray  color,  and  usually  very  fetid  and  pasty.  The  "clay-color" 
of  the  stools  is  also  in  part  due  to  the  presence  of  undigested  fat  which,  ac- 
cording to  Miiller,  may  be  increased  from  7  to  10  per  cent.,  which  is  normal, 
to  55  or  78.5  per  cent.  There  may  be  constipation;  in  many  instances,  owing 
to  decomposition,  there  is  diarrhoea. 

(/)  Sloiv  pulse.  The  heart's  action  may  fall  to  40,  30,  or  even  to  20  per 
minute.  It  is  particularly  noticeable  in  the  cases  of  catarrhal  and  recent  jaun- 
dice, and  is  not  as  a  rule  an  unfavorable  symptom.  Whether  this  is  due  to  in- 
terrupted conductivity  or  to  direct  poisoning  of  the  auriculo-ventricular  bundle 
has  not  been  determined.  It  occurs  only  in  the  early  stages  of  jaundice.  At 
this  time  bile  cicids  pass  into  the  blood,  but  are  produced  in  very  small  quan- 
tities when  jaundice  is  established.  The  respirations  may  fall  to  10  or  even  to 
7  per  minute.    Xanthopsia,  or  yellow  vision,  may  occur. 

(g)  Hcemorrliage.  The  tendency  to  bleeding  in  chronic  icterus  is  a  serious 
feature  and  in  some  cases  the  blood  coagulation  time  is  much  retarded.  This 
is  an  important  point  as  incontrollable  hemorrhage  is  a  well-recognized  acci- 
dent in  operating  upon  patients  with  chronic  jaundice.     Purpura,  large  sub- 


JAUNDICE  547 

cutaneous  extravasations,  more  rarely  haemorrhages  from  the  mucous  mem- 
branes, occur  in  protracted  jaundice,  and  in  the  more  severe  forms. 

{h)  Cerebral  symptoms.  Irritability,  great  depression  of  spirits,  or  even 
melancholia  may  be  present.  In  any  case  of  persistent  jaundice  special  nerv- 
ous phenomena  may  develop  and  rapidly  prove  fatal — such  as  sudden  coma, 
acute  delirium,  or  convulsions.  Usually  the  patient  has  a  rapid  pulse,  slight 
fever,  and  a  dry  tongue,  and  he  passes  into  the  so-called  "typhoid  state." 
These  features  are  not  nearly  so  common  in  obstructive  as  in  febrile  jaundice, 
but  they  not  infrequently  terminate  a  chronic  icterus  in  whatever  way  pro- 
duced. The  group  of  symptoms  has  been  termed  cliolcemia,  or,  on  the  supposi- 
tion that  cholesterin  is  the  poison,  cholestercemia;  but  its  true  nature  has  not 

been  determined.    In  some  cases  the  symptoms  may  be  due  to  uraemia. 

Ik 

II.     TOXIC    AND    HEMOLYTIC    JAUNDICE 

The  term  haematogenous  jaundice  was  formerly  applied  to  this  group  in 
contradistinction  to  the  hepatogenous  jaundice,  associated  with  manifest  ob- 
structive changes  in  the  bile-passages.  The  toxic  jaundice  cases  are  essentially 
obstructive  in  origin,  and  it  is  doubtful  whether  there  are  any  true  non-obstruc- 
tive cases.  For  this  type  the  name  "hsmohepatogenous"  jaundice  has  been 
suggested.  Eolleston  refers  to  them  as  cases  of  "intrahepatic"  jaundice.  Toxic 
substances,  bacterial  or  chemical,  circulate  in  the  blood  and  cause  destruction 
of  red  blood  cells.  The  toxin  and  its  products  cause  a  degeneration  of  the 
liver  cells  and  an  inflammatory  condition  of  the  bile  capillaries.  The  bile 
becomes  viscid  and  the  fine  ducts  are  narrowed  (intrahepatic  obstruction). 
The  bile  pigments  are  absorbed  by  the  lymphatics  and  blood  capillaries.  "The 
absorbed  bile  in  toxaemic  jaundice  is  usually  rich  in  bile  pigments  which  arise 
from  the  increased  destruction  of  haemoglobin ;  it  is  deficient  in  bile  salts  owing 
to  the  impaired  function  of  the  liver  cells"  (Willcox).  The  mucous  membrane 
of  the  duodenum  may  be  swollen  and  show  haemorrhages.  Hunter  groups  the 
causes  as  follows:  1.  Jaundice  produced  by  the  action  of  poisons,  such  as 
toluylendiamin,  phosphorus,  arsenic,  snake-venom.  2.  Jaundice  met  with  in 
various  infections,  such  as  yellow  fever,  malaria,  pyaemia,  relapsing  fever, 
typhus,  typhoid  fever,  scarlatina.  3.  Jaundice  in  various  conditions  of  more 
or  less  infective  nature,  and  variously  designated  as  epidemic,  infectious,  febrile, 
malignant  jaundice,  icterus  gravis,  Weil's  disease,  acute  yellow  atrophy  and 
the  form  due  to  Spirochceta  ictero-liosmorrhagica: 

The  symptoms  are  not  nearly  so  striking  as  in  the  obstructive  variety. 
The  bile  is  present  in  the  stools.  The  skin  has  in  many  cases  only  a  slight 
lemon  tint.  The  urine  may  contain  no  bile-pigment,  but  the  urinary  pigments 
are  considerably  increased.  In  the  severer  forms,  as  in  acute  yellow  atrophy, 
the  color  may  be  more  intense,  but  in  malaria  and  pernicious  anaemia  the  tint 
is  usually  light.  The  constitutional  disturbance  may  be  very  profound,  with 
high  fever,  delirium,  convulsions,  suppression  of  urine,  black  vomit,  and  cuta- 
neous haemorrhages.  In  certain  cases  of  haemolytic  jaundice  the  fragility  of 
the  red  corpuscles  is  greatly  increased  and  they  may  be  smaller  than  normal 
(Widal,  Chauffard)  and  show  granular  degeneration.  This  is  particularly  the 
case  in  the  group  of  congenital  icterus  with  enlarged  spleen. 

The  study  of  digestive  lipaemia  may  be  of  value  in  the  diagnosis  of  the 


548  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

cause  of  jaundice.  A  light  supper  without  fat  is  taken  and  the  blood  exam- 
ined next  morning  before  breakfast  and  again  two  to  five  hours  after  breakfast 
at  which  fat  is  eaten  freely.  Normally  the  blood  contains  many  fat  particles. 
In  total  obstruction  of  the  bile  passages  there  is  no  absorption  of  fat  into  the 
blood.  If  jaundice  is  due  to  retention  of  the  bile  pigment  alone,  absorption 
is  not  altered,  but  if  there  is  retention  of  the  bile  salts  fat  does  not  appear  in 
the  blood.  For  dissociation  of  bile  and  retention  of  part  of  its  elements,  the 
liver  must  be  responsible. 

Certain  special  forms  deserve  notice. 

Tetrachloride  of  Ethane. — The  vapor  inhaled  in  the  coating  of  aeroplane 
wings  is  a  not  uncommon  cause  of  illness.  Headache,  nausea,  and  abdominal 
discomfort  may  be  present  for  a  week  or  more  before  the  jaundice  appears. 
If  quickly  removed  from  the  influence  of  the  vapor,  recovery  is  prompt,  but 
icterus  gravis  may  occur  with  purpura,  convulsions,  suppression  of  urine  and 
coma.  Fever  is  absent  and  there  is  no  anemia,  and  the  jaundice  is  unusually 
deep.  There  is  extensive  degeneration  of  the  liver  cells,  and  if  the  disease 
lasts  many  weeks,  a  "replacement  cirrhosis."  Contraction  of  the  liver  with 
ascites  may  follow. 

Trinitrotoluene. — Many  munition  workers  suffered  severely,  some  from 
the  local  efi^ects,  dermatitis  or  erythema,  many  more  from  the  inhalation  of 
the  dust  or  the  swallowing  of  the  powder.  The  toxic  symptoms  come  on  after 
a  variable  period  of  exposure  from  a  few  days  to  months.  Nausea,  weakness 
and  pallor,  with  signs  of  irritation  of  the  throat  are  early  symptoms.  Then 
jaundice  begins,  and  if  severe,  there  are  the  usual  toxic  features.  The  anaemia 
resembles  the  pernicious  type,  with  a  high  color  index  and  leucopenia.  At 
first  enlarged,  the  liver  may  subsequently  shrink,  and  some  of  the  cases  have 
the  clinical  and.  anatomical  picture  of  acute  yellow  atrophy  with  purpura  and 
haemorrhages.  In  both  these  forms  when  jaundice  is  severe,  full  alkaline 
treatment  is  helpful — sodium  citrate  and  sodium  bicarbonate,  30  grain  (2  gm.) 
doses  of  each  every  two  or  three  hours  and  intravenous  injection  of  normal 
saline  with  two  drams  (8  gm.)  of  bicarbonate  of  soda  to  the  pint  (Willcox). 
Other  substances  used  in  munition  factories  such  as  dinitrophenol,  dinitro- 
benzene  and  picric  acid  may  cause  toxic  jaundice. 

Salvarsan  and  its  substitutes. — Occasional  fever  with  nausea,  irritation  of 
the  skin  and  scattered  purpura  may  follow  a  full  dose.  The  severer  symptoms 
usually  come  on  in  two  or  three  days  with  fever,  delirium,  jaundice  and  death 
in  coma  or  with  convulsions.  The  purpura  may  be  very  extensive  with  haemor- 
rhage from  the  mucous  membranes.  Death  has  followed  within  two  days. 
The  liver  presents  widespread  necroses  with  fatty  degeneration. 

III.     HEEEDITAEY  ICTEKUS 

A  family  form  of  icterus  ha^  long  been  known.  We  must  recognize,  indeed, 
several  groups.  First,  icterus"  neonatorum,  as  in  the  remarkable  instance  de- 
scribed by  Glaister  (Lancet,  March,  1879),  in  which  a  woman  had  eight  chil- 
dren, six  of  whom  died  of  jaundice  shortly  after  birth ;  one  of  the  cases  had  ste- 
nosis of  the  common  duct,  which,  as  John  Thomson  has  shown,  is,  with  angio- 
cholitis,  a  common  lesion  in  this  affection.  Still  more  remarkable  is  it  that  the 
mother  of  this  woman  had  twelve  children,  all  of  whom  were  icteric  after  birth, 
but  the  jaundice  gradually  disappeared.    A  brother  of  the  woman  had  several 


ACUTE  YELLOW  ATEOPHY  549 

children  who  also  were  jaundiced  at  birth.  Glaister  states  that  all  of  the  chil- 
dren of  Morgagni,  fifteen  in  number,  had  icterus  neonatorum.  Secondly,  the 
congenital  acholuric  icterus.  Minkowski  reported  eight  cases  in  three  genera- 
tions. Cases  without  hereditary  basis  are  not  uncommon.  The  jaundice  is 
slight,  the  stools  are  not  clay  colored,  the  urine  has  no  bile  pigment  but  con- 
tains urobilin,  the  general  health  is  little  if  at  all  disturbed.  Splenic  en- 
largement is  a  marked  feature.  There  is  a  tendency  to  hemolysis  of  the  red 
blood  cells.  The  blood  serum  contains  bile  pigment.  jSTo  special  changes  have 
been  found  in  the  liver  or  bile  passages.  Thirdly,  a  group  of  cases  with  en- 
largement of  the  si)leen  and  liver  and  marked  constitutional  disturbances, 
ansemia,  dwarfing  of  stature,  infantilism,  and  slight  jaundice.  Cases  which 
have  been  described  as  Hanot's  cirrhosis  have  occurred  in  two  or  three  mem- 
bers of  a  family,  and  the  jaundice  has  dated  from  early  childhood.  Two  special 
affections  may  here  receive  consideration,  the  icterus  of  the  new-born  and 
acute  yellow  atrophy. 

II.     ICTERUS  NEONATORUM 

New-born  infants  are  liable  to  jaundice,  which  in  some  instances  rapidly 
proves  fatal.    A  mild  and  a  severe  form  may  be  recognized. 

The  mild  or  physiological  icterus  of  the  new-born  is  a  common  disease  in 
foundling  hospitals,  and  is  not  very  infrequent  in  private  practice.  In  900 
consecutive  births  at  the  Sloane  Maternity  icterus  was  noted  in  300  cases 
(Holt).  The  discoloration  appears  early,  usually  on  the  first  or  second  day, 
and  is  of  moderate  intensity.  The  urine  may  be  bile-stained  and  the  faeces 
colorless.  The  nutrition  of  the  child  is  not  usually  disturbed,  and  in  the  ma- 
jority of  cases  the  jaundice  disappears  within  two  weeks.  This  form  is  never 
fatal.  The  cause  of  this  jaundice  is  not  at  all  clear.  Some  have  attributed 
it  to  stasis  in  the  smaller  bile-ducts,  which  are  compressed  by  the  distended 
radicals  of  the  portal  vein.  Others  hold  that  the  jaundice  is  due  to  the  de- 
struction of  a  large  number  of  red  blood-corpuscles  during  the  first  few  days 
after  birth. 

The  severe  form  of  icterus  in  the  new-born  may  depend  upon  (a)  con- 
genital absence  of  the  common  or  hepatic  duct,  of  which  many  instances  are 
on  record;  (&)  congenital  syphilitic  hepatitis;  and  (c)  septic  infection,  as- 
sociated with  phlebitis  of  the  umbilical  vein.  This  is  a  severe  and  fatal  form, 
in  which  hemorrhage  from  the  cord  may  also  occur. 

Curiously  enough,  in  contradistinction  to  other  forms,  the  brain  and  cord 
may  be  stained  yellow  in  icterus  neonatorum,  sometimes  diffusely,  more  rarely 
in  definite  foci  corresponding  to  the  ganglion  cells  which  have  become  deeply 
stained  (Schmorl). 

III.     ACUTE  YELLOW  ATROPHY 

(Malignant  Jaundice;  Icterus  Gravis) 

Definition. — An  acute  widespread  autolytic  necrosis  of  the  liver  cells  of 
unknown  origin,  characterized  by  jaundice,  toxgemia  and  a  reduction  in  the 
volume  of  the  liver. 


550  DISEASES  OF  THE  DIGESTIA^E   SYSTEM 

Etiology. — The  first  authentic  account  was  given  by  the  famous  old  Paris 
doctor  Ballonius — sometimes  called  the  French  Hippocrates  (1538-1616). 
Bright  gave  a  good  description  in  1836.  It  is  a  rare  disease,  as  among  28,000 
medical  cases  admitted  to  the  Johns  Hopkins' Hospital  in  nearly  twenty-three 
years  there  were  only  3  cases.  It  varies  in  frequency  in  different  countries, 
and  seems  to  be  rarer  in  the  United  States  than  in  Germany  and  England. 
The  majority  of  cases  occur  between  the  tenth  and  the  fortieth  year.  Eolleston 
collected  22  cases  occurring  within  the  first  ten  years  of  life. 

Acute  necrosis  of  the  liver  occurs  under  many  conditions:  (a)  In  the  in- 
fections, syphilis,  typhoid  fever,  diphtheria,  septicsemia,  these  necroses  may 
be  widespread.  (&)  Non-bacterial  poisons.  The  remarkable  delayed  chloro- 
form poisoning  is  a  hepatic  necrosis  resembling  very  closely  acute  yellow 
atrophy.  Phosphorus  produces  a  similar  condition,  and  possibly  mercury,  (c) 
Autogenous  poisons,  produced  in  connection  with  pregnancy  and  parturition. 
The  ordinary  necrotic  foci  of  the  liver  in  pregnancy  are  the  same  kind  but 
less  in  degree  than  those  of  acute  yellow  atrophy. 

An  exaggeration  of  any  of  these  types  may  lead  to  a  clinical  condition 
which  we  call  acute  yellow  atrophy.  Its  association  with  pregnancy  is  re- 
markable. More  than  one-half  of  the  cases  occur  in  women,  and  in  a  large  pro- 
portion of  these  during  the  middle  or  latter  half  of  pregnancy.  The  disease 
has  followed  a  profound  shock,  or  mental  emotion.  It  occurs  occasionally  in 
syphilis  and  other  acute  infections,  and  there  are  cases  of  cirrhosis  of  the  liver, 
particularly  of  the  hypertrophic  form,  associated  with  diffuse  necrosis,  intense 
jaundice  and  toxgemia.  We  are  as  yet  ignorant  of  the  conditions  under  which 
the  poisons,  bacterial  or  metabolic,  cause  this  widespread  necrosis. 

Morbid  Anatomy. — The  liver  is  greatly  reduced  in  size,  looks  thin  and 
flattened,  and  sometimes  does  not  reach  more  than  one-half  or  even  one-third 
of  its  normal  weight.  It  is  flabby  and  the  capsule  is  wrinkled.  Externally  the 
organ  has  a  greenish-yellow  color.  On  section  the  color  may  be  yellowish- 
brown,  yellowish-red,  or  mottled,  and  the  outlines  of  the  lobules  are  indistinct. 
The  yellow  and  dark-red  portions  represent  different  stages  of  the  same  process 
— the  yellow  an  earlier,  the  red  a  more  advanced  stage.  The  organ  may  cut 
with  considerable  firmness.  The  liver-cells  are  seen  in  all  stages  of  necrosis, 
and  in  spots  appear  to  have  undergone  complete  destruction,  leaving  a  fatty, 
granular  debris  with  pigment  grains  and  crystals  of  leucin  and  tyrosin. 
Haemorrhages  occur  between  the  liver-cells.  There  is  a  cholangitis  of  the 
smaller  bile-ducts.  Marchand,  MacCallum,  and  others  have  described  re- 
generative changes  in  the  cases  which  do  not  run  an  acute  course. 

The  other  organs  show  extensive  bile-staining,  and  there  are  numerous 
hEemorrhages.  The  kidneys  may  show  marked  granular  degeneration  of  the 
epithelium,  and  usually  there  is  fatty  degeneration  of  the  heart.  In  a  major- 
ity of  the  cases  the  spleen  is  enlarged. 

Symptoms. — In  the  initial  stage  there  is  gastro-duodenal  catarrh,  and 
at  first  the  jaundice  is  thought  to  be  of  a  simple  nature.  In  some  instances 
this  lasts  only  a  few  days,  in  others  two  or  three  weeks.  Then  severe  symp- 
toms set  in — headache,  delirium,  trembling  of  the  muscles,  and,  in  some  in- 
stances, convulsions.  Vomiting  is  a  constant  symptom,  and  blood  may  be 
brought  up.  Haemorrhages  occur  into  the  skin  or  from  the  mucous  surfaces; 
in  pregnant  women  abortion  may  occur.    The  jaundice  usually  increases,  coma 


ACUTE  YELLOW  ATEOPHY  551 

sets  in  and  gradually  deepens  until  death.  The  body  temperature  is  variable ; 
in  a  majority  of  the  cases  the  disease  runs  an  afebrile  course,  though  sometimes 
Just  before  death  there  is  an  elevation.  In  some  instances,  however,  there 
has  been  marked  pyrexia.  The  pulse  is  usually  rapid,  the  tongue  coated  and 
dry,  and  the  patient  is  in  a  "typhoid  state."  There  may  be  complete  oblitera- 
tion of  the  liver  dulness.  This  is  due  to  the  flabby  organ  falling  away  from 
the  abdominal  walls  and  allowing  the  intestinal  coils  to  take  its  place. 

The  urine  is  bile-stained  and  often  contains  tube-casts.  Frequently  albu- 
minuria and  occasionally  albumosuria  occur.  Urea  is  markedly  diminished. 
There  is  a  corresponding  increase  in  the  percentage  of  nitrogen  present  as 
ammonia.  Herter  finds  it  may  be  increased  from  the  normal  2  to  5  per  cent, 
up  to  17  per  cent.  The  diminution  in  urea  is  probably  partly  due  to  the  liver- 
cells  failing  to  manufacture  urea  from  ammonia,  but  it  may  also  be  in  part 
due  to  organic  acids  seizing  on  the  ammonia,  and  thus  preventing  the  forma- 
tion of  urea  out  of  the  basic  ammonia.  Leucin  and  tyrosin  are  not  constantly 
present;  of  23  cases  collected  by  Hunter,  in  9  neither  was  found;  in  10  both 
were  present ;  in  3  tyrosin  only ;  in  1  leucin  only.  The  present  view  is  that  the 
leucin  and  tyrosin  are  derived  from  the  liver-cells  themselves  as  a  result  of 
their  extensive  destruction.  In  the  majority  of  cases  no  bile  enters  the  intes- 
tines, and  the  stools  are  clay-colored.  The  disease  is  almost  invariably  fatal. 
In  a  few  instances  recovery  has  been  noted.  The  senior  author  saw  in  Leube's 
clinic,  at  Wiirzburg,  a  patient  who  was  convalescent. 

The  duration  and  the  type  of  the  disease  depend  upon  the  extent  and  the 
rapidity  of  progress  of  the  necrosis.  Cases  have  lasted  as  long  as  forty  days, 
while  death  has  occurred  as  early  as  the  second  day.  A  sub-acute  form  has 
been  described  by  Milne,  a  slow  necrosis  lasting  many  months,  associated  with 
jaundice — a  protracted  stage  from  which  recovery  is  possible  by  regeneration 
of  liver  tissue,  but  consecutive  cirrhosis  is  the  rule. 

Diagnosis. — Jaundice  with  vomiting,  diminution  of  the  liver  volume,  de- 
lirium, and  the  presence  of  leucin  and  tyrosin  in  the  urine,  form  a  character- 
istic and  unmistakable  group  of  symptoms.  Leucin  and  tyrosin  are  not,  how- 
ever, distinctive.  They  may  be  present  in  cases  of  ■  afebrile  jaundice  with 
slight  enlargement  of  the  liver. 

It  is  not  to  be  forgotten  that  any  severe  jaundice  may  be  associated  with 
intense  cerebral  symptoms.  The  clinical  features  in  certain  cases  of  hyper- 
trophic cirrhosis  are  almost  identical,  but  the  enlargement  of  the  liver,  the 
more  constant  occurrence  of  fever,  and  the  absence  of  leucin  and  tyrosin  are 
distinguishing  signs.  Phosphorus  poisoning  may  closely  simulate  acute  yellow 
atrophy,  particularly  in  the  haemorrhages,  jaundice,  and  the  diminution  in  the 
liver  volume,  but  the  gastric  symptoms  are  usually  more  marked,  and  leucin 
and  tyrosin  are  stated  not  to  occur  in  the  urine. 

Treatment. — No  known  remedies  have  any  influence  on  the  course  of  the 
disease.  Theoretically,  efforts  should  be  made  to  eliminate  the  toxins  before 
they  produce  their  degenerative  effects  by  free  elimination,  the  giving  of  al- 
kalies and  the  use  of  subcutaneous  and  intravenous  saline  injections.  Gastric 
sedatives  may  be  used  to  allay  the  distressing  vomiting. 


55S  DIvSEASES  OE  THE  DIGESTIVE  SYSTEM 


IV.     AFFECTIONS  OF  THE  BLOOD-VESSELS  OF  THE  LIVER 

Anaemia. — When  the  liver  looks  angemic,  as  in  the  fatty  or  amyloid  organ, 
the  blood-vessels,  which  during  life  were  probably  well  filled,  can  be  readily 
injected.     There  are  no  symptoms  indicative  of  this  condition. 

Hyperaemia. —  (a)  Active  Hyperemia. — After  each  meal  the  rapid  ab- 
sorption by  the  portal  vessels  induces  transient  congestion  of  the  organ,  which, 
however,  is  entirely  physiological :  but  it  is  quite  possible  that  in  persons  who 
persistently  eat  and  drink  too  much  this  active  hyperaemia  may  lead  to  func- 
tional disturbance,  or,  in  the  case  of  drinking  too  freely  of  alcohol,  to  organic 
change.    In  the  fevers  an  acute  hyperasmia  may  be  present. 

The  symptoms  are  indefinite.  Possibly  the  sense  of  distress  or  fullness  in 
the  right  hypochondrium,  so  often  mentioned  by  dyspeptics  and  by  those  who 
eat  and  drink  freely,  may  be  due  to  this  cause.  There  are  probably  diurnal 
variations  in  the  volume  of  the  liver.  In  cirrhosis  with  enlargement  the  rapid 
reduction  in  volume  after  a  copious  haemorrhage  indicates  the  important  part 
which  hyperaemia  plays  even  in  organic  troubles.  Andrew  H.  Smith  described 
a  case  of  periodical  enlargement  of  the  liver. 

(&)  Passive  Coxgestion. — This  is  much  more  common  and  results  from 
an  increase  of  pressure  in  the  efferent  vessels  or  sub-lobular  branches  of  the 
hepatic  veins.  Every  condition  leading  to  venous  stasis  in  the  right  heart  at 
once  affects  these  veins. 

In  chronic  valvular  disease,  myocardial  insufficiency,  cirrhosis  of  the  lung. 
and  in  intrathoracic  tumors  mechanical  congestion  occurs  and  finally  leads  to 
very  definite  changes.  The  liver  is  enlarged,  firm,  and  of  a  deep-red  color ;  the 
hepatic  vessels  are  greatly  engorged,  particularly  the  central  vein  in  each  lob- 
ule and  its  adjacent  capillaries.  On  section  the  organ  presents  a  peculiar 
mottled  appearance,  owing  to  the  deeply  congested  hepatic  and  the  anaemic 
portal  territories;  hence  the  term  nutmeg  given  to  this  condition.  Gradually 
the  distention  of  the  central  capillaries  reaches  such  a  grade  that  atrophy  of 
the  intervening  liver-cells  is  induced.  Brown  pigment  is  deposited  about  the 
centre  of  the  lobules  and  the  connective  tissue  is  greatly  increased.  In  this 
cyanotic  induration  or  cardiac  liver  the  organ  is  large  in  the  early  stage,  but 
later  it  may  become  contracted.  Occasionally  in  this  form  the  connective 
tissue  is  increased  about  the  lobules  as  well,  but  the  process  usually  extends 
from  the  sub-lobular  and  central  veins. 

The  symptoms  of  this  form  are  not  always  to  be  separated  from  those  of 
the  associated  conditions.  Gastro-intestinal  catarrh  is  usually  present  and 
haamatemesis  may  occur.  The  portal  obstruction  in  advanced  cases  leads  to 
ascites,  which  may  precede  the  development  of  general  dropsy.  There  is  often 
slight  jaundice,  the  stools  may  be  clay-colored,  and  the  urine  contains  bile- 
pigment.  The  liver  is  increased  in  size,  may  be  a  full  hand's  breadth  below 
the  costal  margin  and  tender  on  pressure.  It  is  in  this  condition  particularly 
that  we  meet  with  pulsation  of  the  liver.  We  must  distinguish  the  communi- 
cated throbbing  of  the  heart,  which  is  very  common,  from  the  heaving,  dif- 
fuse impulse  due  to  regurgitation  into  the  hepatic  veins,  in  which  the  whole 
liver  can  be  felt  to  dilate  with  each  impulse. 

The  indications  for  treatment  in  hyperaemia  are  to  restore  the  balance  of 


DISEASES  OF  THE  BILE-PASSAGES  AXD  GALL-BLADDEE     553 

the  circulation  aud  to  unload  the  engorged  portal  vessels.  In  cases  of  intense 
hypersemia  18  or  20  ounces  of  blood  may  be  directly  aspirated  from  the  liver, 
as  advised  by  George  Harley  and  practised  by  many  Anglo-Indian  physicians. 
Good  results  sometimes  follow  this  hepato-phlebotomy.  The  prompt  relief  and 
marked  reduction  in  the  volume  of  the  organ  which  follow  an  attack  of 
ha3matemesis  or  bleeding  from  piles  suggest  this  practice.  Salts  administered 
by  Matthew  Hay's  method  deplete  the  portal  system  freely  and  thoroughly. 
As  a  rule,  the  treatment  must  be  that  of  the  condition  with  which  it  is  asso- 
ciated. 

Diseases  of  the  Portal  Vein. — (a)  Thrombosis;  Adhesive  Pylephlebi- 
tis.— Coagulation  of  blood  in  the  portal  vein  is  met  with  in  cirrhosis,  in 
syphilis  of  the  liver,  invasion  of  the  vein  by  cancer,  proliferative  peritonitis 
involving  the  gastro-hepatic  omentum,  perforation  of  the  vein  by  gall-stones, 
and  occasionally  follows  sclerosis  of  the  walls  of  the  portal  vein  or  of  its 
branches.  In  rare  instances  a  complete  collateral  circulation  is  established, 
the  thrombus  undergoes  the  usual  change,  and  ultimately  the  vein  is  represent- 
ed by  a  fibrous  cord,  a  condition  which  has  been  called  pyleplilehitis  adhesiva. 
In  a  case  of  this  kind  the  portal  vein  was  represented  by  a  narrow  fibrous  cord ; 
the  collateral  circulation,  which  must  have  been  completely  established  for 
years,  ultimately  failed,  ascites  and  haematemesis  supervened  and  rapidly 
proved  fatal.  The  diagnosis  of  obstruction  of  the  portal  vein  can  rarely  be 
made.  A  suggestive  symptom,  however,  is  a  sudden  onset  of  the  most  intense 
engorgement  of  the  branches  of  the  portal  system,  leading  to  haematemesis, 
melsema,  ascites,  and  swelling  of  the  spleen. 

Infarcts  are  not  common  in  the  liver  and  may  be  anaemic  or  haemor- 
rhagic.  They  are  met  with  in  obstruction  of  the  portal  vessels,  or  of  the  portal 
and  hepatic  veins  at  the  same  time,  occasionally  in  disease  of  the  hepatic  ar- 
tery. 

(&)   Suppurative  pylephlebitis  is  considered  in  the  section  on  afescess. 

Affections  of  the  hepatic  vein  are  extremely  rare.  Dilatation  occurs  in 
cases  of  chronic  enlargement  of  the  right  heart,  from  whatever  cause.  Emboli 
occasionally  pass  from  the  right  auricle  into  the  hepatic  veins. 

Stenosis  of  the  orifices  of  the  hepatic  veins  may  occur  as  a  primary  lesion 
with  a  special  syndrome  described  by  Craven  Moore — a  progressive  enlarge- 
ment of  the  liver,  signs  of  involvement  of  the  inferior  vena  cava,  and  ascites: 

Hepatic  Artery. — Enlargement  of  this  vessel  is  seen  in  cases  of  cirrhosis 
of  the  liver.  It  may  be  the  seat  of  extensive  sclerosis.  Aneurism  of  the 
hepatic  artery  is  rare  and  will  be  referred  to  in  the  section  on  arteries. 

V.     DISEASES  OF  THE  BILE-PASSAGES  AND  GALL-BLADDER 

I.      ACUTE    CATARRH    OF    THE    BILE-DUCTS 

(Catarrhal  Jaundice) 

Definition. — Jaundice  due  to  swelling  and  obstruction  of  the  terminal  por- 
tion of  the  common  duct. 

Etiology. — General  catarrhal  inflammation  of  the  bile-ducts  is  usually  as- 
sociated with  gall-stones.    The  process  now  under  consideration  is  usually  an 


554  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

extension  of  a  gastro-dnodeual  catarrh,  and  the  process  is  most  intense  in  the 
pars  intestinalis  of  the  duct,  which  projects  into  the  duodenum.  The  mucous 
memhrane  is  swollen,  and  a  plug  of  inspissated  mucus  fills  the  diverticulum  of 
Vater,  and  the  narrower  portion  just  at  the  orifice,  completely  obstructing  the 
outflow  of  bile.  It  is  not  known  how  widespread  this  catarrh  is  in  the  bile- 
passages,  and  whether  it  really  passes  up  the  ducts.  It  is  possible  that  an  in- 
fection of  the  finer  ducts  within  the  liver  may  initiate  the  attack,  but  the  evi- 
dence for  this  is  not  strong,  and  it  seems  more  likely  that  the  terminal  portion 
of  the  duct  is  first  involved.  In  one  case  at  post  mortem  the  orifice  was  found 
plugged  with  inspissated  mucus,  the  common  and  hepatic  ducts  were  slightly 
distended  and  contained  a  bile-tinged,  not  a  clear,  mucus,  and  there  were  no 
observable  changes  in  the  mucosa  of  the  ducts. 

This  catarrhal  or  simple  jaundice  results  from  the  follov/ing  causes :  (a) 
Duodenal  catarrh,  in  whatever  M^ay  produced,  most  commonly  following  an  at- 
tack of  indigestion.  It  is  most  frequently  met  with  in  young  persons,  but 
may  occur  at  any  age,  and  may  follow  not  only  errors  in  diet,  but  also  cold, 
exposure,  and  malaria,  as  well  as  the  conditions  associated  with  portal  ob- 
struction, chronic  heart-disease,  and  nephritis.  (&)  Emotional  disturbances 
may  be  followed  by  jaundice,  which  is  believed  to  be  due  to  catarrhal  swelling. 
Cases  of  this  kind  are  rare  and  the  anatomical  condition  is  imknown.  (c) 
Simple  or  catarrhal  jaundice  may  occur  in  epidemic  form,  {d)  Catarrhal 
jaundice  is  occasionally  seen  in  the  infectious  fevers,  such  as  pneumonia  an.d 
typhoid  fever.  The  nature  of  acute  catarrhal  jaundice  is  still  unknown,  but 
it  is  probably  an  acute  infection.  In  favor  of  this  view  are  the  occurrence  in 
epidemic  form  and  the  presence-  of  slight  fever.  The  spleen,  however,  is  not 
often  enlarged.    In  only  4  out  of  23  cases  was  it  palpable. 

Symptoms. — There  may  be  neither  pain  nor  distress,  and  the  patient's 
friends  may  first  notice  the  yellow  tint,  or  the  patient  himself  may  observe  it 
in  the  looking-glass.  In  other  instances  there  are  dyspeptic  symptoms  and 
uneasy  sensations  in  the  hepatic  region  or  pains  in  the  back  and  limbs.  In  the 
epidemic  form  the  onset  may  be  more  severe,  with  headache,  chill,  and  vomit- 
ing. Eever  is  rarely  present,  though  the  temperature  may  reach  101°,  some- 
times 102°.  All  the  signs  of  obstructive  jaundice  are  present,  the  stools  are 
clay-colored,  and  the  urine  contains  bile-pigment.  The  skin  has  a  bright-yel- 
low tint ;  the  greenish,  bronzed  color  is  never  seen  in  the  simple  form.  Spider 
angiomata  may  occur  on  the  face  in  catarrhal  jaundice.  They  disappear  in  a 
few  months.  The  pulse  may  be  normal,  but  occasionally  it  is  remarkably  slow, 
and  may  fall  to  40  or  30  beats  in  the  minute,  and  the  respirations  to  as  low 
as  8  per  minute.  Sleepiness  may  be  present  and  rarely  a  comatose  state.  The 
liver  may  be  normal  in  size,  but  is  usually  slightly  enlarged,  and  the  edge  can 
be  felt  below  the  costal  margin.  Occasionally  the  enlargement  is  more  marked. 
As  a  rule  the  gall-bladder  can  not  be  felt.  The  spleen  may  be  increased  in 
size.  The  duration  is  from  four  to  eight  weeks.  There  a;re  mild  cases  in 
which  the  jaundice  disappears  within  two.  weeks;  on  the  other  hand,  it  may 
persist  for  three  months  or  even  longer.  The  stools  should  be  carefully 
watched,  for  they  give  the  first  intimation  of  removal  of  the  obstruction. 

Diagnosis. — This  is  rarely  difficult.  The  onset  in  young,  comparatively 
healthy  persons,  the  moderate  grade  of  icterus,  the  absence  of  emaciation  or  of 
evidences  of  cirrhosis  or  cancer  usually  make  the  diagnosis  easy.    Cases  which 


DISEASES  OF  THE  BILE-PASSAGES  AND  GALL-BLADDEE      555 

persist  for  two  or  three  months  cause  uneasiness,  as  the  suspicion  is  aroused 
that  it  may  be  more  than  simple  catarrh.  The  absence  of  pain,  the  negative 
character  of  the  physical  examination,  and  the  maintenance  of  the  general 
nutrition  are  the  points  in  favor  of  simple  jaundice.  There  are  instances  in 
which  time  alone  can  determine  the  true  nature  of  the  case.  The  possibility 
of  other  forms  must  be  borne  in  mind  in  anomalous  types. 

Treatment. — The  diet  should  be  simple  and  the  fats  restricted.  Measures 
should  be  used  to  allay  gastric  catarrh,  if  it  is  present.  A  dose  of  calomel  may 
be  given,  and  the  bowels  kept  open  subsequently  by  salines.  The  patient 
should  not  be  violently  purged.  Daily  lavage  of  the  stomach  with  water  at 
95°  is  useful.  Bismuth  and  bicarbonate  of  soda  may  be  given,  and  the  pa- 
tient should  drink  freely  of  the  alkaline  mineral  waters,  of  which  Yichy  is  the 
best.  The  method  devised  by  Lyon,  in  which  a  25  per  cent,  solution  of  mag- 
nesium sulphate  is  introduced  into  the  duodenum,  relaxing  the  sphincter  of 
the  common  duct,  by  which  large  amounts  of  bile  can  be  drained  from  the 
bile  passages  is  of  great  value.  By  the  use  of  this  method  the  duration  is 
usually  greatly  shortened. 

II.      CHEONIC    CATARRHAL   ANGIOCHOLITIS 

This  may  possibly  occur  also  as  a  sequel  of  the  acute  catarrh  but  it  is  un- 
usual to  see  a  chronic,  persistent  jaundice  attributed  to  this  cause.  A  chronic 
catarrh  always  accompanies  obstruction  in  the  common  duct,  whether  by  gall- 
stones,'malignant  disease,  stricture,  or  external  pressure.  There  are  two 
groups  of  cases : 

With  Complete  Obstruction  of  the  Common  Duct. — In  this  form  the  bile- 
passages  are  greatl}^  dilated,  the  common  duct  may  reach  the  size  of  the  thumb 
or  larger,  there  is  usually  dilatation  of  the  gall-bladder  and  of  the  ducts  within 
the  liver.  The  contents  of  the  ducts  and  of  the  gall-bladder  are  a  clear,  color- 
less mucus.  The  mucosa  may  be  everywhere  smooth  and  not  swollen.  The 
clear  mucus  is  usually  sterile.  The  patients  are  the  subjects  of  chronic  jaun- 
dice, usuall}^  without  fever. 

With  Incomplete  Obstruction  of  the  Duct. — There  is  pressure  on  the  duct 
or  there  are  gall-stones,  single  or  multiple,  in  the  common  duct  or  in  the  di- 
verticulum of  Abater.  The  bile-passages  are  not  so  much  dilated,  and  the  con- 
tents are  a  bile-stained,  turbid  mucus.  The  gall-bladder  is  rarely  much  di- 
lated.   In  a  majority  of  all  cases  stones  are  found  in  it. 

The  symptoms  of  this  type  of  angiocholitis  are  sometimes  very  distinctive. 
With  it  is  associated  most  frequently  the  so-called  hepatic  intermittent  fever, 
recurring  attacks  of  chills,  fever,  and  sweats.  It  is  important  to  bear  in  mind 
that  the  chills,  fever,  and  SAveats  do  not  necessarily  mean  suppuration. 

III.      SUPPURATIVE   AND   ULCERATIVE   ANGIOCHOLITIS 

The  condition  is  a  diffuse,  purulent  angiocholitis  involving  the  larger  and 
smaller  ducts.  In  a  large  proportion  of  all  cases  there  is  associated  suppura- 
tive disease  of  the  gall-bladder.  In  all  forms  of  infection  of  the  bile  passages 
cultures  of  the  duodenal  contents  may  give  information  as  to  the  infecting 
organism. 


556  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

Etiology. — It  is  the  most  serious  of  the  sequels  of  gall-stones.  Occa- 
sionally a  diffuse  suppurative  angiocholitis  follows  the  acute  infectious  chole- 
cystitis; this,  however,  is  rare,  since  fortunately  in  the  latter  condition  the 
cystic  duct  is  usually  occluded.  Cancer  of  the  duct,  or  foreign  bodies,  such  as 
lumbricoids  or  fish  bones,  are  occasional  causes.  There  may  be  extension  from 
a  suppurative  pylephlebitis.  In  rare  instances  suppurative  cholangitis  occurs 
in  the  acute  infections,  as  pneumonia  and  influenza. 

The  common  duct  is  greatly  dilated  and  may  reach  the  size  of  the  index 
finger  or  the  thumb ;  the  walls  are  thickened,  and  there  may  be  fistulous  com- 
munications with  the  stomach,  colon,  or  duodenum.  The  hepatic  ducts  and 
their  extensions  in  the  liver  are  dilated  and  contain  pus  mixed  with  bile.  On 
section  of  the  liver  small  abscesses  are  seen,  which  correspond  to  the  dilated 
suppurating  ducts.  The  gall-bladder  is  usually  distended,  full  of  pus,  and  with 
adhesions  to  the  neighboring  parts,  or  it  may  have  perforated. 

Symptoms. — The  symptoms  of  suppurative  cholangitis  are  usually  very 
severe.  A  previous  history  of  gall-stones,  the  development  of  a  septic  fever,  the 
swelling  and  tenderness  of  the  liver,  the  enlargement  of  the  gall-bladder,  and 
the  leucocytosis  are  suggestive  features.  Jaimdice  is  always  present,  but  is 
variable.  In  some  cases  it  is  very  intense,  in  others  it  is  slight.  There  may 
be  very  little  pain.  There  are  progressive  emaciation  and  loss  of  strength.  In 
one  case  parotitis  developed  which  subsided  without  suppuration. 

Treatment. — With  infection  of  the  bile  passage,  the  diet  should  be  simple 
and  water  taken  freely.  Hexamine  may  be  given  in  full  dosage.  In  some  cases 
drainage  of  the  gall-bladder  has  been  of  use.  Vaccines  prepared  from  duodenal 
cultures  may  be  tried.  The  procedure  used  by  Lyon  to  aid  drainage  of  the 
bile-passages  is  often  very  useful. 

IV.     ACUTE  INFECTIOUS   CHOLECYSTITIS 

Etiology. — Acute  inflammation  of  the  gall-bladder  is  usually  due  to  bac- 
terial invasion,  with  or  without  the  presence  of  gall-stones.  Three  varieties  or 
grades  may  be  recognized:  the  catarrhal,  the  suppurative,  and  the  phlegmo- 
nous. The  condition  is  very  serious,  may  be  fatal,  and  may  require  prompt 
surgical  intervention  for  its  relief. 

Acute  non-calculous  cholecystitis  is  a  result  of  bacterial  invasion.  The 
colon  bacillus,  the  typhoid  bacillus,  the  pneumococcus  and  staphylococci  and 
streptococci  have  been  the  organisms  most  often  found.  The  frequency  of 
gall-bladder  infection  in  the  fevers  is  a  point  already  referred  to,  particularly 
in  typhoid  fever.  In  many  cases  the  organisms  are  found  in  the  wall  of  the 
gall-bladder  when  the  contents  are  sterile. 

The  association  of  appendix  lesions  with  cholecystitis  is  interesting,  fully 
69  per  cent,  at  the  Mayo  clinic ;  but  this  is  not  surprising  in  view  of  studies 
which  show  a  normal  appendix  to  be  a  rarity.  There  are  indications,  how- 
ever, that  chronic  changes  in  this  organ  may  reflexly  disturb  the  mechanism 
of  the  secretion,  storage,  and  outflow  of  bile. 

Condition  of  the  Gall-bladder. — The  organ  is  usually  distended  and  the 
walls  tense.  Adhesions  may  have  formed  with  the  colon  or  the  omentum.  In 
the  acute  stage  the  mucous  membrane  is  swollen  and  the  amount  of  mucin 
increased.    As  the  process  continues  the  mucosa  becomes  thickened,  the  epithe- 


DISEASES  OF  THE  BTLE-FASSA(rRS  AND  GALL-BLADDEK      557 

Hum  desquamates,  there  are  areas  of  necrosis,  and  the  villi  may  be  much  hy- 
pertrophied  and  stand  out,  giving  a  strawberry  appearance.  With  the  obstruc- 
tion of  the  duct  and  pyogenic  infection  there  may  be  acute  necrotic  cholecysti- 
tis, with  rapid  perforation,  or  a  more  chronic  purulent  cholecystitis — empyema 
of  the  gall-bladder. 

Symptoms. — Severe  paroxysmal  pain  is,  as  a  rule,  the  first  indication,  most 
commonly  in  the  right  side  of  the  abdomen  in  the  region  of  the  liver.  It 
may  be  in  the  epigastrium  or  low  down  in  the  region  of  the  appendix.  "Nausea, 
vomiting,  rise  of  pulse  and  temperature,  prostration,  distention  of  the  abdo- 
men, rigidity,  general  tenderness  becoming  localized''  usually  follow  (Eichard- 
son).  In  this  form,  without  gall-stones,  jaundice  is  not  often  present.  Leu- 
cocytosis  is  common.  The  local  tenderness  is  extreme,  but  it  may  be  deceptive 
in  its  situation.  Associated  probably  with  the  adhesion  and  inflammatory  proc- 
esses between  the  gall-bladder  and  the  bowel  are  the  intestinal  symptoms,  and 
there  may  be  complete  stoppage  of  gas  and  faeces;  indeed,  the  operation  for 
acute  obstruction  has  been  performed  in  several  cases.  The  distended  gall- 
bladder may  sometimes  be  felt.  As  a  sequel  there  may  be  purulent  distention 
or  empyema. 

Diagnosis. — This  is  by  no  means  easy,  as  the  symptoms  may  not  indicate 
the  section  of  the'  abdomen  involved.  Appendicitis  or  acute  intestinal  obstruc- 
tion may  be  diagnosed.  The  history  is  often  a  valuable  guide.  Occurring  dur- 
ing convalescence  from  typhoid  fever,  after  pneumonia,  or  in  a  patient  with 
previous  cholecystitis,  such  a  group  of  symptoms  as  mentioned  would  be  highly 
suggestive.  The  difl'erentiation  of  the  variety  of  the  cholecystitis  can  not  be 
made.  In  the  acute  suppurative  and  phlegmonous  forms  the  symptoms  are 
usually  more  severe,  perforation  is  very  apt  to  occur,  with  local  or  general 
peritonitis,  and  unless  operative  measures  are  undertaken  death  ensues. 

There  is  an  acute  cholecystitis,  probably  an  infective  form,  in  which  the 
patient  has  recurring  attacks  of  pain  in  the  region  of  the  gall-bladder.  The 
diagnosis  of  gall-stones  is  made,  but  an  operation  shows  simply  an  enlarged 
gall-bladder  filled  with  mucus  and'  bile,  and  the  mucous  membrane  perhaps 
swollen  and  inflamed.  In  some  of  these  cases  gall-stones  may  have  been  pres- 
ent and  have  passed  before  the  operation. 

Treatment. — In  the  milder  catarrhal  forms  the  inflammation  subsides 
spontaneously;  in  severer  form  operation  is  indicated  and  the  results  are  ex- 
cellent. Increase  in  the  local  signs,  an  enlarged  palpable  gall-bladder,  increas- 
ing leucocytosis  and  fever,  are  usually  indications  for  operation.  In  675 
cholecystectomies  at  the  Mayo  clinic  there  were  only  17  deaths. 

V.    CHRONIC  CHOLECYSTITIS 

This  occurs  in  a  number  of  different  forms,  as,  for  example,  an  atrophic 
sclerotic  and  an  ulcerative  form. 

Etiology. — It  often  results  from  a  previous  attack  of  acute  cholecystitis 
or  may  be  associated  with  gall-stones.  In  some  cases  it  is  undoubtedly  chronic 
from  the  onset,  resulting  from  a  persistent  infection  which  is  never  acute 
enough  to  set  up  an  active  attack.  It  may  be  associated  with  chronic  infec- 
tion of  the  ducts. 

Pathology. — The  gall-bladder  is  usually  distended  and  contains  thick  bile 


558  ■         DISEASES  OF  THE  DIGESTIVE   SYSTEM 

and  mucus.  The  walls  ma}^  be  thickened.  The  mucosa  may  be  atrophic  and 
sometimes  the  gall-bladder  is  small  and  sclerotic;  it  may  be  surrounded  by  a 
mass  of  dense  adhesions.  The  relationship  between  the  lymphatics  of  the  gall- 
bladder and  pancreas  is  important  in  explaining  the  association  of  infection 
in  these  organs. 

Symptoms. — These  are  much  the  same  as  those  from  gall-stones  and  a 
differential  diagnosis  may  be  imj)ossible.  There  may  be  attacks  of  acute  pain. 
In  the  intervals  there  may  be  an  entire  absence  of  any  tenderness  in  the  gall- 
bladder region.  Sometimes  the  gall-bladder  is  palpable.  Of  special  importance 
is  the  frequency  of  gastric  symptoms.  W.  J.  ]\Iayo  has  called  attention  to  a 
form  of  chronic  cholecystitis  without  gall-stones  and  accompanied  with  chronic 
interlobular  pancreatitis.  The  mucous  membrane  shows  a  strawberry-like  ap- 
pearance covered  with  yellow  specks  representing  the  tufts  of  exposed  villi 
stripped  of  their  covering  of  epithelium.  The  process  is  confined  to  the  gall- 
bladder ;  the  glands  along  the  ligament  may  be  enlarged.  The  chief  symptom 
is  pain  in  the  region  of  the  gall-bladder,  but  there  is  no  distention  and  the 
chronic  pancreatitis  is  not  always  expressed  clinically. 

Treatment. — The  medical  management  is  much  the  same  as  in  gall-stones ; 
a  simple  diet,  large  amounts  of  water,  keeping  the  bowels  freely  open  and 
taking  regular  exercise.  The  administration  of  salicylate  of  sodium  and  hexa- 
mine  seems  sometimes  to  be  of  use.  The  taking  of  salines  before  breakfast 
is  often  helpful.  The  decision  as  to  surgical  interference  must  depend  on  the 
severity  of  the  symptoms  and  the  interference  with  health  due  to  the  condi- 
tion. In  some  cases  adhesions  are  present  between  the  gall-bladder  and  the 
colon,  pylorus  and  duodenum,  which  are  usually  best  recognized  by  the  X-ray 
examination.  Operation  may  be  justified  to  correct  them.  If  there  is  distinct 
evidence  of  a  chronic  suppurative  process  in  the  gall-bladder,  surgical  measures 
are  indicated  and  should  not  be  delayed. 

VI.      CANCER   OF   THE   BILE-PASSAGES 

Incidence. — Of  3,908  operations  on  the  gall-bladder  and  biliary  passages, 
in  85  or  2.1  per  cent,  cancer  was  found  (Mayo).  It  is  more  common  in 
women,  3  to  1  (Musser),  and  in  three-fourths  of  the  cases  gall-stones  are  or 
have  been  present.    The  fundus  of  the  bladder  is  usually  attacked  first. 

Symptoms. — When  the  disease  involves  the  gall-Madder,  a  tumor  can  be 
detected  extending  diagonally  downward  and  inward  toward  the  navel,  variable 
in  size,  occasionally  very  large,  due  either  to  great  distention  of  the  gall- 
bladder or  to  involvement  of  contiguous  parts.  It  is  usually  very  firm  and 
hard.  Jaundice  is  usually  due  to  involvement  of  the  liver;  it  was  present  in 
69  per  cent,  of  Musser's  cases;  pain  is  often  of  great  severity  and  paroxysmal 
ill. character.  The  pain  and  tenderness  on  pressure  persist  in  the  intervals  be- 
tween the  paroxysmal  attacks.  There  is  loss  of  weight,  sometimes  fever  and 
sweats.  When  the  liver  becomes  involvecl  the  picture  is  that  of  carcinoma  of 
the  organ. 

Primary  malignant  disease  in  the  hile-ducts  is  less  common,  and  rarely 
forms  tumors  that  can  be  felt  externally.  The  tumor  is  usually  in  the  com- 
mon duct,  57  of  80  cases  collected  by  Kolleston.  There  is  usually  an  early, 
intense,  and  persistent  jaundice.     The  gall-bladder  is  usually  enlarged  in  ob- 


DISEASES  OF  THE  BILE-PASSAGES  AND  GALL-BLADDER      559 

struction  of  the  common  duct  by  malignant  disease.  The  dilated  gall-bladder 
may  rapture.  At  best  the  diagnosis  is  very  doubtful,  unless  cleared  up  by  an 
exploratory  operation.  A  very  interesting  form  of  malignant  disease  of  the 
ducts  is  that  which  involves  the  diverticulum  of  Vater.  Eolleston  has  collected 
16  cases. 

VII.     STENOSIS   AND   OBSTRUCTION   OF   THE   BILE-DUCTS 

Stenosis. — Stenosis  or  complete  occlusion  may  follow  ulceration,  most  com- 
monly after  the  passage  of  a  gall-stone.  In  these  instances  the  obstruction  is 
usually  situated  low  down  in  the  common  duct.  Instances  are  extremely  rare. 
Foreign  bodies,  such  as  the  seeds  of  various  fruits,  may  enter  the  duct,  and 
occasionally  round  worms  crawl  into  it.  Liver-flukes  and  echinococci  are  rare 
causes  of  obstruction  in  man. 

Obstruction. — Obstruction  by  pressure  from  without  is  more  frequent. 
Cancer  of  the  head  of  the  pancreas,  less  often  a  chronic  interstitial  inflamma- 
tion, may  compress  the  terminal  portion  of  the  duct;  rarely,  cancer  of  the 
pylorus.  Secondary  involvement  of  the  lymph-glands  of  the  liver  is  a  common 
cause  of  occlusion  of  the  duct,  and  is  met  with  in  many  cases  of  cancer  of  the 
stomach  and  other  abdominal  organs.  Eare  causes  of  obstruction  are  aneu- 
rism of  a  branch  of  the  coeliac  axis  of  the  aorta,  and  pressure  of  very  large 
abdominal  tumors. 

Symptoms. — The  symptoms  produced  are  those  of  chronic  obstructive  jaun- 
dice. At  first,  the  liver  is  enlarged,  but  in  chronic  cases  it  may  be  reduced 
in  size,  and  be  found  of  a  deeply  bronzed  color.  The  hepatic  intermittent  fever 
is  not  often  associated  with  complete  occlusion  of  the  duct  from  any  cause, 
but  it  is  most  frequently  met  with  in  chronic  obstruction  by  gall-stones.  Per- 
manent occlusion  of  the  duct  terminates  in  death.  In  a  majority  of  the  cases 
the  conditions  which  lead  to  the  obstruction  are  in  themselves  fatal.  The 
liver,  which  is  not  necessarily  enlarged,  presents  a  moderate  grade  of  cirrhosis. 
Cases  of  cicatricial  occlusion  may  last  for  years. 

Diagnosis. — A  history  of  colic,  jaundice  of  varying  intensity,  paroxysms 
of  pain,  and  intermittent  fever  point  to  gall-stones.  In  cancerous  obstruction 
the  tumor  mass  can  sometimes  be  felt  in  the  epigastric  region.  In  cases  in 
which  the  lymph-glands  in  the  transverse  fissure  are  cancerous  the  primary 
disease  may  be  in  the  pelvic  organs  or  the  rectum,  or  there  may  be  a  limited 
cancer  of  the  stomach,  which  has  not  given  any  symptoms.  In  these  cases  the 
examination  of  the  other  lymphatic  glands  may  be  of  value.  Involvement  of 
the  clavicular  groups  of  lymph-glands  may  also  be  serviceable  in  diagnosis. 
The  gall-bladder  is  usually  enlarged  in  obstruction  of  the  common  duct,  ex- 
cept in  the  cases  of  gall-stones  (Courvoisier's  law).  Great  and  progressive  en- 
largement of  the  liver  with  jaundice  and  moderate  continued  fever  is  more 
commonly  met  Avith  in  cancer. 

Congenital  Obliteration  of  the  Ducts. — John  Thomson,  in  1892,  collected 
49  cases  and  studied  the  condition  thoroughly.  C.  P.  Howard  and  Wolbach, 
reviewing  the  literature,  bring  the  cases  up  to  7G,  exclusive  of  those  associated 
.with  syphilis.  Jaundice  sets  in  early,  but  may  be  delayed  for  ten  or  twelve 
days,  and  is  progressive  and  deep.  Hamorrhages  in  the  skin,  from'  the  gastro- 
intestinal tract,  and  from  the  umbilical  cord  have  occurred  in  fully  50  per 


560  DISEASES  OF  THE  DIGESTIVE   SYSTEM 

cent.     Nearly  one-half  of  the  cases  die  within  the  first  month,  a  few  live  on 
for  five  or  six  months,  but  rarely  as  long  as  the  tenth  or  twelfth. 

Thomson  regards  congenital  malformation  as  the  chief  cause,  others  are 
due  to  cholangitis  and  a  few  to  congenital  cirrhosis  of  the  liver. 


VI.     CHOLELITHIASIS 

1^0  chapter  in  medicine  is  more  interesting  than  that  which  deals  with  the 
question  of  gall-stones.  Few  aifections  present  so  many  points  for  study — 
chemical,  bacteriological,  pathological,  and  clinical.  There  has  been  a  great 
advance  in  our  knowledge  in  two  directions :  First,  as  to  the  mode  of  forma- 
tion of  the  stones,  and,  secondly,  as  to  the  surgical  treatment  of  the  cases. 

Orig-in  of  Gall-stones. — There  are  three  mechanisms  specially  concerned: 
(1)  infection^,  (2)  stasis,  and  (3)  the  cholesterol  content  of  the  blood. 

(1)  Infection. — The  route  may  be  (1)  hgematogenous,  probably  the  most 
common,  (2)  by  elimination  through  the  liver,  and  (3)  retrograde.  Hgema- 
togenous infection  may  be  from  a  focus  of  infection  in  any  part  of  the  body; 
disease  of  the  appendix  is  sometimes  responsible.  The  gall-bladder  is  a  pe- 
culiarly favorable  habitat  for  organisms.  Streptococci,  staphylococci,  pneu- 
mococci,  colon  bacilli  and  typhoid  bacilli  have  all  been  found  with  varying 
conditions  of  the  bile.  The  typhoid  bacillus  may  live  indefinitely  in  the  gall- 
bladder and  has  been  grown  in  pure  culture  from  the  interior  of  gall-stones. 
The  experimental  production  of  gall-stones  has  been  accomplished  by  inject- 
ing organisms  into  the  gall-bladders  of  animals.  The  calculus  associated  with 
infection  is  composed  largely  of  calcium  salts,  a  point  emphasized  by  Eosen- 
bloom. 

(2)  Stasis. — An  inspissated  condition  of  the  bile  occurs  with  this  and 
precipitation  is  likely  to  occur.  A  nucleus  is  thus  formed  and  other  elements 
are  deposited  on  it.  The  work  of  Boysen  showed  that  the  gall-bladder  was  not 
affected  when  the  gall-stones  were  of  the  primary  bile-pigment  calcium  type. 
Inspissation  of  the  bile  is  favored  by  pregnancy  and  the  acute  infectious  dis- 
eases. The  views  of  Meltzer  on  disturbed  contrary  innervation  of  the  gall- 
bladder with  retention  of  bile  are  of  interest  in  this  connection. 

(3)  Cholesterol. — In  probably  75  per  cent,  of  cases  of  cholelithiasis  there 
is  an  increase  in  the  cholesterol  content  of  the  blood.  In  some  cases  this  may 
be  temporary  and  not  present  when  the  existence  of  gall-stones  is  recognized. 
Cholesterol  may  be  of  exogenous  or  endogenous  origin.  There  is  often  an  in- 
crease in  the  blood  cholesterol  during  typhoid  fever.  In  favor  of  the  import- 
ance of  the  cholesterol  is  the  number  of  cases  in  which  the  gall-bladder  is 
sterile.  It  is  evident  that  with  a  foreign  body  present  there  may  be  subse- 
quent infection.  A  study  of  the  cases  in  which  cholesterol  stones  are  found 
shows  that  a  history  of  infection  is  generally  lacking.  The  formation  of  a 
cholesterol  stone  may  be  favored  by  an  increase  in  the  cholesterol  in  the  blood, 
by  its  increased  excretion  by  the  liver,  or  by  deposit  of  material  from  inspissated 
bile. 

Country. — ^,Grall-stones  are  less  frequent  in  the  United  States  than  in  Ger- 
many, 6.94  to  13  per  cent.  (Mosher).  They  are  less  common  in  England  than 
on  the  Continent. 


CHOLELITHIASIS  561 

Age. — Nearly  50  per  cent,  of  all  the  cases  occur  in  persons  above  forty 
years  of  age.  They  are  rare  under  twenty-five.  They  have  been  met  with  in 
the  new-born,  and  in  infants  (John  Thomson). 

Sex. — Three-fourths  of  the  cases  occur  in  women.  Pregnancy  has  an  im- 
portant influence.  ISTaunyn  states  that  90  per  cent,  of  women  with  gall-stones 
have  borne  children. 

All  conditions  which  favor  stagnation  of  bile  in  the  gall-bladder  predispose 
to  the  formation  of  stones.  Among  these  may  be  mentioned  corset-wearing, 
cnteroptosis,  nephroptosis,  and  occupations  requiring  a  "leaning  forward"  po- 
sition. Lack  of  exercise,  sedentary  occupations,  particularly  when  combined 
with  over-indulgence  in  food,  constipation,  and  depressing  mental  emotions 
are  also  to  be  regarded  as  favoring  circumstances. 

Physical  Characters  of  Gall-stones. — They  may  be  single,  in  which  case 
the  stone  is  usually  ovoid  and  may  attain  a  very  large  size.  Instances  are  on 
record  of  gall-stones  measuring  more  than  5  inches  in  length.  They  may  be 
extremely  numerous,  ranging  from  a  score  to  several  himdreds  or  even  several 
thousands,  in  which  case  the  stones  are  very  small.  When  moderately  numer- 
ous, they  show  signs  of  mutual  pressure  and  have  a  polygonal  form,  with 
smooth  facets ;  occasionally,  however,  five  or  six  gall-stones  of  medium  size  are 
met  with  in  the  bladder  which  are  round  or  ovoid  and  without  facets.  They 
are  sometimes  mulberry-shaped  and  very  dark,  consisting  largely  of  bile-pig- 
ments. Again  there  are  small,  black  calculi,  rough  and  irregular  in  shape, 
and  varying  in  size  from  grains  of  sand  to  small  shot.  These  are  sometimes 
known  as  gall-sand.  On  section,  a  calculus  contains  a  nucleus,  which  consists 
of  bile-pigment,  rarely  a  foreign  body.  The  greater  portion  of  the  stone  is 
made  up  of  cholesterin,  which  may  form  the  entire  calculus  and  is  arranged  in 
concentric  laminae  showing  also  radiating  lines.  Salts  of  lime  and  magnesia, 
bile  acids,  fatty  acids,  and  traces  of  iron  and  copper  are  also  found  in  them. 
Most  gall-stones  consist  of  from  70  to  80  per  cent,  of  cholesterin,  in  either  the 
amorphous  or  the  crystalline  form.  As  above  stated,  it  is  sometimes  pure,  but 
more  commonly  it  is  mixed  with  the  bile-pigment.  The  outer  layer  of  the 
stone  is  usually  harder  and  brownish  in  color. 

Seat  of  Formation. — Within  the  liver  itself  calculi  are  occasionally  found, 
but  are  here  usually  small  and  not  abundant,  and  in  the  form  of  ovoid,  green- 
ish-black grains.  A  large  majority  of  all  calculi  are  formed  within  the  gall- 
bladder. The  stones  in  the  larger  ducts  have  usually  had  their  origin  in  the 
gall-bladder. 

Symptoms. — In  some  cases  gall-stones  cause  no  symptoms  directly  ref- 
erable to  the  gall-bladder.  The  gall-bladder  will  tolerate  the  presence  of  large 
numbers  for  an  indefinite  period  of  time,  and  post  mortem  examinations  show 
that  they  are  present  in  25  per  cent,  of  all  women  over  sixty  years  of  age 
(Naunyn).  Moynihan  claims  that  in  most  cases  there  are  early  symptoms — 
a  sense  of  fullness,  weight,  and  oppression  in  the  epigastrium;  a  catch  in  the 
breath,  a  feeling  of  faintness  or  nausea,  and  a  chilliness  after  eating.  Attacks 
of  indigestion  are  common,  and  it  is  important  to  remember  that  persistent 
gastric  symptoms  are  often  due  to  gall-stones.  The  gastric  secretion  may  be  in- 
creased or  decreased,  more  often  the  latter.  Obstinate  attacks  of  urticaria  may 
occur. 

The  main  symptoms  of  cholelithiasis  may  be  divided  into  (1)  the  aseptic, 


562  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

mechanical  accidents  in  consequence  of  migration  of  the  stone  or  of -obstruc- 
tion, either  in  the  ducts  or  in  the  intestines;  (2)  the  septic,  infectious  acci- 
dents, either  local  (the  angiocholitis  and  cholecystitis  with  empyema  of  the 
gall-bladder,  -and  the  fistulge  and  abscess  of  the  Jiver  and  infection  of  the 
neighboring  parts)  or  general,  fever  and  secondary  visceral  lesions. 

BiLiAEY  Colic. — Gall-stones  may  become  engaged  in  the  cystic  or  the 
common  duct  without  producing  pain  or  severe  symptoms.  More  commonly 
the  passage  of  a  stone  excites  the  violent  symptoms  known  as  biliary  colic.  The 
attack  sets  in  abruptly  with  agonizing  pain  in  the  right  hypochondriac  region, 
which  radiates  to  the  shoulder,  or  is  very  intense  in  the  epigastric  and  in  the 
lower  thoracic  regions.  It  is  often  associated  with  a  rigor  and  a  rise  in  tem- 
perature from  102°  to  103°.  The  pain  is  usually  so  intense  that  the  patient 
rolls  about  in  agony.  There  are  vomiting,  profuse  sweating,  and  great  de- 
pression of  the  circulation.  There  may  be  marked  tenderness  in  the  region 
of  the  liver,  which  may  be  enlarged,  and  the  gall-bladder  may  become  palpable 
and  very  tender.  In  other  cases  the  fever  is  more  marked.  The  spleen  is  en- 
larged (Naunyn)  and  the  urine  contains  albumin  with  red  blood-corpuscles. 
Ortner  holds  that  cholecystitis  acuta,,  occurring  in  connection  with  gall-stones, 
is  a  septic  (bacterial)  infection  of  the  bile-passages.  The  symptoms  of  acute 
infectious  cholecystitis  and  those  of  what  we  call  gall-stone  colic  are  very 
similar,  and  surgeons  have  frequently  performed  cholecystotomy  for  the  for- 
mer condition,  believing  calculi  were  present.  In  a  large  number  of  the  cases 
jaundice  occurs,  but  it  is  not  a  necessary  symptom.  It  does  not  happen  dur- 
ing the  passage  of  the  stone  through  the  cystic  duct  but  only  when  it  becomes 
lodged  in  the  common  duct.  The  pain  is  due  (a)  to  the  slow  progress  in  the 
cystic  duct,  in  which  the  stone  takes  a  rotary  course  owing  to  the  arrange- 
ment of  the  Heisterian  valve ;  the  cystic  duct  is  poor  in  muscle  fibres  but  rich 
in  nerves  and  ganglia;  (6)  to  the  acute  inflammation  which  usually  accom- 
panies an  attack;  (c)  to  the  stretching  and  distention  of  the  gall-bladder  by 
retained  secretions. 

The  attack  varies  in  dviration.  It  may  last  for  a  few  hours,  several  days, 
or  even  a  week  or  more.  If  the  stone  becomes  impacted  in  the  orifice  of  the 
common  duct,  the  jaundice  becomes  intense;  much -more  commonly  it  is  a 
slight  transient  icterus.  The  attack  of  colic  may  be  repeated  at  intervals  for 
some  time,  but  finally  the  stone  passes  and  the  symptoms  disappear. 

Occasionally  accidents  occur,  such  as  rupture  of  the  duct  with  fatal  peri- 
tonitis. Fatal  syncope  during  an  attack  and  the  occurrence  of  repeated  con- 
vulsive seizures  have  come  under  observation  but  these  are  rare  events.  Pal- 
pitation and  distress  about  the  heart  may  be  present,  and  occasionally  a  mitral 
murmur  occurs  during  the  paroxysm,  but  the  cardiac  conditions  described  by 
some  writers  as  coming  on  acutely  in  biliary  colic  are  possibly  preexistent  in 
these  patients. 

The  diagnosis  of  acute  hepatic  colic  is  generally  easy.  The  pain  is  in  the 
upper  abdominal  and  thoracic  regions,  whereas  the  pain  in  nephritic  colic  is 
in  the  lower  abdomen.  A  chill,  with  fever,  is  much  more  frequent  in  biliary 
colic  than  in  gastralgia,  with  which  it  is  liable,  at  times,  to  be  confounded.  A 
history  of  previous  attacks  is  an  important  guide,  and  the  occurrence  of  jaun- 
dice, however  slight,  determines  the  diagnosis.  To  look  for  the  gall-stones, 
the  stools  should  be  thoroughly  mixed  with  water  and  carefully  filtered  through 


CHOLELITHIASIS  '563 

a  iiarrow-meshed  sieve.  Pseudo-biliary  colic  is  not  infrequently  met  with  in 
nervous  women,  and  the  diagnosis  of  gall-stones  made.  This  nervous  hepatic 
colic  may  be  periodical;  the  pain  may  be  in  the  right  side  and  radiating;  some- 
times associated  with  other  nervous  phenomena,  often  excited  by  emotion, 
fatigue  or  excesses.  The  liver  may  be  tender,  but  there  are  neither  icterus  nor 
inflammatory  conditions.  The  combination  of  colic  and  jaundice,  so  distinc- 
tive of  gall-stones,  is  not  always  present.  The  pains  may  not  be  colicky,  but 
more  constant  and  dragging  in  character.  A  remarkable  xanthoma  of  the  bile- 
passages  has  been  found  in  association  with  hepatic  colic.  Many  patients  with 
gall-stones  have  stomach  symptoms — flatulency,  regurgitation,  and  distress 
after  eating.  Sometimes  the  pain  may  be  much  increased  by  food  or  on  ex- 
ertion. In  chronic  gall-bladder  cases,  with  adhesions  and  perforation,  the 
clinical  picture  may  resemble  closely  that  of  ulcer.  The  presence  of  gall- 
stones may  be  proved  by  X-ray  examination  in  a  considerable  proportion  of 
cases. 

Obstruction  of  the  Cystic  Duct. — The  effects  may  be  thus  enumer- 
ated: {a)  Dilatation  of  the  gall-bladder.  In  acute  obstruction  the  contents 
are  bile  mixed  with  much  mucus  or  muco-purulent  material.  In  chronic  ob- 
struction the  bile  is  replaced  by  a  clear  fluid  mucus.  This  is  an  important 
point  in  diagnosis,  particularly  as  a  dropsical  gall-bladder  may  form  a  very 
large  tumor.  The  reaction  is  not  always  constant.  It  is  either  alkaline  or 
neutral;  the  consistence  is  thin  and  mucoid.  Albumin  is  usually  present.  A 
dilated  gall-bladder  may  reach  an  enormous  size,  and  in  one  instance  Tait 
found  it  occupying  the  greater  part  of  the  abdomen.  In  such  cases,  as  is  not 
unnatural,  it  has  been  mistaken  for  an  ovarian  tumor.  In  one  case  it  was 
attached  to  the  right  broad  ligament.  The  dilated  gall-bladcler  can  usually 
be  felt  below  the  edge  of  the  liver,  and  in  many  instances  it  has  a  characteristic 
outline  like  a  gourd.  An  enlarged  and  relaxed  organ  may  not  be  palpable, 
and  in  acute  cases  the  distention  may  be  upward  toward  the  hilus  of  the  liver. 
The  dilated  gall-bladder  usually  projects  directly  downward,  rarely  to  one  side 
or  the  other,  though  occasionally  toward  the  middle  line.  It  may  reach  below 
the  navel,  and  in  persons  wifeh  thin  walls  the  outline  can  be  accurately  defined. 
Eiedel  called  attention  to  a  tongue-like  projection  of  the  anterior  margin  of 
the  right  lobe  in  connection  with  enlarged  gall-bladder.  It  is  to  be  remem- 
bered that  distention  of  the  gall-bladder  may  occur  without  jaundice;  indeed, 
the  greatest  enlargement  has  been  met  with  in  such  cases. 

Palpation. — There  are  two  conditions  in  which  gall-stones  may  be  felt ;  the 
large,  loose,  flaccid  pouch  with  numerous  stones  in  a  person  with  a  very  re- 
laxed abdominal  wall — a  well-known  surgeon  described  the  palpation  of  gall- 
stones in  himself — and  the  hard  top  of  the  single  large  ovoid  stone  about 
which  the  walls  of  the  gall  bladder  have  contracted. 

(b)  Acute  cliolecystitis.  The  simple  form  is  common,  and  to  it  are  due 
probably  very  many  of  the  symptoms  of  the  gall-stone  attack.  Phlegmonous 
cholecystitis  is  rare.     Perforation  may  occur  with  fatal  peritonitis. 

(c)  Suppurative  cholecystitis,  empyema  of  the  gall-bladder,  is  much  more 
common,  and  in  the  great  majority  of  cases  is  associated  with  gall-stones. 
There  may  be  enormous  dilatation,  and  over  a  litre  of  pus  has  been  found. 
Perforation  ajQd  the  formation  of  abscesses  in  the  neighborhood  are  not  un- 
common. 


564  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

(d)  Calcification  of  the  gall-bladder  may  be  a  termination  of  the  previous 
condition.  There  are  two  forms:  incrustation  of  the  mucosa  with  lime  salts 
and  the  true  infiltration  of  the  wall  with  lime,  the  so-called  ossification. 

(e)  Atrophy  of  the  gall-bladder.  This  is  by  no  means  uncommon.  The 
organ  shrinks  into  a  small  fibroid  mass,  not  larger,  perhaps,  than  a  good- 
sized  pea  or  walnut,  or  even  has  the  form  of  a  narrow  fibrous  string;  more 
commonly  the  gall-bladder  tightly  embraces  a  stone.  This  condition  is  usually 
preceded  by  hydrops  of  the  bladder. 

Occasionally  the  gall-bladder  presents  diverticula,  which  may  be  cut  off 
from  the  main  portion,  and  usually  contain  calculi. 

Obsteuctiox  of  the  Common  Duct. — There  may  be  a  single  stone  tightly 
wedged  in  the  duct  in  any  part  of  its  course,  or  a  series  of  stones,  sometimes 
extending  into  both  hepatic  and  cystic  ducts,  or  a  stone  lies  in  the  diverticulum 
of  Yater.  There  are  three  groups  of  cases:  («)  In  rare  instances  a  stone 
tightly  corks  the  common  duct,  causing  permanent  occlusion;  or  it  may  partly 
rest  in  the  cystic  duct,  and  may  have  caused  thickening  of  the  junction  of  the 
ducts;  or  a  big  stone  may  compress  the  hepatic  or  upper  part  of  the  common 
duct.  The  jaundice  is  deep  and  enduring,  and  there  are  no  septic  features. 
The  pains,  the  previous  attacks  of  colic,  and  the  absence  of  enlarged  gall- 
bladder help  to  separate  the  condition  from  obstruction  by  new  growths,  al- 
though it  cannot  be  differentiated  with  certainty.  The  ducts  are  usually  much 
dilated  and  everywhere  contain  a  clear  mucoid  fluid. 

(6)  Incomplete  obstruction,  u-itli  infective  cliolangitis.  There  may  be  a 
series  of  stones  in  the  common  duct,  a  single  stone  which  is  freely  movable, 
or  a  stone  (ball- valve  stone)  in  the  diverticulum  of  Yater.  These  conditions 
may  be  met  with  at  autopsy,  without  the  subjects  having  had  symptoms  point- 
ing to  gall-stones ;  but  in  a  majority  there  are  characteristic  features. 

The  common  duct  may  be  as  large  as  the  thumb ;  the  hepatic  duct  and  its 
branches  through  the  liver  may  be  greatly  dilated,  and  the  distention  may  be 
even  apparent  beneath  the  liver  capsule.  Great  enlargement  of  the  gall-bladder 
is  rarer.  The  mucous  membrane  of  the  ducts  is  usually  smooth  and  clear,  and 
the  contents  consist  of  a  thin,  slightly  turbid  bile-stained  mucus. 

Xaunyn  gave  as  the  distinguishing  signs  of  stone  in  the  common  duct : 
'^(1)  The  continuous  or  occasional  presence  of  bile  in  the  fa?ces;  (2)  distinct 
variations  in  the  intensity  of  the  jaundice;  (3)  normal  size  or  only  slight  en- 
largement of  the  liver;  (4)  absence  of  distention  of  the  gall-bladder;  (5)  en- 
largement of  the  spleen;  (6)  absence  of  ascites;  (7)  presence  of  febrile  dis- 
turbance; and  (8)  duration  of  the  jaundice  for  more  than  a  year." 

In  connection  with  the  ball-valve  stone,  which  is  most  commonly  found  in 
the  diverticulum  of  Yater,  though  it  may  be  in  the  common  duct  itself,  there 
is  a  special  symptom  group:  (a)  Ague-like  paroxysms,  chills,  fever,  and 
sweating;  the  hepatic  intermittent  fever  of  Charcot;  {h)  jaundice  of  varying 
intensity,  which  persists  for  months  or  even  years,  and  deepens  after  each 
paroxysm;  (c)  at  the  time  of  the  paroxysm,  pains  in  the  region  of  the  liver 
with  gastric  disturbance.  These  symptoms  may  continue  on  and  off  for  three 
or  four  years,  without  the  development  of  suppurative  cholangitis.  The  con- 
dition has  lasted  from  eight  months  to  three  years.  The  rigors  are  of  intense 
severity,  and  the  temperature  rises  to  103°  or  105°  F.  The  chills  may  recur 
daily  for  weeks,  and  present  a  tertian  or  quartan  type,  so  that  they  are  often 


CHOLELITHIASIS  565 

attributed  to  malaria,  with  which,  however,  they  have  no  connection.  The 
jaundice  is  variable,  and  deepens  after  each  paroxysm.  The  itching  may  be 
most  intense.  Pain,  which  is  sometimes  severe  and  colicky,  does  not  always 
occur.  There  may  be  marked  vomiting  and  nausea.  As  a  rule  there  is  no 
progressive  deterioration  of  health.  In  the  intervals  between  the  attacks  the 
temperature  is  normal. 

The  clinical  history  and  post  mortem  examinations  show  conclusively  that 
this  condition  may  persist  for  years  without  a  trace  of  suppuration  within  the 
ducts.  It  is  i^robable  that  the  toxic  symptoms  develop  only  when  a  certain 
grade  of  tension  is  reached.  An  interesting  and  valuable  diagnostic  point  is 
the  absence  of  dilatation  of  the  gall-bladder  in  cases  of  obstruction  from  stone 
— Courvoisier's  rule. 

(c)  Incomplete  obstruction,  with  suppurative  cholangitis. — When  suppu- 
rative cholangitis  exists  the  mucosa  is  thickened,  often  eroded  or  ulcerated; 
there  may  be  extensive  suppuration  in  the  ducts  throughout  the  liver,  and  even 
empyema  of  the  gall-bladder.  Occasionally  the  suppuration  extends  beyond 
the  ducts,  and  there  is  localized  liver  abscess,  or  there  is  perforation  of  the 
gall-bladder  with  the  formation  of  abscess  between  the  liver  and  stomach. 

Clinically  it  is  characterized  by  a  fever  which  may  be  intermittent,  but 
more  commonly  is  remittent  and  without  prolonged  intervals  of  apyrexia. 
The  jaundice  is  rarely  so  intense,  nor  do  we  see  the  deepening  of  the  color  after 
the  paroxysms.  There  is  usually  greater  enlargement  of  the  liver,  and  tender- 
ness and  more  definite  signs  of  septicsemia.  The  cases  run  a  shorter  course, 
and  recovery  never  takes  place. 

The  Moee  Eemote  Effects  of  Gall-stoxes. —  (a)  Biliary  Fistulce. — 
(1)  Cutaneous. — The  external  fistula  is  the  most  common,  184  out  of  384:  cases 
(Xaunyn).  A  majority  occur  in  the  region  of  the  navel,  to  which  part  the 
falciform  ligament  directs  the  suppuration.  The  number  of  stones  discharged 
varies  from  one  or  two  to  many  hundreds.  Of  the  184  cases  in  Courvoisier's 
statistics  recovery  took  place  in  78.  In  rare  instances  the  fistula  is  in  the  right 
iliac  fossa,  or  even  in  the  thigh. 

(2)  G astro-intestinal  Fistulce. — The  duodenal  is  the  most  frequent,  108 
of  38-4  cases  (Xaunyn).  L^sually  the  opening  is  between  the  fundus  of  the 
gall-bladder  and  the  first  part  of  the  duodenum.  A  big  stone  may  ulcerate 
through,  leaving  little  or  no  damage.  In  other  instances  the  cicatrization  leads 
to  obstruction.     Communication  with  the  ileum  and  jejunum  is  rare. 

Fistulse  between  the  common  duct  and  the  duodenum  occurred  in  15  cases 
in  Xaunyn's  series.  Biliary  gastric  fistula  are  rare.  The  vomiting  of  gall- 
stones is  not  necessarily  proof  of  the  perforation,  but  in  the  majority  of  such 
cases  the  stones  probably  pass  up  through  the  p^dorus. 

(3)  Broncho-hiliary  Fistulce. — Of  J.  E.  Graham's  collected  series  of  35 
cases,  19  were  due  to  gall-stones;  11  to  hydatids;  2  to  round-worms;  and  in 
2  the  cause  was  doubtful.  In  many  cases  the  amoebic  liver  abscess  perforat- 
ing into  the  lung  is  followed  by  a  permanent  biliary  fistula. 

(4)  Perforation  may  occur  into  the  portal  vein,  of  which  there  are  a  few 
cases  on  record,  one  of  which,  according  to  tradition,  was  the  famous  Ignatius 
Loyola, 

(5)  Perforation  into  the  hepatic  artery  or  one  of  its  branches  is  exceed- 


566  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

ingly  rare.    Either  an  erosion  from  the  common  duct  or  an  hepatic  aneurism 
may  rupture  into  the  gall-bladder. 

(6)  Fistula  into  the  urimiry  passages  may  be  with  the  pelvis  of  the  kidney 
in  which  the  gall-stone  has  been  found,  or  into  the  urinary  bladder,  of  which 
there  are  few  cases  on  record. 

(7)  Lastly,  the  communication  between  the  pericardium  and  the  biliary 
tract  is  referred  to  by  Naunyn  in  a  single  case. 

(&)  Perforation  into  the  Peritoneum. ^Oi  119  cases  (Courvoisier)  in  70 
the  ruptare  occurred  directly  into  the  peritoneal  cavity;  in  49  an  encapsulated 
abscess  formed.    As  a  rule,  the  condition  is  due  to  an  acute  cholecystitis. 

(c)  Obstruction  of  the  Boivel  hy  Gall-stones. — Eeference  has  been  made 
to  this;  its  frequency  appears  from  the  fact  that  of  295  cases  of  obstruction, 
occurring  during  eight  years,  analyzed  by  Fitz,  23  were  by  gall-stones.  Cour- 
voisier's  statistics  give  a  total  number  of  131  cases,  in  6  of  which  the  calculi 
had  a  peculiar  situation,  as  in  a  diverticulum  or  in  the  appendix.  Of  the  re- 
maining 125  cases,  in  70  the  stone  was  spontaneously  passed,  usually  with 
severe  symptoms.  The  post  mortem  reports  show  that  in  some  of  these  cases 
even  very  large  stones  have  passed,  as  the  gall-duct  has  been  enormously  dis- 
tended, its  orifice  admitting  the  finger  freely.  This,  however,  is  extremely 
rare.    The  stones  have  been  found  most  commonly  in  the  ileum. 

Treatment  of  Gall-stones  and  Their  Effects. — General  Treatment. — In 
an  attack  of  biliary  colic  the  patient  should  be  kept  under  morphia,  given 
hypodermically,  in  quarter-grain  (0.016  gm.)  doses.  In  an  agonizing  parox- 
ysm it  is  well  to  give  a  whiff  or  two  of  chloroform  until  the  morphia  has  had 
time  to  act.  Great  relief  is  experienced  from  the  hot  bath  and  from  fomenta- 
tions in  the  region  of  the  liver.  The  patient  should  be  given  laxatives  and 
drink  copiously  of  alkaline  mineral  waters.  Olive  oil  has  proved  useless  in  our 
hands.  When  taken  in  large  quantities,  fatty  concretions  are  passed  with  the 
stools,  which  have  been  regarded  as  calculi;  and  concretions  due  to  eating 
pears  have  been  also  mistaken,  particularly  when  associated  with  colic  attacks. 
Since  the  days  of  Durande,  whose  mixture  of  ether  with  turpentine  is  still 
largely  used  in  France,  various  remedies  have  been  advised  to  dissolve  the 
stones  within  the  gall-bladder,  none  of  which  are  efficacious. 

Foci  of  infection  should  be  treated  and  special  attention  given  to  the  mouth. 
The  patient  should  take  regular  exercise.  The  diet  should  be  simple  and  in 
some  cases  a  cholesterol  free  diet  seems  useful.  Water  should  be  taken  freely. 
The  soda  salts  are  believed  to  prevent  the  concentration  of  the  bile  and  the 
formation  of  gall-stones.  Either  the  sulphate  or  the  phosphate  may  be  taken 
in  doses  of  from  1  to  2  drams  daily.  For  the  itching  McCall  Anderson's  dust- 
ing powder  may  be  used:  starch,  an  ounce  (30  gm.)  ;  camphor,  a  drachm  and 
a  half  (6  gm.)  ;  and  oxide  of  zinc,  half  an  ounce  (15  gm.).  Some  of  this 
should  be  finely  dusted  over  the  skin.  Powdering  with  starch,  strong  alka- 
line baths  (hot),  pilocarpin  hypodermically  (gr.  %-%,  0.008-0.01  gm.),  and 
antipyrin  (gr.  v,  0.3  gm.),  may  be  tried.  Ichthyol  and  lanolin  ointment  or 
menthol  ointment  sometimes  gives  relief. 

Surgical  Treatment. — The  indications  for  operation  are:  (a)  Eepeated 
attacks  of  gall-stone  colic.  The  patient  is  much  safer  in  the  hands  of  a  sur- 
geon than  when  left  to  Nature,  with  the  feeble  assistance  of  drugs  and  min- 
eral waters.      (&)   The  presence  of  a  distended  gall-bladder,  associated  with 


THE  CIEEHOSES  OF  THE  LIVER  567 

attacks  of  pain  or  with  fever,  (c)  When  a  gall-stone  is  permanently  lodged 
in  the  common  dnct  the  question  of  advising  operation  depends  largely  upon 
the  personal  methods  and  success  of  the  surgeon  who  is  available,  (d)  Per- 
sistent ill  health  or  gastric  disturbance  due  to  infection  of  the  biliary  tract  or 
gall-stones. 

Of  4,000  operations  performed  by  the  Mayo  brothers  to  February  20th, 
1911,  the  mortality  M^as  2.57  per  cent.  Of  2,920  cases  in  which  the  gall-bladder 
alone  was  involved  the  mortality  was  1.8  per  cent.  Of  492  cases  in  which  the 
common  duct  was  involved  the  mortality  was  8  per  cent.  In  2.25  per  cent, 
there  was  the  complication  of  malignant  disease. 

The  question  comes  up  as  to  the  re-formation  of  stones,  but  the  possibility 
of  this  is  very  slight.  In  the  Mayo  series  there  were  but  3  cases  and  it  is 
probable  that  in  the  majority  of  instances  the  stones  had  not  re-formed,  but 
were  incompletely  removed.  Deaver  reports  an  instance  in  which  200  stones 
were  removed  two  years  after  the  extraction  of  120.  After  removal  of  the 
gall-bladder  stones  may  be  formed  in  the  hepatic  ducts. 


Vn.     THE  CIRRHOSES  OF  THE  LIVER 

General  Considerations. — The  many  forms  of  cirrhoses  of  the  liver  have 
one  feature  in  common — an  increase  in  the  connective  tissue.  We  use  the 
term  cirrhosis  (by  which  Laennec  characterized  the  tawny,  yellow  color  of  the 
common  atrophic  form)  to  indicate  similar  changes  in  other  organs. 

Etiology. — There  are  five  types  of  primary  lesion,  any  one  of  which  may 
lead  to  cirrhosis. 

1.  Toxic  Cirrhosis. — This  is  the  only  acute  type  and  it  is  seen  post  partum, 
in  chloroform  narcosis  and  sometimes  as  a  terminal  lesion  in  any  form  of 
disease.  There  is  a  central  necrosis  about  the  hepatic  vein  which  may  be  slight 
in  amount,  or  in  some  cases  an  acute  yellow  atrophy,  very  extensive  so  that  the 
liver  is  rapidly  reduced  in  size.  Into  the  necrotic  areas  leucocytes  migrate,  the 
dead  liver  cells  are  quickly  removed  and  there  is  an  apparent  increase  of  the 
connective  tissue.  Great  regeneration  of  the  liver  cells  is  possible.  Clinically 
this  type  can  scarcely  be  spoken  of  as  cirrhosis. 

2.  Infectious  Cirrhosis. — Adami  and  his  school  hold  that  in  many  cases 
the  colon  bacilli  from  the  bowel  pass  to  the  liver  and  there  gradually  excite  a 
slow  proliferation  of  connective  tissue,  regarding  it  as  a  kind  of  subinfection. 
Mallory,  whose  classification  is  followed,  thinks  that  the  only  type  of  true  in- 
fectious cirrhosis  is  through  the  bile  ducts,  usually  when  there  is  bile  stasis  or 
gall-stones  or  other  obstructions  are  present.  Cases  are  described  in  which  in- 
vasion occurs  along  apparently  normal  bile  ducts  and  the  organisms  cause 
necrosis  of  the  liver  cells,  proliferation  of  the  fibroblasts,  and  thickening  of  the 
walls  of  the  smaller  bile  ducts  which  may  be  dilated  and  tortuous.  Clinically 
this  type  is  rare,  and  characterized  by  a  chronic  jaundice  and  enlargement  of 
the  liver. 

3.  Pigment  Cirrhosis. — This  may  be  an  external  pigment  as  in  anthar- 
cosis  in  which  the  irritation  of  the  coal  particles  reaching  the  liver  through  the 
lymphatics  may  excite  a  moderate  grade  of  cirrhosis.     The  endogenous  pig- 


568  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

ment  is  a  transformation  of  haemoglobin  either  as  in  malaria  or  as  in  the  re- 
markable affection  known  as  hsemochromatosis. 

4.  Syphilitic  Cirrhosis. — Whether  congenital  or  acquired,  the  essential  le- 
sion is  produced  by  the  Treponemal  pallidum,  either  a  diffuse  proliferation  of 
fibroblasts,  or  a  more  localized  lesion,  the  gumma. 

5.  Alcoholic  Cirrhosis. — As  a  result  of  the  toxic  action  of  the  alcohol,  the 
liver  cells,  singly  or  in  groups,  undergo  a  slow  necrosis,  following  which  there 
is  a  multiplication  of  the  fibroblasts  with  a  hyalin  degeneration  of  some  cells 
and  multiplication  of  others  and  an  increase  in  the  smaller  bile  ducts.  Fatty 
infiltration  is  common,  so  that  the  organ  may  be  enlarged. 

Of  these  types  the  toxic  and  one  form  of  the  alcoholic  are  associated  with 
shrinkage,  the  infectious,  the  pigmentary  and  the  fatty  cirrhosis  with  enlarge- 
ment of  the  organ.  Clinically  we  may  consider  four  forms,  the  portal,  the 
hypertrophic  (of  Hanot),  the  syphilitic,  and  the  capsular. 

I.    POETAL  CIRKHOSIS 

Etiology. — The  disease  occurs  most  frequently  in  middle-aged  males  who 
have  been  addicted  to  drink.  Whisky,  gin,  and  brandy  are  more  potent  to 
cause  cirrhosis  than  beer.  It  is  more  common  in  countries  in  which  strong 
spirits  are  used  than  in  those  in  which  malt  liquors  are  taken.  It  is  not  always 
due  to  alcohol.  Symmers  believes  that  syphilis  is  an  important  factor  in  the 
etiology  in  the  Laennec  cirrhosis.  Among  1,000  autopsies  in  the  Johns  Hop- 
kins Hospital  there  were  63  cases  of  small  atrophic  liver,  and  8  cases  of  the 
fatty  cirrhotic  organ.  Lancereaux  claims  that  the  vin  ordinaire  of  France  is  a 
common  cause.  Of  210  cases,  excess  in  wine  alone  was  present  in  68  cases. 
He  thinks  it  is  the  sulphate  of  potash  in  the  plaster  of  Paris  used  to  give  the 
"dry"  flavor  which  damages  the  liver. 

Cirrhosis  of  the  liver  in  young  children  is  not  very  rare.  In  a  certain 
number  of  the  cases  there  is  an  alcoholic  history,  in  others  syphilis  has  been 
present,  while  a  third  group,  due  to  the  poisons  of  the  infectious  diseases, 
embraces  a  certain  number  of  the  cases  of  Hanot's  hypertrophic  cirrhosis. 

Morbid  Anatomy. — Portal  cirrhosis  occurs  in  two  well-characterized  forms : 

The  Ateophio  Cirrhosis  of  Laennec. — The  organ  is  greatly  reduced  in 
size  and  may  be  deformed.  The  weight  is  sometimes  not  more  than  a  pound 
or  a  pound  and  a  half.  It  presents  numerous  granulations  on  the  surface;  is 
firm,  hard,  and  cuts  with  great  resistance.  The  substance  is  seen  to  be  made 
up  of  greenish-yellow  islands  surrounded  by  grayish-white  connective  tissue. 
W.  G.  MacCallum  has  shown  that  regenerative  changes  in  the  cells  are  almo^jt 
constantly  present.  This  yellow  appearance  of  the  liver  induced  Laennec  to 
give  to  the  condition  the  name  of  cirrhosis. 

The  Fatty  Cirrhotic  Liver. — E\en  in  the  contracted,  form  the  fat  is  in- 
creased, but  in  typical  examples  of  this  variety  the  organ  is  not  reduced  in 
size,  but  is  enlarged,  smooth  or  very  slightly  granular,  anaemic,  yellowish-white 
in  color,  and  resembles  an  ordinary  fatty  liver.  It  is,  however,  firm,  cuts  with 
resistance,  and  microscopically  shows  a  great  increase  in  the  connective  tissue. 
This  form  occurs  most  frequently  in  beer-drinkers. 

The  two  essential  elements  in  cirrhosis  are  destruction  of  liver-cells  and 
obstruction  to  the  portal  circulation. 


THE  CIREHOSES  OF  THE  LIVER  569 

In  an  autopsy  on  a  case  of  cirrhosis  with  contraction  the  peritoneum  is 
usually  found  to  contain  a  large  quantity  of  fluid,  the  membrane  is  opaque, 
and  there  is  chronic  catarrh  of  the  stomach  and  of  the  small  intestines.  The 
spleen  is  enlarged,  in  part,  at  least,  from  the  chronic  congestion,  possibly  due 
in  part  to  a  toxic  influence.  The  pancreas  frequently  shows  interstitial  changes. 
The  kidneys  are  sometimes  cirrhotic,  the  bases  of  the  lungs  may  be  much 
compressed  by  the  ascitic  fluid,  the  heart  often  shows  marked  degeneration,  and 
arterio-sclerosis  is  usually  present.  A  remarkable  feature  is  the  association 
of  acute  tuberculosis  with  cirrhosis.  In  seven  cases  of  our  series  the  patients 
died  with  either  acute  tuberculous  peritonitis  or  acute  tuberculous  pleurisy. 
Eolleston  has  found  that  tuberculosis  was  present  in  28  per  cent,  of  706  fatal 
cases  of  cirrhosis.  Peritoneal  tuberculosis  was  found  in  9  per  cent,  of  a  series 
of  584  cases. 

The  compensatory  circulation  is  usually  readily  demonstrated.  It  is  car- 
ried out  by  the  following  set  of  vessels:  (1)  The  accessory  portal  system  of 
Sappey,  of  which  important  branches  pass  in  the  round  and  suspensory  liga- 
ments and  unite  with  the  epigastric  and  mammary  systems.  These  vessels  are 
numerous  and  small.  Occasionally  a  large  single  vein,  which  may  attain  the 
size  of  the  little  finger,  passes  from  the  hilus  of  the  liver,  follows  the  round 
ligament,  and  joins  the  epigastric  veins  at  the  navel.  Although  this  has  the 
position  of  the  umbilical  vein,  it  is  usually,  as  Sappey  showed,  a  para-umbilical 
vein — that  is,  an  enlarged  vein  by  the  side  of  the  obliterated  umbilical  vessel. 
There  may  be  produced  about  the  navel  a  large  bunch  of  varices,  the  so-called 
caput  Medusse.  Other  branches  of  this  system  occur  in  the  gastro-epiploic 
omentum,  about  the  gall-bladder,  and,  most  important  of  all,  in  the  suspen- 
sory ligament.  These  latter  form  large  branches,  which  anastomose  freely 
with  the  diaphragmatic  veins,  and  so  unite  with  the  vena  azygos.  (2)  By 
the  anastomosis  between  the  oesophageal  and  gastric  veins.  The  veins  at  the 
lower  end  of  the  oesophagus  may  be  enormously  enlarged,  producing  varices 
which  project  on  the  mucous  membrane.  (3)  The  communications  between 
the  hsemorrhoidal  and  the  inferior  mesenteric  veins.  The  freedom  of  com- 
munication in  this  direction  is  very  variable,  and  in  some  instances  the  hsemor- 
rhoidal veins  are  not  much  enlarged.  (4)  The  veins  of  Retzius,  which  unite 
the  radicles  of  the  portal  branches  in  the  intestines  and  mesentery  with  the  in- 
ferior vena  cava  and  its  branches.  To  this  system  belong  the  whole  group  of 
retroperitoneal  veins,  which  are  in  most  instances  enormously  enlarged,  par- 
ticularly about  the  kidneys,  and  which  serve  to  carry  ofi^  a  considerable  pro- 
portion of  the  portal  blood. 

Symptoms. — The  most  extreme  grade  of  portal  cirrhosis  may  exist  with- 
out symptoms.  So  long  as  the  compensatory  circulation  is  ma.intained  the 
patient  may  suft'er  little  or  no  inconvenience.  The  remarkable  efficiency  of 
this  collateral  circulation  is  well  seen  in  those  rare  instances  of  permanent 
obliteration  of  the  portal  vein.  The  symptoms  may  be  divided  into  two  groups 
— obstructive  and  toxic. 

Obstructive. — ^The  overfilling  of  the  blood-vessels  of  the  stomach  and  in- 
testine leads  to  chronic  catarrh,  and  the  patients  suffer  with  nausea  and  vom- 
iting, particularly  in  the  morning;  the  tongue  is  furred  and  the  bowels  are 
irregular.  Hsemorrhage  from  the  stomach  may  be  an  early  symptom;  it  is 
often  profuse  and  liable  to  recur.     It  seldom  proves  fatal.     The  amount  vom- 


570  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

ited  may  be  remarkable  as  in  a  case  in  which  ten  pounds  were  ejected  in  seven 
.days.  Following  the  hamatemesis  melsena  is  common ;  but  hasmorrhages  from 
the  bowels  may  occur  for  several  years  without  hgematemesis.  The  bleeding 
very  often  comes  from  oesophageal  varices.  Very  frequently  epistaxis  occurs. 
Enlargement  of  the  spleen  may  be  due  to  a  toxgemia.  The  organ  can  usually 
be  felt.  Evidences  of  the  establishment  of  the  collateral  circulation  are  seen 
in  the  enlarged  epigastric  and  mammary  veins,  more  rarely  in  the  presence  of 
the  caput  Medusas  and  the  development  of  haemorrhoids.  The  distended 
venules  in  the  lower  thoracic  zone  along  the  line  of  attachment  of  the  dia- 
phragm are  not  specially  marked  in  cirrhosis.  The  most  striking  feature  of 
failure  in  the  compensatory  circulation  is  ascites,  the  effusion  of  serous  fluid 
into  the  peritoneal  cavity,  which  may  appear  suddenly.  The  conditions  under 
which  this  occurs  are  still  obscure.  In  some  cases  it  is  due  more  to  chronic 
peritonitis  than  to  the  cirrhosis.  The  abdomen  gradually  distends,  may  reach 
a  large  size,  and  contain  as  much  as  15  to  20  litres.  (Edema  of  the  feet  may 
precede  or  develop  with  the  ascites.    The  dropsy  is  rarely  general. 

Jaundice  is  usually  slight,  and  was  present  in  107  of  293  cases  of  cirrhosis 
.collected  by  Eolleston,  The  skin  has  frequently  a  sallow,  slightly  icteroid 
tint.  The  urine  is  often  reduced  in  amount,  contains  urates  in  abundance, 
often  a  slight  amount  of  albumin,  and,  if  jaundice  is  intense,  tube-casts.  The 
'disease  may  be  afebrile  throughout,  but  in  many  cases,  as  shown  by  Carrington, 
.there  is  slight  fever,  from  100°  to  102.5°  F.  ' 

Examination  at  an  early  stage  of  the  disease  may  show  an  enlarged  and 
painful  liver.  In  many  of  the  cases  of  portal  cirrhosis  the  organ  is  "enlarged 
,at  all  stages  of  the  disease,  and,  whether  enlarged  or  contracted,  the  clinical 
symptoms  and  course  are  much  the  same"  (Foxwell).  The  patient  may  first 
come  under  observation  for  dyspepsia,  hsematemesis,  slight  jaundice,  or  nervous 
symptoms.  Later  in  the  disease  the  patient  has  an  unmistakable  hepatic 
fades;  he  is  thin,  the  eyes  are  sunken,  the  conjunctivse  watery,  the  nose 
and  cheeks  show  distended  venules,  and  the  complexion  is  muddy  or  ic- 
teroid. On  the  enlarged  abdomen  the  vessels  are  distended,  and  a  bunch  of 
dilated  veins  may  surround  the  navel.  A  venous  hum,  sometimes  accompanied 
by  a  thrill,  may  be  present  in  the  epigastrium  or  over  varicosities.  Naevi  of 
a  remarkable  character  may  appear  on  the  skin,  either  localized  stellate 
varices — spider  angiomata — usually  on  the  face,  neck,  and  back,  and  also 
"mat"  nsevi — areas  of  skin  of  a  reddish  or  purplish  color  due  to  the  uniform 
distention  of  small  venules.  When  much  fluid  is  in  the  peritoneum  it  is  im- 
possible to  make  a  satisfactory  examination,  but  after  withdrawal  the  area  of 
liver  duln^?ss  is  found  to  be  diminished,  particularly  in  the  middle  line,  and 
on  deep  pressure  the  edge  of  the  liver  can  be  detected,  and  occasionally  the 
hard,  firm,  and  even  granular  surface.  The  spleen  can  be  felt  in  the  left  hypo- 
chondriac region.  Examination  of  the  anus  may  reveal  the  presence  of  hemor- 
rhoids. 

Toxic  Symptoms. — At  any  stage  of  cirrhosis  the  patient  may  have  cere- 
l^ral  symptoms,  either  a  noisy,  joyous  delirium,  or  stupor,  coma,  or  even  con- 
,vulsions.  The  condition  is  not  infrequently  mistaken  for  uraemia.  The  nature 
of  the  toxic  agent  is  not  yet  settled.  Without  jaundice,  and  not  attributable 
to  cholaemia,  the  symptoms  may  come  on  in  hospital  when  the  patient  has  not 
had  alcohol  for  weeks. 


THE  CIEEHOSES  OF  THE  LIVER  571 

The  fatty  cirrhotic  liver  may  produce  symptoms  similar  to  those  of  the 
contracted  form,  but  more  frequently  it  is  latent  and  is  found  accidentally  in 
topers  who  have  died  from  various  diseases.  The  greater  number  of  the  cases 
clinically  diagnosed  as  cirrhosis  with  enlargement  come  in  this  division. 

Diagnosis. — With  ascites,  a  well-marked  history  of  alcoholism,  the  hepatic 
facies,  and  haemorrhage  from  the  stomach  or  bowels,  the  diagnosis  is  rarely 
doubtful.  If,  after  withdrawal  of  the  fluid,  the  spleen  is  found  to  be  enlarged 
and  the  liver  either  not  palpable  or,  if  it  is  enlarged,  hard  and  regular,  the 
probabilities  in  favor  of  cirrhosis  are  very  great.  In  the  early  stages  of  the 
disease,  when  the  liver  is  increased  in  size,  it  may  be  impossible  to  say  whether 
it  is  a  cirrhotic  or  a  fatty  liver.  The  differential  diagnosis  between  common 
and  syphilitic  cirrhosis  can  usually  be  made.  A  marked  history  of  syphilis  or 
the  existence  of  other  syphilitic  lesions,  with  great  irregularity  on  the  sur- 
face or  at  the  edge  of  the  liver,  are  in  favor  of  the  latter.  Thrombosis  or  ob- 
literation of  the  portal  vein  can  rarely  be  differentiated.  In  a  case  of  fibroid 
transformation  of  the  portal  vein  which  came  under  observation,  the  collateral 
circulation  had  been  established  for  years,  and  the  symptoms  were  simply 
those  of  extreme  portal  obstruction,  such  as  occur  in  cirrhosis.  Thrombosis 
of  the  portal  vein  may  occur  in  cirrhosis  and  be  characterized  by  a  rapidly 
developing  ascites. 

Prognosis.— The  outlook  is  bad.  When  the  collateral  circulation  is  fully- 
established  the  patient  may  have  no  symptoms  whatever.  There  are  instances 
of  enlargement  of  the  liver,  slight  jaundice,  cerebral  symptoms,  and  even 
hsematemesis,  in  wdiich  the  liver  becomes  reduced  in  size,  the  symptoms  disap- 
pear, and  the  patient  may  live  in  comparative  comfort  for  many  years.  There 
are  cases,  too,  possibly  syphilitic,  in  which,  after  one  or  two  tappings,  the 
symptoms  have  disappeared  and  the  patients  have  apparently  recovered.  As- 
cites is  a  very  serious  event,  especially  if  due  to  the  cirrhosis  and  not  to  an 
associated  peritonitis.  Of  34  cases  with  ascites  10  died  before  tapping  was 
necessary;  14  were  tapped,  and  the  average  duration  of  life  after  the  swelling 
was  first  noticed  was  only  eight  weeks;  of  10  cases  the  diagnosis  was  wrong  in 
4,  and  in  the  remaining  6,  who  were  tapped  oftener  than  once,  chronic  peri- 
tonitis and  perihepatitis  were  present  (Hale  White). 

II.     HYPEKTEOPHIC    BILIAEY    CIEEHOSIS    (Hanoi) 

This  well-characterized .  form  was  first  described  by  Eequin  in  1846,  but 
our  accurate  knowledge  of  the  condition  dates  from  the  work  of  Hanot  (1875)j 
whose  name  in  France  it  bears — maladie  de  Hanot. 

Cirrhosis  with  enlargement  occurs  in  the  portal  cirrhosis;  there  is  an  en- 
larged fatty  and  cirrhotic  liver  of  alcoholics,  a  pigmentary  form  occurs  in 
ba-mochromatosis,  and  in  association  with  syphilis  the  organ  is  often  very 
large.  The  hypertrophic  cirrhosis  of  Hanot  is  easily  distinguished  from  these 
forms. 

Etiology. — Males  are  more  often  affected  than  females — in  22  of  Schach- 
mann's  26  cases.  The  subjects  are  young;  some  of  the  cases  in  children  prob- 
ably belong  to  this  form.  Alcohol  plays  a  minor  part,  an.l  not  one  of  our  pa- 
tients had  been  a  heavy  drinker.  The  absence  of  all  known  etiological  factors 
is  a  remarkable  feature. 


573  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

Morbid  Anatomy. — The  organ  is  enlarged,  weighing  from  2,000  to  4,000 
grams.  The  form  is  maintained,  the  surface  is  smooth,  or  presents  small 
granulations;  the  color  in  advanced  cases  is  of  a  dark  olive  green;  the  con- 
sistence is  greatly  increased.  The  section  is  uniform,  greenish  yellow  in  color, 
and  the  liver  nodules  may  be  seen  separated  by  connective  tissue.  The  bile- 
passages  present  nothing  abnormal.  The  cirrhosis  is  mono-  or  multilobular, 
with  a  connective  tissue  rich  in  round  cells.  The  bile-vessels  are  the  seat  of  an 
angiocholitis,  catarrhal  and  productive,  and  there  is  an  extraordinary  develop- 
ment of  new  biliary  canaliculi.  The  liver-cells  are  neither  fatty  nor  pigmented, 
and  may  be  increased  in  size  and  show  karyokinetic  figures.  From  the  sup- 
posed origin  about  the  bile-vessels  it  has  been  called  biliary  cirrhosis,  but  the 
histological  details  have  not  been  worked  out  fully,  and  the  separation  of  this 
as  a  distinct  form  rests  upon  clinical  rather  than  anatomical  grounds.  The 
spleen  is  greatly  enlarged  and  may  weigh  600  or  more  grams. 

Symptoms. — The  cases  occur  in  young  persons;  there  is  not,  as  a  rule, 
an  alcoholic  history,  and  males  are  usually  affected.  The  features  are :  (a)  A 
remarkably  chronic  course  of  from  four  to  six,  or  even  ten  years.  (&)  Jaun- 
dice, usually  slight,  often  not  more  than  a  lemon  tint,  or  a  tinging  of  the  con- 
junctivEe.  At  any  time  during  the  course  an  icterus  gravis,  with  high  fever 
and  delirium,  may  develop.  There  is  bile  in  the  urine ;  the  stools  are  not  clay  • 
colored  as  in  obstructive  jaundice,  but  may  be  very  dark  and  "bilious."  (c) 
Attacks  of  pain  in  the  region  of  the  liver,  which  may  be  severe  and  associated 
with  nausea  and  vomiting.  The  pain  may  be  slight  and  dragging,  and  in  some 
cases  is  not  at  all  a  prominent  symptom.  The  jaundice  may  deepen  after  at- 
tacks of  pain,  (d)  Enlarged  liver.  A  fullness  in  the  upper  abdominal  zone 
may  be  the  first  complaint.  On  inspection  the  enlargement  may  be  very 
marked.  In  one  of  our  cases  the  left  lobe  was  unusually  prominent  and  stood 
out  almost  like  a  tumor.  An  exploratory  operation  showed  only  an  enlarged, 
smooth  organ  without  adhesions.  On  palpation  the  hypertrophy  is  uniform, 
the  consistence  is  increased,  and  the  edge  distinct  and  hard.  The  gall-bladder 
is  not  enlarged.  The  vertical  flatness  is  much  increased  and  may  extend  from 
the  sixth  rib  to  the  level  of  the  navel,  (e)  The  spleen  is  enlarged,  easily  pal- 
pable, and  very  hard.  (/)  Certain  negative  features  are  of  moment — the  usual 
absence  of  ascites  and  of  dilatation  of  the  subcutaneous  veins  of  the  abdomen. 
Among  other  symptoms  may  be  mentioned  htemorrhages.  One  patient  had 
bleeding  at  the  gums  for  a  year;  another  had  had  for  years  most  remarkable 
attacks  of  purpura  with  urticaria.  Pruritus,  xanthoma,  lichen,  and  telangiec- 
tasis may  be  present  in  the  skin.  The  skin  may  become  very  bronzed,  almost 
as  deeply  as  in  Addison's  disease.  Slight  fever  may  be  present,  which  increases 
during  the  crises  of  pain.  There  may  be  a  marked  leucocytosis.  A  curious 
attitude  of  the  body  has  been  seen,  in  which  the  right  shoulder  and  right  side 
appear  dragged  down.  The  patients  die  with  the  symptoms  of  icterus  gravis, 
from  haemorrhage,  from  an  intercurrent  infection,  or  in  a  profound  cachexia. 
Certain  of  the  cases  of  cirrhosis  of  the  liver  in  children  are  of  this  type;  the 
enlargement  of  the  spleen  may  be  very  pronounced. 

III.     SYPHILITIC  CIEEHOSIS 

This  is  considered  in  the  section  on  syphilis  (p.  279).  It  is  referred  to 
again  to  emphasize  (1)  its  frequency;  (2)  the  great  importance  of  its  differ- 


THE  CIEEHOSES  OF  THE  LIVER  573 

entiation  from  the  alcoholic  form;  (3)  its  curability  in  many  cases;  and  (4) 
the  tumor  formations  in  connection  with  it. 

IV.     CAPSULAE   CIREHOSIS— PEEIHEPATITIS 

Local  capsulitis  is  common  in  many  conditions  of  the  liver.  The  form  of 
disease  here  described  is  characterized  by  an  enormous  thickening  of  the  entire 
capsule,  with  great  contraction  of  the  liver,  but  not  necessarily  with  special 
increase  in  the  connective  tissue  of  the  organ  itself.  Our  chief  knowledge  of 
the  disease  we  owe  to  the  Guy's  Hospital  physicians,  particularly  to  Hilton 
Fagge  and  to  Hale  A¥hite,  who  collected  22  cases  from  the  records.  The  liver 
substance  itself  was  "never  markedly  cirrhotic;  its  tissue  was  nearly  always 
soft."  Chronic  capsulitis  of  the  spleen  and  a  chronic  proliferative  peritonitis 
are  almost  invariably  present.  In  19  of  the  22  cases  the  kidneys  were  granu- 
lar. Hale  White  regards  it  as  a  sequel  of  interstitial  nephritis.  The  youngest 
case  in  his  series  was  twenty-nine.  The  symptoms  are  those  of  portal  cirrhosis 
— ascites,  often  recurring  and  requiring  many  tappings.  Jaundice  is  not  often 
present.  There  are  two  groups  of  cases — the  one  in  adults  usually  with  ascites 
is  regarded  as  ordinary  cirrhosis  and  the  diagnosis  is  rarely  made.  Signs  of 
interstitial  nephritis,  recurring  ascites,  and  absence  of  jaundice  are  regarded 
by  Hale  White  as  important  diagnostic  points.  In  the  second  group  the 
perihepatitis,  perisplenitis,  and  proliferative  peritonitis  are  associated  with  ad- 
herent pericardium  and  chronic  mediastinitis.  In  one  such  case  the  diagnosis 
of  capsular  hepatitis  was  very  clear,  as  the  liver  could  be  grasped  in  the  hand 
and  formed  a  rounded,  smooth  organ  resembling  the  spleen.  The  child  was 
tapped  121  times  (Archives  of  Paediatrics,  1896). 

Treatment. — The  portal  function  of  the  liver  may  be  put  out  of  action 
without  much  damage  to  the  body.  There  may  be  an  extreme  grade  of  cirrhotic 
atrophy  without  symptoms;  the  portal  vein  may  be  obliterated,  or,  experi- 
mentally, the  portal  vein  may  be  anastomosed  with  the  cava.  So  long  as  there 
is  an  active  compensatory  circulation  a  patient  with  portal  cirrhosis  may  re- 
main well.  In  the  hypertrophic  form  toxaemia  is  the  special  danger  and  we 
have  no  means  of  arresting  the  progress  of  the  disease.  In  the  alcoholic  form 
it  is  too  late,  as  a  rule,  to  do  much  after  symptoms  have  occurred.  In  a  few 
cases  an  attack  of  jaundice  or  ha?matemesis  may  prove  the  salvation  of  the 
patient,  who  may  afterward  take  to  a  temperate  life.  The  diet  should  be 
very  simple  and  large  amounts  of  water  taken  to  aid  elimination.  The  bowels 
should  be  kept  open,  for  which  the  use  of  the  salines  is  generally  best.  An  oc- 
casional course  of  potassium  iodide  may  be  given.  With  the  advent  of  ascites 
the  critical  stage  is  reached.  Restriction  of  fluid  intake  and  free  purgation 
may  relieve  a  small  exudate,  rarely  a  large  one,  and  it  is  best  to  tap  early.  In 
the  syphilitic  cirrhosis  much  more  can  be  done,  and  a  majority  of  the  cases 
of  cure  after  ascites  are  of  this  variety.  Iodide  of  potassium  in  moderate 
doses,  15  to  30  drops  of  the  saturated  solution,  and  mercury  save  a  number  of 
cases  even  after  repeated  tapping.  The  diagnosis  may  be  reached  only  after 
removal  of  the  fluid,  but  in  every  case  with  a  history  of  syphilis,  a  positive 
Wassermaim  reaction,  or  with  irregularity  of  the  liver  this  treatment  should 
be  tried. 

Surgical  Treatment. —  (a)    Tappinrj.—When  the  ascites  increases  it  is 


574  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

better  to  tap  early.  As  Hale  White  remarks,  a  case  of  cirrhosis  of  the  liver 
which  is  tapped  rarely  recovers,  but  there  are  instances  in  which  early  and 
repeated  paracentesis  is  followed  by  cure.  Accidents  are  rare;  haemorrhage, 
acute  peritonitis,  or  erysipelas  at  the  point  of  puncture  occasionally  follow; 
collapse  may  occur  during  the  operation,  to  guard  against  which  Mead  advised 
the  use  of  the  abdominal  binder.  Continuous  drainage  with  Southey's  tubes 
is  not  often  practicable  and  has  no  special  advantages,  (h)  Laparotomy,  with 
complete  removal  of  the  fluid,  and  freshening  or  rubbing  the  peritoneal  sur- 
faces, to  stimulate  the  formation  of  adhesions,  (c)  Omentopexy,  the  stitching 
of  the  omentum  to  the  abdominal  wall,  and  the  establishment  of  collateral 
circulation  in  this  way  between  the  portal  and  the  systemic  vessels.  This  op- 
eration is  sometimes  successful.  In  224  cases  there  were  84  deaths  and  129 
recoveries;  11  cases  doubtful.  Among  the  129  successful  cases,  in  25  the 
ascites  recurred;  70  appeared  to  have  completely  recovered,  {d)  Fistula  of 
EcTh.  The  porto-caval  anastomosis  has  been  performed  once  in  man  in  cirrhosis 
of  the  liver  (Widal,  La  Semaine  Medicale,  1903).  The  patient  lived  for  three 
months,  (e)  Auto-drainage,  in  which  the  fluid  is  drained  into  the  subcuta- 
neous tissues. 

VIII.     ABSCESS  OF  THE  LIVER 

Etiology. — Suppuration  within  the  liver,  either  in  the  parenchyma  or  in 
the  blood  or  bile-passages,  occurs  under  the  following  conditions :    . 

(a.)  The  tropical  abscess,  also  called  the  solitary,  commonly  follows  amoe- 
bic dysentery.  It  frequently  occurs  among  Europeans  in  India,  particularly 
those  who  drink  alcohol  freely  and  are  exposed  to  gTeat  heat.  Cases  may 
occur  without  a  history  of  previous  dysentery,  and  there  have  been  fatal  cases 
without  any  affection  of  the  large  bowel.  In  the  United  States  the  large  soli- 
tary abscess  is  not  very  infrequent.  The  relation  of  this  form  of  abscess  to 
amoebic  dysentery  has  been  considered.  The  number  of  cases  has  been  much 
reduced  since  the  introduction  of  the  emetine  treatment. 

(5)  Traumatism  is  an  occasional  cause.  The  injury  is  generally  in  the 
hepatic  region.  "  Instances  occur  in  trainmen  injured  while  coupling  cars. 
Injury  to  the  head  is  not  infrequently  followed  by  liver  abscess. 

(c)  Embolic  or  pyamic  abscesses  are  the  most  numerous,  occurring  in  a 
general  pysemia  or  following  foci  of  suppuration  in  the  territory  of  the  portal 
vessels.  The  infective  agents  may  reach  the  liver  through  the  hepatic  artery, 
as  in  those  cases  in  which  the  original  focus  of  infection  is  in  the  area  of  the 
systemic  circulation;  though  it  may  happen  occasionally  that  the  infective 
agent,  instead  of  passing  through  the  lungs,  reaches  the  liver  through  the 
inferior  vena  cava  and  the  hepatic  veins.  A  remarkable  instance  of  multiple 
abscesses  of  arterial  origin  was  shown  by  the  case  of  aneurism  of  the  hepatic 
artery  reported  by  Eoss  and  Osier.  Infection  through  the  portal  vein  is  more 
common.  It  results  from  dysentery  and  other  ulcerative  affections  of  the 
bowels,  appendicitis,  occasionally  after  typhoid  fever,  in  rectal  affections,  and 
in  abscesses  in  the  pelvis^  In  these  cases  the  abscesses  are.  multiple  and,  as  a 
rule,  within  the  branches  of  the  portal  vein — suppurative  pylephlebitis. 

(d)  A  not  uncommon  cause  is  inflammation  of  the  bile-passages  caused  by 
gall-stones,  more  rarely  by  parasites — suppurative  cholangitis.     In  some  in- 


ABSCESS  OF  THE  LIVER  575: 

stances  of  tuberculosis  of  the  liver  the  affection  is  chiefly  of  the  bile-ducts, 
with  the  formation  of  multiple  tuberculous  abscesses  containing  a  bile-stained . 
pus.  ■  . 

(e)  Foreign  bodies  and  parasites.     In  rare  instances  foreign  bodies,  such, 
as  a  needle,  may  pass  from  the  stomach  or  gullet,  lodge  in  the  liver,  and  excite.' 
an  abscess,  or  a  foreign  body,  such  as  a  needle  or  a  fish-bone,  has  perforated  a 
branch  or  the  portal  vein  itself  and  induced  pylephlebitis.     Echinococcus  cysts - 
frequently  cause  suppuration,  the  penetration  of  round  worms  into  the  liver 
less  commonly,  and  most  rarely  of  all  the  liver-fluke. 

Morbid  Anatomy. —  (a)  Of  the  Solitary  or  Tropical  Abscess. — This 
has  been  described  under  amoebic  dysentery. 

(&)  Of  Septic  and  PYiEMic  Abscesses. — These  are  usually  multiple, 
though  occasionally,  following  injury,  there  may  be  a  large  solitary  absGess. 

In  suppurative  pylephlebitis  the  liver  is  uniformly  enlarged.  The  cap- 
sule may  be  smooth  and  the  external  surface  of  normal  appearance.  On  sec- 
tion there  are  isolated  pockets  of  pus,  either  having  a  round  outline  or  in 
some  places  distinctly  dendritic,  and  from  these  the  pus  may  be  squeezed.  The 
entire  portal  system  within  the  liver  may  be  involved;  sometimes  territories 
are  cut  off  by  thrombi.  The  suppuration  may  extend  into  the  main  branch 
or  even  into  the  mesenteric  and  gastric  veins.  In  suppurative  cholangitis 
there  is  usually  obstruction  by  gall-stones,  the  ducts  are  greatly  distended,  the 
gall-bladder  enlarged  and  full  of  pus,  and  the  branches  within  the  liver  are 
extremely  distended,  having  an  appearance  not  unlike  that  described  in  pyle- 
phlebitis. An  abscess  may  have  a  sponge-like  appearance  due  to  the  fusion. 
of  numerous  points  of  suppuration.  Suppuration  about  the  echinococcus  cysts 
may  be  very  extensive,  forming  enormous  abscesses,  the  characters  of  which  arc 
at  once  recognized  by  the  remnants  of  the  cysts.  : 

Symptoms.— (a)  Of  ti-ie  Large  Solitary  Abscess. — The  abscess  may  be. 
latent  and  run  a  course  without  definite  symptoms ;  death  may  occur  suddenly , 
from  rupture. 

Fever,  pain,  enlargement  of  the  liver,  and  a  septic  condition  are  the  impor- 
tant symptoms  of  hepatic  abscess.     The  temperature  is  elevated  at  the  outset 
and  is  of  an  intermittent  or  septic  type.     It  is  irregular,  and  may  remain, 
normal  or  even  subnormal  for  a  few  days;  then  the  patient  has  a  rigor  and 
the  temperature  rises  to  103°  F.  or  higher.     Owing  to  this  intermittent  char- 
acter of  the  fever  the  disease  is  often  mistaken  for  malaria.     The  fever  may 
rise  every  afternoon  without  a  rigor.    Profuse  sweating  is  common,  particularly 
when  the  patient  falls  asleep.    In  chronic  cases  there  may  be  little  or  no  fever. ./ 
Patients  with  a  liver  abscess  perforating  the  lung,  may  cough  up  pus  after 
the  temperature  has  been  normal  for  weeks.    The  pain  is  variable  and  usually 
referred  to  the  back  or  shoulder;  or  there  is  a  dull  aching  sensation  in  fhe- 
right  hypochondrium.     When  turned  on  the  left  side,  the  patient  often  com- ; 
plains  of  a  heavy,  dragging  sensation,  so  that  he  usually  prefers  to  lie  on  the 
right  side.     Pain  on  pressure  over  the  liver  is  usually  present,  particularly 
on  deep  pressure  at  the  costal  margin  in  the  nipple  line. 

Tne  enlargement. of  the  liver  is  most  marked  in  the  right  lobe,  and,  as  the 
abscess  cavity  is  usually  situated  more  toward  the  upper  than  the  under  sur- 
face, the  increase  in  volume  is  upward  and  to  the  right,  not  downward,  as 
in  cancer  and  the  other  affections  producing  enlargement.     Percussion  in  the 


576  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

mid-sternal  and  parasternal  lines  may  show  a  normal  limit.  At  the  nipple- 
line  the  curve  of  liver  dulness  begins  to  rise,  and  in  the  mid-axillary  it  mav 
reach  the  fifth  rib,  while  behind,  near  the  spine,  the  area  of  dulness  may  be 
almost  on  a  level  with  the  angle  of  the  scapula.  There  are  instances  in  which 
this  characteristic  feature  is  not  present,  as  when  the  abscess  occupies  the  left 
lobe.  The  enlargement  of  the  liver  may  be  so  great  as  to  cause  bulging  of  the 
right  side,  and  the  edge  may  project  a  hand's-breadth  or  more  below  the  costal 
margin.  In  such  instances  the  surface  is  smooth.  Palpation  is  painful,  and 
there  may  be  fremitus  on  deep  inspiration.  In  some  instances  fluctuation  may 
be  detected.  Adhesions  may  form  to  the  abdominal  wall  and  the  abscess  may 
point  below  the  margin  of  the  ribs,  or  even  in  the  epigastric  region.  In  many 
cases  the  appearance  of  the  patient  is  suggestive.  The  skin  has  a  sallow, 
slightly  icteroid  tint,  the  face  is  pale,  the  complexion  muddy,  the  conjunctivae 
are  infiltrated,  and  often  slightly  bile-tinged.  There  is  in  the  facies  and  in 
the  general  appearance  of  the  patient  a  strong  suggestion  of  the  existence  of 
abscess.  There  is  no  internal  affection  associated  with  suppuration  which 
gives  just  the  same  hue  as  certain  instances  of  abscess  of  the  liver.  Marked 
jaundice  is  rare.  Diarrhoea  may  be  present  and  give  an  important  clue  to 
the  nature  of  the  case,  particularly  if  amoebae  are  found  in  the  stools.  Con- 
stipation may  occur. 

Perforation  of  the  lung  occurred  in  9  of  the  27  cases  in  our  series.  The 
symptoms  are  most  characteristic.  The  extension  may  occur  through  the  dia- 
phragm, without  actual  rupture,  and  with  the  production  of  a  purulent  pleu- 
risy and  invasion  of  the  lung.  With  cough  of  an  aggravated  and  convulsive 
character,  there  are  signs  of  involvement  at  the  base  of  the  right  lung,  de- 
fective resonance,  feeble  tubular  breathing,  and  increase  in  the  tactile  fremi- 
tus ;  but  the  most  characteristic  feature  is  the  presence  of  a  reddish-brown 
expectoration  of  a  brick-dust  color,  resembling  anchovy  sauce.  Amcebge  are 
present  in  variable  numbers  and  display  active  amoeboid  movements.  The 
brownish  tint  of  the  expectoration  is  due  to  blood-pigment  and  blood-corpuscles, 
and  there  may  be  orange-red  crystals  of  hsematoidin. 

The  abscess  may  perforate  externally,  as  mentioned  already,  or  into  the 
stomach  or  bowel;  occasionally  into  the  pericardium.  The  duration  of  this 
form  is  very  variable.  It  may  run  its  course  and  prove  fatal  in  six  or  eight 
weeks  or  may  persist  for  several  j^ears. 

The  prognosis  is  serious,  as  the  mortality  is  more  than  50  per  cent.  The 
death-rate  has  been  lowered  of  late  years,  owing  to  the  great  fearlessness  with 
which  the  surgeons  now  attack  these  cases. 

(&)  Or  THE  Pyemic  Abscess  and  Suppurative  Pylephlebitis. — Clin- 
ically these  conditions  cannot  be  separated.  Occurring  in  a  general  pytemia, 
no  special  features  may  be  added  to  the  case.  When  there  is  suppuration  with- 
in the  portal  vein  the  liver  is  uniformly  enlarged  and  tender,  though  pain  may 
not  be  a  marked  feature.  There  is  an  irregular,  septic  fever,  and  the  complex- 
ion is  muddy,  sometimes  distinctly  icteroid.  The  features  are  indeed  those  of 
pyaemia,  plus  a  slight  icteroid  tinge,  and  an  enlarged  and  painful  liver.  The 
latter  features  alone  are  peculiar.  The  sweats,  chills,  prostration,  and  fever 
have  nothing  distinctive. 

Diagnosis. — Abscess  of  the  liver  may  be  confounded  with  intermittent 
fever,  a  common  mistake  in  malarial  regions.     Practically  an  intermittent 


ABSCESS  OF  THE  LIVEK  577 

feve7'  which  resists  quinine  is  not  malarial.  Laveran's  organisms  are  also 
absent  from  the  blood.  AVhen  the  abscess  bursts  into  the  pleura  a  right-sided 
empyema  is  produced  and  perforation  of  the  lung  usually  follows.  When 
the  liver  abscess  has  been  latent  and  dysenteric  symptoms  have  not  been  marked, 
the  condition  may  be  considered  empyema  or  abscess  of  the  lung.  In  such 
cases  the  anchovy-sauce-like  color  of  the  pus  and  the  presence  of  the  amoebae 
will  enable  one  to  make  a  definite  diagnosis.  Perforation  externally  is  readily 
recognized,  and  yet  in  an  abscess  cavity  in  the  epigastric  region  it  may  be 
difficult  to  say  whether  it  has  proceeded  from  the  liver  or  is  in  the  abdominal 
wall.  When  the  abscess  is  large,  and  the  adhesions  are  so  firm  that  the  liver 
does  not  descend  during  inspiration,  the  exploratory  needle  does  not  make  an 
up-and-down  movement  during  aspiration.  The  diagnosis  of  suppurating 
echinococcus  cyst  is  rarely  possible,  except  in  Australia  and  Iceland,  where 
hydatids  are  so  common. 

Perhaps  the  most  important  aifection  from  which  suppuration  within  the 
liver  is  to  be  separated  is  the  intei'mittent  hepatic  fever  associated  with  gall- 
stones. Of  the  cases  reported  a  majority  have  been  considered  due  to  suppu- 
ration, and  in  two  cases  the  liver  had  been  repeatedly  aspirated.  Post  mortem 
examinations  have  shown  conclusively  that  the  high  fever  and  chills  may  recur 
at  intervals  for  years  without  suppuration  in  the  ducts.  The  distinctive  fea- 
tures of  this  condition  are  paroxysms  of  fever  with  rigors  and  sweats — which 
may  occur  with  great  regularity,  but  which  more  often  are  separated  by  long 
intervals — the  deepening  of  the  jaundice  after  the  paroxysms,  the  entire  apy- 
rexia  in  the  intervals,  and  the  maintenance  of  the  general  nutrition.  The  time 
element  also  is  important,  as  in  some  of  these  cases  the  disease  has  lasted  for 
several  years.  Finally,  it  is  to  be  remembered  that  abscess  of  the  liver,  in 
temperate  climates  at  least,  is  invariably  secondary,  and  the  primary  source 
must  be  carefully  sought  for,  either  in  dysentery,  slight  ulceration  of  the  rec- 
tum, suppurating  haemorrhoids,  ulcer  of  the  stomach,  or  in  suppurative  disease 
of  other  parts  of  the  body,  particularly  within  the  skull  or  in  the  bones. 
Leucocytosis  may  be  absent  in  the  amoebic  abscess  of  the  liver;  in  septic  cases 
it  may  be  very  high. 

In  suspected  cases,  whether  the  liver  is  enlarged  or  not,  exploratory  aspira- 
tion may  be  performed.  The  needle  may  be  entered  in  the  anterior  axillary 
line  in  the  lowest  interspace,  or  in  the  seventh  interspace  in  the  mid-axillary 
line,  or  over  the  centre  of  the  area  of  dulness  behind.  The  patient  should  be 
placed  under  ether,  for  it  may  be  necessary  to  make  several  deep  punctures.  It 
is  not  well  to  use  too  small  an  aspirator.  Operation  should  be  done  at  once 
if  pus  is  found.  Extensive  suppuration  may  exist,  and  yet  be  missed  in  the 
aspiration,  particularly  when  the  branches  of  the  portal  vein  are  distended 
with  pus. 

Treatment.— Pyaemic  abcess  and  suppurative  pylephlebitis  are  invariably 
fatal.  Treves,  however,  reports  a  case  of  pyaemic  abscess  following  appendici- 
tis in  which  the  patient  recovered  after  an  exploratory  operation.  Surgical 
measures  are  not  justified  in  thtsse  cases,  unless  an  abscess  shows  signs  of  point- 
ing. As  the  abscesses  associated  with  dysentery  are  often  single,  they  afford 
a  reasonable  hope  of  benefit  from  operation.  If,  however,  the  patient  is  ex- 
pectorating the  pus,  if  the  general  condition  is  good  and  the  hectic  fever  not 
marked,  it  is  best  to  defer  operation,  as  many  of  these  instances  recover  spon' 


■578  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

taneonsly.     The  large  single  abscesses  are  the  most  favorable  for  operation. 
The  general  medical  treatment  of  the  cases  is  that  of  ordinary  septicaemia. 


IX.     NEW  GROWTHS  IN  THE  LIVER 

These  may  be  cancer,  either  primary  or  secondary,  adenoma,  sarcoma,  or 
angioma. 

Etiology. — Cancer  of  the  liver  is  third  in  order  of  frequency  of  internal 
cancer.  It  is  rarely  primary,  usually  secondary  to  cancer  in  other  organs.  It 
is  a  disease  of  late  adult  life.  According  to  Leichtenstern,  over  50  per  cent, 
of  the  cases  occur  between  the  fortieth  and  the  sixtieth  years.  It  occasionally 
occurs  in  children.  Women  are  attacked  less  frequently  than  men  but  some 
authors  state  that  secondary  cancer  is  more  common  in  women,  owing  to  the 
frequency  of  cancer  of  the  uterus.  In  many  cases  trauma  is  an  antecedent,  and 
cancer  of  the  bile-passages  is  associated  in  many  instances  with  gall-stones. 
Cancer  is  stated  to  be  less  common  in  the  tropics. 

Morbid  Anatomy. — The  following  forms  of  new  growths  occur  in  the  liver 
and  have  a  clinical  importance : 

Cancek. — Primary  Cancer. — This  is  rare.  Of  163  cases  collected  by 
Eggel,  63.3  per  cent,  were  in  males.  There  are  several  varieties.  Kodular 
forms,  in  which  there  are  scattered  growths  throughout  the  organ;  the  mas- 
sive form  in  which  the  solitary  tumor  occupies  a  large  area,  either  a  lobe  or 
the  greater  part  of  it ;  and  small  metastatic  nodules.  A  very  important  form 
is  that  in  which  the  liver  is  diffusely  infiltrated  with  small  growths,  with  much 
hyperplasia  of  the  connective  tissue — the  so-called  cancer  Avith  cirrhosis.  The 
course  of  the  disease  is  rapid,  jaundice  often  occurs,  splenic  enlargement  is  not 
infrequent,  ascites  and  cedema  are  common  and  toxic  features  are  frequent 
toward  the  close. 

Secondary  Cancer. — The  organ  may  reach  an  enormous  size,  301/^  pounds 
(Osier),  33  pounds  (Christian).  The  cancerous  nodules  project  beneath  the 
capsule,  and  can  be  felt  during  life  or  even  seen  through  the  thin  abdominal 
walls.  They  are  usually  disseminated  equally,  though  in  rare  instances  they 
may  be  confined  to  one  lobe.  The  consistence  of  the  nodules  varies;  in  some 
cases  they  are  firm  and  hard  and  those  on  the  surface  show  a  distinct  umbilica- 
tion,  due  to  the  shrinking  of  the  fibrous  tissue  in  the  centre.  These  superficial 
masses  are  sometimes  spoken  of  as  "Farre's  tubercles."  More  frequently  the 
masses  are  on  section  grayish-white  in  color,  or  hsemorrhagic.  Eupture  of 
blood-vessels  is  not  uncommon;  in  one  specimen  there  was  an  enormous  clot 
beneath  the  capsule  of  the  liver,  together  with  hemorrhage  into  the  gall-bladder 
and  into  the  peritoneum.  The  secondary  cancer  shows  the  same  structure  as 
the  initial  lesion,  and  is  usually  an  alveolar  or  cylindrical  carcinoma.  Degener- 
ation is  common  in  these  secondary  growths;  thus  the  hyaline  transformation 
may  convert  large  areas  into  a  dense, ,  dry,  grayish-yellow  mass.  Extensive 
areas  of  fatty  degeneration  may  occur,  sclerosis  is  not  uncommon,  and  hipmor- 
rhages  are  frequent.     Suppuration  sometimes  follows. 

Cancer  of  the  bile-passages  which  has  been  already  considered. 

Primary  ADENOMA.^Gordinier  and  Sawyer  collected  44  cases,  28  of  which 
were  multiple,  and  of  these  21  were  associated  with  the  cirrhosis  of  Laennec. 


NEW  GROWTHS  IN  THE  LIVER  579 

In  a  majority  of  the  cases  the  process  appears  to  be  secondary  to  a  cirrhosis, 
a  compensatory  cell  hypertrophy  to  offset  the  destruction  of  the  liver  cells. 
In  some  cases,  however,  it  may  be  a  primary  affair.     The  clinical  picture  is. 
that  of  cirrhosis,  often  of  the  Hanot  type. 

Sarcoma. — Of  primary  sarcoma  of  the  liver  very  few  cases  have  been  re- 
ported. Secondary  sarcoma  is  more  frequent,  and  many  examples  of  lympho- 
sarcoma and  myxo-sarcoma  are  on  record,  less  frequently  glio-sarcoma  or  the 
smooth  or  striped  myoma.  The  most  important  form  is  the  m  el  an  o -sarcoma, 
secondary  to  sarcoma  of  the  eye  or  of  the  skin.  Very  rarely  melano-sarcoma 
occurs  primarily  in  the  liver.  In  this  form  the  liver  is  greatly  enlarged,  is 
either  uniformly  infiltrated  with  the  growth,  which  gives  the  cut  surface  the 
appearance  of  dark  granite,  or  there  are  large  nodular  masses  of  a  deep  black 
or  marbled  color.  There  are  usually  extensive  metastases,  and  in  some  in- 
stances every  organ  of  the  body  is  involved.  Nodules  of  melano-sarcoma  of 
the  skin  may  give  a  clue  to  the  diagnosis. 

Other  Forms  of  Liver  Tumor. — Angioma  occurs  as  a  small,  reddish  body 
the  size  of  a  walnut,  and  consists  simply  of  a  series  of  dilated  vessels.  Occa- 
sionally in  children  angiomata  grow  and  produce  large  tumors. 

Cysts  are  occasionally  found,  either  single,  which  is  not  very  uncommon,  or 
multiple,  when  they  usually  coexist  with  congenital  cystic  kidneys. 

Symptoms. — It  is  often  impossible  to  differentiate  primary  and  secondary 
cancer  of  the  liver  unless  the  primary  seat  of  the  disease  is  evid'ent,  as  in  the 
case  of  scirrhus  of  the  breast,  cancer  of  the  rectum,  or  of  a  tumor  in  the 
stomach.  As  a  rule,  cancer  of  the  liver  is  associated  with  progressive  enlarge- 
ment; but  in  some  cases  of  primary  nodular  cancer  and  in  the  cancer  with 
cirrhosis  the  organ  may  not  be  enlarged.  Gastric  disturbance,  loss  of  appe- 
tite, nausea,  and  vomiting  are  frequent.  Progressive  loss  of  flesh  and  strength 
may  be  the  first  symptoms.  Pain  or  a  sensation  of  uneasiness  in  the  right 
hypochondriac  region  may  be  present,  but  enormous  enlargement  of  the  liver 
may  occur  without  the  slightest  pain.  Jaundice,  which  is  present  in  at  least 
half  of  the  cases,  is  usually  of  moderate  extent,  unless  the  common  duct  is 
occluded.  Ascites  is  rare,  except  in  the  form  of  cancer  with  cirrhosis,  in  which 
the  picture  is  that  of  the  atrophic  form.  Pressure  by  nodules  on  the  portal 
vein  or  extension  of  the  cancer  to  the  peritoneum  may  induce  ascites. 

Inspection  shows  the  abdomen  to  be  distended,  particularly  in  the  upper 
zone.  In  late  stages,  when  emaciation  is  marked,  the  cancerous  nodules  can 
be  plainly  seen  beneath  the  skin,  and  in  rare  instances  even  the  umbilications. 
The  superficial  veins  are  enlarged.  On  palpation  the  liver  is  felt,  a  hand's- 
breadth  or  more  below  the  costal  margin,  descending  with  each  inspiration. 
The  surface  is  usually  irregular,  and  may  present  large  masses  or  smaller 
nodular  bodies,  either  rounded  or  with  central  depressions.  In  instances  of 
diffuse  infiltration  the  liver  may  be  greatly  enlarged  and  present  a  perfectly 
smooth  surface.  The  growth  is  progressive,  and  the  edge  of  the  liver  may 
ultimately  extend  below  the  level  of  the  navel.  Although  generally  uniform 
and  producing  enlargement  of  the  whole  organ,  occasionally  the  tumor  in  the 
left  lobe  forms  a  solid  mass  occupying  the  epigastric  region.  By  percussion 
the  outline  can  be  accurately  limited  and  the  progressive  growth  of  the  tumor 
estimated.  The  spleen  is  rarely  enlarged.  Pyrexia  is  present  in  many  cases, 
usually  a  continuous  fever,  ranging  from  100°  to  102°  F. ;  it  may  be  inter- 


580  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

mittent,  with  rigors.  Tliis  may  be  associated  with  the  cancer  alone,  or,  as  in 
one  of  our  eases,  with  suppuration.  (Edema  of  the  feet,  from  anaemia,  usually 
supervenes.  Cancer  of  the  liver  kills  in  from  three  to  fifteen  months.  One  of 
our  patientc  lived  for  more  than  two  years. 

Dia^osis. — The  diagnosis  is  easy  w-hen  the  liver  is  greatly  enlarged  and 
the  surface  nodular.  The  smoother  forms  of  diffuse  carcinoma  may  at  first 
be  mistaken  for  fatty  or  amyloid  liver,  but  the  presence  of  jaundice,  the  rapid 
enlargement,  and  the  more  marked  cachexia  will  usually  suffice  to  differen- 
tiate it.  Perhaps  the  most  puzzling  conditions  occur  in  the  cases  of  enlarged 
syphilitic  liver  with  irregular  gummata.  The  large  eehinococcus  liver  may 
present  a  striking  similarity  to  carcinoma,  but  the  nodules  are  usually  softer, 
the  disease  lasts  much  longer,  and  the  cachexia  is  not  marked. 

Hypertrophic  cirrhosis  may  at  first  be  mistaken  for  carcinoma,  as  the 
jaundice  is  usually  deep  and  the  liver  very  large;  but  the  absence  of  a  marked 
cachexia  and  wasting  and  the  painless,  smooth  character  of  the  enlargement 
are  points  against  cancer.  In  large,  rapidly  growing  secondary  cancers  the 
superficial  rounded  masses  may  almost  fluctuate  and  these  soft  tumor-like  pro- 
jections may  contain  blood.  The  form  of  cancer  with  cirrhosis  can  scarcely  bc' 
separated  from  atrophic  cirrhosis  itself.  Perhaps  the  wasting  is  more  extreme 
and  more  rapid,  but  the  jaundice  and  the  ascites  are  identical.  Melano-sar- 
coma  causes  great  enlargement  of  the  organ.  There  are  frequently  symptoms 
of  involvement  of  other  viscera,  as  the  lungs,  kidneys,  or  spleen.  Secondary 
tumors  may  occur  in  the  skin.  A  very  important  symptom,  not  present  in  al! 
cases,  is  melanuria,  the  passage  of  a  very  dark-colored  urine,  w^hich  may,  how- 
ever, when  first  voided,  be  quite  normal  in  color.  The  existence  of  a  melano- 
sarcoma  of  the  eye,  or  the  history  of  blindness  in  one  eye,  with  subsequent 
extirpation,  may  indicate  at  once  the  true  nature  of  the  hepatic  enlargement. 

There  are  several  conditions  in  w^hich  the  liver  itself,  or  portions  of  it, 
may  be  mistaken  for  tumor,  (a)  In  a  progressive  cirrhosis  with  enlargement 
the  left  lobe  may  increase  out  of  all  proportion  to  the  right,  and  form  a  promi- 
nent mass  in  the  epigastrium,  (h)  Eieders  tongue-like  lobe  projecting  from 
the  edge  in  the  neighborhood  of  the  gall-bladder,  and  often  associated  with  dis- 
tention of  this  organ,  (c)  The  extreme  left  portion  of  the  organ  may  be 
almost  separated  by  a  broad,  flat  band,  containing  little  or  no  liver  tissue.  In 
a  very  thin  person  this  section  may  feel  like  a  separate  tumor  mass.  A  small 
portion  of  the  liver  may  rest  directly  upon  the  coeliac  axis,  connected  with  the 
left  lobe  by  a  mesentery.  Lastly,  the  contracted,  deformed  organ  in  perihepa- 
titis may  form  a  visible,  freely  movable  tumor  in  the  upper  portion  of  the 
al)domen,  without  a  semblance  of  the  normal  liver.  Such  an  instance  is 
figured  in  Osier's  lectures  on  Abdominal  Tumors. 

Treatment. — Eesection  of  tumors  of  the  liver'  has  been  performed  in  many 
cases.     Otherwise  the  treatment  is  sj'mptomatic. 


X.     FATTY  LIVER 

Two  different  forms  of  this  condition  are  recognized — the  fatty  infiltration 
and  fatty  degeneration.  Fatty  infiUration  occurs,  to  a  certain  extent,  in  normal 
livers,  since  the  cells  always  contain  minute  globules  of  oil.    In  fatty  degenera- 


AMYLOID  LIVER  581 

lion,  which  is  much  less  common,  the  protoplasm  of  the  liver-cells  is  destroyed 
and  the  fat  takes  its  place,  as  seen  in  cases  of  malignant  jaundice  and  in  phos- 
phorus poisoning. 

Fatty  liver  occurs  under  the  following  conditions:  {a)  In  association  with 
general  obesity,  in  which  case  the  liver  appears  to  be  one  of  the  storehouses 
of  the  excessive  fat.  (&)  In  conditions  in  which  the  oxidation  processes  are 
interfered  with,  as  in  cachexia,  profound  anaemia,  and  in  pulmonary  tubercu- 
losis. The  fatty  infiltration  of  the  liver  in  heavy  drinkers  is  to  be  attributed 
to  the  excessive  demand  made  by  the  alcohol  upon  the  oxygen,  (c)  Certain 
jjoisons.  of  which  phosphorus  is  the  most  charactex'istic,  produce  an  intense 
fatty  degeneration  with  necrosis  of  the  liver-cells.  The  poison  of  acute  yellow 
atrophy,  whatever  its  nature,  acts  in  the  same  way. 

The  liver  is  uniformly  increased  in  size.  The  edge  may  reach  below  the 
level  of  the  navel.  It  is  smooth,  looks  pale  and  bloodless;  on  section  it  is 
dry,  and  renders  the  surface  of  the  knife  greasy.  The  liver  may  weigh  many 
pounds,  but  the  specific  gravity  is  so  low  that  the  entire  organ  floats  in  water. 

The  symptoms  of  fatty  liver  are  not  definite.  Jaundice  is  never  present; 
the  stools  may  be  light  colored,  but  even  in  the  most  advanced  grades  the  bile 
is  still  formed.  Signs  of  portal  obstruction  are  rare.  Haemorrhoids  are  not 
very  infrequent.  Altogether,  the  symptoms  are  chiefly  those  of  the  disease 
with  which  the  degeneration  is  associated.  In  cases  of  great  obesity  the  physi- 
cal examination  is  uncertain;  Ijut  in  cachectic  conditions  the  organ  can  be  felt 
to  be  greatly  enlarged,  though  smooth  and  painless.  Fatty  livers  are  among 
the  largest  met  with  at  the  bedside. 


XI.     AMYLOID  LIVER 

The  waxy,  lardaceous,  or  amyloid  liver  occurs  as  part  of  a  general  degen- 
eration, associated  with  cachexias,  particularly  when  the  result  of  long-stand- 
ing suppuration.    It  is  rare  in  the  United  States. 

In  practice,  it  is  found  oftenest  in  the  prolonged  suppuration  of  tubercu- 
lous disease,  either  of  the  lungs  or  of  the  bones,  i^  ext  in  order  of  frequency 
are  the  cases  associated  with  syphilis.  Here  there  may  be  ulceration  of  the 
rectum,  with  which  it  is  often  connected,  or  chronic  disease  of  the  bone,  or  it 
may  be  present  when  there  are  no  suppurative  changes.  It  is  found  occasion- 
ally in  rickets,  in  prolonged  convalescence  from  the  infectious  fevers,  and  in 
the  cachexia  of  cancer. 

The  amyloid  liver  is  large,  and  may  attain  dimensions  equalled  only  by 
those  of  the  cancerous  organ.  Wilks  speaks  of  a  liver  weighing  fourteen 
pounds.  It  is  solid,  firm,  resistant,  on  section  anaemic,  and  has  a  semitranslu- 
cent,  infiltrated  appearance.  Stained  with  a  dilute  solution  of  iodine,  the 
areas  infiltrated  with  the  amyloid  matter  assume  a  rich  mahogany-brown 
■  color. 

There  are  no  characteristic  symptoms.  Jaundice  does  not  occur;  the  stools 
may  be  light-colored,  but  the  secretion  uf  bile  persists.  The  physical  examina- 
tion shows  the  organ  to  be  uniformly  enlarged  and  painless,  the  surface  smooth, 
the  edge  rounded,  and  the  consistence  greatlv  increased.     Sometimes  the  edge. 


582  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

even  in  great  enlargement,  is  sharp  and  hard.     The  spleen  may  be  involved, 
but  there  are  no  evidences  of  portal  obstruction. 

The  diagnosis  is,  as  a  rule,  easy.  Progressive  and  great  enlargement  in 
connection  with  suppuration  of  long  standing  or  with  syphilis  is  almost  always 
of  this  nature.  In  rare  instances,  however,  the  amyloid  liver  is  reduced  in 
size.  In  leuhcemia  the  liver  may  attain  considerable  size  and  be  smooth  and 
uniform,  resembling,  on  physical  examination,  the  fatty  organ.  The  blood 
condition  at  once  indicates  the  true  nature  of  the  case. 


XII.     ANOMALIES  IN  FORM  AND  POSITION  OF  THE  LIVER 

In  transposition  of  the  viscera  the  right  lobe  of  the  organ  may  occupy  the 
left  side.  A  common  and  important  anomaly  is  the  tilting  forward  of  the 
organ,  so  that  the  antero-posterior  axis  becomes  vertical,  not  horizontal.  In- 
stead of  the  edge  of  the  right  lobe  presenting  Just  below  the  costal  margin,  a 
considerable  portion  of  the  surface  of  the  lobe  is  in  contact  with  the  abdomi- 
nal parietes,  and  the  edge  may  be  felt  as  low,  perhaps,  as  the  navel.  This  ante- 
version  is  apt  to  be  mistaken  for  enlargement  of  the  organ. 

The  "lacing^'  liver  is  met  with  in  two  chief  types.  In  one  the  anterior 
portion,  chiefly  of  the  right  lobe,  is  greatly  prolonged,  and  may  reach  the 
transverse  navel  line,  or  even  lower.  A  shallow  transverse  groove  separates 
the  thin  extension  from  the  main  portion  of  the  organ.  The  peritoneal  coating 
of  this  groove  may  be  fibroid,  and  in  rare  instances  the  deformed  portion  is 
connected  with  the  organ  by  an  almost  tendinous  membrane.  The  liver  may 
be  compressed  laterally  and  have  a  pyramidal  shape,  and  the  extreme  left 
border  and  the  hinder  margin  of  the  left  lobe  may  be  much  folded  and  in- 
curved. The  projecting  portion  of  the  liver,  extending  low  in  the  right  flank, 
may  be  mistaken  for  a  tumor,  or  more  frequently  for  a  movable  right  kidney. 
Its  continuity  with  the  liver  itself  may  not  be  evident  on  palpation  or  on 
percussion,  as  coils  of  intestine  may  lie  in  front.  It  descends,  however,  with 
inspiration,  and  usually  the  margin  can  be  traced  continuously  with  that  of 
the  left  lobe  of  the  liver.  The  greatest  difficulty  arises  when  this  anomalous 
lappet  is  naturally  very  thick  and  united  to  the  liver  by  a  very  thin  mem- 
brane, or  when  it  is  swollen  in  conditions  of  great  congestion  of  the  organ. 

The  other  principal  type  of  lacing  liver  is  quite  different  in  shape.  It  is 
thick,  broader  above  than  below,  and  lies  almost  entirely  above  the  transverse 
line  of  the  cartilages.  There  is  a  narrow  groove  just  above  the  anterior  bor- 
der, which  is  placed  more  transversely  than  normal. 

Movable  Liver. — This  rare  condition  has  received  much  attention,  and 
J.  E.  Graham  collected  70.  cases  from  the  literature.  In  a  very  considerable 
number  of  these  there  had  been  a  mistaken  diagnosis.  A  slight  grade  of  mo- 
bility of  the  organ  is  found  in  the  pendulous  abdomen  of  enteroptosis,  and 
after  repeated  ascites. 

The  organ  is  so  connected  at  its  posterior  margin  with  the  inferior  vena 
cava  and  diaphragm  that  any  great  mobility  from  this  point  is  impossible,  ex- 
cept oh' the  theory  of  a  meso-hepar  or  congenital  ligamentous  union  between 
these  structures.  The  ligaments,  however,  may  show  an  extreme  grade  of 
relaxation  (the  suspensory  7.5  cm.,  and  the  triangular  ligament  4  cm.,  in  one 


PANCREATIC  INSUFFICIENCY  583 

of  Leube's  caoes)  ;  and  when  the  patient  is  in  the  erect  posture  the  organ  may 
drop  down  so  far  that  its  upper  surface  is  entirely  below  the  costal  margin. 
The  condition  is  rarely  met  with  in  men ;  56  of  the  cases  were  in  women. 


I.   DISEASES  OF  THE  PANCREAS 
I.     PANCREATIC  INSUFFICIENCY 

Failure  of  the  internal  secretion  is  followed  by  disturbance  in  the  carbo- 
hydrate metabolism,  of  the  external  secretion  by  disturbances  of  digestion,  or 
by  the  injurious  effects  of  the  retained  secretion.  The  low  sugar  tolerance, 
the  chief  sign  of  impairment  of  the  internal  secretion,  has  been  considered 
under  diabetes.     Insufficiency  of  the  external  secretion  is  indicated  by: 

Changes  in  the  Character  of  the  Stools. —  (a)  Steatorrhcea.' — The  pro- 
portion of  fat  in  the  fgeces  varies ;  above  30  per  cent,  of  the  dried  weight  sug- 
gests pancreatic  insufficiency.  The  stools  are  either  oily  like  butter,  or  gray 
like  asbestos.  The  ability  to  digest  fat  differs  greatly  and  there  are  healthy 
persons  who  constantly  have  a  high  percentage  of  fat  in  the  stools.  Steator- 
rhcea may  last  for  years  without  impairment  of  health.  There  is  also  a  dis- 
turbance in  the  ratio  between  the  neutral  fats  and  the  fatty  acids.  Cammidge 
gives  the  following  average  figures:  Normal  per  cent.,  total  fats  21,  neutral 
fats  11,  fatty  acids  10;  malignant  disease,  total  fats  77,  neutral  fats  50,  fatty 
acids  27 ;  chronic  pancreatitis,  total  fats  50,  neutral  fats  32,  fatty  acids  18. 

(&)  AzOTOERHCEA,  the  presence  of  undigested  protein  materials  in  the 
stools,  has  long  been  known  as  an  association  of  pancreatic  disease.  Normally 
only  5  or  6  per  cent,  of  the  undigested  proteins  appears  in  the  fseces,  but  in 
pancreatic  disease  as  much  as  30  or  40  per  cent,  may  be  recovered.  Schmidt 
claims  that  the  nuclear  material  of  meat  is  digested  by  the  pancreatic  juice 
alone  and  that  persistence  of  the  nuclei  of  the  meat  fibres  in  the  stools  indi- 
cates defective  tryptic  digestion. 

In  jaundice  due  to  malignant  disease  of  the  head  of  the  pancreas  sterco- 
bilin  is  absent;  in  that  due  to  chronic  pancreatitis  or  gall-stones  it  is  either 
absent  or  present  only  in  traces. 

Cammidge's  Pancreatic  Reaction. — For  details  of  the  reaction  the  student 
must  consult  special  manuals.  It  is  claimed  that  the  reaction  is  positive  in 
all  cases  of  active  inflammatory  changes  in  the  pancreas,  and  that  by  it  acute 
forms  of  pancreatitis  can  be  differentiated  from  intestinal  obstruction,  and 
that  by  it  chronic  pancreatitis  causing  blocking  of  the  common  duct  can  be 
diagnosed  from  gall-stones.  In  malignant  disease  the  reaction  is  negative  in 
about  three-fourths  of  the  cases.  The  studies  at  the  Mayo  clinic  under  Wil- 
son's direction  lead  to  the  conclusion  that  "if  knowledge  of  the  clinical  his- 
tories and  other  factors  of  the  personal  equation  be  eliminated,  the  end  re- 
sults, judged  by  Cammidge's  own  criteria,  must  be  considered,  as  a  means  of 
diagnosing  disease  of  the  pancreas,  as  both  valueless'  and  misleading."  From 
observations  of  Whipple  and  others  it  seems  that  rapid  disintegration  of  any 
of  the  body  cells,  particularly  the  polynuclear  leucocytes,  may  give  rise  to  the 
reaction. 


584  DISEASES  OF  THE  DIGESTIVE  SYSTEM 


n.     PANCREATIC  NECROSIS 

The  entire  series  of  pancreatic  lesions,  from  haemorrhage  to  gangrene,  and 
from  fat  necrosis  to  pancreatic  cyst,  may  result  from  tryptic  auto-digestion 
(Chiari).  This  is  met  with  under  four  conditions:  (a)  Trauma,  as  in  gun- 
shot wounds,  blows,  or  perforation  of  a  peptic  ulcer,  (b)  Primary  thrombosis 
in  the  venous  radicles  of  the  glands,  (c)  Obstruction  of  the  free  flow  of  se- 
cretion in  the  duct,     (d)   Entrance  of  bile  into  the  ducts. 

In  the  mildest  forms  there  are  only  a  few  small  hsemorrhages  or  circum- 
scribed areas  of  necrosis  of  the  gland  tissue  with  fat  necrosis  in  the  neigh- 
borhood ;  in  severer  forms  groups  of  acini  or  the  whole  gland  may  be  involved. 

Fat  necrosis  occurs  whenever  the  pancreatic  juice,  obstructed  from  any 
cause  and  dammed  back  on  the  gland,  infiltrates  its  tissues,  or  escaping  by 
the  l}Tnph  spaces  finds  its  way  to  structures  at  some  distance  from  the  gland. 
The  necrosis  is  due  to  the  fat-splitting  ferment  in  the  secretion  (Opie). 

Balser  first  called  attention  to  this  remarkable  change  which  is  found  in 
the  interlobular  pancreatic  tissue,  in  the  mesentery,  in  the  omentum,  in  the 
abdominal  fatty  tissue  generally,  and  occasionally  in  the  pericardial  and  sub- 
cutaneous fat.  The  necroses  are  most  frequent  in  the  acute  and  necrotic 
forms  of  pancreatitis,  less  common  in  the  suppurative.  In  the  pancreas  the 
lobules  are  seen  to  be  separated  by  a  dead  white  necrotic  tissue,  which  gives 
a  remarkable  appearance  to  the  section.  In  the  abdominal  fat  the  areas  are 
usually  not  larger  than  a  pin's  head ;  they  at  once  attract  attention,  and  may  be 
mistaken,  on  superficial  examination,  for  miliary  tubercles  or  neoplasms.  They 
may  be  larger;  instances  have  been  reported  in  which  they  were  the  size  of  a 
hen's  egg.  On  section  they  have  a  soft  tallowy  consistence,  and  the  substance 
is  a  combination  of  lime  with  certain  fatty  acids.  The  necroses  may  be  crusted 
with  lime. 

m.     HEMORRHAGE 

Both  Spiess  (1866)  and  Zenker  (187-4:)  were  acquainted  with  hemorrhage 
into  the  pancreas  as  a  cause  of  sudden  death,  but  the  great  medico-legal  im- 
portance of  the  subject  was  first  fully  recognized  by  F.  "W.  Draper,  of  Bos- 
ton, whose  townsmen,  Harris,  Fitz,  Whitney,  and  others,  have  contributed  ad- 
ditional studies.  In  4,000  autopsies  Draper  met  Avith  19  cases  of  pancreatic 
haemorrhage,  in  9  or  10  of  which  no  other  cause  of  death  was  found.  When 
the  bleeding  is  extensive  the  entire  tissue  of  the  gland  is  destroyed  and  the 
blood  invades  the  retro-peritoneal  tissue.  In  other  instances  the  peritoneal  cov- 
ering is  broken  and  the  blood  fills  the  lesser  peritoneum  (see  hgemoperitoneum). 
The  haemorrhage  may  be  in  connection  with  an  acute  pancreatitis  or  with  ne- 
crotic inflammation  of  the  gland. 

The  symptoms  are  thus  briefly  summarized  by  Prince :  "^'The  patient,  who 
has  previously  been  perfectly  well,  is  suddenly  taken  with  the  illness  which 
terminates  his  life.  .  .  .  When  the  ha?morrhage  occurs  the  patient  may  be. 
quietly  resting  or  pursuing  his  usual  occupation.  The  pain  which  ushers  in 
the  attack  is  usually  very  severe  and  located  in  the  upper  part  of  the  abdo- 
men.   It  steadily  increases  in  severity,  is  sharp  or  perhaps  colicky  in  charac- 


ACUTE  PAXCREATITIS  585 

ter.  It  is  abnost  from  the  first  accompanied  by  nausea  and  vomiting;  the 
latter  becomes  frequent  and  obstinate,  but  gives  no  relief.  The  patient  soon 
becomes  anxious,  restless,  and  depressed;  be  tosses  about,  and  only  witb  dif- 
ficulty can  be  be  restrained  in  bed.  The  surface  is  cokl  and  the  forehead  is 
covered  witb  a  cold  sweat.  The  pulse  is  weak,  rapid,  and  sooner  or  later  im- 
perceptible. The  abdomen  becomes  tender,  the  tenderness  being  located  in  the 
upper  part  of  the  abdomen  or  epigastrium.  Tympanites  is  sometimes  marked. 
The  temperature  is  usually  normal  or  subnormal.  The  bowels  are  consti- 
pated." A  well  marked  tumor  may  sometimes  be  felt  in  the  epigastrium. 
There  may  be  tenderness  and  swelling  in  the  course  of  the  descending  colon, 
with  frequent  stools,  containing  blood  and  mucus,  and  suggesting  intussuscep- 
tion. 

rV.     ACUTE  PANCREATITIS 

Acute  Pancreatitis. — While  for  convenience  a  distinction  is  made  between 
hsemorrhagic,  suppurative,  and  gangrenous  pancreatitis,  yet  they  are  prac- 
tically different  manifestations  of  the  same  process.  The  principal  etiological 
factors  are  stasis  and  infection.  The  latter  is  probably  metastatic  from  some 
abdominal  focus.  This  may  be  in  the  gall-bladder,  an  ulcer,  or  in  the  bowel, 
more  often  the  colon.  The  appendix  does  not  seem  to  be  responsible  in  many 
cases.  Infection  from  the  biliary  duct  occurs^  but  probably  is  not  the  coinmon 
cause.  It  seems  likely  that  the  infection  may  be  carried  to  the  pancreas  by  the 
lymphatics  in  the  retroperitoneal  tissues.  Association  with  cholelithiasis  is 
common,  but  the  calculi  are  usually  in  the  gall-bladder  and  rarely  in  the 
ampulla,  which  suggests  that  direct  regurgitation  of  bile  into  the  pancreatic 
duct  occurs  rarely.  Injection  of  bile  into  the  pancreatic  duct  of  dogs  re- 
produces the  lesion. 

Patholo^. — The  fat  necrosis  is  probably  due  to  the  action  of  the  fat  split- 
ting ferment.  It  has  been  suggested  that  the  hsemorrhages  may  be  due  to 
trypsin  digesting  the  walls  of  the  vessels.  The  pancreatic  juice  is  activated  by 
calcium  salts,  by  the  action  of  bacteria  or  by  the  products  of  aseptic  necrosis. 
It  has  been  suggested  that  the  toxic  features  may  be  much  the  same  as  those 
found  in  acute  intestinal  obstruction,  of  which  the  symptoms  are  due  to  pro- 
teose, one  of  the  earliest  productions  of  the  action  of  trypsin  on  protein. 

The  pancreas  is  found  enlarged,  and  tne  interlobular  tissue  infiltrated  with 
blood,  and  perhaps  witb  clots.  The  anatomical  appearances  are  very  charac- 
teristic. The  tissues  about  the  gland  are  infiltrated  with  blood  and  there  may 
be  fluid  in  the  lesser  peritoneum.  Areas  of  fat  necrosis  are  seen  in  the  retro- 
peritoneal fat,  the  mesocolon  and  mesentery.  The  gland  itself  is  swollen  and 
in  section  the  stroma  has  a  mottled  dark  brown  appearance  and  the  outlines 
of  the  acini  may  be  lost. 

Symptoms. — In  some  cases  there  nave  been  premonitory  attacks  of  pain 
which  may  be  general  or  in  the  upper  part  of  the  abdomen,  which  may  sug- 
gest gastric  ulcer  or  gall-stones.  The  onset  is  very  sudden  witb  severe  pain 
usually  referred  to  the  epigastrium.  In  the  most  acute  cases  there  is  a  condi- 
tion of  shock.  The  symptoms  of  the  attack  are  those  of  a  very  acute  abdominal 
condition  suggesting  the  perforation  of  an  ulcer  or  sudden  intestinal  obstruc- 
tion.    There  may  be  persistent  vomiting  and  constipation  is  common.     Ex- 


586  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

amination  shows  fullness  and  tenderness  in  the  upper  abdomen  and  usually  in- 
creasing distention.  The  tenderness  may  be  specially  marked  across  the  epi- 
gastrium and  there  may  be  a  distinct  sense  of  resistance  over  the  region  of  the 
pancreas.  There  is  not  likely  to  be  any  tumor  mass  felt  until  at  least  the 
third  day.  There  may  be  marked  leucocytosis.  The  temperature  is  usually 
low  or  subnormal;,  and  the  pulse  rapid.  The  most  acute  caseS;,  often  termed 
fulminating,  show  a  very  severe  onset  with  marked  shock  and  collapse.  This 
has  been  explained  as  probably  due  to  pressure  on  the  cceliac  axis.  In  thesa 
cases  there  is  profuse  haemorrhage  into  the  pancreas  and  death  usually  follows 
in  two  or  three  days. 

In  the  acute  cases  of  average  severity,  the  onset  is  sudden,  but  less  severe 
than  in  the  preceding.  Only  part  of  the  pancreas  may  be  damaged  by  the 
ha:morrhagic  process  and  the  most  greatly  damaged  part  may  go  on  to  ne- 
crosis and  gangrene.  Suppuration  may  follow,  giving  the  picture  of  an  acute 
suppurative  pancreatitis.  There  may  be  either  a  single  abscess  or  numerous 
small  ones.  In  one  series  of  38  cases,  in  24  there  was  a  single  abscess.  In 
some  cases  there  is  a  diffuse  purulent  infiltration.  Among  the  results  are 
peripancreatic  abscess  with  perforation  into  the  stomach,  duodenum  or  perito- 
neum and  thrombosis  of  the  portal  vein.  The  course  of  the  suppurative  form 
is  likely  to  be  chronic.  Jaundice,  diarrhoea,  and  glycosuria  have  occurred, 
but  these  are  rare.  A  tumor  mass  in  the  epigastrium  may  result.  In  the  less 
acute  forms  the  process  may  be  limited  to  only  a  part  of  the  pancreas,  usually 
the  head,  and  the  hgemorrhage  is  slight.  The  main  symptoms  are  pain  in  the 
abdomen  with  nausea  and  vomiting,  but  the  pulse  and  temperature  may  show 
no  change  and  the  condition  may  be  overlooked,  especially  as  it  is  often  asso- 
ciated with  cholecystitis. 

In  gangrenous  pancreatitis,  complete  necrosis  of  the  gland,  or  part  6i  it, 
may  follow  either  haemorrhage  or  hsemorrhagic  inflammation,  and  in  excep- 
tional cases  may  occur  after  suppurative  infiltration  or  after  injury  or  per- 
foration of  an  ulcer  of  the  stomach.  Symptoms  of  hsemorrhagic  pancreatitis 
may  precede  or  be  associated  with  it.  Death  usually  follQws  in  from  ten  to 
twenty  days,  with  symptoms  of  collapse.  The  pancreas  may  present  a  dry 
necrotic  appearance,  but  as  a  rule  the  organ  is  converted  into  a  dark  slaty- 
colored  mass  lying  nearly  free  in  the  omental  cavity  or  attached  by  a  few 
shreds.  In  other  instances  the  totally  or  partially  sequestrated  organ  may  lie 
in  a  large  abscess  cavity,  forming  a  palpable  tumor  in  the  epigastric  region. 
The  necrotic  pancreas  may  be  discharged  per  rectum,  with  recovery. 

Diagnosis. — The  sudden  dramatic  onset  in  the  severe  forms  should  always 
suggest  the  possibility  of  acute  pancreatitis.  Perforation  of  the  stomach  or 
bowel  and  intestinal  obstruction  give  features  very  similar,  also  the  rupture  of 
an  aneurism.  "Acute  pancreatitis  is  to  be  suspected  when  a  previously  healthy 
person  or  a  sufferer  from  occasional  attacks  of  indigestion  is  suddenly  seized 
with  a  violent  pain  in  the  epigastrium  followed  by  vomiting  and  collapse,  and 
in  the  course  of  twenty-four  hours  by  a  circumscribed  epigastric  swelling, 
tympanitic  or  resistant,  with  slight  elevation  of  temperature.  Circumscribed 
tenderness  in  the  course  of  the  pancreas  and  tender  spots  throughout  the  ab- 
domen are  valuable  diagnostic  signs"  (Fitz).  The  mild  forms  are  more  dif- 
ficult to  recognize  and  are  usually  mistaken  for  chelecystitis.    The  presence  of 


CHRONIC  PANCREATITIS  587 

a  tumor  mass  is  of  the  greatest  moment.     Consideration  of  the  possibility  of 
acute  pancreatitis  is  the  best  safeguard  against  error. 

Treatment. — It  is  well  to  stop  all  intake  by  mouth  and  give  fluid  by  rectum. 
Morphia  should  be  given  in  full  doses  to  control  the  pain.  The  decision  as  to 
exploration  must  depend  on  the  condition;  in  the  fulminant  cases  it  may  not 
be  possible,  in  the  less  severe  cases  it  is  usually  wise,  in  the  mild  cases  it  is  not 
necessary.  With  signs  of  suppuration  and  abscess  formation  drainage  is  indi- 
cated.   Otherwise  symptomatic  measures  are  indicated. 


V.     CHRONIC  PANCREATITIS 

Forms." — There  is  still  a  great  deal  of  uncertainty  about  this  condition. 
The  truth  is  if  operators  regard  an  indurated  or  even  nodular  head  of  the 
pancreas  as  indicating  a  chronic  pancreatitis  they  will  find  it  in  80  per  cent, 
of  all  adults.  Those  who  follow  Virchow's  technique  in  post  mortem  work 
and  open  the  stomach  and  duodenum  and  press  on  the  course  of  the  bile  duct 
know  how  almost  invariable  is  this  sensation  over  the  head  of  the  organ,  which 
may  be  sliced  with  the  conviction  that  there  must  be  some  special  morbid 
change.  W.  J.  Mayo  remarks  how  frequently  he  has  found  the  pancreas  en- 
larged, indurated  and  nodulated  in  cases  in  which  no  symptomatic  evidence 
whatever  existed  of  pancreatic  inflammation.  Anatomically  there  are  two 
forms : 

(a)  Interlobular  pancreatitis  which  follows  occlusion  of  the  duct,  or  an 
infection,  such  as  occurs  in  the  presence  of  calculi,  biliary  or  pancreatic,  with 
which  organisms  of  the  colon  group,  streptococci,  or  occasionally  the  typhoid 
bacillus  are  associated.  Even  in  advanced  sclerosis  of  this  type  the  islands  of 
Langerhans  are  spared.  It  may  occur  as  an  independent  afl^ection.  It  is  not 
at  all  uncommon  in  the  bodies  of  adults  to  find  the  head  of  the  pancreas  ex- 
traordinarily hard  and  so  dense  that  it  feels  like  scirrhus;  surgeons  have  long 
noted  this.  The  condition  is  often  present  without  symptoms  of  pancreatic 
disease  during  life.  A  very  special  form  is  the  chronic  interstitial  pancreatitis 
which  accompanies  hsemochromatosis,  described  elsewhere.  Mayo  Robson, 
]\Ioynihan  and  other  surgeons  have  called  attention  to  the  fact  that  sclerosis 
of  the  head  of  the  pancreas  may  cause  obstruction  of  the  duct. 

(b)  Chronic  interacinar  pancreatitis  is  characterized  by  a  diffuse  fibrosis 
penetrating  between  the  acini,  with  little  or  no  involvement  of  the  interlobular 
tissues.  It  may  follow  infection  through  the  duct,  but  is  more  common  in 
association  with  cirrhosis  of  the  liver  and  arterio-sclerosis. 

The  possibility  of  syphilis  as  an  etiological  factor  should  be  kept  in  mind. 
Warthin  has  shown  that  syphilis  of  the  pancreas  is  not  uncommon. 

So  much  influenced  is  our  present  picture  of  chronic  pancreatitis  by  per- 
sonal equation  on  the  part  of  surgical  and  laboratory  workers  that  we  are  not 
in  a  position  to  speak  very  definitely  on  several  important  points. 

Symptoms. — It  must  be  confessed  that  the  clinical  picture  is  very  obscure, 
in  spite  of  the  good  work  done  by  our  surgical  colleagues,  Cammidge,  who 
has  had  the  advantage  of  seeing  Mayo  Robson's  cases,  describes  four  types: 
(a)  The  dyspeptic,  in  which  the  disease  is  due  to  morbid  conditions  of  the 
bowels,  and  the  symptoms  are  mainly  referred  to  the  digestive  organs,     (&) 


588  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

The  cholelithic,  associated  with  the  presence  of  gall-stones  in  the  common 
duct;  there  is  usuaUy  chronic  jaundice  and  the  dominant  symptoms  are  hepatic, 
(c)  A  miscellaneous  group  in  which  the  pancreatitis  is  secondary  to  malignant 
disease,  etc.  (d)  The  diabetic  group  with  glycosuria,  into  which  the  members 
of  the  preceding  groups  ma}^  merge  in  course  of  time. 

Symptoms  of  pancreatic  insufficiency  of  the  internal  or  external  secretion 
are  generally  present;  there  is  pain  after  food,  very  often  jaundice,  and  on  deep 
pressure  the  head  of  the  pancreas  may  sometimes  be  felt.  Bulky  stools  are 
suggestive.  With  Schmidt's  test  diet  the  average  weight  of  the  dried  stools  is 
from  45  to  65  grams.  With  pancreatic  disease  weights  of  125  to  400  grams 
may  be  found.  The  stools ,  are  fatty  and  light  and  greasy  in  appearance. 
There  is  marked  loss  of  fat  and  nitrogen  in  the  stools.  There  is  a.  large  amount 
of  unsplit  fat  present.  The  extent  of  digestion  of  cell  nuclei  is  of  some  value. 
The  estimation  of '  diastase  in  the  faeces  and  urine  is  of  assistance  in  some 
cases.    The  stools  maj^  show  both  steatorrhoea  and  azotorrhoea. 

Treatment. — Owing  to  the  difficulty  of  diagnosis  in  the  early  stages  it  is 
impossible  to  speak  positively  in  a  great  many  cases,  but  in  the  forms  which 
are  associated  with  pain,  jaundice,  the  presence  of  calculi,  and  infection  of  the 
ducts  excellent  results  have  followed  free  drainage  of  the  bile  passages.  .  Ee- 
moval  of  the  gall-bladder  is  sometimes  more  effectual  than  drainage  alone. 


VI.     PANCREATIC  CYSTS 

Of  121  cases  operated  upon  60  were  in  males  and  56  in  females,  in  5  the 
sex  was  not  given  (Korte).  Sixty-six  of  the  cases  occurred  in  the  fourth 
decade..  Eailton's  case  (not  in  Ivorte's  series),  an  infant  aged  six  months, 
and  Shattuck's  case  in  a  child  of  thirteen  and  a  half  months  are  the  youngest 
in  the  literature.    According  to  the  origin  Korte  recognizes  three  varieties. 

Varieties. — Traumatic  Cases. — In  this  list  of  33  cases  30  were  in  men 
and  only  3  in  women.  Blows  on  the  abdomen  or  constantly  repeated  pressure 
are  the  most  common  forms  of  trauma.  One  case  followed  severe  massage. 
Usually  with  the  onset  there  are  inflammatory  symptoms,  pain,  and  vomiting, 
sometimes  suggestive  of  peritonitis.  The  contents  of  the  cyst  are  usually- 
bloody,  though  in  13  of  the  traumatic  cases  it  was  clear  or  yellowish. 

Cysts  Following  Inflammatory  Conditions. — In  51  cases  the  trouble 
began  gradually  after  attacks  of  dyspepsia  with  colic,  simulating  somewhat 
that  of  gall-stones.  Occasionally  the  attack  set  in  with  very  severe  symptoms, 
suggestive  of  obstruction  of  the  bowel.  In  this  group  the  tumor  appeared  in 
19  cases  soon  after  the  onset  of  the  pain;  in  others  it  was  delaj'ed  for  a  period 
of  from  a  few  weeks  to  two  or  three  years.  McPhedran  reported  a  remarkable 
instance  in  which  the  tumor  appeared  in  the  epigastrium  with  signs  of  severe 
inflammation.  It  was  opened  and  drained  and  believed  to  be  a  hydrops  of 
the  lesser  peritoneal  cavity.  Three  months  later  a  second  cyst  developed,  which 
appeared  to  spring  directly  from  the  pancreas. 

Cysts  without  Any  Inflammatory  or  Traumatic  Etiology. — Of  33 
cases  in  this  group  26  were  in  women.  A  remarkable  feature  is  the  prolonged 
period  of  their  existence — in  one  case  for  forty-seven  years,  in  one  for  between 


PANCREATIC  CYSTS  589 

sixteen  and  twenty  years,  in  others  for  sixteen,  nine,  and  eight  years,  in  the 
majority  for  from  two  to  four  years. 

Morbid  Anatomy. — Anatomically  Korte  recognizes  (1)  retention  cysts  due 
to  plugging  of  the" main  duct;  (2)  proliferation  cysts  of  the  pancreatic  tissue 
— and  cysto-adenoma ;  (3)  retention  cysts  arising  from  the  alveoli  of  the  gland 
and  of  the  smaller  duets,  which  become  cut  off  and  dilate  in  consequence  of 
chronic  interstitial  pancreatitis;  (4)  pseudo-cysts  following  inflammatory  or 
traumatic  affections  of  the  pancreas,  usually  the  result  of  injury,  causing  haem- 
orrhage and  hydrops  of  the  lesser  peritoneum. 

Situation. — In  its  growth  the  cyst  may  ( 1 )  be  in  the  lesser  peritoneum, 
push  the  stomach  upward,  and  reach  the  abdominal  wall  between  the  stomach 
and  the  transverse  colon;  (2)  more  rarely  the  cyst  appears  above  the  .lesser 
curvature  and  pushes  the  stomach  downward;  in  both  of  these  cases  the  situa- 
tion of  the  tumor  is  high  in  the  abdomen;  but  (3)  it  may  develop  between  the 
leaves  of  the  transverse  meso-colon  and  lie  below  both  the  colon  and  the  stom- 
ach. The  relation  of  these  two  organs  to  the  tumor  is  variable.,  but  in  the  ma- 
jority of  cases  the  stomach  lies  above  and  the  transverse  colon  below  the  cyst. 
Occasionally,  too,  as  in  T,  C.  Eailton's  case,  the  cyst  may  arise  in  the  tail  of  the 
pancreas  and  project  far  over  in  the  left  hypochondrium  in  the  position  of  the 
spleen  or  of  a  renal  tumor. 

General  Symptoms. — Apart  from  the  features  of  onset  already  referred 
to,  the  patient  may  complain  of  no  trouble  unless  the  cyst  reaches  a  very  large 
size.  Painful  colicky  attacks,  with  nausea  and  vomiting  and  progressive  en- 
largement of  the  abdomen,  have  frequently  been  noted.  Fatty  diarrhoea  from 
disturbance  of  the  function  of  the  pancreas  is  rare.  Sugar  in  the  urine  has 
been  present  in  a  number  of  cases.  Increased  secretion  of  the  saliva,  the 
so-called  pancreatic  salivation,  is  also  rare.  Pressure  of  the  cyst  may  some- 
times cause  jaundice,  and  in  rare  instances  dyspnoea.  Very  marked  loss  of 
flesh  has  been  present  in  a  number  of  cases.  A  remarkable  feature  often  noticed 
has  been  the  transitory  disappearance  of  the  cyst.  In  one  of  Halsted's  cases 
the  girth  of  the  abdomen  decreased  from  43  to  31  inches  in  ten  days  with 
profuse  diarrhoea.    Sometimes  the  disappearance  has  followed  blows. 

Diagnosis. — The  cyst  occupies  the  upper  abdomen,  usually  forming  a  semi- 
circular bulging  in  the  median  line,  rarely  to  either  side.  In  16  cases  Korte 
states  that  the  chief  projection  was  below  the  navel.  In  one  case  operated 
upon  by  Halsted  the  tumor  occupied  the  greater  part  of  the  abdomen.  The 
cyst  is  immobile,  respiration  having  little  or  no  influence  on  it.  As  already 
mentioned,  the  stomach,  as  a  rule,  lies  above  it  and  the  colon  below. 

In  a  majority  of  the  cases  the  fluid  is  of  a  reddish  or  dark-brown  colo]-, 
and  contains  blood  or  blood  coloring  matter,  cell  detritus,  fat  granules,  and 
sometimes  cholesterin.  The  consistence  of  the  fluid  is  usually  mucoid,  rarely 
thin.  The  reaction  is  alkaline,  the  specific  gravity  from  1.010  to  1.020.  In 
22  cases  Korte  states  that  the  fluid  was  not  hsemorrhagic. 

The  existence  of  ferments  is  important.  In  54  cases  they  were  present 
in  the  fluid  or  in  the  material  from  the  fistula.  In  20  cases  only  one  ferment 
was  present,  in  20'  cases  two,  and  in  14  cases  all  three  of  the  pancreatic  fer- 
ments were  found.  In  view  of  the  wide  occurrence  of  disastatic  and  fat-emul- 
sifying ferments  in  various  exudates,  the  only  positive  sign  in  the  diagnosis 
of  the  pancreatic  secretion  is  the  digestion  of  fibrin  and  albumin. 


590  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

Operation. — Of  160  cases  of  operation  there  were  150  recoveries.     Incision 
and  drainage  were  done  in  138  cases  and  in  15  excision. 


Vn.     TUMORS  OF  THE  PANCREAS 

Of  new  groAvths  in  the  organ  carcinoma  is  the  most  frequent.  Sarcoma, 
adenoma,  and  lymphoma  are  rare. 

Frequency. — At  the  General  Hospital  in  Vienna  in  18,069  autopsies  there 
were  22  cases  of  cancer  of  the  pancreas  (Biach).  In  11,472  post  mortems  at 
Milan  Segre  found  132  tumors  of  the  pancreas,  127  of  which  were  carcino- 
mata,  2  sarcomata,  2  cysts,  and  1  syphiloma.  In  6,000  autopsies  at  Guy's 
Hospital  there  were  only  20  cases  of  primary  malignant  disease  of  the  organ 
(Hale  White).  In  the  first  1,500  autopsies  at  the  Johns  Hopkins  Hospital 
there  were  6  eases  of  adeno-carcinoma,  and  1  doubtful  case  in  which  the  exact 
origin  could  not  be  stated.  There  were  8  cases  of  secondary  malignant  disease 
of  the  pancreas.  The  head  of  the  gland  is  most  commonly  involved,  but  the 
disease  may  be  limited  to  the  body  or  to  the  tail.  The  majority  of  the  pa- 
tients are  in  the  middle  period  of  life. 

Symptoms. — The  diagnosis  is  not  often  possible.  The  following  are  the 
most  important  and  suggestive  features :  (a)  Epigastric  pains,  often  occur- 
ring in  paroxysms,  (b)  Jaundice,  due  to  pressure  of  the  tumor  in  the  head 
of  the  pancreas  on  the  bile-duct.  The  jaundice  is  intense  and  permanent,  and 
associated  with  dilatation  of  the  gall-bladder,  which  may  reach  a  very  large 
size,  (c)  The  presence  of  a  tumor  in  the  epigastrium.  This  is  very  variable. 
In  137  cases  Da  Costa  found  the  tumor  present  in  only  13.  Palpation  under 
anesthesia  with  the  stomach  empty  would  probably  give  a  very  much  larger 
percentage.  As  the  tumor  rests  directly  upon  the  aorta  there  is  usually  a 
marked  degree  of  pulsation,  sometimes  with  a  bruit.  There  may  be  pressure 
on  the  portal  vein,  causing  thrombosis  and  its  usual  sequels,  (d)  Symptoms 
due  to  loss  of  function  of  the  pancreas  are  less  important.  Fatty  diarrhoea  is 
not  very  often  present.  In  consequence  of  the  absence  of  bile  the  stools  are 
usually  very  clay-colored  and  greasy.  Diabetes  also  is  not  common,  (e)  A 
very  rapid  wasting  and  cachexia.  Of  other  symptoms  nausea  and  vomiting 
are  common.  In  some  instances  the  pylorus  is  compressed  and  there  is  great 
dilatation  of  the  stomach.     In  a  few  cases  there  has  been  profuse  salivation. 

The  points  of  greatest  importance  in  the  diagnosis  are  the  intense  and 
permanent  jaundice,  with  dilatation  of  the  gall-bladder,  rapid  emaciation, 
and  the  presence  of  a  tumor  in  the  epigastric  region.  Of  less  importance  are 
features  pointing  to  disturbance  of  the  functions  of  the  gland. 

Of  other  new  growths  sarcoma  and  lymphoma  have  been  occasionally  found. 
Miliary  tubercle  is  not  very  uncommon  in  the  gland.  Syphilis,  which  the 
work  of  Warthin  shows  to  be  common,  may  occur  as  a  chronic  interstitial  in- 
flammation, or  in  the  form  of  gummata.  , 

The  outlook  in  tumors  of  the  pancreas  is,  as  a  rule,  hopeless;  but  of  late 
years  a  number  of  successful  cases  of  operation  have  been  reported. 


ACUTE  GENERAL  PJERITONlTlh  591 


VIII.     PANCREATIC  CALCULI 

• 

Pancreatic  lithiasis  is  comparatively  rare.  Lazarus  in  1904  collected  57 
cases  of  which  47  were  males.  The  majority  were  between  30  and  50  years  of 
age.     In  1,500  autopsies  at  the  Johns  Hopkins  Hospital  there  were  2  cases. 

The  stones  are  usually  numerous,  either  round  in  shape  or  rough,  spinous 
and  coral-like.  The  color  is  opaque  white.  They  are  composed  chiefly  of  car- 
bonate of  lime.  The  effects  of  the  stones  are:  (1)  A  chronic  interstitial  in- 
flammation of  the  gland  substance  with  dilatation  of  the  duct;  sometimes 
there  is  cystic  dilatation  of  the  gland;  (2)  acute  inflammation  with  suppura- 
tion; (3)  the  irritation  of  the  stones  may  lead  to  carcinoma. 

Symptoms. — The  cases  are  not  often  diagnosed.  Pains  in  the  epigastrium, 
often  very  severe,  but  not  characteristic  and  the  signs  of  pancreatic  insuf- 
ficiency already  described,  are  suggestive  features.  The  X-rays  may  be  of  aid 
in  diagnosis.  An  analysis  of  the  calculi  passed  with  the  stools  may  alone  serve 
to  distinguish  a  case  from  one  of  gall-stones.  Operation  has  been  performed 
successfully. 


J.     DISEASES   OF   THE  PERITONEUM 

I.     ACUTE  GENERAL  PERITONITIS 

Definition. — Acute  inflammation  of  the  peritoneum, 

Etiolo^. — The  condition  may  be  primary  or  secondary. 

(a)  Primary  Peritonitis. — In  this  the  organisms,  usually  the  penumo- 
coccus  or  streptococcus,  reach  the  peritoneum  by  the  blood  or  lymphatics.  It 
is  often  a  terminal  infection,  as  seen  in  nephritis,  gout,  and  arterio-sclerosis. 
Of  102  cases  of  peritonitis  which  came  to  autopsy  at  the  Johns  Hopkins  Hos- 
pital, 12  were  of  this  form, 

(&)  Secondary  peritonitis  is  due  to  extension  of  inflammation  from,  or 
perforation  of,  one  of  the  organs  covered  by  the  peritoneum.  Peritonitis  from 
extension  may  follow  inflammation  of  the  stomach  or  intestines,  ulceration  in 
these  parts,  cancer,  acute  suppurative  inflammations  of  the  spleen,  liver,  pan- 
creas, retroperitoneal  tissues,  and  the  pelvic  viscera. 

Perforative  peritonitis  is  the  most  common,  following  external  wounds, 
perforation  of  an  ulcer  of  the  stomach  or  bowels,  perforation  of  the  gall- 
bladder, abscess  of  the  liver,  spleen,  or  kidneys.  Two  important  causes  are 
appendicitis  and  suppurating  inflammation  about  the  Fallopian  tubes  and 
ovaries.  There  are  instances  in  which  peritonitis  has  followed  rupture  of  an 
apparently  normal  Graafian  follicle. 

Of  the  above  102  cases,  56  originated  in  an  extension  from  some  diseased 
abdominal  viscus.  The  remaining  34  followed  surgical  operations  upon  the 
peritoneum  or  the  contained  organs. 

The  peritonitis  of  septicaemia  and  pya?mia  is  almost  invariably  the  result 
of  a  local  process.  An  exceedingly  acute  form  of  peritonitis  may  1)e  caused  by 
the  development  of  tubercles  on  the  membrane. 


592  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

Morbid  Anatomy. — In  recent  cases,  on  opening  the  abdonien  the  intes- 
tinal coils  are  distended  and  glued  together  with  lymph,  and  the  peritoneum 
presents  a  patchy,  sometimes  a  uniform  injection.  The  exudation  may  be : 
(a)  Fibrinous,  with  little  or  no  fluid,  except  a  few  pockets  of  clear  serum 
between  the  coils,  (h)  Sero-fibrinous.  The  coils  are  covered  with  lymph, 
and  there  is  in  addition  a  large  amount  of  a  yellowish,  sero-fibrinous  fluid.  In 
instances  in  which  the  stomach  or  intestine  is  perforated  this  may  be  mixed 
with  food  or  faeces,  (c)  Purulent,  in  which  the  exudate  is  either  thin  and 
greenish  yellow  in  color,  or  opaque  white  and  creamy,  (d)  Putrid.  Occasion- 
ally in  puerperal  and  perforative  peritonitis,  particularly  when  the  latter  has 
been  caused  by  cancer,  the  exudate  is  thin,  grayish  green  in  color,  and  has  a 
gangrenous  odor,  (e)  Hsemorrhagic.  This  is  sometimes  found  as  an  admix- 
ture in  cases  of  acute  peritonitis  following  wounds,  and  occurs  in  the  cancerous 
and  tuberculous  forms.  (/)  A  rare  form  occurs  in  which  the  injection  is 
present,  but  almost  all  signs  of  exudation  are  wanting.  Close  inspection  may 
be  necessary  to  detect  a  slight  dulling  of  the  serous  surfaces. 

The  amount  of  the  effusion  varies  from  half  a  litre  to  20  or  30  litres. 
There  are  essential  differences  between  the  various  kinds  of  peritonitis. 

Bacteriolog^y. — A  large  number  of  organisms  have  been  found.  In  the 
cases  following  operation  the  staphylococcus  was  present  alone  in  12  out  of 
33,  the  streptococcus  in  5,  and  the  colon  bacillus  in  5.  Other  organisms  were 
the  pneumococcus,  bacillus  pyocyaneus,  and  bacillus  aerogei^es.  Of  56  cases  of 
peritonitis  following  intestinal  infections,  the  colon  bacillus  occurred  in  43, 
usually  in  connection  w^'th  streptococci.  The  bacillus  lactis  aerogenes  has 
also  been  found  as  the  sole  organism.  The  gonococcus  is  present  in  the  form 
which  arises  from  salpingitis  and  may  occur  in  the  gonorrhoeal  infections  of 
children. 

Much  attention  has  been  paid  to  the  pneum.o coccus  as  an  agent  in  the 
causation  of  peritonitis,  and  many  cases  are  of  the  primary  form  without 
recognizable  portal  of  entry;  but  there  are  many  latent  pneimiococcic  lesions, 
particularly  those,  of  the  middle  ear,  and  of  the  accessory  sinuses  of  the  nose. 
Cameron  makes  two  groups  of  cases ;  a  diffuse  form  setting  in  with  abdominal 
pain,  high  fever,  vomiting,  and  diarrhoea,  in  which  death  may  occur  within  36 
hours.  In  the  other  group  the  peritonitis  is  local,  and  the  symptoms  may  sug- 
gest appendicitis.  Gradually  a  localized  abscess  develops,  which  may  rupture 
internally.     The  creamy  greenish  yellow  odorless  pus  is  very  characteristic. 

Symptoms. — In  the  perforative  and  septic  cases  the  onset  is  marked  by 
chilly  feelings  or  an  actual  rigor  with  intense  pain  in  the  abdomen.  In  typhoid 
fever,  when  the  sensorium  is  benumbed,  the  onset  may  not  be  noticed.  The 
pain  is  general,  and  is  usually  intense  and  aggravated  by  movements  and  pres- 
sure. A  position  is  taken  which  relieves  the  tension  of  the  abdominal  muscles, 
so  that  the  patient  lies  on  the  ba-ck  with  the  thighs  drawn  up  and  the  shoulders 
elevated.  The  greatest  pain  is  usually  beloAV  the  umbilicus,  but  in  peritonitis 
from  perforation  of  the  stomach  pain  may  be  referred  to  the  back,  the  chest, 
or  the  shoulder.  The  respiration  is  superficial — costal  in  type — as  it  is  pain- 
ful to  use  the  diaphragm.  For  the  same  reason  the  action  of  coughing  is 
restrained,  and  even  the  movements  necessary  for  talking  are  limited.  In  this 
early  stage  the  sensitiveness  may  be  great  and  the  abdominal  muscles  are  often 
rigidly  contracted.     If  the  patient  is  at  perfect  rest  the  pain  may  be  very 


ACUTE  GENERAL  PEi:iTONITIS  593 

slight,  and  there  are  instances  in  which  it  is  not  at  all  marked,  and  may, 
indeed,  be  absent. 

The  abdomen  gradually  becomes  distended  and  tense  and  is  tympanitic  on 
percnssion.  The  pulse  is  rapid,  small,  and  hard,  and  often  has  a  peculiar  wiry 
quality.  It  ranges  from  110  to  150.  The  temperature  may  rise  rapidly  after 
the  chill  and  reach  104°  or  105°  F.,  but  the  subsequent  elevation  is  moderate. 
In  some  very  severe  eases  there  may  be  no  fever  throughout.  The  leucocyte 
count  varies  with  the  grade  of  infection.  In  the  severe  cases  it  may  not  be 
increased.  The  tongue  at  first  is  white  and  moist,  but  subsequently  becomes 
dry  and  often  red  and  fissured.  Vomiting  is  an  early  and  prominent  feature 
and  causes  great  pain.  The  contents  of  the  stomach  are  first  ejected,  then  a 
yellowish  and  bile  stained  fluid,  and  finally  a  greenish  and,  in  rare  instances, 
a  brownish  black  liquid  with  slight  faecal  odor.  The  bowels  may  be  loose  at 
the  onset  and  then  constipation  may  follow.  Frequent  micturition  may  be 
present,  less  often  retention.  The  urine  is  usually  scanty  and  high-colored, 
and  contains  a  large  quantity  of  indican. 

The  appearance  of  the  patient  when  these  symptoms  have  fully  developed 
is  very  characteristic.  The  face  is  pinched,  the  eyes  are  sunken,  and  the  ex- 
pression is  very  anxious.  The  constant  vomiting  of  fluids  causes  a  wasted 
appearance,  and  the  hands  sometimes  present  the  washer-woman's  skin.  Ex- 
cept in  cholera,  we  see  the  Hippocratic  facies  more  frequently  in  this  than  in 
any  other  disease — "^a  sharp  nose,  hollow  eyes,  collapsed  temples;  the  ears  cold, 
contracted,  and  their  lohes  turned  out;  the  skin  adout  the  forehead  being 
rough,  distended,  and  parched;  the  color  of  the  ichole  face  being  brown,  black, 
livid,  or  lead-colored/'  There  are  one  or  tAvo  additional  points  about  the  abdo- 
men. The  tympany  is  usually  excessive,  owing  to  the  great  relaxation  of  the 
walls  of  the  intestines  by  inflammation  and  exudation.  There  is  absence  of 
the  sounds  of  peristalsis  and  the  breath  and  heart  sounds  may  be  heard  loudly. 
The  splenic  dulness  may  be  obliterated,  the  diaphragm  pushed  up,  and  the  apex 
beat  of  the  heart  dislocated  to  the  fourth  interspace.  The  liver  dulness  may 
be  greatly,  reduced,  or  may,  in  the  mammary  line,  be  obliterated.  It  has  been 
claimed  that  this  is  a  distinctive  feature  of  perforative  peritonitis,  but  the 
liver  dulness  in  the  mammary  line  may  be  obliterated  by  tympanites  alone.  In 
the  axillary  line,  on  the  other  hand,  the  liver  dulness,  though  diminished,  may 
persist.  Pneumo-peritoneum  following  perforation  more  certainly  obliterates 
the  hepatic  dulness.  In  such  cases  the  fluid  effused  produces  a  dulness  in  the 
lateral  region ;  but  with  gas  in  the  peritoneum,  if  the  patient  is  turned  on  the 
left  side,  a  clear  note  is  heard  beneath  the  seventh  and  eighth  rib.  Acute 
peritonitis  may  present  a  flat,  rigid  abdomen  throughout  its  course. 

Effusion  of  fluid — ascites — is  usually  present  except  in  some  acute,  rapidly 
fatal  cases.  The  flanks  are  dull  on  percussion.  The  dulness  may  be  movable, 
though  this  depends  altogether  upon  the  degree  of  adhesions.  There  may  be 
considerable  effusion  without  either  movable  dulness  or  fluctuation.  A  fric- 
tion rub  may  be  present,  as  flrst  pointed  out  by  Bright,  but  it  is  not  nearly  so 
common  in  acute  as  in  chronic  peritonitis. 

Prognosis. — In  the  cases  due  to  injury  or  perforation  of  an  abdominal 
organ  much  depends  on  the  interval  between  this  and  operation.  Every  hour 
of  delay  increases  the  risk.  In  the  group  due  to  extension  from  the  pelvic 
organs  the  outlook  is  more  favorable.     The  acute  diffuse  peritonitis  usually 


594  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

terminates  in  death.  The  most  intense  forms  may  kill  within  thirty-six  to 
forty-eight  hours;  more  commonly  death  results  in  four  or  five  days,  or  the 
attack  may  be  prolonged  to  eight  or  ten  days.  The  pulse  becomes  irregular, 
the  heart-sounds  weak,  the  breathing  shallow ;  there  are  lividity  with  pallor,  a 
cold  skin  with  high  rectal  temperature — a  group  of  symptoms  indicating  pro- 
found failure  of  the  vital  functions.  Occasionally  death  occurs  with  great  sud- 
denness. A  low  temperature,  rapid  pulse,  marked  distention,  absence  of 
leucocytosis  and  severe  toxaemia  point  to  a  fatal  ending.  The  causal  organism 
influences  the  outlook ;  cases  due  to  the  gonococcus  and  some  forms  of  staphy- 
lococci are  more  favorable  than  those  due  to  the  streptococcus.  There  are  dif- 
ferent views  as  to  the  gravity  of  the  colon  bacillus  infections. 

Diagnosis. — In  typical  cases  the  severe  pain  at  onset,  the  distention  of  the 
abdomen,  the  tenderness,  the  fever,  the  gradual  onset  of  efl:usion,  collapse,  and 
the  vomiting  give  a  characteristic  picture.  Careful  inquiries  should  at  once 
be  made  concerning  the  previous  condition,  from  which  a  clue  can  often  be 
had  as  to  the  starting-point  of  the  trouble.  In  young  adults  a  considerable 
proportion  of  all  cases  depends  upon  perforating  appendicitis,  and  there  may 
be  an  account  of  previous  attacks  of  pain  in  the  iliac  region,  or  of  constipa- 
tion alternating  with  diarrhoea.  In  women  the  most  frequent  causes  are  sup- 
purative processes  in  the  pelvic  viscera,  associated  with  salpingitis,  abscesses 
in  the  broad  ligaments,  or  acute  puerperal  infection.  It  is  not  always  easy  to 
determine  the  cause.  Many  cases  come  under  observation  for  the  first  time 
with  the  abdomen  distendecl  and  tender,  and  it  is  impossible  to  make  a  satis- 
factory examination.  In  such  instances  the  pelvic  organs  should  be  examined 
with  the  greatest  care.  Suggestive  points  in  the  pneumococcus  form  in  chil- 
dren are  the  sudden  onset,  the  severe  toxaemia,  high  fever,  marked  leucocytosis, 
vomiting-,  and  diarrhoea  with  markedly  less  abdominal  pain  and  tenderness  as 
compared  with  other  acute  forms.  The  following  conditions  are  most  apt 
to  be  mistaken  for  acute  peritonitis: 

(a)  Acute  Entero-colitis. — Here  the  pain  and  distention  and  the  sensitive- 
ness on  pressure  may  be  marked.  The  pain  is  more  colicky  in  character,  the 
diarrhoea  is  more  frequent,  and  the  collapse  is  more  extreme. 

(6)  The  So-called  Hysterical  Peritonitis. — This  has  deceived  the  very 
elect,  as  almost  every  feature  of  genuine  peritonitis,  even  the  collapse,  may 
be  simulated.  The  onset  may  be  sudden,  with  severe  pain  in  the  abdomen, 
tenderness,  vomiting,  diarrhoea,  diificulty  in  micturition,  and  the  character- 
istic decubitus.  Even  the  temperature  may  be  elevated.  There  may  be  recur- 
rence of  the  attack.  A  case  has  been  reported  by  Bristowe  in  which  four  at- 
tacks occurred  within  a  year,  and  it  was  not  until  special  hysterical  symptoms 
developed  that  the  true  nature  of  the  trouble  was  suspected. 

(c)  Obstruction  of  the  bowel  may  simulate  peritonitis,  both  having  pain, 
vomiting,  tympanites,  and  constipation.  It  may  be  impossible  to  make  a 
diagnosis  before  exploration  in  the  absence  of  a  satisfactory  history. 

(d)  Rupture  of  an  abdominal  aneurism  or  embolism  of  the  superior  mes- 
enteric artery  may  cause  symptoms  which  simulate  peritonitis.  In  the  latter, 
a  sudden  onset  with  severe  pain,  the  collapse  symptoms,  frequent  vomiting,  and 
great  distention  of  the  abdomen  may  be  present. 

(e)  Acute  h^emorrhagic  pancreatitis  or  a  ruptured  tubal  pregnancy  may 
be  mistaken  for  peritonitis. 


LOCALIZED  PEEITONITIS  595 

Treatment. — Something  can  be  done  in  prevention  by  recognition  and 
prompt  treatment  of  conditions  wliicli  may  lead  to  general  peritonitis,  such  as 
gastric  ulcer,  appendicitis,  cholecystitis,  etc.  An  early  surgical  consultation  is 
important.  With  signs  or  suspicion  of  peritonitis,  the  patient  should  be  at 
absolute  rest  and  propped  up  in  bed  in  a  sitting  position;  nothing  should  be' 
given  by  mouth;  a  solution  of  glucose  (5  per  cent.)  and  sodium  bicarbonate 
(2  per  cent.)  should  be  given  per  rectum  by  the  drop  method.  Purgatives 
should  not  be  given.  If  there  is  shock  from  perforation,  fluid  may  be  given 
subcutaneously,  and  epinephrin  (iTL  xv,  1  c.  c.)  and  camphorated  oil  (gr.  iii, 
2  gm.)  as  indicated.  If  there  is  much  vomiting  gastric  lavage  is  indicated. 
If  there  is  constant  secretion  into  the  stomach  a  small  tube  may  be  kept  in 
position  so  that  frequent  lavage  is  possible  without  disturbing  the  patient. 
The  rectal  tube  may  be  used  to  relieve  tympanites.  Turpentine  stupes,  an  ice 
bag  or  hot  applications  may  be  applied  to  the  abdomen  if  they  give  comfort. 
It  is  usually  well  to  withhold  morphia  until  a  definite  course  of  action  is  de- 
cided upon.  In  general,  operation  is  indicated  and  as  soon  as  possible,  es- 
pecially after  perforation.  In  some  cases  delay  may  be  advisable,  for  example 
until  shock  has  passed,  but  this  should  be  left  to  the  judgment  of  the  surgeon. 
In  pneumococcus  peritonitis  delay  is  advisable  unless  an  abscess  forms. 


II.     PERITONITIS  IN  INFANTS 

Peritonitis  may  occur  in  the  fetus  as  a  consequence  of  syphilis,  and  may 
lead  to  constriction  of  the  bowel  by  fibrous  adhesions. 

In  the  new-born  a  septic  peritonitis  may  extend  from  an  inflamed  cord. 
Distention  of- the  abdomen,  slight  swelling  and  redness  about  the  cord,  and 
not  infrequently  jaundice  are  present.  It  is  uncommon  and  existed  in  only 
4  of  51  infants  dying  with  inflammation  of  the  cord  and  septicaemia  (Eunge). 

During  childhood  peritonitis  arises  from  causes, similar  to  those  affecting 
the  adult.  Perforative  appendicitis  is  common.  Peritonitis  following  blows 
or  kicks  on  the  abdomen  occurs  more  frequently  at  this  period.  In  boys  injury 
while  playing  football  may  be  followed  by  diffuse  peritonitis.  A  rare  cause 
in  children  is  extension  through  the  diaphragm  from  an  empyema.  There 
are  on  record  instances  of  peritonitis  occurring  in  several  children  at  the  same 
school.  It  was  in  investigating  an  epidemic  of  this  kind  at  the  Wandsworth 
school,  in  London,  that  Anstie  received  the  post  mortem  wound  of  which  he 
died.  It  is  to  be  remembered  that  peritonitis  in  children  may  follow  the 
gonorrhoeal  vulvitis  so  common  in  infant  homes  and  hospitals. 


III.     LOCALIZED  PERITONITIS 

Subphrenic  Peritonitis. — The  general  peritoneum  covering  the  right  and 

left  lobes  of  the  liver  may  be  involved  in  an  extension  from  the  pleura  of  sup- 
purative, tuberculous,  or  cancerous  processes.  In  various  affections  of  the 
liver — cancer,  abscess,  hydatid  disease,  and  in  affections  of  the  gall-bladder — 
the  inflammation  may  be  localized  to  the  peritoneum  covering  the  upper  sur- 
iace  of  the  organ.     These  forms  of  localized  subphrenic  peritonitis  in  the 


596  DISEASES  OE  THE  DIGESTIVE  SYSTEM 

greater  sac  are  not  so  important  in  reality  as  those  which  occur  in  the  lesser 
peritoneum.  The  anatomical  relations  of  this  structure  are  as  follows:  It 
lies  behind  and  below  the  stomach,  the  gastro-hepatic  omentum,  and  the  an- 
terior layer  of  the  great  omentum.  Its  lower  limit  forms  the  upper  layer  of 
the  transverse  meso-colon.  On  either  side  it  reaches  from  the  hepatic  to  the 
splenic  flexure  of  the  colon,  and  from  the  foramen  of  Winslow  to  the  hilus 
of  the  spleen.  Behind  it  covers  and  is  tightly  adherent  to  the  front  of  the 
pancreas.  Its  upper  limit  is  formed  by  the  transverse  fissure  of  the  liver,  and 
by  that  portion  of  the  diaphragm  which  is  covered  by  the  lower  layer  of  the 
right  lateral  ligament  of  the  liver;  the  lobus  Spigelii  lies  bare  in  the  cavity. 
The  foramen  of  Winslow,  through  which  the  lesser  communicates  with  the 
greater  peritoneum,  is  readily  closed  by  inflammation. 

Inflammatory  processes,  exudates,  and  hsemorrhages  may  be  confined  en- 
tirely to  the  lesser  peritoneum.  The  exudate  of  tuberculous  peritonitis  may 
be  confined  to  it.  Perforations  of  certain  parts  of  the  stomach,  of  the  duode- 
num, and  of  the  colon  may  excite  inflammation  in  it  alone;  and  in  various 
affections  of  the  pancreas,  particularly  trauma  and  hfemorrhage,  the  effusion 
into  the  sac  has  often  been  confounded  with  cyst  of  this  organ. 

Special  mention  must  be  made  of  the  remarkable  form  of  subphrenic  ab- 
scess containing  air,  which  may  simulate  closely  pneumothorax,  and  hence  was 
called  by  Leyden  pyo-pneumothorax  subplirenicus.  The  affection  has  been 
thoroughly  studied  by  Scheurlen,  Mason,  Meltzer,  and  Lee  Dickinson.  In 
142  out  of  170  recorded  cases  the  cause  was  known.  In  a  few  instances,  as  in 
one  reported  by  Meltzer,  the  subphrenic  abscess  seemed  to  have  followed  pneu- 
monia. Pyothorax  is  an  occasional  cause.  By  far  the  most  frequent  condi- 
tion is  gastric  ulcer,  which  occurred  in -80  of  the  cases.  Duodenal  ulcer  was 
the  cause  in  6  per  cent.  In  about  10  per  cent,  of  the  cases  the  appendix  was 
the  starting-point  of  the  abscess.  Cancer  of  the  stomach  is  an  occasional 
cause.  Other  rare  causes  are  trauma,  perforation  of  an  hepatic  or  a  renal 
abscess,  lesions  of  the  spleen,  abscess,  and  cysts  of  the  pancreas.  In  a  ma- 
jority of  all  the  cases  in  which  the  stomach  or  duodenum  is  perforated — some- 
times, indeed,  in  the  cases  following  trauma — the  abscess  contains  air. 

The  symptoms  of  sul^phrenic  abscess  vary  very  considerably,  depending  a 
good  deal  upon  the  primary  cause.  The  onset,  as  a  rule,  is  abrupt,  particularly 
when  due  to  perforation  of  a  gastric  ulcer.  There  are  severe  pain,  vomiting, 
often  of  bilious  or  of  bloody  material;  respiration  is  embarrassed,  owing  to  the 
involvement  of  the  diaphragm;  then  the  constitutional  symptoms  occur  asso- 
ciated with  suppuration,  chills,  irregular  fever,  and  emaciation.  Subsequently 
perforation  niny  take  place  into  the  pleura  or  into  the  lung,  with  severe  cough 
and  abundant  purulent  expectoration. 

The  perihepatic  abscess  beneath  the  arch  of  the  diaphragm,  whether  to  the 
right  or  left  of  the  suspensory  ligament,  when  it  does  not  contain  air,  is  almost 
invariably  mistaken  for  empyema.  Eemarkable  features  are  superadded  when 
the  abscess  cavity  contains  air.  On  the  right  side,  when  the  abscess  is  in  the 
greater  peritoneum,  above  the  right  lobe  of  the  liver,  the  diaphragm  may  be 
pushed  up  to  the  level  of  the  second  or  third  rib,  and  the  physical  signs  on 
percussion  and  auscultation  are  those  of  pneumothorax,  particularly  the  tym- 
panitic resonance  and  the  movable  dulness.  The  liver  is  usually  greatly  de- 
pressed and  there  is  bulging  on  the  right  side.     Still  more  obscure  are  the 


CHROXTC  PEETTONITIS  597 

cases  of  air-containing  abscesses  due  to  perforation  of  the  stomach  or  duode- 
num, in  which  the  gas  is  contained  in  the  lesser  peritoneum.  Here  the  dia- 
phragm is  pushed  up  and  there  are  signs  of  pneumothorax  on  the  left  side. 
In  a  large  majority  of  all  the  cases  which  follow  perforation  of  a  gastric  ulcer 
the  effusion  lies  between  the  diaphragm  above,  and  the  spleen,  stomach,  and 
the  left  lobe  of  the  liver  below.  The  X-ra}'  is  of  value  and  on  the  left  side  the 
sign  described  by  Fussell  and  Pancoast  in  perinephritic  abscess  may  be  help- 
ful. This  consists  in  a  wave  in  the  fluid  seen  with  the  fluoroscope  when  the 
patient's  body  is  moved  quickly  from  side  to  side. 

The  prognosis  in  subphrenic  abscess  is  not  very  hopeful.  Of  the  cases  on 
record  about  20  per  cent,  only  have  recovered. 

Appendicular. — The  most  frequent  cause  of  localized  peritonitis  in  the 
male  is  appendicitis.  The  situation  varies  with  the  position  of  this  extremely 
variable  organ.  The  adhesion,  perforation,  and  intraperitoneal  abscess  cavity 
may  be  within  the  pelvis,  or  to  the  left  of  the  median  line  in  the  iliac  region, 
ni  the  lower  right  quadrant  of  the  umbilical  region — a  not  uncommon  situa- 
tion— or,  of  course,  most  frequently  in  the  right  iliac  fossa.  In  the  most  com- 
mon situation  the  localized  abscess  lies  upon  the  psoas  muscle,  bounded  by  the 
caecum  on  the  right  and  the  terminal  portion  of  the  ileum  and  its  mesentery 
in  front  and  to  the  left.  In  many  of  these  cases  the  limitation  is  perfect,  and 
post  mortem  records  show  that  complete  healing  may  take  place  with  the 
obliteration  of  the  appendix  in  a  mass  of  firm  scar  tissue. 

Pelvic  Peritonitis. — The  most  frequent  cause  is  inflammation  about  the 
uterus  and  Fallopian  tubes.  Puerperal  septicaemia,  gonorrhoea,  and  tubercu- 
losis are  the  usual  causes.  The  tubes  are  the  starting-point  in  a  majority  of 
the  cases.  The  fimbriae  become  adherent  and  closely  matted  to  the  ovary,  and 
a  thickening  of  the  parts,  in  which  the  individual  organs  are  scarcely  recog- 
nizable, is  gradually  produced.  The  tubes  are  dilated  and  filled  with  cheesy 
matter  or  pus,  and  there  may  be  s'mall  abscess  cavities  in  the  broad  ligaments. 
Rupture  of  one  of  these  may  cause  general  peritonitis,  or  the  membrane  may 
be  involved  by  extension,  as  in  tuberculosis  of  these  parts. 

The  treatment  of  these  forms  is  surgical. 


IV,     CHRONIC  PERITONITIS 

The  following  varieties  may  be  recognized : 

Local  adhesive  peritonitis,  a  very  common  condition,  which  occurs  par- 
ticularly about  the  spleen,  forming  adhesions  between  the  capsule  and  the 
diaphragm,  about  the  liver,  less  frequently  about  the  intestines  and  mesentery. 
Points  of  thickening  or  puckering  on  the  peritoneum  occur  sometimes  with 
union  of  the  coils  or  with  fibrous  bands.  In  a  majority  of  such  cases  the  con- 
dition is  met  accidentally  post  mortem.  Two  sets  of  symptoms  may,  however, 
be  caused  by  these  adhesions.  When  a  fibrous  band  is  attached  in  such  a  way 
as  to  form  a  loop  or  snare,  a  coil  of  intestine  may  pass  through  it.  Thus,  of 
the  295  cases  of  intestinal  obstruction  analyzed  by  Fitz,  63  were  due  to  this 
•  cause.  The  second  group  is  less  serious  and  comprises  cases  with  persistent 
abdominal  pain  of  a  colicky  character,  sometimes  rendering  life  miserable.     A 


598  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

careful  X-ray  study  is  the  greatest  aid  in  determining  the  situation  of  and 
results  from  the  adhesions. 

Diffuse  Adhesive  Peritonitis. — This  is  a  consequence  of  an  acute  inflam- 
mation, either  simple  or  tuberculous.  The  peritoneum  is  obliterated.  On 
cutting  through  the  abdominal  wall,  the  coils  of  intestines  are  uniformly 
matted  together  and  can  neither  be  separated  from  each  other  nor  can  the 
visceral  and  parietal  layers  be  distinguished.  There  may  be  thickening  of  the 
layers,  and  the  liver  and  spleen  are  usually  involved  in  the  adhesions. 

Proliferative  Peritonitis. — Apart  from  cancer  and  tubercle,  which  produce 
typical  lesions  of  chronic  peritonitis,  the  most  characteristic  form  is  that  which 
may  be  described  under  this  heading.  The  essential  anatomical  feature  is 
great  thickening  of  the  peritoneal  layers,  usually  without  much  adhesion. 
The  eases  are  sometimes  seen  with  sclerosis  of  the  stomach.  It  may  occur  in 
connection  with  a  sclerotic  condition  of  the  cfecum  and  the  first  part  of  the 
colon.  It  is  not  uncommon  with  cirrhosis  of  the  liver.  In  a  case  of  this  kind 
there  is  usually  moderate  effusion,  more  rarely  extensive  ascites.  The  perito- 
neum is  opaque  white  in  color,  and  everywhere  thickened,  often  in  patches.  The 
omentum  is  usually  rolled  and  forms  a  thickened  mass  transversely  placed, 
between  the  stomach  and  the  colon.  The  peritoneum  over  the  stomach,  in- 
testines, and  mesentery  is  sometimes  greatly  thickened.  The  liver  and  spleen 
may  simply  be  adherent,  or  there  is  a  condition  of  chronic  perihepatitis  or 
perisplenitis,  so  that  a  layer  of  firm,  almost  gristly  connective  tissue  of  from 
one-fourth  to  half  an  inch  in  thickness  encircles  these  organs.  Usually  the 
volume  of  the  liver  is  in  consequence  greatly  reduced.  The  gastro-hepatic 
omentum  may  be  constricted  by  this  new  growth  and  the  calibre  of  the  portal 
vein  much  narrowed.  A  serous  effusion  may  be  present.  On  account  of  the 
adhesions  which  form,  the  peritoneimi  may  be  divided  into  three  or  four  dif- 
ferent sacs,  as  is  described  under  tuberculous  peritonitis.  In  these  cases  the 
intestines  are  usually  free,  though  the  mesentery  is  greatly  shortened.  There 
are  instances  of  chronic  peritonitis  in  which  the  mesentery  is  so  shortened  hj 
this  proliferative  change  that  the  intestines  form  a  ball  not  larger  than  a  co- 
coanut  situated  in  the  middle  line,  and  after  the  removal  of  the  exudation  can 
be  felt  as  a  solid  tumor.  The  intestinal  wall  is  greatly  thickened  and  the 
mucous  membrane  of  the  ileum  is  thrown  into  folds  like  the  valvulaB  conni- 
ventes.  This  proliferative  peritonitis  is  found  frequently  in  the  subjects  of 
chronic  alcoholism.  In  cases  of  long-continued  ascites  the  serous  surfaces 
generally,  become  thickened  and  present  an  opaque,  dead  white  color.  This  con- 
dition is  observed  especially  in  hepatic  cirrhosis,  but  attends  tumors,  chronic 
passive  congestion,  etc. 

In  all  forms  of  chronic  peritonitis  a  friction  may  be  felt  usually  in  the 
upper  zone  of  the  abdomen.  Polyorrhomenitis,  polyserositis,  general  chronic 
inflammation  of  the  serous  membranes,  Concato's  disease  (as  the  Italians  call 
it)  may  occur  with  this  form  as  well  as  in  the  tuberculous  variety.  The  peri- 
cardium and  both  pleurfe  mav  be  involved.  The  pericardial  pseudocirrhosis 
described  by  Pick  is  an  allied  condition. 

In  some  instances  of  chronic  peritonitis  the  membrane  presents  numerous 
nodular  thickenings,  which  may  be  mistaken  for  tubercles..  J.  F.  Payne  de- 
scribed a  case  of  this  sort  associated  with  disseminated  growths  throufrhout 
the  liver  which  were  not  cancerous.     It  has  been  suoo-ested  that  some  of  the 


NEW  GEOWTHS  IN  THE  PERITONEUM  599 

cases  of  tuberculous  peritonitis  cured  by  operation  have  been  of  this  nature, 
but  histological  examination  should  determine  between  the  conditions.  Miura, 
in  Japan,  reported  a  case  in  which  these  nodules  contained  the  ova  of  a  para- 
site. One  case  has  been  reported  in  which  the  exciting  cause  was  regarded  as 
cholesterin  plates,  which  were  contained  within  the  granulomatous  nodules. 

Chronic  Hsemorrhagic  Peritonitis. — Blood-stained  effusions  in  the  peri- 
toneum occur  particularly  in  cancerous  and  tuberculous  disease.  A  chronic 
inflammation  analogous  to  the  hsemorrhagic  pachymeningitis  of  the  brain  was 
described  first  by  Virchow,  and  is  localized  most  commonly  in  the  pelvis. 
Layers  of  new  connective  tissue  form  on  the  surface  of  the  peritoneum  with 
large  wide  vessels  from  which  haemorrhage  occurs.  This  is  repeated  from 
time  to  time  with  the  formation  of  regular  layers  of  hgemorrhagic  effusion. 
It  is  rarely  diffuse,  more  commonly  circumscribed.  Probably  the  spontaneous 
peritoneal  lia?morrhage  with  the  features  of  an  "acute  abdomen'^  (Church- 
man) may  represent  the  primary  form  of  this  rare  condition. 

Treatment. — In  cases  with  adhesions  which  are  causing  symptoms,  great 
caution  should  be  exercised  in  advising  operation  and  a  thorough  X-ray  study 
made  to  determine,  if  possible,  the  exact  condition.  For  local  adhesions  of  the 
pylorus,  duodenum,  and  colon,  causing  obstruction,  surgery  may  be  beneficial. 
In  the  cases  with  extensive  adhesions  about  the  csscum  and  ascending  colon, 
the  chances  are  less  favorable.  Every  effort  should  be  made  to  help  the  action 
of  the  bowels  by  medical  measures.  For  the  cases  of  chronic  proliferative 
peritonitis  very  little  can  be  done.  If  a  primary  cause  is  present,  such  as 
renal  and  cardiac  disease  or  syphilis  of  the  liver,  treatment  should  be  directed 
to  that.  The  treatment  in  general  is  practically  that  of  ascites  and  tapping 
should  be  done  whenever  necessary.  The  injection  of  epinephrin  (nx  xv,  1 
c.  c.)  into  the  peritoneal  cavity  after  tapping  has  been  of  benefit  in  some  cases. 
As  a  rule  operation  is  not  advisable  and  no  benefit  results  from  an  attempt  to 
produce  additional  adhesions. 


V.    NEW  GROWTHS  IN  THE  PERITONEUM 

Tuberculous  Peritonitis. — This  has  already  been  considered. 

Cancer  cf  the  Peritoneum. — Although,  as  a  rule,  secondary  to  disease  of 
the  stomach,  liver,  or  pelvic  organs,  cases  of  primary  cancer  have  been  de- 
scribed. It  is  probable  that  the  so-called  primary  cancers  of  the  serous  mem- 
branes are  endotheliomata  and  not  carcinomata.  Secondary  malignant  perito- 
nitis occurs  in  connection  with  all  forms  of  cancer.  It  is  usually  characterized 
by  a  number  of  round  tumors  scattered  over  the  entire  peritoneum,  sometimes 
small  and  miliary,  at  other  times  large  and  nodular,  with  puckered  centres. 
The  disease  most  commonly  starts  from  the  stomach  or  the  ovaries.  The 
omentum  is  indurated  and,  as  in  tuberculous  peritonitis,  forms  a  mass  which 
lies  transversely  across  the  upper  portion  of  the  abdomen.  Primary  malig- 
nant disease  of  the  peritoneum  is  extremely  rare.  Colloid  sometimes  occurs, 
forming  enormous  masses,  which  in  one  case  Aveighed  over  100  pounds.  Cancer 
of  this  mem))rane  spreads,  either  by  the  detachment  of  small  particles  which 
are  carried  in  the  lymph  currents  and  by  the  movements  to  distant  parts,  or 
by  contact  of  opposing  surfaces.     It  occurs  more  frequently  in  women  than 


600  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

in  men,  and  more  commonly  at  the  later  period  of  life  than  in  the  young. 

The  diagnosis  of  cancer  of  the  peritoneum  is  easy  with  a  history  of  a  local 
malignant  disease;  as  when  it  occurs  with  ovarian  tumor  or  with  cancer  of 
the  pylorus.  In  cases  in  which  there  is  no  evidence  of  a  primary  lesion  the 
diagnosis  may  he  doubtful.  The  clinical  picture  is  usually  that  of  chronic 
ascites  with  progressive  emaciation.  There  may  be  no  fever.  If  there  is 
much  effusion  nothing  definite  can  be  felt  on  examination.  After  tapping, 
irregulrr  nodules  or  the  curled  omentum  may  be  felt  lying  transversely  across 
the  upper  portion  of  the  abdomen.  Multiple  nodules,  if  large,  indicate  cancer, 
particularly  in  persons  above  middle  life.  Xodular  tuberculous  peritonitis  is 
most  frequent  in  children.  The  presence  about  the  navel  of  secondary  nodules 
and  indurated  masses  is  more  common  in  cancer.  Inflammation,  suppuration. 
and  the  discharge  of  pus  from  the  navel  rarely  occur  except  in  tuberculous 
disease.  Considerable  enlargement  of  the  inguinal  glands  may  be  present  in 
cancer.  The  nature  of  the  fluid  in  cancer  and  in  tubercle  may  be  much  alike. 
It  may  be  ha?morrhagic  in  both ;  more  often  in  the  latter.  The  histological 
examination  in  cancer  may  show  large  multinu clear  cells  or  groups  of  cells — 
the  sprouting  cell-groups  of  Foulis — which  are  extremely  suggestive.  The  col- 
loid cancer  may  give  a  different  picture;  instead  of  ascitic  fluid,  the  abdomen 
is  occupied  by  semi-solid  gelatinous  substance,  and  is  firm,  not  fluctuating. 
Echinococci  in  the  peritoneum  ma}'  simulate  cancer  very  closely. 

Free  solid  iumors  are  sometimes  met  with,  usually  fibroid  or  calcareous, 
as  in  the  case  reported  by  Campbell  and  Ower,  in  which  a  man  had  had  a  mov- 
al)le  tumor  in  his  abdomen  for  more  than  twenty  years.  It  had  increased  in 
size,  and  at  his  death  was  a  rounded  mass  8  by  9  cm. 

VI.     ASCITES 

[Hydro-peritoneum ) 

Definition.— The  accumulation  of  serous  fluid  in  the  peritoneal  cavity. 

Etiolo^. — Local  Causes. —  {a)  Chronic  inflammation  of  the  peritoneum, 
either  simple,  cancerous,  or  tuberculous.  (&)  Portal  obstruction  in  the  ter- 
minal branches  within  the  liver,  as  in  cirrhosis,  syphilis  and  chronic  passive 
congestion,  or  by  compression  of  the  vein  in  the  gastro-hepatic  omentum,  by 
proliferative  peritonitis,  gumma,  new  growths,  or  aneurism,  (c)  Thrombosis 
of  the  portal  vein,  [d)  Tumors  of  the  abdomen.  The  solid  growths  of  the 
ovaries  may  cause  considerable  ascites,  which  may  completely  mask  the  true 
condition.  It  is  important  to  bear  in  mind  this  possibility  in  the  obscure  ascites 
of  women.  The  enlarged  spleen  in  leukaemia,  less  commonly  in  malaria,  may  be 
associated  with  recurring  ascites. 

Gexeeal  Causes. — The  ascites  is  part  of  a  general  dropsy,  the  result  of 
mechanical  effects,  as  in  heart-disease.  In  cardiac  lesions  the  effusion  is  some- 
times conflned  to  the  peritoneum,  in  whidi  case  it  is  due  to  secondary  changes 
in  the  liver,  or  it  has  been  suggested  to  be  connected  with  a  failure  of  the 
suction  action  of  this  organ  by  which  the  peritoneum  is  kept  dry.  Ascites  oc- 
curs also  in  the  dropsy  of  nephritis  and  in  hydrgemic  states  of  the  blood. 

Symptoms. — A  gradual  uniform  enlargement  of  the  abdomen  is  the  char- 
acteristic sign  of  ascites,     (a)  Inspection. — According  to  the  amount  of  fluid 


ASCITES  -  601 

the  abdomen  is  protuberant  and  flattened  at  the  sides.  With  large  effusions, 
the  skin  is  tense  and  may  present  the  linese  albicantes.  Frequently  the  navel 
itself  and  the  parts  about  it  are  very  prominent.  In  many  cases  the  superficial 
veins  are  enlarged  and  a  plexus  joining  the  mammary  vessels  can  be  seen. 
Often  it  can  be  determined  that  the  current  is  from  below  upward.  In  some 
instances,  as  in  thrombosis  or  obliteration  of  the  portal  vein,  these  superficial 
abdominal  vessels  may  be  extensively  varicose.  About  the  navel  in  cases  of 
cirrhosis  there  is  occasionally  a  large  bunch  of  distended  veins,  the  so-called 
caput  Medusae.    The  heart  may  be  displaced  upward. 

(h)  Palpation. — Fluctuation  is  obtained  by  placing  one  hand  upon  one 
side  of  the  abdomen  and  giving  a  sharp  tap  on  the  opposite  side  with  the 
other  hand,  when  a  wave  is  felt  to  strike  as  a. definite  shock  against  the  applied 
hand.  Even  comparatively  small  quantities  of  fluid  may  give  this  fluctua- 
tion shock.  When  the  abdominal  walls  are  thick  or  very  fat,  an  assistant  may 
place  the  edge  of  the  hand  in  front  of  the  abdomen.  A  different  precedure  is 
adopted  in  palpating  for  the  solid  organs  in  case  of  ascites.  Instead  of  placing 
the  hand  flat  upon  the  abdomen,  as  in  the  ordinary  method,  the  pads  of  the 
fingers  only  are  placed  lightly  upon  the  skin,  and  then  by  a  sudden  depres- 
sion of  the  fingers  the  fluid  is  displaced  and  the  solid  organ  or  tumor  may  be 
felt.  By  this  method  of  "dipping"  or  displacement,  the  liver  may  be  felt  below 
the  costal  margin,  or  the  spleen,  or  sometimes  solid  tumors  of  the  omentum  or 
intestine. 

(c)  Percussion. — In  the  dorsal  position  with  a  moderate  quantity  of  fluid 
in  the  peritoneum  the  flanks  are  dull,  while  the  umbilical  and  epigastric  re- 
gions, in  which  the  intestines  float,  are  tympanitic.  This  area  of  clear  reso- 
nance may  have  an  oval  outline.  Having  obtained  the  lateral  limit  of  the 
dulness  on  one  side,  if  the  patient  turns  on  the  opposite  side,  the  fluid  gravi- 
tates to  the  dependent  part  and  the  uppermost  flank  is  now  tympanitic.  In 
moderate  effusions  this  movable  dnilness  changes  greatly  in  the  different  pos- 
tures. Small  amounts  of  fluid,  probably  under  a  litre,  would  scarcely  give 
movable  dulness,  as  the  pelvis  and  the  renal  regions  hold  a  considerable  quan- 
tity. In  such  cases  it  is  best  to  place  the  patient  in  the  knee-elbow  position, 
when  a  dull  note  will  be  determined  at  the  most  dependent  portion.  By  care- 
ful attention  to  these  details  mistakes  are  usually  avoided. 

Differential  Dia^osis. — The  following  are  among  the  conditions  which 
may  be  mistaken  for  dropsy :  Ovarian  tumor,  in  which  the  sac  develops,  as  a 
rule,  unilaterally,  though  when  large  it  is  centrally  placed.  The  dulness  is  an- 
terior and  the  resonance  is  in  tlic  flanks,  into  which  the  intestines  are  pushed 
liy  the  cyst.  Examination  jier  rar/iruini,  may  give  important  indications.  In 
those  rare  instances  in  which  gas  develops  in  the  cyst  the  diagnosis  may  be 
very  difficult.  Succussion  has  been  obtained  in  such  cases.  A  distended  bladder 
may  reach  above  the  umbilicus.  In  such  instances  some  urine  dribbles  away, 
and  suspicion  of  ascites  or  a  cyst  is  occasionally  entertained.  A  trocar  may  be 
thrust  into  a  distended  bladder,  supposed  to  be  an  ovarian  cyst,  and  it  is 
stated  that  John  Hunter  tapped  a  bladder,  thinking  it  to  be  ascites.  Such  a 
mistake  should  be  avoided  by  careful  catheterization  prior  to  any  operative 
procedures.  And  lastly,  there  are  large  pancreatic  or  hydatid  cysts  in  the 
al)domen  which  may  simulate  ascites. 

Nature  of  the  Ascitic  Fluid. — Usually  this  is  a  clear  serum,  light  yellow 


603  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

in  the  ascites  of  anaemia  and  nephritis,  often  darker  in  color  in  cirrhosis  of 
the  liver.  The  specific  gravity  is  low,  seldom  more  than  1.010  or  1.015, 
whereas  in  the  fluid  of  ovarian  cysts  or  chronic  peritonitis  the  specific  gravity 
is  over  1.015.  It  is  albuminous  and  sometimes  coagvxlates  spontaneously. 
Dock  has  called  attention  to  the  importance  of  the  study  of  the  cells  in  the 
exudate.  In  cancer  very  characteristic  forms,  with  nuclear  figures,  may  be 
found.  Hsemorrhagic  effusion  usually  occurs  in  cancer  and  tuberculosis,  oc- 
casionally in  cirrhosis  and  with  ruptured  tubal  pregnancy. 

Chylous  Ascites. — Of  the  cases  tabulated  by  Maclvenzie,  Wallis,  and 
Scholberg,  81  were  in  association  with  tumors,  46  with  the  infections,  chiefly 
tuberculosis,  37  in  association  with  affections  of  the  thoracic  duct  and  lym- 
phatic system,  and  78  in  connection  with  general  diseases  such  as  cirrhosis  of 
the  liver,  cardiac  disease,  nephritis,  amyloid  disease,  and  thrombosis  of  the 
blood-vessels.  In  a  certain  number  of  cases  the  cause  of  the  condition  is  un- 
known. Quincke  recognized  that  there  were  two  types,  one  in  which  there 
was  a  true  milky  or  fatty  fluid,  the  other  in  which  the  turbidity  is  due  to  fatty 
degeneration  of  cells  or  to  chemical  substances  of  a  non-fatty  nature.  Tha 
fluid  of  the  true  chylous  ascites  is  yellowish-white  in  color,  contains  fine  fat 
globules,  a  creamy  layer  collects  on  standing,  the  specific  gravity  generally 
exceeds  1.012,  and  the  fat  content  is  high.  As  a  rule,  it  tends  to  accumulate 
rapidly  and  large  amounts  may  be  removed.  The  fluid  of  pseudo-chylous  as- 
cites is  milky  white,  the  opacity  often  may  vary  at  different  tappings.  Micro- 
scopically there  are  many  fine  retractile  granules,  but  they  do  not  give  reac- 
tions for  fat,  the  cellular  elements  may  be  numerous,  and  a  creamy  layer 
rarely  forms.  The  specific  gravity  is  less  than  1.012,  and  the  total  solids 
rarely  exceed  2  per  cent.  The  fat  content  is  low.  Lecithin  combined  with 
globulin  appears  to  be  the  cause  of  the  opalescence.  These  authors  conclude 
that  milky  ascites  is  characteristic  of  no  specific  morbid  lesion.  The  prog- 
nosis is  usually  grave. 

Treatment.- — This  depends  somewhat  on  the  nature  of  the  case.  Treat- 
ment should  be  directed  to  the  underlying  cause  if  this  is  possible.  In  cirrhosis 
early  and  repeated  tapping  may  give  time  for  the  establishment  of  the  collateral 
circulation,  and  temporary  cures  have  followed  this  procedure.  The  injection 
of  epinephrin  (3  ss,  2  c.  c.  of  a  1-1000  solution)  into  the  peritoneal  cavity 
after  tapping  has  been  useful  in  some  cases.  Permanent  drainage  with  South- 
ey's  tube,  incision,  and  washing  out  the  peritoneum  have  also  been  practised. 
In  the  ascites  of  cardiac  and  renal  disease  the  cathartics  are  most  satisfactory, 
particularlv  the  bitartrate  of  potash,  given  alone  or  with  jalap,  and  the  large 
doses  of  salts  given  an  hour  before  breakfast  with  as  little  water  as  possible. 
These  sometimes  cause  rapid  disappearance  of  the  effusion,  but  are  not  so 
successful  in  ascites  as  in  pleurisy  with  effusion.  The  stronger  cathartics  may 
sometimes  be  necessary.  The  ascites  forming  part  of  the  general  anasarca 
of  nephritis  will  receive  consideration  under  another  section. 

K.    DISEASES  OF  THE  OMENTUM 

Torsion. — Though  the  first  case  was  reported  by  Oberst  in  1882,  Bookman 
collected  131  cases  in  1915.  It  is  one  of  the  recognized  causes  of  the  "acute 
abdomen."     The  torsion  may  occur  with  or  without  the  presence  of  a  hernial 


DISEASES  OF  THE  OMENTUM  603 

sac,  with  which  fully  90  per  cent,  of  the  cases  have  occurred.  The  twist  is 
usually  associated  with  adhesion  of  the  free  extremity  to  some  structure.  As 
the  cases  are  usually  in  connection  with  hernia,  the  diagnosis  of  strangulation 
is  made.  Pain,  muscular  rigidity  and  vomiting  are  the  usual  symptoms  and 
the  condition  is  mistaken  for  hernia,  acute  appendicitis,  or  intestinal  obstruc- 
tion. The  esistence  of  a  hernia  and  the  sudden  appearance  of  an  abdominal 
mass  are  suggestive.  Early  operation  with  removal  of  the  strangulated  por- 
tion is  the  only  treatment. 


SECTION  VII 
DISEASES  OF  THE  RESPIKATORY  SYSTEM 
A.    DISEASES  OF  THE  NOSE 

EPISTAXIS 

Etiology. — Among  local  causes  may  be  mentioned  traumatism,  small  ulcers, 
picking  or  scratching  the  nose,  new  growths,  and  the  presence  of  foreign 
bodies.  In  chronic  nasal  catarrh  bleeding  is  not  infrequent.  The  blood  may 
come  from  one  or  both  nostrils.    The  flow  may  be  profuse  after  an  injury. 

Among  general  conditions  the  following  are  the  most  important:  It  oc- 
curs in  growing  children,  particularly  about  the  age  of  puberty;  more  fre^ 
quently  in  the  delicate  than  in  the  strong  and  vigorous.  There  is  a  family 
form  in  which  many  members  in  several  generations  are  affected,  a  hereditary 
multiple  telangiectasis,  a  special  feature  of  which  is  recurring  epistaxis.  The 
disease  has  nothing  to  do  with  hemophilia,  with  which  it  has  been  confounded. 
The  bleeding  occurs  from  the  telangiectasis  in  the  nasal  mucosa,  and  from 
those  in  the  lips,  tongue,  and  skin.  In  1915,  Gjessing  found  reports  of  nine- 
teen families  in  Avhich  it  occurred. 

Epistaxis  is  common  in  persons  of  so-called  plethoric  habit.  It  is  stated 
sometimes  to  precede,  or  to  indicate  a  liability  to,  apoplexy.  There  may  be  a 
most  extreme  grade  of  cyanosis  without  its  occurrence.  It  is  frequent  in 
hepatic  cirrhosis.  In  balloon  and  mountain  ascensions  epistaxis  is  common. 
In  haemophilia  the  nose  ranks  first  of  the  mucous  membranes  from  which  bleed- 
ing arises.  It  occurs  in  all  forms  of  chronic  ansemias  and  in  chronic  intersti- 
tial nephritis.  It  precedes  the  onset  of  certain  fevers  and  is  associated  in 
some  special  way  with  typhoid  fever.  Vicarious  epistaxis  has  been  described  in 
suppression  of  the  menses.  Lastly,  it  is  said  to  be  brought  on  by  certain 
psychical  impressions,  but  the  observations  on  this  point  are  not  trustworthy. 
The  blood  comes  from  capillary  oozing  or  diapedesis  but  may  come  from  a 
small  vessel  or  from  capillary  angiomata  situated  in  the  respiratory  portion 
of  the  nostril  and  upon  the  cartilaginous  septum. 

Symptoms. — Slight  hemorrhage  is  not  associated  with  any  special  features. 
When  the  bleeding  is  protracted  the  patients  have  the  more  serious  manifesta- 
tions of  loss  of  blood.  In  the  slow  dripping  which  takes  place  in-  some  in- 
stances of  hemophilia,  a  remarkable  blood  tumor  projecting  from  one  nostril 
and  extending  even  below  the  mouth  may  be  formed. 

Death  from  ordinary  epistaxis  is  very  rare.  The  more  blood  is  lost  the 
greater  is  the  tendency  to  clotting  with  spontaneous  cessation  of  the  bleeding. 

Diagnosis. — This  is  usually  easy.  One  point  only  need  be  mentioned ; 
namely,  that  bleeding  from  the  posterior  nares  occasionally  occurs  during  sleep 

6C4 


ACUTE  CATARRHAL  LARYNGITIS  605 

and  the  blood  trickles  into  the  pharynx  and  may  be  swallowed.  If  vomited, 
it  may  be  confounded  with  ha^matemesis ;  or,  if  coughed  up,  with  haemoptysis. 
Treatment. — In  a  majority  of  the  cases  the  bleeding  ceases  of  itself.  Vari- 
ous simple  measures  may  be  employed,  such  as  holding  the  arms  above  the 
head,  the  application  of  ice  to  the  nose,  or  the  injection  of  cold  or  hot  water 
into  the  nostrils.  Astringents,  such  as  zinc,  alum,  or  tannin,  may  be  used; 
and  the  tincture  of  the  perchloride  of  iron,  diluted  with  ice-water,  may  be 
introduced  into  the  nostrils.  If  the  bleeding  comes  from  an  ulcerated  surface, 
an  attempt  should  be  made  to  apply  chromic  acid  or  the  cautery.  If  the  bleed- 
ing is  at  all  severe  and  obstinate,  the  posterior  nares  .should  be  plugged.  A 
patient  with  epistaxis  and  spider  angiomata  of  the  skin  and  mucous  membranes 
used  a  finger  of  a  rubber  glove  with  a  small  rubber  tube  and  stopcock  by  which 
he  could  dilate  the  glove  finger,  inserted  into  the  nostril,  and  so  eiTectually 
control  the  bleeding.  A  solution  of  gelatine,  epinephrine  or  thromboplastine 
may  be  injected  into  the  nostril.  The  injection  of  blood  serum  may  be  tried 
or  transfusion  done  in  severe  cases. 


B.     DISEASES  OF  THE  LARYNX 

I.     ACUTE  CATARRHAL  LARYNGITIS 

This  may  come  on  as  an  independent  affection  or  in  association  with  gen- 
eral catarrh  of  the  upper  respiratory  passages. 

Etiology. — Many  cases  are  due  to  catching  cold  ot  to  overuse  of  the  voice; 
others  come  on  in  consequence  of  the  inhalation  of  irritating  gases  especially 
in  the  recent  war.  Very  severe  laryngitis  is  excited  by  traumatism,  either  in- 
juries from  without  or  the  lodgment  of  foreign  bodies.  It  may  be  caused  by 
the  action  of  very  hot  liquids  or  corrosive  poisons.  It  may  occur  in  the  general 
catarrh  associated  with  influenza  and  measles.  The  pneumococcus,  influenza 
bacillus  and  Micrococcus  catarrlialis  are  the  organisms  most  commonly  found. 

Symptoms. — There  is  a  sense  of  tickling  referred  to  the  larynx;  the  cold 
air  irritates  and,  owing  to  the  increased  sensibility  of  the  mucous  membrane, 
the  act  of  inspiration  may  be  painful.  There  is  a  dry  cough,  and  the  voice  is 
altered.  At  first  it  is. simply  husky,  but  soon  phonation  becomes  painful,  and 
finally  the  voice  may  be  completely  lost.  In  adults  the  respirations  are  not 
increased  in  frequency,  but  in  children  dyspnoea  is  not  uncommon  and  may 
occur  in  spasmodic  attacks  and  become  urgent  if  there  is  much  oedema  with 
the  inflammatory  swelling. 

The  laryngoscope  shows  a  swollen  mucous  membrane  of  the  larynx,  par- 
ticularly the  ary-epiglpttidean  folds.  The  vocal  cords  have  lost  their  smooth 
and  shining  appearance  and  are  reddened  and  swollen.  Their  mobility  also 
is  greatly  impaired,  owing  to  the  infiltration  of  the  adjoining  nmcous  mem- 
brane and  of  the  muscles.  A  slight  mucoid  exudation  covers  the  parts.  The 
constitutional  symptoms  are  not  severe.  There  is  rarely  much  fever,  and  in 
many  cases  the  patient  is  not  seriously  ill.  Occasionally  cases  come  on  with 
greater  intensity,  the  cough  is  very  distressing,  deglutition  is  painful,  and  there 
may  be  urgent  dyspnoea. 


606  DISEASES  OF  THE  EESPIEATOEY  SYSTEM 

Diagnosis. — There  is  rarely  any  difficulty  in  determining  the  nature  of  a 
case  if  a  satisfactory  laryngoscopic  examination  can  be  made.  The  severer 
forms  may  simulate  oedema  of  the  glottis.  When  the  loss  of  voice  is  marked, 
the  case  may  be  mistaken  for  one  of  nervous  aphonia,  but  the  laryngoscope 
decides  the  question  at  once.  Much  more  difficult  is  the  diagnosis  of  acute 
laryngitis  in  children,  particularly  in  the  very  young,  in  whom  it  is  so  hard 
to  make  a  proper  examination.  Erom  ordinary  laryngismus  it  is  to  be  dis- 
tinguished by  the  presence  of  fever,  the  mode  of  onset,  and  particularly  the 
coryza  and  the  previous  symptoms  of  hoarseness  or  loss  of  voice.  Membranous 
laryngitis  may  at  first  be  quite  impossible  to  differentiate,  but  in  a  majority 
of  cases  of  this  affection  there  are  patches  on  the  pharynx  and  early  swelling 
of  the  cervical  glands.    The  symptoms,  too,  are  much  more  severe. 

Treatment. — Eest  of  the  larynx  should  be  enjoined,  so  far  as  phonation  is 
concerned;  smoking  should  be  forbidden.  In  cases  of  any  severity  the  patient 
should  be  kept  in  bed.  The  room  should  be  at  an  even  temperature  and  the 
air  saturated  with  moisture.  Inhalations  of  menthol  and  eucalyptus  are  help- 
ful. Early  in  the  disease,  if  there  is  much  fever,  aconite  and  citrate  of  potash 
may  be  given,  and  for  the  irritating  painful  cough  a  full  dose  of  Dover's 
powder  or  heroin  at  night.    An  ice-bag  externally  often  gives  great  relief. 

II.     CHRONIC  LARYNGITIS 

Etiology. — The  disease'-usually  follows  repeated  acute  attacks.  The  most 
common  cause  is  overuse  of  the  voice,  particularly  in  persons  whose  occupation 
necessitates  shouting  in  the  open  air.  The  constant  inhalation  of  irritating 
substances,  as  tobacco-smoke,  may  also  cause  it. 

Symptoms. — The  voice  is  usually  hoarse  and  rough  and  in  severe  cases  may 
be  almost  lost.  There  is  usually  very  little  pain ;  only  the  unpleasant  sense  of 
tickling  in  the  larynx,  which  causes  a  frequent  desire  to  cough.  With  the 
laryngoscope  the  mucous  membrane  looks  swollen,  but  much  less  red  than  in 
the  acute  condition.  In  association  with  the  granular  pharyngitis,  the  mucous 
glands  of  the  epiglottis  and  of  the  ventricles  may  be  involved. 

Treatment. — The  nostrils  should  be  carefully  examined,  since  in  some 
instances  chronic  laryngitis  is  associated  with  and  even  dependent  upon  ob- 
struction to  the  free  passage  of  air  through  the  nose.  Local  application  must 
be  made  directly  to  the  larynx,  either  with  a  brush  or  by  means  of  a  spray. 
Among  the  remedies  most  recommended  are  the  solutions  of  nitrate  of  silver, 
chlorate  of  potash,  perchloride  of  zinc,  and  tannic  acid.  Insufflations  of  bis- 
muth are  sometimes  useful.  Among  directions  to  be  given  are  the  avoidance 
of  heated  rooms  and  loud  speaking,  and  abstinence  from  tobacco  and  alcohol. 
The  throat  should  not  be  too  much  muffled,  and  morning  and  evening  the 
neck  should  be  sponged  with  cold  water. 

III.     (EDEMATOUS  LARYNGITIS 

It  was  described  by  Matthew  Baillie  (1812)  and  Pitcairn  (one  of  the 
owners  of  the  famous  Gold-headed  Cane)  was  one  of  the  first  cases. 

Etiology. — (Edema  of  the  structures  which  form  the  glottis  is  met  with  {a) 


SPASMODIC  LARYNGITIS  607 

as  a  rare  sequence  of  ordinary  acute  laryngitis;  (b)  in  chronic  diseases  of  the 
larynx,  as  syphilis  or  tubercle;  (c)  in  severe  inflammatory  diseases  like  diph- 
theria, in  erysipelas  of  the  neck,  and  in  various  forms  of  cellulitis;  (cZ)  oc- 
casionally in  the  acute  infections — scarlet  fever,  typhus,  or  typhoid ;  in  ne- 
phritis, either  acute  or  chronic,  there  may  be  a  rapidly  developing  oedema;  (e) 
in  angio-neurotic  oedema. 

Symptoms. — There  is  dyspnoea,  increasing  in  intensity,  so  that  within  an 
hour  or  two  the  condition  becomes  very  critical.  There  is  sometimes  marked 
stridor  in  respiration.  The  voice  becomes  husky  and  disappears.  The  laryn- 
goscope shows  enormous  swelling  of  the  epiglottis,  which  can  sometimes  be 
felt  with  the  finger  or  even  seen  when  the  tongue  is  strongly  depressed  with  a 
spatula.  The  ary-epiglottidean  folds  are  the  seat  of  the  chief  swelling  and 
may  almost  meet  in  the  middle  line.  Occasionally  the  oedema  is  below  the 
true  cords.  The  diagnosis  is  rarely  difficult,  inasmuch  as  even  without  the 
laryngoscope  the  swollen  epiglottis  can  be  seen  or  felt  with  the  finger.  The 
condition  is  very  often  fatal. 

Treatment. — An  ice-bag  should  be  placed  on  the  larynx,  and  the  patient 
given  ice  to  suck.  The  air  of  the  room  should  be  moist.  If  the  symptoms 
are  urgent,  the  throat  should  be  sprayed  with  a  strong  solution  of  cocaine  or 
epinephrin  and  the  swollen  epiglottis  scarified.  If  relief  does  not  follow, 
tracheotomy  should  immediately  be  performed.  The  high  rate  of  mortality 
is  due  to  the  fact  that  this  operation  is,  as  a  rule,  too  long  delayed. 


IV.     SPASMODIC  LARYNGITIS 

{Laryngismus  stridulus) 

Definition. — Spasmodic  contraction  of  the  intrinsic  muscles  of  the  larynx, 
usually  in  children,  leading  to  closure  of  the  glottis  and  dyspncea. 

Etiology. — In  children  it  may  be  a  purely  nervous  affection,  without  any 
inflammatory  condition  of  the  larynx,  and  is  most  commonly  seen  in  connec- 
tion with  rickets.  The  disease  has  close  relations  with  tetany  and  may  display 
many  of  the  accessory  phenomena  of  this  disease.  Often  the  attack  comes  on 
when  the  child  has  been  crossed  or  scolded.  Mothers  sometimes  call  the  at- 
tacks "passion  fits"  or  attacks  of  "holding  the  breath."  It  was  supposed  at  one 
time  that  they  were  associated  with  enlargement  of  the  thymus,  and  the  con- 
dition therefore  received  the  name  of  thymic  asthma. 

In  adults  it  may  follow  irritation  of  the  pneumogastric  nerves,  as  in  aneu- 
rism or  mediastinal  tumor.  The  crises  in  tabes  dorsalis  are  due  to  sudden 
spasm  of  the  intrinsic  muscles.  It  is  occasionally  seen  in  hysteria.  There  are 
attacks  of  spasmodic  cough  in  adults  with  distressing  spasm  of  the  glottis, 
lasting  two  or  three  months  and  arousing  the  suspicion  of  aneurism  or  tumor. 

The  actual  state  of  the  larynx  during  a  paroxysm  is  a  spasm  of  the  ad- 
ductors, but  the  precise  nature  of  the  influences  causing  it  is  not  yet  known, 
whether  centric  or  reflex  from  peripheral  irritation.  The  disease  is  not  so 
common  in  America  as  in  England. 

Symptoms. — The  attacks  may  come  on  either  in  the  night  or  m  the  day; 
often  just  as  the  child  awakes.    There  is  no  cough,  no  hoarseness,  but  the  res- 


G08  DISEASES  OE  THE  EESPIEATORY  SYSTEM 

piration  is  arrested  and  the  child  struggles  for  breath,  the  face  gets  congested, 
and  then,  with  a  sudden  relaxation  of  the  spasm,  the  air  is  drawn  into  the 
lungs  with  a  high-pitched  crowing  sound^  which  has  given  to  the  affection 
the  name  of  "child-crowing."  Convulsions  may  occur  during  an  attack  or 
there  may  be  carpo-pedal  spasms.  Death  may,  but  rarely  does,  occur  during 
the  attack.  With  the  cyanosis  the  spasm  relaxes  and  respiration  begins.  The 
attacks  may  recur  with  great  frequency  throughout  the  day. 

Treatment. — The  gums  should  be  carefully  examined  and,  if  swollen  and 
hot,  freely  lanced.  The  bowels  should  be  carefully  regulated  and,  as  these 
children  are  usually  delicate  or  rickety,  nourishing  diet  and  cod-liver  oil  should 
be  given.  By  far  the  most  satisfactory  method  of  treatment  is  the  cold  spong- 
ing. In  severe  cases,  two  or  three  times  a  day  the  child  should  be  placed  in 
a  warm  bath,  and  the  back  and  chest  thoroughly  sponged  for  a  minute  or  two 
with  cold  water.  It  may  be  employed  when  the  child  is  in  a  paroxysm,  though 
if  the  attack  is  severe  and  the  lividity  is  great  it  is  much  better  to  dash  cold 
water  into  the  face.  Sometimes  the  introduction  of  the  finger  far  back  into 
the  throat  relieves  the  spasm.  Small  doses  of  sodium  bromide,  chloral  hydrate 
or  antipyrine  are  sometimes  useful. 

Spasmodic  croup,  believed  to  be  a  functional  spasm  of  the  muscles  of  the 
larynx,  is  an  affection  seen  most  commonly  between  the  ages  of  two  and  five 
years.  According  to  Trousseau's  description,  the  child  goes  to  bed  well,  and 
about  midnight  or  in  the  early  morning  hours  aAvakes  with  oppressed  breath- 
ing, harsh,  croupy  cough,  and  perhaps  some  huskiness  of  voice.  The  oppres- 
sion and  distress  for  a  time  are  very  serious,  the  face  is  congested,  and  there 
are  signs  of  approaching  cyanosis.  The  attack  passes  off  abruptly,  the  child 
falls  asleep  and  awakes  the  next  morning  feeling  perfectly  well.  These  attacks 
may  be  repeated  for  several  nights  in  succession,  and  usually  cause  great  alarm 
to  the  parents.  There  are  instances  in  which  the  child  is  somewhat  hoarse 
throughout  the  day,  and  has  slight  catarrhal  symptoms  and  a  brazen,  croupy 
cough.  There  is  probably  slight  catarrhal  laryngitis  with  it.  These  cases  are 
not  infrequently  mistaken  for  lar3mgeal  diphtheria.  To  allay  the  spasm  a 
whiff  of  chloroform  may  be  administered,  which  will  in  a  few  moments  give 
relief,  or  the  child  may  be  placed  in  a  hot  bath.  A  prompt  emetic,  such  as 
wine  of  ipecac,  will  usually  relieve  the  spasm,  and  is  specially  indicated  if  the 
child  has  overloaded  the  stomach  through  the  clay. 


V.     TUBERCULOUS  LARYNGITIS 

Etiology. — Tubercles  may  arise  primarily  in  the  laryngeal  mucosa,  but  in 
the  great  majority  of  cases  the  affection  is  secondary  to  pulmonary  tubercu- 
losis, in  which  it  is  met  with  in  a  variable  proportion  of  from  18  to  30  per 
cent.  Laryngitis  may  occur  very  early  in  pulmonary  tuberculosis.  There 
may  be  well-marked  involvement  of  the  larynx  with  signs  of  very  limited 
trouble  at  one  apex. 

Morbid  Anatomy.— The  mucosa  is  at  first  swollen  and  presents  scattered 
tubercles,  which  seem  to  begin  in  the  neighborhood  of  the  Ijlood-vessels.  By 
their  fusion  small  tuberculous  masses  arise,  which  caseate  and  finally  ulcerate, 
leaving  shallow  irregular  losses  of  substance.     The  ulcers  are  usually  covered 


SYPHILITIC  LAEYNGITIS  609 

with  a  gra3'ish  exudation,  and  there  is  a  general  thickening  of  the  mucosa 
about  them,  which  is  particularly  marked  upon  the  arytenoids.  The  ulcers 
may  erode  the  true  cords  and  finally  destroy  them,  and  passing  deeply  may 
cause  perichondritis  with  necrosis  and  occasionally  exfoliation  of  the  cartilages. 
The  disease  may  involve  the  pharynx  and  fauces  and  the  mucous  membrane, 
covering  the  cricoid  cartilage  toward  the  oesophagus.  The  epiglottis  may  be 
entirely  destroyed.  There  are  rare  instances  in  which  cicatricial  changes  go 
on  to  such  a  degree  that  stenosis  of  the  larynx  is  induced. 

Symptoms. — The  first  indication  is  slight  huskiness  of  the  voice,  which 
finally  deepens  to  hoarseness,  and  in  advanced  stages  there  may  be  complete 
loss  of  voice.  There  is  something  very  suggestive  in  the  early  hoarseness  of 
tuberculous  laryngitis.  The  attention  may  be  directed  to  the  lungs  simply  by 
the  quality  of  the  voice. 

The  cough  is  in  part  due  to  involvement  of  the  larynx.  Early  in  the  disease 
it  is  not  very  trouljlesome,  but  when  the  ulceration  is  extensive  it  becomes 
husky  and  ineffectual.  Of  the  symptoms,  none  is  more  aggravating  than  the 
dysphagia,  which  is  met  with  particularly  when  the  epiglottis  is  involved,  and 
when  the  ulceration  has  extended  to  the  pharynx.  In  instances  in  which  the 
epiglottis  is  in  great  part  destroyed,  with  each  attempt  to  take  food  there  are 
distressing  paroxysms  of  cough,  and  even  of  suffocation. 

With  the  laryngoscope  there  is  seen  early  in  the  disease  a  pallor  of  the 
mucous  membrane,  which  also  looks  thickened  and  infiltrated,  particularly 
that  covering  the  arytenoid  cartilages.  The  ulcers  are  very  characteristic. 
They  are  broad  and  shallow,  with  gray  bases  and  ill-defined  outlines.  The 
vocal  cords  are  infiltrated  and  thickened,  and  ulceration  is  very  common. 

The  diagnosis  is  rarely  difficult,  as  it  is  usually  associated  with  well-marked 
pulmonary  disease.  In  case  of  doubt  the  secretion  from  the  base  of  an  ulcer 
should  be  examined  for  bacilli. 

Treatment. — The  voice  should  not  be  used.  In  the  early  stages  no  method 
of  treatment  is  more  effectual.  Applications  of  lactic  acid  in  glycerine  and 
the  electro-cautery  are  the  best  local  measures.  The  insufflation,  three  times 
a  day,  of  a  powder  of  iodoform  with  morphia,  after  cleansing  the  ulcers  with 
a  spray,  relieves  the  pain  in  a  majority  of  the  cases.  Cocaine  (4-per-cent.  so- 
lution) applied  with  the  atomizer  will  often  enable  the  patient  to  swallow  his 
food  comfortably.  There  are,  however,  distressing  cases  of  extensive  laryngeal 
and  pharyngeal  ulceration  in  which  even  cocaine  loses  its  good  effects.  With 
loss  of  the  glottis  the  difficulty  in  swalloAving  is  less  when  the  patient  hangs 
the  head  over  and  sucks  food  through  a  tube.  Heliotherapy  has  given  good 
results. 

VI.     SYPHILITIC  LARYNGITIS 

Syphilis  attacks  the  larynx  with  great  frequency.  It  may  be  congenital 
or  a  secondary  or  tertiary  manifestation  of  the  acquired  form. 

Symptoms. — In  secondary  syphilis  there  is  occasionally  erythema  of  the 
larynx,  which  may  go  on  to  definite  catarrh,  but  has  nothing  characteristic. 
The  process  may  proceed  to  the  formation  of  superficial  whitish  ulcers,  usually 
symmetrically  placed  on  the  cords  or  ventricular  bands.  Mucous  patches  and 
condylomata  are  rarely  seen.    The  symptoms  are  practically  those  of  slight  loss 


610  DISEASES  OF  THE  EESPIRATOEY  SYSTEM 

of    voice    with    laryngeal    irritation^     as    in    the    simple     catarrhal    form. 

The  tertiary  laryngeal  lesions  are  numerous  and  serious.  True  gummata, 
varying  in  size  from  the  head  of  a  pin  to  a  small  nut,  arise  in  the  submucous 
tissue,  most  commonly  at  the  base  of  the  epiglottis.  They  go  through  the 
characteristic  changes  and  may  break  down,  producing  extensive  and  deep 
ulceration,  or — and  this  is  more  characteristic  of  syphilitic  laryngitis — in  their 
healing  form  a  fibrous  tissue  which  shrinks  and  produces  stenosis.  The  ulcera- 
tion may  involve  the  cartilage,  inducing  necrosis  and  exfoliation,  and  even 
hsemorrhage  from  erosion  of  the  arteries.  CEdema  maylsuddenly  prove  fatal. 
The  cicatrices  which  follow  the  sclerosis  of  the  gummata  or  the  healing  of  the 
ulcers  produce  great  deformity.  The  epiglottis  may  be  tied  down  to  the 
pharyngeal  wall  or  to  the  epiglottic  folds,  or  even  to  the  tongue;  and  event- 
ually a  stenosis  results,  which  may  necessitate  tracheotomy. 

The  laryngeal  symptoms  of  congenital  syphilis  have  the  usual  course  of 
these  lesions  and  appear  either  early,  within  the  first  five  or  six  months,  or 
after  puberty;  most  commonly  in  the  former  period.  The  gummatous  infil- 
tration leads  to  ulceration,  most  commonly  of  the  epiglottis  and  in  the  ven- 
tricles, and  the  process  may  extend  deeply  and  involve  the  cartilage.  Cica- 
tricial contraction  may  also  occur. 

The  diagnosis  of  syphilis  of  the  larynx  is  rarely  difficult,  since  it  occurs 
most  commonly  in  connection  with  other  symptoms  of  the  disease. 

Treatment. — The  administration  of  anti-syphilitic  remedies  is  the  most 
important,  and  under  these  the  secondary  lesions  usually  subside  promptly. 
The  tertiary  laryngeal  manifestations  are  always  serious  and  difficult  to  treat. 
The  deep  ulceration  is  specially  hard  to  combat,  and  the  cicatrization  may 
necessitate  tracheotomy  or  gradual  dilatation. 


C.   DISEASES  OF  THE  BRONCHI 

I.     ACUTE  TRACHEOBRONCHITIS 

Acute  catarrhal  inflammation  of  the  trachea  and  larger  bronchi  is  a  very 
common  disease,  rarely  serious  in  healthy  adults,  but  very  fatal  in  the  old  and 
in  the  young,  owing  to  associated  pulmonary  complications.  It  is  bilateral  and 
affects  either  the  larger  and  medium  sized  tubes  or  the  smaller  bronchi,  in 
which  case  it  is  known  as  capillary  bronchitis.  We  shall  speak  only  of  the 
former,  as  the  latter  is  part  and  parcel  of  broncho-pneumonia. 

Etiology. — In  a  majority  of  cases  it  is  an  acute  infection  beginning  as  a 
simple  coryza  and  extending  to  the  air  passages.  It  is  very  contagious,  as 
noted  by  Benjamin  Franklin,  and  prevails  at  times  in  epidemic  form;  even 
apart  from  influenza  with  which  it  is  usually  associated.  It  prevails  in  the 
cold  changeable  months  of  the  year.  The  association  with  cold  is  indicated 
in  the  popular  expression  "cold  on  the  chest."  It  attacks  person  of  all  ages, 
but  more  particularly  the  young  and  the  old.  Some  individuals  have  a  special 
disposition  and  the  slightest  exposure  may  bring  on  an"  attack. 

Acute  bronchitis  is  associated  with  many  infections,  notably  measles  and 
tvphoid  fever.     It  is  present  also  in  asthma  and  whooping-cough.     The  sub- 


ACUTE  TRACHEO-BEO^^CHITIS  611 

jects  of  spinal  curvature  are  specially  liable  to  the  disease.  The  bronchitis  o!; 
nephritis,  gout,  and  heart-disease  is  usually  a  chronic  form.  Inhalation  of 
dust  is  a  contributing  factor  in  many  cases.  Irritating  gases  of  all  sorts  may 
cause  bronchitis.  Some  of  the  worst  types  ever  seen  have  followed  the  various 
gases  used  in  the  recent  war.  Ether  inhalation  is  only  too  often  followed  by 
bronchitis.  There  is  a  spirochastal  form  which  may  be  acute  or  chronic.  The 
spirochgetes  are  found  in  the  sputum. 

Bacteriology. — The  pneumococcus  is  responsible  for  many  cases  both  in 
young  and  old.  The  infection  may  follow  pneumonia,  and  bronchitis  may 
recur  winter  after  winter,  with  the  sputum  showing  an  almost  pure  culture 
of  the  pneumococcus.  These  germs  may  persist  in  the  sputum  for  many  years, 
with  an  almost  daily  cough,  aggravated  in  the  winter.  The  influenza  bacillus 
is  very  common  and  may  be  found  alone  or  with  streptococci.  The  Micrococcus 
catarrlialis  is  present  in  a  number  of  the  ordinary  cases,  very  often  in  combi- 
nation with  other  organisms.  Less  frequently  the  staphylococci,  colon  bacillus, 
and  typhoid  bacilli  have  been  found.  It  is  not  possible  to  separate  clinical 
groups  of  bronchitis  to  correspond  with  the  chief  infective  agent*  found  in  the 
sputum.  The  pneumococcus  carrier  appears  to  be  very  liable  to  recurring  at- 
tacks. The  influenza  bacillus  may  cause  more  prostration  and  there  is  a  greater 
tendency  to  chronicity  and  bronchiectasis. 

Morbid  Anatomy. — The  mucous  membrane  of  the  trachea  and  bronchi  is 
reddened,  congested,  and  covered  with  mucus  and  muco-pus,  which  may  be 
seen  oozing  from  the  smaller  bronchi,  some  of  which  are  dilated.  The  finer 
changes  in  the  mucosa  consist  in  desquamation  of  the  ciliated  epithelium, 
swelling  and  cedema  of  the  submucosa,  and  infiltration  of  the  tissue  with  leu- 
cocytes.    The  mucous  glands  are  much  swollen. 

Symptoms. — General. — The  symptoms  of  an  ordinary  "cold"  accompany 
the  onset;  the  coryza  extends  to  the  larynx,  producing  hoarseness,  and 
then  to  the  trachea  and  bronchi,  causing  cough.  A  chill  is  rare,  but  there  is 
a  sense  of  oppression,  with  heaviness  and  languor  and  pains  in  the  bones  and 
back.  In  mild  cases  there  is  scarcely  any  fever,  but  in  severer  forms  the  range 
is  from  101°  to  103°  F.  The  bronchial  symptoms  set  in  with  a  feeling  of 
tightness  and  rawness  beneath  the  sternum  and  a  sensation  of  oppression  in 
the  chest.  The  cough  is  rough  at  first,  and  often  of  a  ringing  character.  It 
comes  on  in  paroxysms  which  rack  and  distress  the  patient  extremely.  The 
pain  may  be  very  intense  beneath  the  sternum  and  along  the  attachments  of 
the  diaphragm.  At  first  the  cough  is  dry  and  the  expectoration  scanty  and 
viscid,  but  in  a  few  days  the  secretion  becomes  muco-purulent  and  abundant, 
and  finally  purulent.  AVith  the  loosening  of  the  cough  great  relief  is  ex- 
perienced. The  sputum  is  made  up  largely  of  pus-cells,  with  a  variable  num- 
ber of  the  large  round  alveolar  cells,  many  of  which  contain  carbon  grains, 
while  others  have  undergone  the  myelin  degeneration. 

Physical  Signs. — The  respiratory  movements  are  not  greatly  increased 
in  frequency  unless  the  fever  is  high.  There  are  instances,  however,  in  which 
the  breathing  is  rapid  and  when  the  smaller  tubes  are  involved  there  is  dysp- 
noea. On  palpation  the  bronchial  fremitus  may  often  be  felt.  On  auscultation 
in  the  early  stage,  piping  sibilant  rales  are  everywhere  to  be  heard.  They  are 
very  changeable,  and  appear  and  disappear  with  coughing.  With  the  relaxa- 
tion of  the  bronchial  membranes  and  the  greater  abundance  of  the  secretion. 


613  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

the  rales  change  and  become  mucous  and  bubbling  in  quality.  The  bronchi  of 
the  posterior  and  lower  parts  of  the  lungs  are  most  involved.  The  bases  of  the 
hmgs  should  be  examined  each  day,  particularly  in  children  and  the  aged. 

Course. — -This  depends  on  the  conditions  under  which  the  disease  arises. 
In  healthy  adults,  by  the  end  of  a  week  the  fever  subsides  and  the  cough 
loosens.  In  another  week  or  ten  days  convalescence  is  fully  established.  In 
young  children  the  chief  risk  is  in  the  extension  of  the  process  downward. 
In  measles  and  whooping-cough  the  ordinary  bronchial  catarrh  is  very  apt  tc 
descend  to  the  finer  tubes,  which  become  dilated  and  plugged  with  muco-pus, 
inducing  areas  of  collapse,  and  finally  broncho-pneumonia.  This  extension  is 
indicated  by  changes  in  the  physical  signs.  Usually  at  the  base  the  rales  are 
subcrepitant  and  numerous  and  there  may  be  areas  of  defective  resonance  and 
of  feeble  or  distant  tubular  breathing.  In  the  aged  and  debilitated  there  aro 
similar  dangers  if  the  process  extends  from  the  larger  to  the  smaller  tubes. 
In  old  age  the  broncliial  mucosa  is  less  capable  of  expelling  the  mucus,  whicli 
is  more  apt  to  sag  to  the  dependent  ^Darts  and  induce  dilatation  of  the  tubes 
with  extension  of  the  inflammation  to  the  contiguous  air-cells. 

Diagnosis. — This  is  rarely  difficult.  Although  the  mode  of  onset  may  be 
brusque  and  perhaps  simulate  pneumonia,  yet  the  absence  of  dulness  and  blow- 
ing breathing,  and  the  general  character  of  the  bronchial  inflammation,  render 
the  diagnosis  easy.  The  complication  of  broncho-pneumonia  is  indicated  by 
the  greater  severity  of  the  symptoms,  particularly  the  dyspnoea,  the  more 
paroxysmal  and  insistent  cough,  the  changed  color,  and  the  physical  signs. 

Treatment. — We  should  do  all  in  our  power  to  lessen  the  risks  of  con- 
tagion. The  patient  should  sleep  alone,  the  sputum  should  be  carefully  col- 
lected and  disinfected,  and,  when  possible,  there  should  be  an  abundance  of 
sunlight'  and  fresh  air.  In  mild  cases  household  measures  suffice.  The  hot 
foot-bath,  or  the  Avarm  bath,  a  drink  of  hot  lemonade,  and  a  mustard  plaster  on 
the  chest  will  often  give  relief.  In  severe  cases  the  patient  should  be  in  bed : 
liquids  should  be  taken  freely.  For  the  dry,  racking  cough,  the  symptom  most 
complained  of  by  the  patient,  Dover's  powder  is  a  useful  remedy.  It  is  a  popu- 
lar belief  that  quinine,  in  full  doses,  will  check  an  oncoming  cold  on  the  chest, 
but  this  is  doubtful.  It  is  a  common  custom  when  persons-  feel  the  approach 
of  a  cold  to  take  a  Turkish  bath,  and  though  the  tightness  and  oppression  may 
be  relieved  by  it,  there  is  in  a  majority  of  the  cases  great  risk.  Hydrotherapy 
is  most  useful  in  the  form  of  compresses  to  the  thorax  or  a  wet  pack.  Relief 
is  obtained  from  the  unpleasant  sense  of  rawness  by  keeping  the  air  of  the 
room  saturated  with  moisture,  and  in  this  dry  stage  the  old-fashioned  mixture 
of  the  wines  of  antimony  and  ipecacuanha  with  liquor  ammonii  acetatis  and 
nitrous  ether  is  useful.  If  the  pulse  is  very  rapid,  tincture  of  aconite  may  be 
given,  particularly  in  the  case  of  children.  The  use  of  inhalations,  such  as  the 
compound  tincture  of  benzoin,  often  gives  relief.  For  the  cough,  when  dry 
and  irritating,  opium  should  be  freely  used  in  the  form  of  Dover's  powder  or 
paregoric.  In  the  very  young  and  the  aged  care  must  be  exercised  in  the  use  of 
opium,  particularly  if  the  secretions  are  free ;  but  for  the  distressing,  irritative 
cough,  which  keeps  the  patient  awake,  opium  in  some  form  gives  the  only  relief. 
Heroin  is  often  helpful.  As  the  cough  loosens  and  the  expectoration  is  more 
abundant,  the  patient  becomes  more  comfortable.  In  this  stage  it  is  customary 
to  ply  him  with  expectorants  of  various  sorts.     Though  useful  occasionally, 


CHRONIC  BEONCHITIS  613 

they  should  not  be  given  as  a  routine.  Vaccine  treatment  is  very  uncertain, 
even  when  a  single  organism  has  been  recovered,  but  occasionally  prompt  and 
satisfactory  results  are  seen,  both  in  prophylaxis  and  treatment. 

In  the  acute  bronchitis  of  children,  if  the  amount  of  secretion  is  large  and 
difficult  to  expectorate,  or  if  there  is  dyspncea  and  the  color  begins  to  get 
dusky,  an  emetic  (a  tablespoonful  of  ipecac  wine)  should  be  given  at  once 
and  repeated  if  necessary. 


II.     CHRONIC  BRONCHITIS 

Etiology. — This  affection  may  follow  repeated  attacks  of  acute  bronchitis, 
but  it  is  most  commonly  met  with  in  chronic  lung  affections,  heart-disease, 
aneurism  of  the  aorta,  gout,  and  renal  disease.  It  is  most  frequent  in  the  aged 
and  in  males.  Climate  and  season  have  an  important  influence.  It  is  the 
cause  of  the  winter  cough  of  the  aged,  which  recurs  with  regularity  as  the 
weather  gets  cold  and  changeable.  Owing  to  the  more  uniform  heating  of  the 
houses,  it  is  much  less  conmion  in  Canada  and  in  the  United  States  than  in 
England. 

Morbid  Anatomy. — The  bronchial  mucosa  presents  a  variety  of  changes, 
depending  somewhat  upon  the  disease  with  which  chronic  bronchitis  is  as- 
sociated. In  some  cases  the  mucous  membrane  is  very  thin,  so  that  the  longi- 
tudinal bands  of  elastic  tissue  stand  out  prominently.  The  tubes  are  dilated, 
the  muscular  and  glandular  tissues  atrophied,  and  the  epithelium  is  in  great 
part  shed.  In  other  instances  the  mucosa  is  thickened  and  infiltrated.  There 
may  be  ulceration,  particularly  of  the  mucous  follicles.  Bronchial  dilatations 
are  not  uncommon  and  emphysema  is  a  constant  accompaniment. 

Symptoms. — In  the  form  met  with  in  old  men,  associated  with  emphysema, 
gout,  or  heart-disease,  the  chief  symptoms  are  as  follows :  Shortness  of  breath, 
which  may  not  be  noticeable  except  on  exertion.  The  patients  "puff  and  blow"' 
on  going  up  hill  or  up  a  flight  of  stairs.  This  is  due  not  so  much  to  the 
chronic  bronchitis  itself  as  to  associated  emphysema  or  even  to  cardiac  weak- 
ness. They  complain  of  no  pain.  The  cough  is  variable,  changing  with  the 
weather  and  with  the  season.  During  the  summer  they  may  remain  free,  but 
each  succeeding  winter  the  cough  comes  on  with  severity  and  persists.  There 
may  be  only  a  spell  in  the  morning,  or  the  chief  distress  is  at  night.  The 
sputum  in  chronic  bronchitis  is  very  variable.  In  cases  of  the  so-called  dry 
catarrh  there  is  no  expectoration.  Usually,  however,  it  is  abundant,  muco- 
purulent, or  distinctly  purulent  in  character.  There  are  instances  in  which 
the  patient  for  years  coughs  up  a  thin  fluid  sputum.  There  is  rarely  fever. 
The  general  health  may  be  good  and  the  disease  may  present  no  serious  fea- 
tures apart  from  the  liability  to  induce  emphysema  and  bronchiectasis.  In 
many  cases  it  is  an  incurable  affection.  Patients  improve  and  the  cough  dis- 
appears in  the  summer  time  only  to  return  during  the  winter  months. 

Physical  Signs. — The  chest  is  usually  distended,  the  movements  are 
limited,  and  the  condition  is  often  that  which  we  see  in  emphysema.  The 
percussion  note  is  clear  or  hyperresonant.  On  auscultation,  expiration  is  pro- 
longed and  wheezy,  and  rhonchi  of  various  sorts  are  heard — some  liigb-pitched 


614  DISEASES  OF  THE  EESPIEATOEY  SYSTEM 

and  piping,  others  deep-toned  and  snoring.     Crepitant  rales  are  common  at 
the  bases. 

In  children  apart  from  chronic  disease  of  the  lungs,  chronic  bronchitis  with 
cough,  chiefly  nocturnal,  is  a  common  accompaniment  of  enlarged  tonsils  and 
adenoids.  The  child,  a  mouth  breather,  with  the  characteristic  facies  and  chest, 
is  often  thin  and  underdeveloped,  with  an  evening  temperature  of  99.5°.  Dif- 
fuse rales  are  present  at  the  apices,  or,  more  commonly,  the  bases.  The  cough, 
the  fever  and  the  chest  condition  may  lead  to  the  diagnosis  of  tuberculosis. 

Clinical  Varieties. — The  description  just  given  is  of  the  ordinary  chronic, 
bronchitis  which  occurs  in  connection  with  emphysema  and  heart-disease  and 
in  many  elderly  men.  There  are  certain  forms  which  merit  special  descrip- 
tion: (a)  There  is  a  form  in  women  which  comes  on  between  the  ages  of 
twenty  and  thirty  and  may  continue  indefinitely  without  serious  impairment 
of  the  health.  In  some  cases  it  follows  influenza,  and  there  may  be  slight 
bronchiectasis. 

(b)  Beonchoerh(ea. — Excessive  bronchial  secretion  is  met  with  vmder 
several  conditions.  It  must  not  be  mistaken  for  the  profuse  expectoration  of 
bronchiectasis.  The  secretion  may  be  very  liquid  and  watery — hronchorrhcea 
serosa — and  in  extraordinary  amount.  More  commonly,  it  is  purulent  though 
thin,  and  with  greenish  or  yellow-green  masses.  It  may  be  thick  and  uniform. 
This  profuse  bronchial  secretion  is  usually  a  manifestation  of  chronic  bron- 
chitis, and  may  lead  to  dilatation  of  the  tubes  and  ultimately  to  fetid  bron- 
chitis. In  the  young  the  condition  may  persist  for  years  without  impairment 
of  health  and  without  apparently  damaging  the  lungs. 

(c)  PuTEiD  Beonchitis. — Fetid  expectoration  is  met  with  in  connection 
with  bronchiectasis,  gangrene,  abscess,  or  with  decomposition  of  secretions 
within  tuberculous  cavities  and  in  an  empyema  which  has  perforated  the  lung. 
There  are  instances  in  which,  apart  from  any  of  these  states,  the  expectora- 
tion has  a  fetid  character.  The  sputum  is  abundant,  usually  thin,  grayish- 
white  in  color,  and  separates  into  an  upper  fluid  layer  capped  with  frothy 
mucus  and  a  thick  sediment  in  which  may  sometimes  be  found  dirty  yellow 
masses  the  size  of  peas  or  beans — the  so-called  Dittrich's  plugs.  The  affection 
is  very  rare  apart  from  the  above-mentioned  conditions.  In  severe  cases  it 
leads  to  changes  in  the  bronchial  walls,  pneumonia,  and  often  to  abscess  or 
gangrene.     Metastatic  brain  abscess  has  followed  in  a  number  of  cases. 

(f/)  Dey  Cataeeh. — The  caiarrhe  sec  of  Laennec,  a  not  uncommon  form, 
is  characterized  by  paroxysms  of  coughing  of  great  intensity,  with  little  or  no 
expectoration.  It  is  usually  met  with  in  elderly  persons  with  emphysema, 
and  is  one  of  the  most  obstinate  of  all  varieties  of  bronchitis. 

The  bronchitis  with  an  unusual  number  of  eosinophiles  in  the  sputum  is 
really  a  form  of  asthma. 

Treatment. — Removal  to  a  southern  latitude  may  prevent  the  onset.  In 
England  the  milder  climate  of  Falmouth,  Torquay,  and  Bournemouth  is  suit- 
able for  those  who  cannot  go  elsewhere.  Egypt,  southern  France,  southern 
California,  and  Florida  furnish  winter  climates  in  which  the  subjects  of 
chronic  bronchitis  live  with  the  greatest  comfort.  With  care  chronic  bron- 
chitis may  prove  to  be  the  slight  ailment  that,  as  Oliver  Wendell  Holroes 
remarked,  promotes  longevity. 

The  first  endeavor  is  to  ascertain,  if  possible,  whether  there  are  constitu- 


BRONCHIECTASIS  615 

tional  or  local  affections  with  which  it  is  associated.  In  many  instances  the 
urine  is  found  to  be  highly  acid,  perhaps  slightly  albuminous,  and  the  arteries 
are  stiff.  In  the  form  associated  with  this  condition,  sometimes  called  gouty 
bronchitis,  the  attacks  seem  related  to  the  defective  renal  elimination,  and  to 
this  condition  the  treatment  should  be  first  directed.  In  other  instances  there 
are  heart-disease  and  emphysema.  In  the  form  occurring  in  the  old  prophy- 
laxis is  most  important.  There  is  no  doubt  that  with  prudence  even  in  the 
most  changeable  winter  weather  much  may  be  done  to  prevent  the  onset  of 
chronic  bronchitis.  Woollen  undergarments  should  be  used  and  especial  care 
should  be  taken  in  the  spring  months  not  to  change  them  for  lighter  ones 
before  the  warm  weather  is  established.  The  use  of  autogenous  vaccines  as  a 
preventive  is  sometimes  successful  and  is  worthy  of  trial.  A  careful  bacterio- 
logical study  of  the  sputum  should  be  made  and  the  causal  organism  or  or- 
ganisms identified. 

Cure  is  seldom  effected  by  medicinal  remedies.  There  are  instances  in 
which  iodide  of  potassium  acts  with  remarkable  benefit,  and  it  should  always 
be  given  a  trial  in  cases  of  paroxysmal  bronchitis  of  obscure  origin.  For  the 
morning  cough,  bicarbonate  of  sodium  (gr.  xv,  1  gm.),  chloride  of  sodium 
(gr.  V,  0.3  gm.),  spirit  of  chloroform  {vi\  v,  0.3  c.  c.)  in  anise  water  and 
taken  with  an  equal  amount  of  warm  water  will  be  found  useful  (Fowler). 
When  there  is  much  sense  of  tightness  and  fullness  of  the  chest,  the  portable 
Turkish  bath  may  be  tried.  When  the  secretion  is  excessive  atropine  is  some- 
times useful.  When  the  heart  is  feeble,  the  combination  of  digitalis  and 
strychnia  is  very  beneficial.  Turpentine,  the  old-fashioned  remedy  so  warmly 
recommended  by  the  Dublin  physicians,  has  in  many  quarters  fallen  unde- 
servedly into  disuse.  Preparations  of  tar,  creosote,  and  terebene  are  sometimes 
useful.  Of  other  balsamic  remedies,  the  compound  tincture  of  benzoin  and 
the  balsam  of  Peru  or  tolu  may  be  used.  Inhalations  of  eucalyptus  and  of  the 
spray  of  ipecacuanha  wine  are  often  useful.  If  fetor  be  present,  carbolic  acid 
in  the  form  of  spray  (1  per  cent,  solution)  will  lessen  the  odor,  or  thymol 
(1  to  1,000),  but  the  intratracheal  medication  is  the  most  efficient.  After  the 
larynx  is  ansesthetized  with  a  4  per  cent,  cocaine  solution,  inject  with  a  suit- 
able syringe  about  two  drams  (8  c.  c.)  of  olive  oil,  with  gr.  I/2  (0.032  gm.)  of 
iodoform,  and  gr.  %  (0.008  gm.)  of  morpbia  if  there  is  irritating  cough.  For 
urgent  dyspnoea  with  cyanosis,  venesection  gives  most  relief.  In  the  form  in 
children  associated  with  adenoids,  complete  removal,  followed  by  respiratory 
exercises,  is  indicated. 

III.     BRONCHIECTASIS 

Etiology. — Dilatation  follows  various  affections  of  the  bronchi  themselves, 
of  the  lungs,  and  of  the  pleura.  The  condition  may  be  unsuspected  clinically 
and  is  much  more  common  than  indicated  in  the  literature.  Either  the  cases 
are  now  more  often  recognized  or  the  disease  has  become  more  frequent.  It  oc- 
curs in  from  2  to  4  per  cent,  of  the  post  mortems  in  general  hospitals.  A 
majority  of  the  cases  occur  between  the  ages  of  20  and  40  years.  j\Iales  are 
more  often  affected.     Following  Fowler's  classification,  the  causes  are : 

A.  Intrinsic,  acting  directly  through  the  bronchi. 

1.  Bronchitis. — Chronic  cough  is  a  common  antecedent,  and  the  dilatation 


616  DISEASES  OF  THE  RESPIRATORY  SYSTEM 

is  a  mechanical  effect  of  constant  forced  expiration  acting  on  bronchial  walls 
weakened  by  disease.  There  are  three  groups:  (a)  the  remarkable  form  of 
generalized  dilatation  of  the  smaller  bronchi  seen  in  children  after  the  infec- 
tions, particularly  measles,  described  by  Sharkey,  Carr  and  others.  (&)  Fol- 
lowing an  infective  bronchitis,  pneumococcal  or  influenzal,  the  cough  per- 
sists and  gradually  the  signs  of  diffuse  bronchiectasis  appear  with  fetid  spu- 
tum. Such  cases  are  not  easy  to  differentiate  from,  some  indeed  are,  fetid 
bronchitis,  (c)  The  bronchitis  following  prolonged  exposure  to  dust,  as  in 
miners  and  potters,  is  very  often  associated  with  bronchiectasis. 

2.  Stenosis  of  a  bronchus,  either  by  compression  from  without  by  a  tumor 
or  aneurism,  a  growth  in  the  wall  as  in  syphilis,  or  a  foreign  body  within.  The 
last  is  an  imiDortant  cause.  As  a  result  of  the  narrowing  the  secretions  ac- 
cumulate, the  walls  are  weakened  and  dilatation  follows. 

B.  Extrinsic  Causes  associated  with  changes  in  the  lung  tissue  or  pleura. 
(a)  Fibrosis  of  the  lung  from  whatever  cause,  syphilis,  chronic  pneumonia, 
anthracosis,  and  chronic  fibroid  pleurisy,  (h)  Acute  broncho-pneumonia.  It 
is  rare  after  delayed  resolution  in  lobar  pneumonia  but  it  may  occur  with 
broncho-pneumonia.  In  a  patient  dead  six  weeks  from  the  onset  there  were 
areas  of  broncho-pneumonia,  dilatation  of  the  bronchi  of  both  lower  lobes, 
several  spots  of  gangrene,  and  secondary  abscess  of  the  brain,  (c)  Compres- 
sion of  the  lung.  The  tubes  are  rarely  found  dilated  in  the  extreme  com- 
pressed form  of  chronic  empyema.  Local  compression  by  tumor  or  aneurism 
may  be  a  cause  without  stenosis  of  the  bronchus.  The  atelectatic  bronchiectasis 
occurs  in  an  area  of  lung  which  has  not  developed  or  not  expanded. after  birth. 
The  bronchial  walls  show  an  overgrowth  of  cartilage,  (d)  Tuberculosis.  It 
is  rare  to  dissect  a  lung  in  the  chronic  ulcerative  form  without  finding  some- 
where a  dilated  bronchus.  The  more  chronic  the  disease  and  the  greater  the 
fibrosis  the  more  widespread  the  dilatation,  and  most  often  in  the  upper  lobes. 

C.  CoNGEKiTAL. — This  rare  form,  described  by  Grawitz,  occurs  as  a  univer- 
sal saccidar  distention  of  the  bronchi,  usually  of  one  lung;  or  it  may  be  con- 
fined to  the  bronchi  of  the  third  and  fourth  order  in  local  areas  of  atelectasis. 

Morbid  Anatomy. — Two  chief  forms  are  recognized — the  cylindrical  and 
the  saccular — which  may  exist  together  in  the  same  lung.  The  condition  may 
be  general  or  partial.  Universal  bronchiectasis  is  usually  unilateral,  occurs 
in  rare  congenital  cases  and  is  occasionally  seen  as  a  sequence  of  interstitial 
pneumonia.  The  entire  bronchial  tree  is  represented  by  a  series  of  sacculi 
opening  one  into  the  other.  The  walls  are  smooth  and  possibly  without  ul- 
ceration or  erosion  except  in  the  dependent  parts.  The  lining  membrane  of 
the  sacculi  is  usually  smooth  and  glistening.  The  dilatations  may  form  large 
cysts  immediately  beneath  the  pleura.  Intervening  between  the  sacculi  is  a 
dense  cirrhotic  lung  tissue.  The  partial  dilatations — the  saccular  and  cylin- 
drical— are  common  in  chronic  tuberculosis,  particularly  at  the  apex,  in  chronic 
pleurisy  at  the  base,  and  in  emphysema.  Here  the  dilatation  is  more  com- 
monly cylindrical,  sometimes  fusiforn;.  The  bronchial  mucous  membrane  is 
much  involved  and  sometimes  there  is  a  narrowing  of  the  lumen.  Occasionally 
one  meets  with  a  single  saccular  bronchiectasis  in  connection  with  chronic 
bronchitis  or  emphysema.  Some  of  these  look  like  simple  cysts,  with  smooth 
walls,  without  fluid  contents.  Bronchiolectasis  as  an  acute  condition  may  fol- 
low the  infectious  diseases. 


BRONCHIECTASIS  617 

Symptoms. — There  are  acute  cases,  usually  the  bronchiolectasis  of  chil- 
dren; but  a  case  of  the  broncho-pneumonic  form  died  in  six  weeks  from  the 
onset.  In  the  limited  dilatations  of  tuberculosis,  emphysema,  and  chronic 
bronchitis  the  symptoms  are  in  great  part  those  of  the  original  disease,  and 
often  the  condition  is  not  suspected  during  life. 

In  extensive  saccular  bronchiectasis  the  characters  of  the  cough  and  expec- 
toration are  distinctive.  The  patient  will  pass  the  greater  part  of  the  day 
without  any  cough  and  then  in  a  severe  paroxysm  will  bring  up  a  large  quan- 
tity of  sputum.  Of  23  cases  the  amount  for  twenty-four  hours  was  in  2  less 
than  100  c.  c,  in  11  from  100-300  c.  c,  in  2  almost  500  c.  c,  in  7  over  600 
c.  c.  In  one  case  with  over  one  litre  per  day  the  cavities  found  were  very 
small.  Sometimes  change  of  position  will  bring  on  a  violent  attack,  probably 
due  to  the  fact  that  some  of  the  secretion  flows  from  the  dilatation  to  a  normal 
tube.  The  daily  spell  of  coughing  is  usually  in  the  morning.  The  expectora- 
tion is  in  many  instances  very  characteristic,  grayish  or  grayish  brown  in 
color,  fluid,  purulent,  with  a  peculiar  acid,  sometimes  fetid,  odor.  Placed  in  a 
conical  glass,  it  separates  into  a  thick  granular  layer  below  and  a  thin  mucoid 
intervening  layer  above,  which  is  capped  by  a  brownish  froth.  Microscopically 
it  consists  of  pus-corpuscles,  often  large  crystals  of  fatty  acids,  which  are  some- 
times in  enormous  numbers  over  the  field  and  arranged  in  bunches.  Haema- 
toidin  crystals  are  sometimes  present.  Elastic  fibres  are  seldom  found  except 
when  there  is  ulceration  of  the  bronchial  walls.  Tubercle  bacilli  are  not  pres- 
ent. In  some  cases  the  expectoration  is  very  fetid.  Nummular  expectoration, 
such  as  comes  from  tuberculous  cavities,  is  not  common.  Haemorrhage  oc- 
curred in  li  out  of  35  cases  analyzed  by  Fowler,  in  17  of  our  2-i  cases,  slight 
in  8,  and  extreme  in  3.  Arthritis  may  occur,  and  it  is  one  of  the  conditions 
with  which  the  pulmonary  osteo-arthropathy  is  commonly  associated.  Club- 
bing of  the  fingers  and  toes  is  common.  There  is  a  remarkable  association  of 
bronchiectasis  with  abscess  of  the  brain.  Among  13,700  autopsies  at  the  Lon- 
don Hospital  and  the  Brompton  Hospital  there  were  19  instances  of  cerebral 
abscess  Math  pulmonary  disease,  usually  bronchiectasis  (Schorstein). 

Physical  Signs. — The  associated  conditions  are  so  various  that  the  signs 
vary  greatly.  In  deep-seated  eases  there  may  be  no  signs.  The  co-existence 
of  tuberculosis,  chronic  bronchitis,  emphysema  or  fibrosis  gives  a  complicated 
picture.  The  signs  on  inspection,  palpation  and  percussion  are  influenced  by 
these  factors.  Dilatations  near  the  surface  yield  a  tympanitic  note.  In  sac- 
cular bronchiectasis  the  signs  vary  as  the  cavity  is  empty  or  filled  with  secre- 
tion. On  auscultation  the  breath  sounds  depend  on  associated  changes  unless 
the  bronchiectasis  is  superficial,  when  cavernous  breathing  may  be  heard. 
Many  varieties  of  rales  are  heard.  In  diffuse  early  cases  they  may  have  a 
very  intense  crackling  quality  which  is  sometimes  suggestive  of  dilatation. 

Diagnosis. — In  the  extensive  sacculated  forms,  unilateral  and  associated 
with  interstitial  pneumonia  or  chronic  pleurisy,  the  diagnosis  is  easy.  There 
is  contraction  of  the  side,  which  in  some  instances  is  not  at  all  extreme.  The 
cavernous  signs  may  be  chiefly  at  the  base  and  may  vary  according  to  the  con- 
dition of  the  cavity,  whether  full  or  empty.  There  may  be  the  most  exquisite 
amphoric  phenomena  and  loud  resonant  rales.  The  condition  persists  for 
years  and  is  not  inconsistent  with  a  tolerably  active  life.  The  patients  fre- 
quently show  signs  of  marked  embarrassment  of  tlie  circulation  with  dyspnoea 


618  DISEASES  OF  THE  EESPIRATOEY  SYSTEM 

and  cyanosis  on  exertion.  A  condition  very  difficult  to  distinguish  from 
bronchiectasis  is  a  limited  pleural  cavity  communicating  with  a  bronchus. 
The  X-ray  examination  is  of  value  in  localizing  the  area  of  the  lung  in 
which  the  tubes  are  chiefly  involved.  The  intensity  of  the  shadow  in  plates 
taken  before  and  after  evacuation  may  be  very  suggestive. 

The  disease  is  often  regarded  as  tuberculosis,  which  may  co-exist,  but  proper 
sputum  examination  should  prevent  this.  The  acuteness  of  abscess  of  the 
lung  and  the  character  of  the  sputum  are  usually  distinctive.  From  chronic 
bronchitis  the  diagnosis  is  difficult  but  the  sputum  and  clubbing  of  the  fin- 
gers are  aids. 

Treatment. — Medical  treatment  is  not  satisfactory,  since  it  is  impossible 
to  heal  the  cavities.  Postural  treatment  is  important,  and  the  most  favorable 
position  should  be  studied  for  each  patient.  Sleeping  with  the  head  low  fa- 
vors '''drainage."  The  reduction  of  the  fluid  intake  to  a  minimum  is  sometimes 
useful.  Intratracheal  injections  have  been  recommended ;  with  a  suitable 
syringe  a  dram  may  be  injected  twice  a  day  of  the  following  solution :  Menthol 
10  parts,  guaiacol  2  parts,  olive  oil  88  parts.  Or  better  still  when  the  odor  is 
very  offensive  iodoform  in  olive  oil.  The  creosote  vapor  bath  may  be  given 
in  a  small  room.  The  patient's  eyes  must  be  protected  with  well-fltting  goggles, 
and  the  nostrils  stuffed  with  cotton-wool.  Twenty  to  thirty  drops  of  creosote 
are  poured  upon  water  in  a  saucer  and  vaporized  by  placing  the  saucer  over  a 
spirit  lamp.  At  first  the  vapor  is  very  irritating  and  disagreeable,  but  the  pa- 
tient gets  used  to  it.  This  should  be  done  at  first  every  other  day  for  fifteen 
minutes,  then  gradually  increased  to  an  hour  daily.  This  should  be  continued 
for  three  months  and  is  a  most  satisfactory  method. 

Surgical  treatment. — Collapse  of  the  affected  lung  by  nitrogen  displace- 
ment has  been  tried.  Drainage  of  the  cavities  in  the  lower  lobe  and  subperios- 
teal resection  of  three  or  four  ribs  with  the  application  of  a  compression  pad 
have  given  good  results.  The  bronchiectatic  lobe  has  been  resected.  Sauer- 
bruch  in  seven  cases  ligated  the  branch  of  the  pulmonary  artery  going  to  the 
affected  lobe,  which  is  followed  by  cicatrization.  Morriston  Davies  advises 
section  of  the  phrenic  nerves  in  the  neck,  causing  paralysis  of  the  diaphragm, 
when  bronchiectasis  begins  to  develop  in  interstitial  pneumonia. 


IV.  HAY  FEVER  AND  BRONCHIAL  ASTHMA 

Definition. — A  reaction  of  an  anaphylactic  nature  in  sensitized  persons,  in 
others  possibly  a  refiex  neurosis,  characterized  by  swelling  of  the  nasal  or 
respiratory  mucous  membrane,  increased  secretion,  and,  in  asthma,  spasm  of 
the  bronchial  muscles  with  dyspnoea,  chiefiy  expiratory.  There  are  no  essen- 
tial differences  between  hay  fever  and  asthma ;  in  the  one  the  nasal  portion  of 
the  respiratory  tract  is  affected,  in  the  other  the  bronchial,  in  many  instances 
both. 

Etiology. — The  word  "Asthma,"  which  means  a  panting,  was  used  by  the 
older  writers  as  we  use  the  term  dyspnoea.  We  still  speak  of  "cardiac  and 
renal  asthma,"  but  the  term  should  be  restricted  to  the  independent  disease, 
first  separated  in  the  17th  century  by  Van  Helmont  and  by  Willis.  The  latter 
speaks  of  the  "tyranny  and  cruelty"  of  the  disease,  and  suspected  the  cause  to 


HAY  FEYEE  AND  BEONCHIAL  ASTHMA  619 

lurk  in  the  "Muscular  coats  of  the  pneumonic  vessels,"  meaning  the  bronchi. 
Floyer  (1698),  Avho  gives  a  good  account  of  his  own  case  in  his  "Treatise  of 
the  Asthma/'  held  the  same  views.  With  the  introduction  of  accurate  methods 
of  diagnosis  by  Laennec  the  independent  disease  was  separated  from  a  host 
of  maladies  with  dyspnoea  as  a  prominent  symptom. 

Our  modern  conception  of  hay  fever  dates  from  the  description  by  Bostock 
in  1819  and  1828  of  the  summar  catarrh — Catarrhus  estivus.  He  recognized 
the  periodicity,  the  disturbance  of  respiration  as  sometimes  the  only  feature, 
and  the  association  with  the  "effluvium  from  new  hay."  Elliotson  (1831) 
first  suggested  that  it  was  caused  by  the  "effluvia  of  the  grass  and  probably  the 
pollen."  Morrill  Wyman  (1854)  separated  the  spring  and  autumn  forms  of 
hay  fever.  Blackley  (1873)  demonstrated  that  "pollen  possesses  the  power  of 
producing  hay  fever  both  in  its  asthmatic  and  catarrhal  forms,"  and,  as  early 
ag  1865,  showed  that  skin  reactions  were  present  in  sensitive  persons.  Then 
came  many  observations  on  the  relation  of  nasal  conditions  to  asthma  and  hay 
fever.  Dunbar  applied  modern  methods  to  the  study  of  the  pollen  problem, 
separated  the  toxins,  studied  their  reactions,  cutaneous  and  serological,  and 
introduced  a  specific  therapy. 

Finally  Meltzer  and  his  pupils  Auer  and  Lewis  (1910)  brought  the  disease 
into  the  category  of  anaphylactic  phenomena.  Following  an  injection  of  nor- 
mal horse  serum  a  guinea-pig  has  no  reaction,  but  ten  days  later  if  a  second 
dose  be  given  the  animal  will  be  found  to  have  been  "sensitized"  by  the  first 
dose,  and,  in  consequence,  has  alarming  symptoms — sneezing,  dyspnoea  at  first, 
and  the  more  laboured  breathing  and  choreic  convulsions.  Anatomically  the 
lungs  are  voluminous,  do  not  collapse,  and  the  bronchi  show  marked  conges- 
tion of  the  mucosa.  An  asthmatic  subject,  sensitive,  say,  to  eggs,  if  injected 
with  a  small  amount  of  egg  albumen  will  have  an  attack  with  difficulty  in 
expiring,  not  inspiring.  The  lungs  become  distended  and,  as  seen  with  the 
fluoroscope,  the  diaphragm  does  not  move.  The  alveolar  air  has  a  low  carbon 
dioxide  content.  An  injection  of  epinephrin  relieves  the  condition;  just  as,  if 
given  in  time,  it  will  remove  the  anaphylactic  symptoms  in  the  guinea-pig.  The 
only  possible  explanation  of  the  pulmonary  features  is  that  the  air  is  imprisoned 
in  the  alveoli  by  the  spasmodic  contraction  of  the  bronchial  muscles;  there  is 
marked  over-distention  of  the  lungs,  great  difficulty  in  inspiration  and  still 
greater  difficulty  in  expiration.  The  prompt  relief  by  atropine  and  epinephrhi 
supports  this  view  of  bronchial  spasm.  With  it  there  is  in  both  forms  marked 
swelling  with  increased  secretion  from  the  mucous  membrane.  The  subjects 
of  hay  fever  and  of  asthma  are  sensitized  to  various  "asthmogenic"  agents, 
usually  proteins,  which  may  be  inhaled,  injected,  or  autogenous,  the  result  of 
bacterial  or  other  actiAdty.  The  effect  of  pollen  on  the  mucous  membrane  is 
direct  by  irritation  and  indirect  by  absorption  of  the  protein.  Sensitive  in- 
dividuals give  skin  reactions  to  the  agents  causing  the  asthma.  In  children 
sensitive  to  eggs,  even  the  rubbing  of  egg  albumen  on  the  thoroughly  cleansed 
skin  may  cause  an  urticaria  (Talbot).  Longcope  and  Eackemann  demonstrated 
the  presence  of  antibodies  after  artificial  sensitization. 

Walker's  study  of  400  cases  of  asthma  gives  the  following  results: — 191 
patients  were  sensitive  to  some  protein  by  skin  tests,  animal  hair  protein  in 
78,  food  proteins  in  68,  pollen  protein  in  92,  and  bacterial  proteins  in  33. 
Many  of  the  patients  were  sensitive  to  more  than  one  protein  (multiple  sensi- 


620  DISEASES  OF  THE  EESPIRATOEY  SYSTEM 

tization).  The  same  patient  may  be  sensitive  to  plant,  animal  and  bacterial 
proteins.  Practically  the  majority  of  patients  with  bronchial  asthma  are  sensi- 
tive to  pollens,  horse  dandruff,  staphylococci,  cat  hair  and  a  few  common  foods 
as  wheat,  eggs  and  meat.  In  the  nonsensitive  group  the  disease  appears  later, 
after  the  fortieth  year,  and  many  of  them  have  chronic  bronchitis  and  cardio- 
renal  changes.  "As  the  age  of  onset  increases  the  frequency  of  sensitization 
decreases." 

We  may  group  the  exciting  agents  into : — 

1.  Inspieatoey. — Vegetable,  the  pollens  of  various  grasses  and  flowers. 
Animal,  the  emanations  from  horses,  cats,  birds  and  other  substance  contained 
in  dust. 

2.  Ingested. — A  host  of  vegetable  and  animal  proteins,  various  grasses, 
wheat,  oats ;  leguminous  foods,  peas,  beans  and  lentils ;  fruits  and  nuts.  Many 
animal  substances,  meat,  milk  and  eggs,  oysters,  lobsters  and  crabs. 

3.  Metabolic. — Abnormal  products  of  primary  digestion  in  stomach  or 
bowels;  faulty  transmutation  in  the  liver;  lack  of  quantity  or  quality  in  the 
internal  secretions;  imperfect  assimilation  in  the  tissues  is  probably  respon- 
sible for  many  of  the  obscure  cases  which  do  not  react  to  the  ordinary  animal 
and  vegetable  products, 

4.  Bacteeial. — The  studies  of  Goodale  and  others  have  shown  that  many 
asthmatic  and  hay  fever  patients  are  sensitized  to  the  staphylococcus  and  vari- 
ous organisms,  reacting  to  one  or  another.  The  exciting  cause  may  exist  in 
the  air  passages  themselves.  It  is  difficult  in  any  other  way  to  explain  severe 
asthma  following  whooping  cough  in  a  woman  who  never  had  attacks  pre- 
viously. 

The  causes  under  3  and  4  demand  careful  study,  as  in  Walkers  list  45  per 
cent,  of  150  patients  did  not  react  to  the  ordinary  animal  and  vegetable  pro- 
teins. 

The  disease  may  "run"  in  families.  Transmission  of  hypersensitiveness  to 
certain  substances  has  long  been  recognized,  and  the  females  of  animals  sensi- 
tized to  a  foreign  protein,  such  as  horse  serum,  transmit  the  susceptibility  to 
this  protein  to  their  offspring.  An  extraordinary  variety  of  circumstances  may 
induce  the  paroxysms,  among  which  local  conditions  of  atmosphere  are  most 
important.  A  person  may  be  free  in  the  city  and  invariably  suffer  from  an 
attack  in  the  country  or  in  one  place.  In  many  of  these  cases  the  individual 
becomes  exposed  to  the  special  agent  to  which  he  is  sensitized.  Sleeping  on 
a  horsehair  mattress  or  on  a  feather  pillow  may  cause  attacks  in  persons  sus- 
ceptible to  these  substances.  There  are  children  naturally  sensitized  to  extra- 
ordinarily minute  quantities  of  egg  or  meat. 

The  subjects  of  asthma,  particularly  of  horse  asthma,  are  liable  to  serious 
attacks  of  serum  sickness  after  the  administration  of  antitoxin.  The  symp- 
toms are  identical  with  anaphylactic  shock  in  animals.  The  site  of  the  injec- 
tion becomes  red  and  swollen,  there  is  irritation  of  the  skin,  often  with  urticaria, 
sudden  dyspnoea,  cyanosis,  great  cardiac  weakness,  and  death  may  follow  within 
a  few  minutes.  Of  28  cases  collected  by  Gillette  (quoted  by  Lord)  death  fol- 
lowed in  fifteen.  Inquiry  should  always  be  made  as  to  previous  asthma  before 
giving  either  prophylactic  or  curative  doses  of  antitoxin. 

Asthma  as  a  Reflex  Neurosis. — Prior  to  the  recent  studies  the  disease  was 
regarded  as  following  irritation  in  various  localities,  nose,  stomach  and  bowels, 


HAY  FEVER  AXD  BEOXCHTAL  ASTmiA  621 

etc.,  and  the  subjects  were  regarded  as  neurotic.  Emotional  disturbances  as 
fright,  apprehension,  the  smelling  of  an  artificial  rose  in  a  person  the  subject 
of  ''rose''  cold,  may  cause  attacks,  and  it  is  difficult  to  bring  such  cases  into  the 
anaphjdactic  category.  The  prompt  and  permanent  relief  which  sometimes 
follows  removal  of  irritation,  e.  g.  a  polypus  of  the  nose,  supports  the  view  that 
this  factor  may  prevail  in  the  group  of  asthmatics  not  sensitive  to  animal  or 
vegetable  proteins.  There  is  a  morbid  sensitiveness  of  the  nasal  mucous  mem- 
brane in  many  patients  with  hay  fever. 

Pathology. — We  have  no  knowledge  of  the  morbid  anatomy  of  true  asthma. 
In  long-standing  cases  the  lesions  are  those  of  chronic  bronchitis  and 
emphysema. 

Symptoms. — Bostock's  account  of  his  attacks  of  hay  fever  (1819)  may  be 
abstracted.  "A  sensation  of  heat  and  fulness  is  experienced  in  the  eyes  with 
redness  and  a  discharge  of  tears.  There  is  much  smarting  and  itching,  the 
eyes  become  inflamed  and  discharge  copiously.  This  state  of  the  eyes  recurs  in 
paroxysms  in  June  and  July.  There  follow  fulness  in  the  head,  particularly 
the  fore  part,  irritation  of  the  nose  causing  sneezing  which  may  occur  in  fits 
of  extreme  violence.  There  is  tightness  in  the  chest,  with  difficulty  in  hreath- 
ing  and  a  feeling  of  want  of  air.  The  voice  may  be  husky  and  to  these  symp- 
toms may  be  added  languor,  loss  of  appetite,  incapacity  for  exertion,  restless 
nights  often  with  profuse  perspiration."  In  his  second  paper  (1828)  Bostock 
recognized  that  the  eyes,  the  nose,  the  fauces  and  the  lungs  may  be  involved  in 
varying  degrees. 

The  asthma  fit  is  thus  described  by  Floyer  (1698).  "At  first  waking  about 
one  or  two  o'clock  in  the  night  the  fit  begins,  the  breath  is  very  slow,  but  after 
a  little  time  more  strait,  the  diaphragm  seems  stiff  and  tied  and  is  with  dif- 
ficulty moved  downwards,  but  for  enlarging  the  breast  in  inspiration  the  in- 
tercostal muscles,  which  serve  for  the  raising  of  the  ribs  and  the  scapular 
muscles  all  join  their  force,  and  strain  themselves  for  the  enlarging  of  the 
cavity  of  the  breast.  He  has  to  rise  out  of  his  bed  and  sit  erect  that  the  weight 
of  the  viscera  may  pull  down  the  diaphragm.  The  muscles  which  serve  for 
expiration  cannot  easily  perform  the  contraction  of  the  thorax,  being  hindered 
by  tli^  stifl'ness  and  inflation  of  the  membranes.  The  expiration  is  slow,  lei- 
surely and  wheezing,  and  the  muscular  fibres  of  the  bronchi  and  the  vesiculffi  of 
the  lungs  are  contracted,  and  that  produces  the  wheezing  noise  which  is  best 
heard  in  expiration,"    There  is  not  much  to  add  to  this  description. 

The  attack  may  last  from  a  few  minutes  to  several  hours.  When  severe 
there  are  signs  of  defective  aeration,  cyanosis,  with  sweating,  feeble  pulse  and 
cold  extremities.  Coughing  is  difficult,  very  tight  and  dry  at  first,  and  then 
more  violent,  with  the  expectoration  of  the  distinctive  sputum. 

Physical  Signs. — The  chest  looks  full  and  fixed,  and  in  spite  of  the  active 
muscular  efforts  there  is  very  little  expansion.  The  breathing  is  costal,  the 
diaphragm  is  low  and  the  movement  much  restricted.  Inspiration  is  short, 
expiration  much  prolonged,  labored  and  accompanied  by  wheezing  rales. 
Percussion  may  be  hyperresonant — Biermer's  "box  tone" — the  cardiac  flatness 
is  obliterated,  and  the  liver  dulness  low.  On  auscultation  inspiration  is  feeble, 
expiration  prolonged  and  in  both  the  normal  cliaracters  are  obscured  by  sibi- 
lant and  sonorous  rales.  Towards  the  end  the  rales  become  moister.  It  is 
•  remarkable  Avith  what  rapidity  they  may  disappear.     The  sputum  is  distinc- 


622  DISEASES  OF  THE  EESPIEATOEY  SYSTEM 

tive.  Early  in  the  attack  it  is  brought  up  with  difficulty  and  consists  of  small 
round  masses,  gelatinous,  like  sago  balls  in  a  thin  mucus,  the  so-called  "perles" 
of  Laennec.  Spread  on  glass  with  a  black  background,  they  can  be  unfolded 
and  are  seen  to  be  moulds  of  the  smaller  tubes,  many  of  which  have  a  twisted 
appearance.  A  smaller  number  show  the  spirals  described  by  Curschmann,  of 
which  there  are  two  forms,  one  a  simple  loose  twist  in  which  are  entangled 
leucocytes  and  larger  cells  with  coarse  granulations — eosinophiles.  The  other, 
a  form  of  spiral  probably  never  met  with  except  in  true  asthma,  is  a  tightly 
coiled  skein  of  mucus  in  which  cells  are  entangled  and  through  the  centre  of 
which  runs  a  thread  of  clear  translucent  mucin.  Curschmann's  spirals  are 
found  in  nearly  all  cases  when  looked  for  early  and  in  the  right  way.  In  addi- 
tion to  the  spirals  and  the  eosinophiles,  a  third  element  is  often  present,  the 
Charcot-Leyden  crystals,  hexagonal,  elongated  pointed  structures.  They  are 
found  more  often  when  the  sputum  changes  to  muco-purulent  or  if  it  is  let 
stand  for  twenty-four  hours.  The  remarkable  character  of  the  sputum  in 
bronchial  asthma  points  to  a  process  which  differs  from  the  ordinary  forms  of 
bronchitis.  The  small  size  of  many  of  the  casts  indicates  involvement  of  the 
smaller  tubes  and  Curschmann  suggested  the  name  hroncJiiolitis  exudativa. 
There  is  no  satisfactory  explanation  of  the  spiral  form,  or  the  central  thread, 
unless  it  be  that  the  former  is  due  to  a  rotary  action  of  the  ciliated  epithelium, 
and  the  latter  to  a  compression  of  mucous  filaments  by  the  spasm  of  the 
bronchial  muscles  in  the  smaller  tubes. 

The  eosinophiles  in  the  blood  are  much  increased,  up  to  53  per  cent,  in  one 
of  our  cases,  and  the  increase  may  persist  in  moderate  grade  in  the  intervals 
between  attacks. 

The  course  is  variable.  Hay  fever  usually  recurs  year  by  year,  in  spring 
or  autumn,  varying  with  the  pollen  to  which  the  individual  is  sensitive.  Forms 
of  asthma  depending  on  protein  intoxication  are  more  variable.  A  child  may 
recover  completely  after  years  of  severe  attacks.  The  milder  forms  may  per- 
sist through  long  life,  and  be,  as  Oliver  Wendell  Holmes  said  of  his  asthma, 
"the  slight  ailment  that  promotes  longevity."  In  long  standing  cases  emphy- 
sema and  chronic  bronchitis  complicate  the  disease,  and  later  is  added  hyper- 
trophy of  the  heart.  Even  with  these  complications,  in  a  suitable  climate  or 
with  great  care,  the  patients  may  survive  well  into  the  seventh  decade. 

Diagnosis. — There  is  not  any  difficulty  in  recognizing  hay  fever  but  it  is 
necessary  to  determine  the  particular  pollen  which  is  responsible  if  specific 
treatment  is  to  be  given.  This  is  done  by  trying  the  skin  reaction  with  ex- 
tracts of  various  pollens.  A  positive  result  is  shown  by  a  local  reaction.  The 
picture  of  asthma  is  distinctive  but  to  determine  the  particular  protein  (if  any) 
responsible  requires  careful  tests. 

Treatment. — For  hay  fever  change  of  locality  during  the  pollen  season 
may  give  freedom.  Local  treatment  of  the  nose,  if  required,  sometimes  gives 
relief.  The  use  of  a  cocaine  spray  is  helpful,  but  is  a  dangerous  remedy. 
Epinephrin  (1-1000  solution)  may  be  applied.  Remedies  which  sometime^ 
are  of  benefit  are  sodium  bicarbonate  internally  in  full  dosage  and  locally  as  a 
spray,  and  calcium  lactate  which  should  be  taken  for  a  considerable  period  in 
doses  of  gr.  xv  (1  gm.)  three  times  a  day.  Active  immunization  by  pollen 
extracts  is  sometimes  effective  as  a  prophylactic.  The  particular  pollen  to 
which  the  patient  is  sensitive  having  been  determined,  an  alcoholic  solution 


HAY  FEVER  AND  BRONCHIAL  ASTHMA  623 

of  it  is  used,  the  first  dose  having  a  dilution  insufficient  to  produce  a  skin  re- 
action. The  strength  of  the  injections  is  increased  very  gradually;  they  are 
repeated  every  four  or  five  days  until  ten  to  twenty  have  been  given.  This 
should  be  done  if  possible  before  the  usual  time  for  the  attacks.  It  is  wise  to 
repeat  the  treatment  at  least  for  two  successive  years.  The  prevention  of  re- 
currence offers  many  difficulties,  and  each  case  should  be  studied  in  the  light  of 
recent  investigations.  Change  of  climate  relieves  many  hay  fever  patients 
and,  when  the  offending  protein  is  found,  immunization  is  practicable  though 
unfortunately  the  duration  is  short.  In  the  non-sensitive  forms  a  study  of  the 
bronchial  flora  may  show  some  dominant  organism  from  which  a  vaccine  may 
be  prepared. 

Careful  study  of  each  case  of  asthma  by  modern  methods  is  an  essential 
preliminary.  The  tests  are  not  very  difficult,  but  the  intelligent  cooperation 
of  the  patient  or  of  the  parents  o'f  a  child  is  essential.  The  reactions  should 
first  be  studied.  The  nonsensitive  group  comprise  as  a  rule  older  patients  in 
whom  the  disease  has  come  on  late  and  who  are  subject  to  bronchitis  or  show 
cardio-renal  changes.  The  treatment  of  these  conditions  may  give  relief  and 
it  is  in  these  patients  that  the  iodide  of  potassium  is  helpful.  To  be  of  any 
service  it  should  be  used  freely,  increasing  the  dose  until  symptoms  are  caused. 
Vaccines  may  be  prepared  from  the  dominant  organism  in  the  sputum.  The 
teeth  and  tonsils  should  be  eliminated  as  factors  of  infection,  and  the  condition 
of  the  intestines  and  bowels  carefully  studied.  Nasal  and  sinus  disease  should 
be  excluded  and  it  is  in  the  elderly  patients  that  one  sees  striking  relief  from 
cauterization  or  from  the  removal  of  polypi. 

In  the  sensitive  groups— ingestion,  inhalation,  and  bacterial — separation 
from  the  exciting  factor  is  important;  this  may  be  in  occupation,  environment, 
contact  with  animals  or  in  diet.  Desensitization  for  the  responsible  food  pro- 
tein occurs  if  it  is  totally  abstained  from  for  a  long  period.  The  best  results 
are  obtained  from  dieting  in  this  group.  Walker  could  not  increase  the  toler- 
ance for  the  wheat  proteins  by  subcutaneous  injections,  and,  as  in  the  case  of 
eggs  and  meat  and  milk,,  it  is  better  to  cut  out  the  articles  from  the  diet. 
Special  care  has  to  be  taken  in  the  case  of  eggs  as  very  minute  quantities  of 
the  protein  may  cause  attacks.  Such  articles  as  cakes,  custards  and  puddings 
containing  eggs  must  be  excluded.  The  proteins  of  the  cereals,  wheat,  barley, 
rice,  rye,  oat,  buckwheat,  may  be  the  cause,  and,  as  Goodale  points  out,  the 
hay  fever  patient  sensitive  to  the  pollen  of  the  grasses  will  react  also  to  the 
proteins  of  wheat  or  rye.  Protection  may  be  obtained  by  giving  small  doses 
of  the  protein  over  long  periods. 

The  horse  asthmatics  may  be  treated  by  beginning  with  the  injection  of  a 
dilution  of  the  hair  protein  of  1 :100,000  and  this  must  be  slowly  and  gradually 
increased.  Injections  of  horse  serum  is  of  little  or  no  value  in  the  treatment 
of  horse  asthma  (Walker).  Treatment  with  horse  hair  protein  does  not  de- 
sensitize against  cat  hair  protein.  The  prophylactic  treatment  is  not  without 
risks  as  in  the  case  of  an  asthmatic  of  fifteen  years'  standing  who  received  an 
injection  on  successive  days  of  0.01  and  0.02  mg.  of  an  extract  of  horse  hair, 
on  the  fourth  day  she  had  another  of  0.03  mg.  Within  two  minutes  she  com- 
plained of  feeling  hot,  in  three  minutes  the  face  was  flushed,  the  eyes  and 
nose  ''running"  and  the  skin  prickling.  In  five  minutes  asthma  began  with  a 
choking  sensation  in  the  throat.    Twelve  minims  of  a  1 :1000  epinephrin  solu- 


624  DISEASES  OF  THE  EESPIEATOEY  SYSTEM 

tion  was  injected  which  relieved  the  attack.  Urticaria  appeared  and  the  at- 
tack was  over  in  an  hour  and  a  half.  In  another  patient  a  severe  attack  of 
serum  disease  followed  a  desensitizing  dose  of  horse  hair  extract.  In  the  bac- 
terial cases  the  best  results  have  been  obtained  by  the  use  of  vaccines  of  Stapliy- 
lococcus  pyogenes  aureus.  Streptococcus  licernolyticus,  and  diphtheroid  organ- 
isms, when  these  have  been  the  predominating  organisms  in  the  sputum. 

Xose  and  throat  operations  appear  to  be  of  very  little  value  in  the  sensitive 
group.  The  liability  to  colds  and  bronchitis  disappears  with  the  successful 
treatment  with  proteins,  but  when  of  the  bacterial,  not  the  anaphylactic,  t}'pe 
vaccines  may  be  more  helpful. 

Treatment  of  the  Attack. — Hypodermics  of  epinephrin  (ttl  xv,  1  c.  c,  of 
a  1-1000  solution)  or  of  atropine  (gr.  1/100,  0.00065  gm.)  may  give  prompt 
relief,  but  individual  cases  A'ary  greatly.  Smaller  doses  of  epinephrin  are 
sometimes  efiicient.  Some  patients  are  helped  by  injections  of  epinephrin  given 
once  a  week  over  a  long  period.  Caution  should  be  exerted  in  patients  with  scle- 
rosis or  high  blood  pressure.  ]\Iorphia  (gr.  %-i/4,  0.01-0.016  gm.)  hypodermic- 
ally  is  one  of  the  best  remedies.  The  inhalation  of  aniyl  nitrite  may  give 
prompt  relief  or  a  whiff  of  chloroform  may  relieve  the  spasm.  Pilocarpin  (gr. 
3/s,  0.008  gm.)  hypodermically  may  be  tried. 

Usually  a  chronic  asthmatic  has  some  favorite  substance  to  inhale  or  to 
smoke.  ]\Iost  of  the  cigarettes  used  for  the  purpose  contain  leaves  of  the 
Solanacese,  to  which  nitrate  of  potash  is  added.  Stramonium  leaves  and  po- 
tassium nitrate  burnt  together  on  a  plate  may  be  used.  A  majority  of  patients 
use  the  patent  cures,  the  virtues  of  which  are  largely,  in  many  entirely,  due 
to  the  solanaceoup  leaves  or  potassium  nitrate,  in  a  few  to  iodide  or  opium. 
Ordinary  tobacco  cigarettes  are  sometimes  helpful. 


V.    FIBRINOUS  BRONCHITIS 

(Plastic  or  Croupous  Bronchitis) 

Definition. — An  acute  or  chronic  affection,  characterized  by  the  formation 
in  certain  of  the  bronchial  tubes  of  fibrinous  casts,  which  are  expelled  in 
paroxysms  of  dyspnoea  and  cough. 

Fibrinous  moulds  of  the  bronchi  are  formed  in  diphtheria  (Avith  extension 
into  the  trachea  and  bronchi)  in  pneumonia,  and  occasionally  in  pulmonary 
tuberculosis,  conditions  which,  however,  have  nothing  to  do  with  true  fibrinous 
bronchitis.  As  to  tuberculosis  Landis  states  that  no  instance  has  occurred 
during  thirteen  years  at  the  Phipps  Institute,  nor  was  it  found  in  any  of  the 
662  autopsies  on  tuberculous  subjects.  Fibrinous  casts  are  expectorated  in 
connection  with  chronic  heart-disease  and  in  the  albuminous  expectoration  fol- 
lowing tapping  of  a  pleural  exudate.  In  haemoptysis  blood-casts  may  be  ex- 
pectorated, and  they  are  not  to  be  confounded  with  the  casts  of  true  fibrinous 
bronchitis  which  may  be  coughed  up  with  profuse  haemorrhage.  In  pneu- 
monia small  fibrinous  plugs  are  not  uncommon  in  the  sputum,  and  in  a  few 
rare  instances  quite  large  moulds  of  the  tubes  may  be  coughed  up.  The 
mycelium  of  Aspergillus  fumigatus  may  form  membranous  casts  in  the 
bronchi. 


FIBRINOUS  BRONCHITIS  625 

Pathology. — This  is  obscure.  The  membrane  is  identical  with  that  to 
M'hich  the  term  croupous  is  applied,  and  the  obscurity  relates  not  so  much  to 
the  mechanism  of  the  production,  which  is  probably  the  same  as  in  other  mu- 
cous surfaces,  as  to  the  curious  limitation  of  the  affection  to  certain  bronchial 
territories  and  in  the  chronic  form  to  the  remarkable  recurrence  at  stated  or 
irregular  intervals  throughout  a  period  of  many  years.  In  the  fatal  cases  the 
bronchial  mucous  membrane  may  be  found  injected  or  pale.  In  Biermer's 
case  the  epithelial  lining  was  intact  beneath  the  cast,  but  in  that  of  Kretschy 
the  bronchi  were  denuded  of  their  epithelium.  Emphysema  is  almost  invari- 
ably present.    Evidences  of  recent  or  antecedent  pleurisy  are  sometimes  found. 

Clinical  Description. — Bettman  (1901)  analyzed  the  cases  from  the  litera- 
ture since  1869,  grouping  them  into  different  classes.  The  most  important  is 
chronic  idiopathic  -fibrinous  bronchitis.  It  is  a  rare  affection  and  most  common 
at  the  middle  period  of  life.  Of  27  cases,  15  were  in  males.  The  attacks  may 
occur  at  definite  intervals  for  months  or  years.  The  form  and  size  of  the 
casts  may  be  identical  at  each  attack  as  though  each  time  precisely  the  same 
bronchial  area  was  involved.  The  expectoration  of  the  casts  is  associated  with 
paroxysms  of  dyspnoea  and  coughing,  which  occur  at  longer  or  shorter  inter- 
vals. Fever  and  hsemoptysis  may  be  present  during  the  attack.  Physical  signs 
usually  indicate  the  portion  of  the  lung  affected,  as  there  are  suppressed  breath 
sounds  and  numerous  rales  on  coughing.  A  very  dry  rale,  called  the  ''bruit  de 
drapeau"  has  been  described,  caused  by  the  vibration  of  a  loosened  portion  of 
the  cast. 

In  five  cases  there  were  skin  lesions.  Tuberculosis  is  rarely  present.  The 
easts  are  usually  rolled  up  and  mixed  with  mucus  and  blood.  When  unrolled 
they  are  large  white  branching  structures.  The  main  stem  may  be  as  thick  as 
the  little  finger.  From  the  consistency  and  appearance  they  have  been  described 
as  fibrinous,  but  they  consist  mainly  of  mucin.  On  cross-section  they  show  a 
concentrically  stratified  structure,  with  leucocytes  and  alveolar  epithelium. 
Leyden's  crystals  and  Curschmann's  spirals  are  sometimes  found,  and  in 
Bettman's  case  there  were  protozoan-like  bodies.  Death  occurred  in  only  one 
case  of  the  series. 

The  acute  form,  of  which  Bettman  collected  15  cases,  comes  on  most  fre- 
quently during  some  fever,  as  typhoid,  pneumonia,  or  the  eruptive  fevers. 
After  a  preliminary  bronchitis  the  dyspnoea  increases,  and  then  the  casts  are 
coughed  up.  Chills  and  fever  have  been  present.  Four  of  the  15  cases  proved 
fatal,  and  the  casts  were  found  m  situ.  It  is  much  more  serious  than  the 
chronic  form  into  which  it  may  pass.  Night  after  night  distressing  attacks 
of  coughing  may  occur,  with  dyspnoea  and  cyanosis,  only  relieved  by  the  ex- 
pectoration of  large  quantities  of  sputum  with  casts  of  all  sizes,  sometimes 
very  small  ones  which  "tail  off"  into  true  spirals.  In  a  case  of  this  type  there 
were  attacks  of  fever  with  toxaemia  and  delirium.  The  casts  may  have  an 
arborescent  structure  or  come  from  a  single  tube  or  its  bifurcation. 

Treatment. — In  the  acute  cases  the  treatment  should  be  that  of  ordinary 
acute  bronchitis.  We  know  of  nothing  which  can  prevent  the  recurrence  of  the 
attacks  in  the  chronic  form.  In  the  uncomplicated  cases  there  is  rarely  any 
danger  during  the  paroxysm,  even  though  the  symptoms  may  be  most  distress- 
ing and  the  dyspnoea  and  cough  very  severe.  Inhalations  of  ether,  steam,  or 
atomized  lime-water  aid  in  the  separation  of  the  membranes.     Intratracheal 


626  DISEASES  OF  THE  EESPIRATORY  SYSTEM 

injections  of  olive  oil  with  iodoform  may  be  tried.  Pilocarpine  might  be 
useful,  as  in  some  instances  it  increases  the  bronchial  secretion.  The  employ- 
ment of  emetics  may  be  necessary,  and  in  some  cases  they  are  effective  in 
promoting  the  removal  of  the  casts. 


VI.     FOREIGN  BODIES  IN  THE  BRONCHI 

Largely  as  a  result  of  the  splendid  work  of  Chevalier  Jackson  of  Phila- 
delphia, we  have  learned  that  foreign  bodies  in  the  bronchi  are  not  infrequent. 
A  great  variety  of  objects  may  gain  entrance  to  the  trachea,  the  majority  of 
which  (75  per  cent.)  pass  into  the  right  bronchus.  There  is  not  necessarily 
any  occurrence  of  severe  symptoms  with  this  and  the  history  may  be  quite 
negative.  No  age  is  exempt  but  the  accident  is  particularly  apt  to  occur  in 
children. 

Symptoms. — These  are  very  varied,  depending  principally  on  the  char- 
acter of  foreign  body.  A  very  acute  general  process  may  result  which  ends 
fatally  in  a  few  days,  as  seen  after  the  inhalation  of  a  peanut,  or  there  may  be 
an  acute  process  which  gradually  subsides  into  a  chronic  condition.  Cough  is 
common  and  resulting  conditions  such  as  abscess  or  bronchiectasis  give  their 
usual  symptoms. 

Physical  Signs. — These  are  very  varied  and  no  set  picture  can  be  de- 
scribed. The  most  acute  signs  result  from  the  inhalation  of  a  nut,  the  peanut 
being  most  common  in  the  United  States.  To  this  the  name  Aracliidic  Bron- 
chitis has  been  given.  The  condition  is  an  oedematous,  purulent  tracheo-bron- 
chitis  which  often  results  in  lung  abscess.  The  cases  are  in  children;  the 
symptoms  come  on  rapidly  with  high  irregular  fever,  severe  toxaemia  and  the 
signs  of  an  intense  general  bronchitis,  with  a  great  variety  of  rales  mostly 
coarse  and  bubbling.  The  "asthmatoid  wheeze"  is  often  present.  The  dysp- 
noea is  extreme,  cyanosis  is  marked  and  there  is  tenacious  purulent  sputum. 
If  a  bronchus  is  plugged  there  is  dulness  with  absence  of  breath  and  voice 
soiinds.  The  lung  supplied  by  the  plugged  bronchus  contains  much  secre- 
tion and  is  described  as  "drowned"  lung. 

The  signs  in  the  more  chronic  cases  vary  greatly  depending  on  the  character 
of  the  substance,  the  reaction  set  up,  whether  the  bronchus  is  plugged  and  the 
changes  in  the  supplied  lung.  In  all  cases  there  may  be  auscultation  signs  on 
the  unaffected  side  due  to  extension  of  inflammation.  Decreased  expansion  is 
the  rule  on  the  affected  side.  Two  special  signs  are  important.  One  is  the  oc- 
currence of  very  fine  rales  over  a  small  area  in  the  case  of  metallic  bodies 
which  do  not  plug  the  bronchus  and  the  other  the  "asthmatoid  wheeze"  de- 
scribed by  Jackson.  This  is  a  wheezing  sound  heard  with  the  ear  or  stetho- 
scope close  to  the  patient's  mouth.  It  varies  in  pitch  and  loudness  and  may  be 
with  in-  and  expiration. 

Diagnosis. — The  acute  features  may  lead  to  the  diagnosis  of  pneumonia 
which  a  careful  examination  should  prevent.  In  the  chronic  cases  tuberculosis 
is  often  diagnosed  but  the  frequency  of  the  lesions  in  the  lower  lobes  should 
prevent  this.  The  X-rays  are  of  great  aid  in  many  cases  but  not  all  foreign 
bodies  show  in  the  plates.  The  thought  of  the  possibility  of  foreign  body  is 
the  surest  aid  against  error. 


CIRCULATOEY  DISTUEBANCES  IN  THE  LUNGS  627 

Treatment. — This  is  removal  by  bronchoscopy  done  by  skilled  hands.    No 
one  should  attempt  it  without  special  training. 


D.    DISEASES  OF  THE  LUNGS 

I.     CIRCULATORY  DISTURBANCES  IN  THE  LUNGS 

Congestion. — There  are  two  forms — active  and  passive. 

1.  Active  Congestion. — About  this  much  doubt  and  confusion  still  exist. 
French  writers  regard  it  as  an  independent  primary  affection  (maladie  de 
Woillez),  and  allot  much  space  to  it.  English  and  American  authors  more 
correctly  regard  it  as  a  symptomatic  affection.  Active  fluxion  to  the  lungs 
occurs  with  increased  action  of  the  heart,  and  when  very  hot  air  or  irritating 
substances  are  inhaled.  In  diseases  which  interfere  locally  with  the  circula- 
tion the  capillaries  in  the  adjacent  unaffected  portions  may  be  greatly  dis- 
tended. The  importance  of  this  collateral  fluxion,  as  it  is  called,  is  probably 
exaggerated.  In  a  whole  series  of  pulmonary  affections  there  is  this  asso- 
ciated congestion — in  pneumonia,  bronchitis,  pleurisy,  and  tuberculosis. 

The  symptoms  of  active  congestion  of  the  lungs  as  given  by  French  writers 
are  of  an  affection  difficult  to  distinguish  from  anomalous  or  larval  forms  of 
pneumonia.  The  chief  features  are  initial  chill,  pain  in  the  side,  dyspnoea, 
moderate  cough,  and  temperature  from  101°  to  103°  F.  The  physical  signs 
are  defective  resonance,  feeble  breathing,  sometimes  bronchial  in  character, 
and  fine  rales.  A  majority  of  physicians  would  undoubtedly  class  such  cases 
under  pneunionia.  In  many  epidemics  the  abnormal  and  larval  forms  are 
specially  prevalent. 

The  occurrence  of  an  intense  and.  rapidly  fatal  congestion  of  the  lung,  fol- 
lowing extreme  heat  or  cold  or  sometimes  violent  exertion,  is  recognized  by 
some  authors.  Eenforth,  the  oarsman,  is  said  to  have  died  from  this  cause 
during  a  race  near  St.  John,  N.  B.  Leuf  has  described  cases  in  which,  in  as- 
sociation with  drunkenness,  exposure,  and  cold,  death  occurred  suddenly,  or 
within  twenty-four  hours,  the  only  lesion  found  being  an  extreme,  almost 
hajmorrhagic,  congestion  of  the  lungs.  It  is  by  no  means  certain  that  in  these 
cases  death  really  occurs  from  pulmonary  congestion  in  the  absence  of  specific 
statements  with  reference  to  the  coronary  arteries  and  the  heart. 

2.  Passive  Congestion. — Two  forms  of  this  may  be  recognized,  the  me- 
chanical and  the  hypostatic. 

(a)  Mechanical  congestion  occurs  whenever  there  is  an  obstacle  to  the  re- 
turn of  the  blood  to  the  heart.  It  is  a  common  event  in  many  affections  of 
the  left  heart,  particularly  mitral  stenosis.  The  lungs  are  voluminous,  russet 
brown  in  color,  cutting  and  tearing  with  great  resistance.  On  section  they 
show  at  first  a  brownish  red  tinge,  and  then  the  cut  surface,  exposed  to  the  air, 
becomes  rapidly  of  a  vivid  red  color  from  oxidation  of  the  abundant  htpmoglo- 
bin.  This  is  the  condition  known  as  hroirn  induration  of  the  lung.  Occasion- 
ally this  mechanical  hyperagmia  of  the  lung  follo^vs  pressure  by  tumors.  So 
long  as  compensation  is  maintained  the  mechanical  congestion  of  the  lung 
in  heart  disease  does  not  produce  any  symptoms,  but  with  enfeebled  heart 


628  DISEASES  OF  THE  EESPIEATORY  SYSTEM 

action  the  engorgement  becomes  marked  and  there  are  dyspnoea,  cough,  and 
expectoration  with  the  characteristic  alveolar  cells. 

(b)  Hypostatic  Congestion. — In  fevers  and  adynamic  states  generally  it  is 
very  common  to  find  the  bases  of  the  lungs  deeply  congested,  a  condition  in- 
duced partly  by  the  effect  of  gravity,  the  patient  lying  recumbent  in  one  pos- 
ture for  a  long  time,  but  chiefly  by  vreakened  heart  action.  That  it  is  not  an 
effect  of  gravity  alone  is  shown  by  the  fact  that  a  healthy  person  may  remain 
in  bed  an  indefinite  time  without  its  occurrence.  The  posterior  parts  of  the 
lung  are  dark  in  color  and  engorged  with  blood  and  serum;  in  some  instances 
to  such  a  degree  that  the  alveoli  no  longer  contain  air  and  portions  of  the  lung 
sink  in  water.  The  terms  splenization  and  hypostatic  pneumonia  have  been 
given  to  these  advanced  grades.  It  is  a  common  affection  in  protracted  cases 
of  typhoid  fever  and  in  long  debilitating  illness.  In  ascites,  meteorism,  and 
abdominal  tumors  the  bases  of  the  lungs  may  be  compressed  and  congested. 
In  this  connection  must  be  mentioned  the  form  of  passive  congestion  met  with 
in  injury  to,  and  organic  disease  of,  the  brain.  In  cerebral  apoplexy  the  bases 
of  the  lungs  are  deeply  engorged,  not  quite  airless,  but  heavy,  and  on  section 
drip  with  blood  and  serum.  This  condition  may  occur  in  an  extreme  grade 
throughout  the  lungs  in  death  from  morphia  poisoning.  In  some  instances  the 
lung  tissue  has  a  blackish,  gelatinous,  infiltrated  appearance,  almost  like  dif- 
fuse pulmonary  apoplexy.  Occasionally  this  congestion  is  most  marked  in, 
and  even  confined  to,  the  hemiplegic  side.  In  prolonged  coma  the  hypostatic 
congestion  may  be  associated  with  patches  of  consolidation,  due  to  the  as- 
piration of  portions  of  food  into  the  air-passages. 

The  symptoms  of  hypostatic  congestion  are  not  at  all  characteristic.  There 
are  shortness  of  breath  and  cough  with  abundant  sputum  containing  alveolar 
epithelium  filled  with  yellow  and  black  pigment — the  so-called  "heart-failure 
cells."  On  examination  slight  dulness,  feeble,  sometimes  blowing,  breath- 
ing and  liquid  rales  can  be  detected. 

Treatment. — The  treatment  is  usually  that  of  the  condition  with  which 
the  congestion  is  associated.  In  the  intense  pulmonary  engorgement,  which 
may  j)ossibly  occur  primarily,  and  which  is  met  with  in  heart  disease  and  em- 
physema, free  bleeding  should  be  practised.  From  20  to  30  ounces  of  blood 
should  be  taken  and  if  the  blood  does  not  flow  freely  and  the  condition  is  des- 
perate aspiration  of  the  right  auricle  may  be  performed. 

(Edema. — In  all  forms  of  intense  congestion  of  the  lungs  there  is  a  transu- 
dation of  serum  from  the  engorged  capillaries  chiefly  into  the  air-cells,  but 
also  into  the  alveolar  walls.  Not  only  is  it  very  frequent  in  congestion,  but 
also  Avith  inflammation,  with  new  growths,  infarcts,  and  tubercles.  When 
limited  to  the  neighborhood  of  an  affected  part,  the  name  collateral  oedema  is 
sometimes  applied  to  it. 

Acute  cedema  is  met  with:  (1)  in  the  infections;  (2)  in  nephritis;  (3) 
in  heart  disease,  particularly  angina  pectoris,  myocarditis,  and  valve  lesions; 
(4)  in  arterio-sclerosis  with  high  tension ;  (5)  pregnancy;  (6)  angio-neurotic 
cedema;  (7)  as  a  complication  of  the  epileptic  fit,  and  (8)  after  thoracentesis. 
The  theory  most  generally  accepted  is  that  of  W.  H.  Welch,  whose  experiments 
indicate  that  pulmonary  oedema  is  due  to  a  disproportionate  weakness  of  the 
left  ventricle,  so  that  the  blood  accumulates  in  the  lung  capillaries  until  trans- 
udation occurs.     Cardiac  failure  is  the  most  important  cause.     Others  regard 


CIECULATOEY  DISTURBANCES  IX  THE  LUXaS  629 

it  is  an  efTect  of  disturbance  in  the  vasomotor  mechanism  of  the  lungs  with 
increased  permeability  of  the  capillaries.  In  some  cases  there  are  recurring 
attacks  of  acute  oedema  without  obvious  cause. 

Anatomically  the  lung  is  ana?mic,  heavy,  sodden,  pits  on  pressure,  and  on 
section  a  large  quantity  of  clear  or  blood-tinged  serum  flows  out.  It  may 
have  in  places  a  gelatinous  aspect. 

Symptoms. — The  onset  is  sudden  with  a  feeling  of  oppression  and  pain  in 
the  chest  and  rapid  breathing  which  soon  becomes  dyspnoeic  or  orthopnoeic. 
There  may  be  an  incessant  short  cough  and  a  copious  frothy,  sometimes  blood- 
tinged,  expectoration,  which  may  be  expelled  in  a  gush  from  the  mouth  and 
nose.  The  face  is  pale  and  covered  with  a  cold  sweat;  the  pulse  is  feeble  and 
the  heart's  action  weak.  Over  the  entire  chest  may  be  heard  piping  and  bub- 
bling rales.  The  attack  may  be  fatal  in  a  few  hours  or  may  persist  for  twelve 
or  twenty-four  hours  and  then  pass  off.  Steven,  of  Glasgow,  reported  a  case 
with  72  attacks  in  two  and  a  half  years.  This  recurrent  form  may  be  associated 
with  angina  pectoris. 

Treatment. — Venesection  should  be  done  at  once  and  is  often  most  help- 
ful. Morphia  (gr.  14,  0.016  gm.)  Math  atropine  (gr.  1/100,  0.0006  gm.)  should 
be  given  hypodermic-ally  and  the  atropine  repeated  in  fifteen  minutes  if  there 
is  no  change.  Aromatic  spirit  of  ammonia  (5  i,  4  c.  c.)  may  be  given  by 
mouth.  One  of  the  digitalis  preparations  should  be  given  intramuscularly 
and  repeated  every  three  hours  if  indicated.  If  hypertension  is  present  nitro- 
glycerine (gr.  1/100,  0.0006  gm.)  is  to  be  given  under  the  tongue  and  repeated 
until  an  effect  is  produced.  Inhalation  of  chloroform,  artificial  respiration, 
dry  cupping  and  the  use  of  oxygen  may  be  helpful.  Patients  who  have  repeated 
attacks  should  be  warned  against  over-exertion  and  with  the  first  symptoms  of 
an  attack  should  be  given  ammonia,  and  morphia  and  atropine  hypodermically. 

Pulmonary  Hsemorrhage. — This  occurs  in  two  forms — broncho-pulmonary 
luemorrliagc,  sometimes  called  bronchorrhagia,  in  which  the  blood  is  poured 
into  the  bronchi  and  expectorated,  and  pulmonary  apoplexy  or  pneumorrhagia, 
in  which  the  hsemorrhage  takes  place  into  the  air-cells  and  lung  tissue. 

1.  Broxctio-pulmoxary  Hemorrhage  ;  Hemoptysis. — Spitting  of  blood, 
to  which  the  term  haemoptysis  should  be  restricted,  results  from  a  variety  of 
conditions,  among  which  the  following  are  the  most  important:  (a)  In  young 
healthy  persons  haemoptysis  may  occur  without  warning,  and  after  continuing 
for  a  few  days  disappear  and  leave  no  ill  traces.  There  may  be  at  the  time  of 
the  attack  no  physical  signs  indicating  pulmonary  disease.  In  such  cases  good 
health  may  be  preserved  for  years  and  no  further  trouble  occur.  These  cases 
are  not  very  uncommon,  but  in  spite  of  the  good  health  tuberculosis  should  be 
suspected.  In  Ware's  important  contribution,  of  386  cases  of  haemoptysis 
noted  in  private  practice  62  recovered  and  pulmonary  disease  did  not  subse- 
quently develop,  (h)  Hcemoptysis  in  pulmonary  tuberculosis,  which  is  consid- 
ered on  page  194.  (c)  In  connection  with  certain  diseases  of  the  lung,  as  pneu- 
monia (in  the  initial  stage)  and  cancer,  occasionally  in  gangrene,  abscess;  and 
bronchiectasis,  [d)  In  many  heart  affections,  particularly  mitral  lesions.  It 
may  be  profuse  and  recur  at  intervals  for  years,  (e)  In  ulceraiive  affections  of 
the  larynx,  trachea,  or  bronchi.  Sometimes  the  haemorrhage  is  profuse  and 
rapidly  fatal,  as  when  the  ulcer  erodes  a  large  branch  of  the  pulmonary  artery. 
(/)   Aneurism.    It  may  be  sudden  and  rapidly  fatal  when  the  sac  bursts  into 


630  DISEASES  OF  THE  EESPIEATOEY  SYSTEM 

the  air-passages.  Slight  bleeding  may  continue  for  weeks  or  months,  due  to 
pressure  on  the  mucous  membrane  or  erosion  of  the  lung;  or  in  some  cases  the 
sac  "weeps"  through  the  exposed  laminag  of  fibrin,  (g)  Vicarious  licemorrliage, 
which  occurs  in  rare  instances  in  cases  of  interrupted  menstruation.  The 
instances  are  well'  authenticated.  Flint  mentions  a  case  which  he  had  had 
under  observation  for  four  years,  and  Hippocrates  refers  to  it  in  the  aphorism. 
"Hemoptysis  in  a  woman  is  removed  by  an  eruption  of  the  menses."  Periodi- 
cal haemoptysis  has  been  met  with  after  the  removal  of  both  ovaries.  Fatal 
ha?morrhage  has  occurred  from  the  lung  during  menstruation  when  no  lesion 
was  found  to  account  for  it.  (h)  Permanent  high  arterial  tension.  Haemopty- 
sis, sometimes  profuse  and  lasting  for  days,  may  occur  at  intervals.  In  this 
group  probably  come  the  cases  described  by  Sir  Andrew  Clark  in  arthritic  sub- 
jects, [i)  Hcemoptysis  occurs  sometimes  in  malignant  fevers  and  in  purpura 
haim.orrhagicO:  (j)  AYith  gun-shot  injuries  and  foreign  bodies  in  the  lung. 
Lastly,  there  is  endemic  haemoptysis,  due  to  the  bronchial  fluke,  an  affection 
confined  to  parts  of  China  and  Japan. 

Symptoms. — Htemoptysis  sets  in,  as  a  rule,  suddenly.  Often  without  warn- 
ing the  patient  experiences  a  warm,  saltish  taste  as  the  mouth  fills  with  blood. 
Coughing  is  usually  induced.  There  may  be  only  an  ounce  or  so  brought  up 
before  the  haemorrhage  stops,  or  the  bleeding  may  continue  for  days,  the  pa- 
tient bringing  up  small  quantities.  In  other  instances,  particularly  when  a 
large  vessel  is  eroded  or  an  aneurism  bursts,  the  amount  is  large,  and  the  pa- 
tient, after  a  few  attempts  at  coughing,  shows  signs  of  suffocation  and  death 
is  produced  by  inundation  of  the  bronchial  system.  Fatal  haemorrhage  may 
occur  into  a  large  cavity  in  a  patient  debilitated  by  tuberculosis  without  thj 
production  of  haemoptysis.  The  blood"from  the  lungs  generally  has  characters 
which  render  it  readily  destinguishable  from  vomited  blood.  It  is  alkaline  in 
reaction,  frothy,  mixed  with  mucus,  and  air-bubbles  are  present  in  the  clot. 
Blood-moulds  of  the  smaller  bronchi  are  sometimes  seen.  Patients  can  usually 
tell  whether  the  blood  has  been  brought  up  by  coughing  or  by  vomiting,  and 
in  a  majority  of  cases  the  history  gives  important  indications.  In  paroxysmal 
haemoptysis  connected  with  menstrual  disturbances  the  practitioner  should  see 
that  the  blood  is  actually  coughed  up,  since  deception  may  be  practised.  The 
spurious  haemoptysis  of  hysteria  is  considered  with  that  disease.  Naturally, 
the  patient  is  alarmed  at  the  occurrence  of  bleeding,  but,  unless  very  profuse, 
as  when  due  to  rupture  of  an  aneurism  in  a  pulmonary  cavity,  the  danger  is 
rarely  immediate.  The  attacks,  however,  are  apt  to  recur  for  a  few  days  and 
the  sputum  may  remain  blood-tinged  for  a  longer  period.  In  the  great  ma- 
jority of  cases  the  haemorrhage  ceases  spontaneously.  Blood  may  be  swallowed 
and  produce  vomiting,  and,  after  a  day  or  two,  the  stools  may  be  dark  in  color. 
It  is  not  advisable  to  examine  the  chest  during  an  attack  of  haemoptysis. 

2.  Pulmonary  "Apoplexy";  Hemorrhagic  Infarct. — The  blood  is  ef- 
fused into  the  air-cells  and  interstitial  tissue.  It  is  usually  diffuse,  the  paren- 
chyma not  being  broken,  as  is  the  brain  tissue  in  cerebral  apoplexy.  Some- 
times, in  disease  of  the  brain,  in  septic  conditions,  and  in  the  malignant  forms 
of  fevers,  the  lung  tissue  is  uniformly  infiltrated  with  blood  and  has,  on  sec- 
tion, a  black,  gelatinous  appearance. 

As  a  rule,  the  haemorrhage  is  limited  and  results  from  the  blocking  of  a 
branch  of  the  pulmonary  artery  either  by  a  thrombus  or  an  embolus.     The 


CIECULATOKY  DISTUEBANCES  IN  THE  LUXGS  631 

condition  is  most  common  in  chronic  heart-disease.  Although  the  pulmonary 
arteries  are  terminal  ones,  blocking  is  not  always  followed  by  infarction; 
partly  because  the  wide  capillaries  furnish  sufficient  anastomosis,  and  partly 
because  the  bronchial  vessels  may  keep  up  the  circulation.  The  infarctions  are 
chiefly  at  the  periphery  of  the  lung,  usually  wedge-shaped,  with  the  base  of 
the  wedge  toward  the  surface.  When  recent,  they  are  dark  in  color,  hard  and 
firm,  and  look  on  section  like  an  ordinary  blood-clot.  Gradual  changes  go  on, 
and  the  color  becomes  a  reddish  brown.  The  pleura  over  an  infarct  is  usually 
inflamed.  A  microscopic  section  shows  the  air-cells  to  be  distended  Avith  red 
blood  corpuscles,  which  may  also  be  in  the  alveolar  walls.  The  infarcts  are 
usually  multiple  and  vary  in  size  from  a  walnut  to  an  orange.  Very  large 
ones  may  involve  the  greater  part  of  a  lobe.  In  the  artery  passing  to  the  af- 
fected territory  a  thrombus  or  an  embolus  is  found.  The  globular  thrombi, 
formed  in  the  right  auricular  appendix,  play  an  important  part  in  the  produc- 
tion of  hemorrhagic  infarction.  In  many  cases  the  source  of  the  embolus  can 
not  be  discovered,  and  the  infarct  may  have  resulted  from  thrombosis  in  the 
pulmonary  artery,  but  it  is  not  infrequent  to  find  total  obstruction  of  a  large 
branch  of  a  pulmonary  artery  without  haemorrhage  into  the  corresponding 
lung  area.  The  further  history  of  an  infarction  is  variable.  It  is  possible 
that  in  some  instances  the  circulation  is  re-established  and  the  blood  removed. 
More  commonly,  if' the  patient  lives,  the  usual  changes  go  on  in  the  extrava- 
sated  blood  and  ultimately  a  pigmented,  puckered,  fibroid  patch  results. 
Sloughing  may  occur  with  the  formation  of  a  cavity.  Occasionally  gangrene 
results.     A  gangrenous  infarct  may  rupture  and  produce  fatal  pneumothorax. 

The  symptoms  of  pulmonary  infarction  are  by  no  means  definite.  The 
condition  may  be  suspected  in  chronic  heart-disease  when  haemoptysis  occurs, 
I'articularly  in  mitral  stenosis,  but  the  bleeding  may  be  due  to  the  extreme  en- 
gorgement. When  the  infarcts  are  very  large,  and  particularly  in  the  'lower 
lobe,  in  which  they  most  commonly  occur,  there  may  be  signs  of  consolidation 
with  blowing  breathing  and  a  pleuritic  friction. 

Treatment  of  Pulmonary  Hemorrhage. — The  pressure  within  the  pul- 
monary artery  is  considerably  less  than  that  in  the  aortic  system.  The  system 
is  under  vaso-motor  control,  but  our  knowledge  of  the  mutual  relations  of 
l)ressure  in  the  aorta  and  in  the  pulmonary  artery,  under  varying  conditions, 
is  imperfect  (Bradford).  There  may  be  an  influence  on  the  systemic  blood- 
pressure  without  any  on  the  pulmonary,  and  the  pressure  in  the  one  may  rise 
while  it  falls  in  the  other,  or  it  may  rise  and  fall  in  both  together.  The  re- 
searches of  Brodie  and  Dixon  indicate  that  drugs  which  raise  the  peripheral 
blood  pressure  by  vaso-constriction  increase  the  total  blood  in  the  lung.  Thus 
ergot,  a  remedy  commonly  used,  causes  a  distinct  rise  in  the  pulmonary  blood- 
pressure,  while  aconite  produces  a  definite  fall. 

The  question  is  beset  with  difficulties,  and  experimental  work  is  by  no 
means  in  accord.  Wiggers  concludes  that  in  the  early  stages  of  hemoptysis, 
when  the  breathing  is  not  altered,  lowering  of  the  blood  pressure  within  the 
pulmonary  circuit  can  not  be  accomplished  by  the  nitrites,  but  only  by  the  car- 
diac depressants,  and  in  the  later  stages  of  an  attack,  when  the  heart  is  very 
rapid,  pituitary  extract  is  the  only  drug  that  raises  systemic  pressure  while 
simultaneously  lowering  that  in  the  pulmonary  circuit. 

The  anatomical  condition  in  haemoptysis  is  either  hyperemia  of  the  bron- 


632  DISEASES  OF  THE  EESPIEATOEY  SYSTEM 

chial  mucosa  (or  of  the  lung  tissue)  or  a  perforated  vessel.  In  the  latter  case 
the  patient  often  passes  rapidly  beyond  treatment,  though  there  are  instances 
of  the  most  profuse  haemorrhage,  which  must  have  come  from  a  perforated 
artery  or  a  ruptured  aneurism,  in  which  recovery  has  occurred.  Practically, 
for  treatment,  we  should  separate  these  cases,  as  the  remedies  which  would  be 
applicable  in  the  case  of  congested  and  bleeding  mucosa  would  be  as  much 
out  of  place  in  a  case  of  hgemorrhage  from  ruptured  aneurism  as  in  a  cut  radial 
artery.  When  the  blood  is  brought  up  in  large  quantities,  it  is  almost  certain 
either  that  an  aneurism  has  ruptured  or  a  vessel  has  been  eroded.  In  the  in- 
stances in  which  the  sputum  is  blood  tinged  or  when  the  blood  is  in  smaller 
quantities,  bleeding  comes  by  diapedesis  from  hyper^emic  vessels.  In  such 
cases  the  hgemorrhage  may  be  beneficial  in  relieving  congestion. 

The  indications  are  to  reduce  the  frequency  of  the  heart-beats  and  to  lower 
the  blood-pressure.  The  truth,  Das  Blut  ist  ein  ganz  hesonderer  Saft,  is 
strikingly  emphasized  by  the  frightened  state  of  the  patient.  Eest  of  the 
body  and  peace  of  the  mind — "quies,  securitm,  silentium"  of  Celsus — should 
be  secured.  If  there  is  marked  restlessness,  morphia  hypodermically  (gr.  %, 
0.011  gm.)  is  advisable.  Turn  the  patient  on  the  affected  side,  if  known,  as 
regurgitation  is  less  apt  to  occur  into  the  bronchi  of  the  sound  lung.  As 
Aretseus  remarks,  in  haemoptysis  the  patient  despairs  from  the  first,  and  needs 
to  be  strongly  reassured.  Death  is  rarely  due  directly  to  haemoptysis ;  patients 
die  after,  not  of  it  (S.  West).  In  the  majority  of  cases  of  mild  haemoptysis 
this  is  sufficient.  Even  when  the  patient  insists  upon  going  about,  the  bleed- 
ing may  stop  spontaneously.  The  diet  should  be  light  and  unstimulating. 
Alcohol  should  nut  be  used.  The  patient  may,  if  he  wishes,  have  ice  to  suck. 
Small  doses  of  aromatic  sulphuric  acid  may  be  given,  but  unless  the  bleeding  is 
protracted  styptic  and  astringent  medicines  are  not  indicated.  For  cough, 
which  is  always  present  and  disturbing,  opium  should  be  freely  given,  and  is 
of  all  medicines  most  serviceable  in  haemoptysis.  Digitalis  should  not  be 
used,  as  it  raises  the  blood-pressure  in  the  pulmonary  artery.  Aconite  may  be 
used  when  there  is  much  vascular  excitement.  Ergot,  tannic  acid,  and  lead 
have  little  or  no  influence  in  haemoptysis;  ergot  probably  does  harm.  One  of 
the  most  satisfactory  means  of  lowering  the  blood-pressure  is  purgation,  and 
when  the  bleeding  is  protracted  salts  may  be  freely  given.  In  profuse  haemopty- 
sis, as  from  erosion  of  an  artery  or  rupture  of  an  aneurism,  a  fatal  result  is 
common,  and  yet  post  mortem  evidence  shows  that  thrombosis  may  occur  with 
healing  in  a  rupture  of  considerable  size.  The  fainting  induced  by  the  loss  of 
blood  is  probably  the  most  efficient  means  of  promoting  thrombosis,  and  it  was 
on  this  principle  that  formerly  patients  were  bled  from  the  arm,  or  from  both 
arms,  as  in  the  case  of  Laurence  Sterne.  Ligatures,  or  Esmarch's  bandages, 
placed  around  the  legs  may  serve  temporarily  to  check  the  bleeding.  The  ice- 
bag  is  of  doubtful  utility.  In  protracted  cases  pneumothorax  has  been  in- 
duced, sometimes  with  success. 

Briefly,  then,  we  may  say  that  haemorrhage  from  rupture  of  aneurism  or 
erosion  of  a  blood-vessel  usually  proves  fatal.  The  fainting  induced  by  the 
loss  of  blood  is  beneficial,  and,  if  the  patient  can  be  kept  alive  for  twenty-four 
hours,  a  thrombus  of  sufficient  strength  to  prevent  further  bleeding  may  form. 
The  chief  danger  is  the  inundation  of  the  bronchial  system  with  the  blood,  so 


CHEONIC  INTERSTITIAL  PNEUMONIA  633 

that  while  the  haemorrhage  is  profuse  the  cough  should  be  encouraged.    Opium 
should  not  then  be  used,  and  stimulants  should  be  given  with  caution. 

In  the  other  group,  in  which  the  hsemorrhage  comes  from  a  congested  area 
and  is  limited,  the  patient  gets  well  if  kept  absolutely  quiet,  and  fatal  hgemor- 
rhage  probably  never  occurs  from  this  source.  Eest,  reduction  of  the  blood- 
pressure  by  minimum  diet,  purging,  if  necessary,  and  the  administration  of 
some  preparation  of  opium  to  allay  the  cough  are  the  main  indications. 


II.     CHRONIC  INTERSTITIAL  PNEUMONIA 

A  fibroid  change  may  have  its  starting  point  in  the  tissue  about  the  bronchi 
and  blood-vessels,  the  interlobular  septa,  the  alveolar  walls,  or  in  the  pleura.  So 
diverse  are  the  forms  and  so  varied  the  conditions  under  which  this  change 
occurs  that  a  proper  classification  is  difficult.  We  may  recognize  two  chief 
forms — the  local,  involving  only  a  limited  area  of  the  lung  substance,  and  the 
diffuse,  invading  either  both  lungs  or  an  entire  organ. 

Etiolo^. —  (a)  Local  fibroid  change  in  the  lungs  is  common.  It  is  a 
constant  accompaniment  of  tubercle,  in  the  evolution  of  which  interstitial 
changes  play  a  very  important  role.  In  tumors,  abscess,  gummata,  hydatids, 
and  emphysema  it  also  occurs.  Eibroid  processes  are  frequently  met  with  at 
the  apices  of  the  lung  and  may  be  due  either  to  a  limited  healed  tuberculosis, 
to  fibroid  induration  in  consequence  of  pigment,  or,  in  a  few  instances,  may 
result  from  thickening  of  the  pleura. 

(&)  Diffuse  interstitial  pneumonia  is  met  with:  (1)  As  a  sequence 
of  acute  fibrinous  pneumonia.  Although  extremely  rare,  this  is  recognized  as 
a  possible  termination.  From  unknown  causes  resolution  fails  to  take  place. 
Organization  goes  on  in  the  fibrinous  plugs  within  the  air-cells  and  the  alveo- 
lar walls  become  greatly  thickened  by  a  new  growth,  first  of  nuclear  and  subse- 
quently of  fibrillated  connective  tissue.  Macroscopically  there  is  produced  a 
smooth,  grayish,  homogeneous  tissue  which  has  the  peculiar  translucency  of 
all  new-formed  connective  tissue.  This  has  been  called  gray  induration.  A 
majority  of  the  cases  terminate  within  a  few  months,  but  instances  which  have 
been  followed  from  the  outset  are  very  rare. 

(2)  Chronic  Broncho-pneumonia. — The  relation  of  broncho-pneumonia  to 
cirrhosis  of  the  lung  was  specially  studied  by  Charcot,  who  stated  that  it 
may  follow  the  acute  or  subacute  form  of  this  disease,  particularly  in  children. 
The  fibrosis  extends  from  the  bronchi,  which  are  usually  dilated.  Bron- 
chiectasis may  be  followed  by  fibrosis  of  the  lung.  The  alveolar  walls  are 
thickened  and  the  lobules  converted  into  firm  grayish  masses,  in  which  there 
is  no  trace  of  normal  lung  tissue.  This  may  go  on  and  involve  an  entire  lobe 
or  even  the  whole  lung.    Many  of  these  cases  are  tuberculous  from  the  outset. 

(3)  Pleurogenous  Interstitial  Pneumonia. — Charcot  applied  this  term  to 
that  form  of  cirrhosis  of  the  lung  which  follows  invasion  from  the  pleura. 
Doubt  has  been  expressed  by  some  writers  whether  this  really  occurs.  While 
Wilson  Fox  was  probably  correct  in  questioning  whether  an  entire  lung  can 
become  cirrhosed  by  the  gradual  invasion  from  the  pleura,  there  can  be  no 
doubt  that  there  are  instances  of  primitive  dry  pleurisy,  which,  as  Sir  Andrew 
Clark  pointed  out,  gradually  compress  the  lung  and  lead  to  interstitial  cirrho- 


634  DISEASES  OF  THE  EESPIRATOEY  SYSTEM 

sis.  This  may  be  due  in  part  to  the  fibroid  change  which  follows  prolonged 
compression.  In  some  cases  there  seems  to  be  a  distinct  connection  between 
the  greatly  thickened  pleura  and  the  dense  strands  of  fibrous  tissue  passing 
from  it  into  the  lung  substance.  Instances  occur  in  which  one  lobe  or  the 
greater  part  of  it  presents^  on  section,  a  mottled  appearance,  owing  to  the 
increased  thickness  of  the  interlobar  septa — a  condition  which  may  exist  with- 
out a  trace  of  involvement  of  the  pleura.  In  many  other  cases,  however,  the 
extension  seems  to  be  so  definitely  associated  with  pleurisy  that  there  is  no 
doubt  as  to  the  caiisal  connection  between  the  two  processes.  In  these  instances 
the  lung  is  removed  with  great  difficulty,  owing  to  the  thickness  and  close  ad- 
hesion of  the  pleura  to  the  chest  wall. 

(4)  Chronic  interstitial  pneumonia^  due  to  inhalation  of  dust,  which  is 
considered  in  a  separate  section. 

(5)  Syphilis  of  the  lung  may  present  the  features  of  a  chronic  fibrosis. 

(6)  Indurative  changes  in  the  lung  may  follow  the  compression  by  aneu- 
rism or  new  groT\d;h  or  the  irritation  of  a  foreign  body  in  a  bronchus. 

Morbid  Anatomy. — There  are  two  chief  forms,  the  massive  or  lobar  and 
the  insular  or  broncho-pneumonic  form.  In  the  massive  type  the  disease  is 
unilateral ;  the  chest  of  the  afi^ected  side  is  sunken,  deformed,  and  the  shoulder 
much  depressed.  On  opening  the  thorax  the  heart  is  seen  drawn  far  over  to 
the  affected  side.  The  unaffected  lung  is  emphysematous  and  covers  the  greater 
portion  of  the  mediastinum.  It  is  scarcely  credible  in  how  small  a  space,  close 
to  the  spine,  the  cirrhosed  lung  may  lie.  The  adhesions  between  the  pleural 
membranes  may  be  extremely  dense  and  thick,  particularly  in  the  pleurogenous 
cases ;  but  when  the  disease  has  originated  in  the  lung  there  may  be  little  thick- 
ening of  the  pleura;.  The  organ  is  airless,  firm,  and  hard.  It  strongly  resists 
cutting,  and  on  section  shows  a  grayish  fibroid  tissue  of  variable  amount, 
through  which  pass  the  blood-vessels  and  bronchi.  The  latter  may  be  either 
slightly  or  enormously  dilated.  There  are  instances  in  which  the  entire  lung 
is  converted  into  a  series  of  bronchiectatic  cavities  and  the  cirrhosis  is  ap- 
parent only  in  certain  areas  or  at  the  root.  The  tuberculous  cases  can  usually 
be  differentiated  by  the  presence  of  an  apical  cavity,  not  bronchiectatic,  often 
large,  and  the  other  lung  almost  invariably  shows  tuberculous  lesions.  Aneu- 
risms of  the  pulmonary  artery  are  not  infrequent  in  the  cavities.  The  other 
lung  is  always  enlarged  and  emphysematous.  The  heart  is  hypertrophied,  par- 
ticularly the  right  ventricle,  and  there  may  be  marked  atheromatous  changes 
in  the  vessels.     An  am5doid  condition  of  the  viscera  is  found  in  some  cases. 

In  the  broncho-pneumonic  form  the  areas  are  smaller,  often  centrally 
placed,  and  most  frequently  in  the  lower  lobes.  They  are  deeply  pigmented, 
show  dilated  bronchi,  and  when  multiple  are  separated  by  emphysematous 
lung  tissue. 

A  reticular  form  of  fibrosis  of  the  lung  has  been  described  by  Percy  Kidd 
and  W.  ]\rcCollum,  in  which  the  lungs  are  intersected  by  grayish  fibroid 
strands  following  the  lines  of  the  interlobular  septa. 

Symptoms  and  Course. — The  disease  is  essentially  chronic,  extending  over 
a  period  of  many  years,  and  when  once  the  condition  is  established  the  health 
may  be  fairly  good.  In  a  well  marked  case  the  patient  complains  only  of  his 
chronic  cough,  perhaps  a  slight  shortness  of  breath.  In  other  respects  he  is 
quite  well,  and  is  usually  able  to  do  light  work.    The  cases  are  commonly  re- 


CHROmC  INTEESTITIAL  PNEUMONIA  635 

garded  as  tuberculous,  though  there  may  be  scarcely  a  symptom  of  that  afEec- 
tion  except  the  cough.  There  are  instances,  however,  of  fibroid  tuberculosis 
which  can  not  be  distinguished  from  cirrhosis  of  the  lung  except  by  the  presence 
of  tubercle  bacilli  in  the  expectoration.  As  the  bronchi  are  usually  dilated,  the 
symptoms  and  physical  signs  may  be  those  of  bronchiectasis.  The  cough  is 
paroxysmal  and  the  expectoration  is  generally  copious  and  of  a  muco-purulent 
or  sero-purulent  nature.  It  is  sometimes  fetid.  Hgemorrhage  is  by  no  means 
infrequent,  and  occurred  in  more  than  one-half  of  the  cases  analyzed  by 
Bastian.  Walking  on  the  level  and  in  the  ordinary  affairs  of  life,  the  patient 
may  show  no  shortness  of  breath,  but  in  the  ascent  of  stairs  and  on  exertion 
there  may  be  dyspnoea. 

PiiTSiCAL  SiGXS. — Inspection. — The  affected  side  of  the  chest  is  immo- 
bile, retracted,  and  shrunken,  and  contrasts  in  a  striking  way  with  the  volu- 
minous healthy  one.  The  intercostal  spaces  are  obliterated  and  the  ribs  may 
even  overlap.  The  shoulder  is  drawn  down  and  from  behind  it  is  seen  that 
the  spine  is  bowed.  The  muscles  of  the  shoulder-girdle  are  wasted.  The  heart 
is  greatly  displaced,  being  drawn  over  by  the  shrinkage  of  the  lung  to  the 
affected  side.  When  the  left  lung  is  affected  there  may  be  a  large  area  of 
visible  impulse  in  the  second,  third,  and  fourth  interspaces.  Mensuration 
shows  a  great  diminution  in  the  affected  side,  and  with  the  saddle-tape  the 
expansion  may  be  seen  to  be  negative.  The  percussion  note  varies  with  the 
condition  of  the  bronchi.  It  may  be  absolutely  flat,  particularly  at  the  base 
or  at  the  apex.  In  the  axilla  there  may  be  a  flat  tympany  or  even  an  am- 
phoric note  over  a  large  sacculated  bronchus.  On  the  opjDOsite  side  the  per- 
cussion note  is  usually  hyperresonant.  On  auscultation  the  breath-sounds 
have  eiither  a  cavernous  or  amphoric  quality  at  the  apex,  and  at  the  base  are 
feeble,  with  mucous,  bubbling  rales.  The  voice-sounds  are  usually  exaggerated. 
Cardiac  murmurs  are  not  uncommon,  particularly  late  in  the  disease,  when 
the  right  heart  fails.  These  are,  of  course,  the  physical  signs  of  the  disease 
when  it  is  well  established.  They  naturally  vary  considerably,  according  to 
the  stage  of  the  process.  The  disease  is  essentially  chronic,  and  may  persist 
for  flfteen  or  twenty  years.  Death  occurs  sometimes  from  haemorrhage,  more 
commonly  from  gradual  failure  of  the  right  heart  with  dropsy,  and  occasion- 
ally from  amyloid  degeneration  of  the  organs. 

Diagnosis. — This  is  never  difficult  but  it  may  be  impossible  to  say,  without 
a  clear  history,  whether  the  origin  is  pleuritic  or  pneumonic.  Between  cases 
of  this  kind  and  fibroid  tuberculosis  it  is  not  always  easy  to  discriminate,  as 
the  conditions  may  be  almost  identical.  When  tuberculosis  is  present,  how- 
ever, even  in  long-standing  cases,  bacilli  are  present  in  the  sputum,  and  there 
may  be  signs  of  disease  in  the  other  lung. 

Treatment. — It  is  only  for  an  intercurrent  affection  or  for  an  aggravation 
of  the  congh  that  the  patient  seeks  relief.  Nothing  can  be  done  for  the  con- 
dition itself.  When  possible  the  patient  should  live  in  a  mild  climate,  and 
avoid  exposure  to  cold  and  damp.  A  distressing  feature  in  some  eases  is  the 
putrefaction  of  the  contents  of  the  dilated  tubes,  for  which  the  same  measures 
may  be  used  as  in  fetid  bronchitis. 


636  DISEASES  OF  THE  EESPIEATOEY  SYSTEM 


m.     PNEUMOCONIOSIS 

Definition. — Under  this  term,  introduced  by  Zenker,  are  embraced  those 
forms  of  fibrosis  of  the  lung  due  to  the  inhalation  of  dusts  in  various  occupa- 
tions. They  have  received  various  names,  according  to  the  nature  of  the  in- 
haled particles — anthracosis,  or  coal-miner's  disease,  siderosis,  chalicosis  and 
silicosis. 

Etiology. — The  dust  is  inorganic  or  organic;  the  former  is  the  more 
common  and  more  dangerous.  The  following  are  the  chief  forms: — (1)  An- 
thracosis. Dwellers  in  cities  inhale  coal  dust  and  soot,  and  the  lungs  gradually 
become  carbonized.  Ivlotz  has  shown  that  the  lungs  of  the  inhabitants  of 
Pittsburgh  have  an  excessive  amount  of  carbon,  which  leads  to  varying  degrees 
of  fibrosis.  (2)  Silicosis,  from  the  dust  of  flint  in  small  angular  particles, 
occurs  in  the  South  African  gold  mines  and  the  zinc  mines  in  Missouri.  (3) 
Chalicosis,  from  the  dust  of  quarries  and  potteries,  and  occupations  of  grind- 
ing steel,  etc.  (4)  Siderosis,  from  iron  dust,  in  workers  with  red  oxide  of 
iron,  and  in  brass  and  bronze.  (5)  Dust  from  crushed  slag  which  may  cause 
an  acute  inflammation  of  a  lower  lobe. 

Organic  dust  is  not  nearly  so  serious,  and  it  is  doubtful  if  pneumoconiosis 
is  ever  produced  by  it  alone.  The  workers  in  cotton  and  woolen  mills  have  a 
high  death  rate  from  tuberculosis,  but  the  dust  is  probably  not  a  serious  factor. 
In  the  grinding  of  rags,  new  workers  may  have  attacks  of  catarrh  and  fever 
with  shivering  ("Shoddy  fever,''  Oliver).  The  dust  of  grain  in  threshing 
may  cause  irritation  of  the  bronchi,  headache  and  sometimes  fever.  The  dust 
particles  inhaled  into  the  lungs  are  dealt  with  by  the  ciliated  epithelium  and 
by  the  phagocytes.  The  ordinary  mucous  corpuscles  take  in  a  large  number 
of  the  particles,  which  fall  upon  the  trachea  and  main  bronchi.  The  cilia  sweep 
the  mucus  out  to  a  point  from  which  it  can  be  expelled  by  coughing.  It  is 
mucosa,  reaching  the  lymph  spaces,  where  they  are  attacked  at  once  by  the  cells 
(in  which  they  are  in  numbers)  probably  pick  them  up  on  the  way.  The 
mucous  and  the  alveolar  cells  are  the  normal  respiratory  scavengers.  "In  dwel- 
lers in  the  country,  where  the  air  is  pure,  they  are  able  to  prevent  the  access 
of  dust  particles  to  the  lung  tissue,  so  that  even  in  adults  these  organs  present 
a  rosy  tint,  very  different  from  the  dark,  carbonized  appearance  of  the  lungs 
of  dwellers  in  cities.  When  the  impurities  in  the  air  are  very  abundant,  a 
certain  proportion  of  the  dust  particles  escapes  these  cells  and  penetrates  the 
mucosa,  reaching  the  lymph  spaces,  where  they  are  attacked  at  once  by  the  cells 
of  the  connective-tissue  stroma,  which  are  capable  of  ingesting  and  retaining 
a  large  quantity.  In  coal-miners,  coal-heavers,  and  others  whose  occupations 
necessitate  the  constant  breathing  of  a  very  dusty  atmosphere  even  these  forces 
are  insufficient.  Pulmonary  anthracosis  may  be  induced  by  passing  an  emul- 
sion of  china  ink  into  the  stomach  of  an  animal  through  a  catheter  so  that 
anthracosis  may  be  due  to  the  intestinal  absorption  of  carbon  particles  ar- 
rested in  the  nose  and  pharynx,  and  then  swallowed.  The  experimental  work 
shows  that  both  the  tracheal  and  intestinal  routes  are  used — through  the 
former  the  particles  reach  the  bronchi  and  external  portions  of  the  alveoli, 
through  the  latter  the  parenchyma  of  the  lung.  Occasionally  in  anthracosis  the 
carbon  grains  reach  the  general  circulation,  and  the  coal  dust  is  found  in  the 


PNEUMOCONIOSIS  637 

liver  and  spleen.  This  occurs  when  the  densely  pigmented  bronchial  glands 
closely  adhere  to  the  pulmonary  veins,  through  the  walls  of  which  the  carbon 
particles  pass  to  the  general  circulation.  The  lung  tissue  has  a  remarkable  tol- 
erance for  these  particles;  but  by  constant  exposure  a  limit  is  reached,  and  a 
definite  pathological  condition,  an  interstitial  sclerosis,  results.  In  coal-miners 
this  may  occur  in  patches,  even  before  the  lung  tissue  is  uniformly  infiltrated. 
In  others  it  appears  only  after  the  entire  organs  have  become  so  laden  that 
they  are  dark  in  color,  and  an  ink-like  juice  flows  from  the  cut  surface.  The 
lungs  of  a  miner  may  be  black  throughout  and  yet  show  no  local  lesions  and  be 
everywhere  crepitant. 

Morbid  Anatomy. — In  anthracosis  the  particles  of  carbon  are  found  de- 
posited in  large  numbers  in  the  follicular  cords  of  the  tracheal  and  bronchial 
glands  and  of  the  peri-bronchial  and  peri-arterial  lymph  nodules,  and  in  these 
they  finally  excite  proliferation  of  the  connective  tissue  elements.  It  is  by  no 
means  uncommon  to  find  in  persons  whose  lungs  are  only  moderately  carbonized 
the  bronchial  glands  sclerosed  and  hard.  In  anthracosis  the  fibroid  changes 
usually  begin  in  the  peri-bronchial  lymph  tissue,  and  in  the  early  stage  of  the 
process  the  sclerosis  may  be  largely  confined  to  these  regions.  A  Nova  Scotian 
miner,  aged  thirty-six,  died  at  the  Montreal  General  Hospital,  of  black  small- 
pox, after  an  illness  of  a  few  days.  In  his  lungs  (externally  coal-blac£)  there 
were  round  and  linear  patches  ranging  in  size  from  a  pea  to  a  hazel-nut,  of  an 
intensely  black  color,  airless  and  firm,  and  surrounded  by  a  crepitant  tissue, 
slate  gray  in  color.  In  the  centre  of  each  of  these  areas  was  a  small  bronchus. 
Many  were  situated  just  beneath  the  pleura,  and  formed  typical  examples  of 
limited  fibroid  broncho-pneumonia.  In  addition  there  is  usually  thickening  of 
the  alveolar  walls,  particularly  in  certain  areas.  By  the  gradual  coalescence 
of  these  fibroid  patches  large  portions  of  the  lung  may  be  converted  into  firm 
areas  of  cirrhosis,  grayish  black  in  the  coal-miner,  steel  gray  in  the  stone- 
worker.  In  the  case  of  a  Cornish  miner,  aged  sixty-three,  one  of  these  fibroid 
areas  measured  18  by  6  cm.  and  4.5  cm.  in  depth. 

A  second  important  factor  is  chronic  bronchitis,  which  is.  present  in  a  large 
proportion  and  really  causes  the  chief  syptoms.  A  third  is  the  occurrence  of 
emphysema,  which  is  almost  invariably  associated  with  long-standing  cases 
of  pneumoconiosis.  With  the  changes  so  far  described,  unless  the  cirrhotic 
area  is  unusually  extensive,  the  case  may  present  the  features  of  chronic  bron- 
chitis with  emphysema,  but  finally  another  element  comes  into  play.  In  the 
fibroid  areas  softening  occurs,  |)robably  a  process  of  necrosis  similar  to  that 
by  which  softening  is  produced  in  fibro-myomata  of  the  uterus.  At  first  these 
•are  small  and  contain  a  dark  liquid.  Charcot  calls  them  ulceres  du  poumon. 
They  rarely  attain  a  .large  size  unless  a  communicaticn  is  formed  with  the 
bronchus,  in  which  case  they  may  become  converted  into  suppurating  cavities. 

Anthracosis  and  Tuberculosis. — In  the  Pennsylvania  anthracite  district  tu- 
berculosis is  relatively  less  common  among  the  miners,  the  figures  for  ten 
years  at  Scranton  for  male  adults  being  3.37  per  cent,  in  mine  workers,  9.97 
per  cent,  in  those  of  other  occupations  (Wainwright).  Goldman  in  Germany, 
Oliver  and  Trotter  in  England,  all  agree  upon  the  comparative  rarity  of  tu- 
berculosis among  coal  miners.  Dust  does  not  favor  tuberculosis  because  it 
excites  fibrosis  which  is  opposed  to  tuberculosis. 


638  DISEASES  OF  THE  EESPIEATOEY  SYSTEM 

Haldane  points  out  that  the  death  rate  among  old  miners  from  bronchitis 
is  exceptionally  high. 

Symptoms. — The  symptoms  do  not  come  on  until  the  patient  has  worked 
for  a  variable  number  of  years,  usually  twelve,  in  the  dusty  atmosphere.  As  a 
rule  there  are  cough  and  failing  health  for  a  prolonged  period  of  time  before 
complete  disability.  The  coincident  emphysema  is  responsible  in  great  part 
for  the  shortness  of  breath  and  wheezy  condition  of  these  patients.  The  ex- 
pectoration is  usually  muco-purulent,  often  profuse,  and  in  anthracosis  very 
dark  in  color — the  so-called  "black  spit,"  while  in  chalicosis  there  may  be  seen 
under  the  microscope  the  bright  angular  particles  of  silica. 

Even  with  the  physical  signs  of  cavity,  tubercle  bacilli  are  not  usually  pres- 
ent. It  is  remarkable  for  how  long  a  coal-miner  may  br'mg  up  sputum  laden 
with  coal  particles  even  when  there  are  signs  only  of  a  chronic  bronchitis. 
Many  of  the  particles  are  contained  in  the  cells  of  the  alveolar  epithelium.  In 
these  instances  it  appears  that  an  attempt  is  made  by  the  leucocytes  to  rid  the 
lungs  of  the  carbon  grains.  In  the  late  stages  the  condition  is  that  of  cirrhosis 
of  the  lungs. 

Diagnosis. — This  is  rarely  difficult;  the  expectoration  is  usually  character- 
istic. It  must  always  be  borne  in  mind  that  chronic  bronchitis  and  emphysema 
form  essential  parts  of  the  process  and  that  in  late  stages  there  may  be  tubercu- 
lous infection.  The  X-ray  picture  in  the  early  stages  shows  a  broadening  of 
the  normal  shadows  and  as  the  disease  advances  there  are  circumscribed  dense 
areas  throughout  both  lungs. 

Prophylaxis. — Much  has  been  done  to  reduce  the  prevalence  of  the  disease 
by  proper  ventilation  of  works  and  the  protection  of  the  men.  The  conversion 
of  dry  into  wet  mining  prevents  the  distribution  of  injurious  dust.  On  the 
whole  the  health  of  British  miners  is  good.  Silicosis  is  a  dangerous  condition 
and  in  the  Eand  and  Missouri  mines  the  average  age  at  death  of  198  cases  was 
36.7  years  (Lanza). 

Treatment. — This  is  practically  that  of  chronic  bronchitis  and  emphysema. 


IV.     EMPHYSEMA 

Definition. — The  condition  in  which  the  infundibular  passages  and  the 
alveoli  are  dilated  and  the  alveolar  walls  atrophied. 

Floyer  of  Litchfield  first  described  the  anatomical  condition  and  spoke  of 
the  disease  as  "flatulent  asthma"  (1698),  meaning  a  disorder  in  which  the 
lungs  were  blown  up  with  air. 

A  practical  division  may  be  made  into  compensatory,  hypertrophic,  and 
atrophic  forms,  the  acute  vesicular  emphysema,  and  the  interstitial  forms. 
The  last  two  do  not  in  reality  come  under  the  above  definition,  but  for  con- 
venience they  may  be  considered  here. 

I.    COMPENSATORY   EMPHYSEMA 

Whenever  a  region  of  the  lung  does  not  expand  fully  in  inspiration,  either 
another  portion  of  the  lung  must  expand  or  the  chest  wall  sink  in  order  to 
occupy  the  space.     The  former  almost  invariably  occurs.     We  have  already 


EMPHYSEMA  639 

mentioned  that  in  broncho-pneumonia  there  is  a  vicarious  distention  of  the 
air-vesicles  in  the  adjacent  healthy  lobules,  and  the  same  happens  in  the  neigh- 
borhood of  tuberculous  areas  and  cicatrices.  In  general  pleural  adhesions  there 
is  often  compensatory  emphysema,  particularly  at  the  anterior  margins  of  the 
lung.  The  most  advanced  example  of  this  form  is  seen  in  cirrhosis,  when  the 
unaffected  lung  increases  greatly  in  size,  owing  to  distention  of  the  air-vesicles. 
A  similar  though  less  marked  condition  is  seen  in  extensive  pleurisy  with  ef- 
fusion and  in  pneumothorax. 

At  first,  this  distention  is  a  simple  physiological  process  and  the  alveolar 
walls  are  stretched  but  not  atrophied.  Ultimately,  however,  in  many  cases  they 
waste  and  the  contiguous  air-cells  fuse,  producing  true  emphysema. 

■       II.     HYPEETEOPIC  EMPHYSEMA 

The  large-lunged  emphysema  of  Jenner,  also  known  as  substantive  or 
idiopathic  emphysema,  is  a  well-marked  clinical  affection,  characterized  by  en- 
largement of  the  lungs,  due  to  distention  of  the  air-cells  and  atrophy  of  their 
walls,  and  clinically  by  imperfect  aeration  of  the  blood  and  more  or  less  marked 
dyspnoea. 

Etiology. — Emphysema  is  the  result  of  persistently  high  intra-alveolar 
tension  acting  upon  a  congenitally  weak  lung  tissue.  Strongly  in  favor  of  the 
view  that  the  nutritive  change  in  the  air-cells  is  the  primary  factor  are  the 
markedly  hereditary  character  of  the  disease  and  the  frequency  with  which  it 
starts  early  in  life.  To  James  Jackson,  Jr.,  of  Boston,  we  owe  the  first  ob- 
servations on  the  hereditary  character  of  emphysema.  Working  under  Louis' 
direction,  he  found  that  in  18  out  of  28  cases  one  or  both  parents  were  affected. 

In  childhood  it  may  folloAv  recurring  asthmatic  attacks  due  to  adenoid 
vegetations.  It  may  occur,  too,  in  several  members  of  the  same  family.  We 
are  still  ignorant  as  to  the  nature  of  this  congenital  pulmonary  weakness. 
Cohnlieim  thinks  it  probably  due  to  a  defect  in  the  development  of  the  elastic- 
tissue  fibres — a  statement  which  is  borne  out  by  Eppinger's  observations. 

Heightened  pressure  within  the  air-cells  may  be  due  to  forcible  inspiration 
or  expiration.  Much  discussion  has  taken  place  as  to  the  part  played  by  these 
two  acts  in  the  production  of  the  disease.  The  inspiratory  theory  was  advanced 
by  Laennec  and  subsequently  modified  by  Gairdner,  who  held  that  in  chronic 
bronchitis  areas  of  collapse  were  induced,  and  compensatory  distention  took 
place  in  the  adjacent  lobules.  This  unquestionably  does  occur  in  the  vicarious 
or  compensatory  emphysema,  but  it  probably  is  not  a  factor  of  much  moment 
in  the  form  now  under  consideration.  The  expiratory  theory,  supported  by 
Mendelssohn  and  Jenner,  accounts  for  the  condition  in  a  more  satisfactory 
way.  In  all  straining  efforts  and  violent  attacks  of  coughing  the  glottis  is  closed 
and  the  chest  walls  strongly  compressed  by  muscular  efforts,  so  that  the  strain 
is  thrown  upon  those  parts  of  the  lung  least  protected,  as  the  apices  and  the 
anterior  margins,  where  we  always  find  the  emphysema  most  advanced.  The 
sternum  and  costal  cartilages  gradually  yield  to  the  heightened  intrathoracic 
pressure  and  are,  in  advanced  cases,  pushed  forward,  giving  the  characteristic 
rotundity  to  the  thorax. 

Freuxd's  Theory. — A  primary  disease  of  the  costal  cartilages — a  chronic 
hyperplasia  with  premature  ossification  brings  about  gradually  a  state  of  rigid 


640  DISEASES  OF  THE  EESPIEATORY  SYSTEM 

t 

dilatation  of  the  chest,  to  which  the  emphysema  is  secondary.     It  is  probable 

that  there  is  a  group  of  cases  in  which  such  changes  occur  in  young  persons, 

particularly  in  the  cartilages  of  the  first  three  ribs.    Niemeyer  met  with  a  few 

such  cases,  and  instances  have  been  reported  in  which  the  cartilages  increased 

in  size  and  stood  out  prominently.     For  such  a   condition  what  is  called 

Freund's  operation  (of  resection)  would  be  indicated. 

Of  other  etiological  factors  occupation  is  the  most  important.  The  dis- 
ease is  met  with  in  players  on  wind  instruments,  in  glass-blowers,  and  in  oc- 
cupations necessitating  heavy  lifting  or  .straining.  Whooping-cough  and  bron- 
chitis play  an  important  role,  not  so  much  in  the  changes  which  they  induce 
in  the  bronchi  as  in  consequence  of  the  prolonged  attacks  of  coughing. 

Morbid  Anatomy.- — The  thorax  is  capacious,  usually  barrel-shaped,  and  the 
cartilages  are  calcified.  On  removal  of  the  sternum,  the  anterior  mediastinum 
is  found  completely  occupied  by  the  margins  of  the  lungs,  and  the  pericardial 
sac  may  not  be  visible.  The  organs  are  very  large  and  have  lost  their  elas- 
ticity, so  that  they  do  not  collapse  either  in  the  thorax  or  when  placed  on  the 
table.  The  pleura  is  pale  and  there  is  often  an  absence  of  pigment,  sometimes 
in  patches,  termed  by  Virchow  albinism  of  the  lung.  To  the  touch  they  have 
a  peculiar,  downy,  feathery  feel,  and  pit  readily  on  pressure.  This  is  one  of 
the  most  marked  features.  Beneath  the  pleura  greatly  enlarged  air-vesicles 
may  be  readily  seen.  They  vary  in  size  from  .5  to  3  mm.,  and  irregular 
bullffi,  the  size  of  a  walnut  or  larger,  may  project  from  the  free  margins.  The 
best  idea  of  the  extreme  rarefaction  of  the  tissue  is  obtained  from  sections  of 
a  lung  distended  and  dried.  At  the  anterior  margins  the  structure  may  form 
an  irregular  series  of  air-chambers,  resembling  the  frog's  lung.  On  careful 
inspection,  remnants  of  the  interlobular  septa  or  even  of  the  alveoli  may  be 
seen  on  these  large  emphysematous  vesicles.  Though  general,  the  distention  is 
more  marked,  as  a  rule,  at  the  anterior  margins,  and  is  often  specially  marked 
at  the  inner  surface  of  the  lobe  near  the  root,  where  in  extreme  cases  air- 
spaces as  large  as  a  hen's  egg  may  sometimes  be  found.  Microscopically  there 
is  atrophy  of  the  alveolar  walls,  by  which  is  produced  a  coalescence  of  neigh- 
boring air-cells.  In  this  process  the  capillary  network  disappears  before  the 
walls  are  completely  atrophied.  The  loss  of  the  elastic  tissue  is  a  special  fea- 
ture. In  certain  cases  there  may  be  a  congenital  defect  in  the  development 
of  this  tissue.  The  epithelium  of  the  air-cells  undergoes  a  fatty  change,  but 
the  large  distended  air-spaces  retain  a  pavement  layer. 

The  bronchi  show  important  changes.  In  the  larger  tubes  the  mucous 
membrane  may  be  rough  and  thickened  from  chronic  bronchitis;  often  the 
longitudinal  lines  of  submucous  elastic  tissue  stand  out  prominently.  In  the 
advanced  cases  many  of  the  smaller  tubes  are  dilated,  particularly  when,  in 
addition  to  emphysema,  there  are  peri-bronchial  fibroid  changes.  Bronchiecta- 
sis is  not  an  invariable  accompaniment  of  emphysema,  but,  as  Laennec  re- 
marks, it  is  difficult  to  understand  why  it  is  not  more  common.  Of  associated 
morbid  changes  the  most  important  are  found  in  the  heart.  The  right  cham- 
bers are  dilated  and  hypertrophied,  the  tricuspid  orifice  is  large,  and  the  valve 
segments  are  often  thickened  at  the  edges.  In  advanced  cases  the  cardiac 
hypertrophy  is  general.  The  pulmonary  artery  and  its  branches  may  be  wide 
and  show  marked  atheromatous  changes. 

The  changes  in  the  other  organs  are  those  commonly  associated  with  pro-;. 


EMPHYSEMA  641 

longed  venous  congestion.  Pneumothorax  may  follow  the  rupture  of  an  em- 
physematous bleb. 

Symptoms. — The  disease  may  be  tolerably  advanced  before  any  special 
symptoms  occur.  A  child^  for  instance,  may  be  somewhat  short  of  breath  on 
going  upstairs  or  may  be  unable  to  run  and'  play  as  other  children  without 
great  discomfort;  or,  perhaps,  has  attacks  of  slight  lividity.  Doubtless  much 
depends  upon  the  completeness  of  cardiac  compensation.  When  this  is  perfect, 
there  may  be  no  special  interruption  of  the  pulmonary  circulation  and,  except 
with  violent  exertion,  there  is  no  interference  with  the  aeration  of  the  blood. 
In  well-marked  cases  the  following  are  the  inost  important  symptoms:  Dysp- 
noea,  which  may  be  felt  only  on  slight  exertion,  or  may  be  persistent,  and  ag- 
gravated by  intercurrent  attacks  of  bronchitis.  The  respirations  are  often 
harsh  and  wheezy,  and  expiration  is  distinctly  prolonged. 

Cyanosis  of  an  extreme  grade  is  more  common  in  emphysema  than  in  other 
affections  with  the  exception  of  congenital  heart-disease.  It  is  one  of  the  few 
diseases  in  which  a  patient  may  be  able  to  go  about  and  walk  into  the  hospital 
or  consulting-room  with  a  lividity  of  startling  intensity.  The  contrast  between 
the  extreme  cyanosis  and  the  comparative  comfort  of  the  patient  is  very  strik- 
ing. In  other  affections  of  the  heart  and  lungs  associated  with  a  similar  degree 
of  cyanosis  the  patient  is  invariably  in  bed  and  usually  in  a  state  of  orthopnoea. 
One  condition  must  be  referred  to,  viz.,  the  extraordinary  cyanosis  in  cases  of 
poisoning  by  aniline  products,  which  is  in  most  part  due  to  the  conversion  of 
the  haemoglobin  into  methtemoglobin. 

Bronchitis  with  associated  cough  is  frequent  and  often  the  direct  cause  of 
the  pulmonary  distress.  The  contrast  between  emphysematous  patients  in  the 
winter  and  summer  is  marked  in  this  respect.  In  the  latter  they  may  be 
comfortable  and  able  to  attend  to  their  work,  but  with  the  cold  and  changeable 
weather  they  are  laid  up  with  attacks  of  bronchitis.  Finally  the  two  condi- 
tions become  inseparable  and  the  patient  has  persistently  more  or  less  cough. 
The  acute  bronchitis  may  produce  attacks  not  unlike  asthma.  In  some  in- 
stances this  is  true  spasmodic  asthma,  with  which  emphysema  is  frequently 
associated. 

As  age  advances,  and  with  successive  attacks  of  bronchitis,  the  condition 
grows  slowly  worse.  In  hospital  practice  it  is  common  to  admit  patients  over 
sixty  with  well  marked  signs  of  advanced  emphysema.  The  affection  can 
generally  be  told  at  a  glance — the  rounded  shoulders,  barrel  chest,  the  thin  yet 
oftentimes  muscular  form,  and  sometimes  a  characteristic  facial  expression. 
There  is  another  group  of  patients  from  twenty-five  to  forty  years  of  age  who, 
winter  after  winter,  have  attacks  of  intense  cyanosis  in  consequence  of  an  ag- 
gravated bronchial  catarrh.  On  inquiry  we  find  that  these  patients  have  been 
short-breathed  from  infancy,  and  they  belong  to  a  category  in  which  there  has 
been  a  primary  defect  of  structure  in  the  lung  tissue. 

Physical  Signs. — Inspection. — The  thorax  is  markedly  altered  in  shape; 
the  antero-posterior  diameter  is  increased  and  may  be  even  greater  than  the 
lateral,  so  that  the  chest  is  barrel-shaped.  The  appearance  is  somewhat  as  if 
the  chest  was  in  a  permanent  inspiratory  position.  The  sternum  and  costal 
cartilages  are  prominent.  The  lower  zone  of  the  thorax  looks  large  and  the 
intercostal  spaces  are  much  widened,  particularly  in  the  hypochondriac  regions. 
The  sternal  fossa  is  deep,  the  clavicles  stand  out  with  great  prominence,  and 


643  DISEASES  OF  THE  EESPIRATOEY  SYSTEM 

the  neck  looks  shortened  from  the  elevation  of  the  thorax  and  the  sternum.  A 
zone  of  dilated  venules  may  be  seen  along  the  line  of  attachment  of  the  dia- 
phragm. Though  this  is  common  in  emphysema,  it  is  by  no  means  peculiar 
to  it  or  indeed  to  any  special  affection. 

The  curve  of  the  spine  is  iiicreased  and  the  back  is  remarkably  rounded, 
so  that  the  scapulae  seem  to  be  almost  horizontal.  Mensuration  shows  the 
rounded  form  of  the  chest  and  the  very  slight  expansion  on  deep  inspiration. 
The  respiratory  movements,  which  may  look  energetic  and  forcible,  exercise 
little  or  no  influence.  The  chest  does  not  expand,  but  there  is  a  general  ele- 
vation. The  inspiratory  effort  is  short  and  quick;  the  expiratory  movement  is 
prolonged.  There  may  be  retraction  instead  of  distention  in  the  upper  ab- 
dominal region  during  inspiration,  and  a  transverse  curve  crossing  the  ab- 
domen at  the  level  of  the  twelfth  rib  is  sometimes  seen.  The  apex  beat  of  the 
heart  is  not  visible,  and  there  is  usually  marked  pulsation  in  the  epigastric 
region.    The  cervical  veins  stand  out  prominently  and  may  pulsate. 

Palpation. — The  vocal  fremitus  is  somewhat  enfeebled  but  not  lost.  The 
apex  beat  can  rarely  be  felt.  There  is  a  marked  shock  in  the  lower  sternal 
region  and  very  distinct  pulsation  in  the  epigastrium.  Percussion  gives  greatly 
increased  resonance,  full  and  drum-like — hyperresonance.  The  note  is  not  often 
distinctly  tympanitic.  There  may  be  marked  variations  in  the  note  in  local 
areas.  The  area  of  resonance  is  greatly  extended,  the  heart  dulness  may  be 
obliterated,  the  upper  limit  of  liver  dulness  is  greatly  lowered,  and  the  reso- 
nance may  extend  to  the  costal  margin.  Behind,  a  clear  percussion  note  extends 
to  a  much  lower  level  than  normal.  The  level  of  splenic  dulness,  too,  may  be 
lowered. 

On  auscultation  the  breath-sounds  are  usually  enfeebled  and  may  be  masked 
by  brohchitic  rales.  The  most  characteristic  feature  is  the  prolongation  of 
the  expiration,  and  the  normal  ratio  may  be  reversed — 4  to  1  instead  of  1  to  4. 
It  is  often  wheezy  and  harsh  and  associated  with  coavse  rales  and  sibilant 
rhonchi.  It  is  said  that  in  interstitial  emphysema  there  may  be  a  friction 
sound  heard,  not  unlike  that  of  pleurisy.  The  heart-sounds  are  usually  feeble 
but  clear;  in  advanced  cases,  when  there  is  marked  cyanosis,  a  tricuspid  re- 
gurgitant murmur  may  be  heard.  Accentuation  of  the  pulmonary  second  sound 
may  be  present. 

Course. — This  is  slow  but  progressive,  the  recurring  attacks  of  bronchitis 
aggravating  the  condition.  Death  may  occur  from  intercurrent  pneumonia, 
either  lobar  or  lobular,  and  dropsy  may  supervene  from  cardiac  failure.  Oc- 
casionally death  resuits  from  overdistention  of  the  heart,  with  extreme  cyanosis. 
Duckworth  has  called  attention  to  the  occasional  occurrence  of  fatal  hsemor- 
rhage  in  emphysema.  In  an  old  emphysematous  patient  at  the  Montreal  Gen- 
eral Hospital  death  followed  the  erosion  of  a  main  branch  of  the  pulmonary 
artery  by  an  ulcer  near  the  bifurcation  of  the  trachea. 

Treatment. — Practically,  the  measures  mentioned  in  connection  with 
bronchitis  should  be  employed.  In  children  with  asthma  and  emphysema  the 
nose  should  be  carefully  examined.  No  remedy  is  known  which  has  any  influ- 
ence over  the  progress  of  the  condition  itself.  Bronchitis  is  the  great  danger 
of  these  patients,  and  therefore  when  possible  they  should  live  in  an  equable 
climate.  They  do  well  in  southern  California  and  in  Egypt.  In  consequence 
of  the  venous  engorgement  they  are  liable  to  gastric  and  intestinal  disturbance, 


GANGRENE  OF  THE  LUNG  643 

and  it  is  particularly  important  to  keep  the  bowels  regulated  and  to  avoid 
flatulency,  which  often  seriously  aggravates  the  dyspnoea.  Patients  who  come 
into  the  hospital  in  a  state  of  urgent  dyspnoea  and  lividity,  with  great  engorge- 
ment of  the  veins,  particularly  if  they  are  young  and  vigorous,  should  be  bled 
freely.  Inhalation  of  oxygen  may  be  used.  Epinephrin  hypodermically  (nx  xv, 
1  c.  c.)  often  gives  relief.  Strychnine  will  be  found  useful.  In  children,  with 
insufficiency  of  expiration  and  the  lower  edge  of  the  lungs  below  the  usual  level, 
pressure  on  the  lower  ribs  may  correct  this.  Breathing  exercises  to  aid  expira- 
tion are  helpful.  Breathing  of  compressed  air  in  a  pneumatic  cabinet  gives 
temporary  relief.  Resection  of  the  first  costal  cartilage  or  of  the  first  three 
cartilages  on  either  side  has  been  practised  (Freund's  operation).  It  is  not 
likely  to  be  of  any  benefit  in  the  aged  in  whom  the  condition  is  established,  but 
in  a  special  group  in  the  young  in  which  the  primary  trouble  appears  to  be 
in  the  cartilages  good  results  may  follow. 

III.     ATEOPHIC  EMPHYSEMA 

A  senile  change,  called  by  Sir  William  Jenner  small-lunged  emphysema,  is 
really  a  primary  atrophy  of  the  lung,  coming  on  in  advanced  life,  and  scarcely 
constitutes  a  special  afl:ection.  It  occurs  in  "withered-looking  old  persons" 
who  may  perhaps  have  had  a  winter  cough  and  shortness  of  breath  for  years.  In 
striking  contrast  to  the  essential  hypertrophic  emphysema,  the  chest  is  small 
and  the  ribs  obliquely  placed.  The  thoracic  muscles  are  usually  atrophied. 
The  lung  is  converted  into  a  series  of  large  vesicles,  on  the  walls  of  which  th3 
remnants  of  air-cells  may  be  seen. 

IV,     ACUTE  VESICULAR  EMPHYSEMA. 

When  death  occurs  from  bronchitis  of  the  smaller  tubes  or  diffuse  broncho- 
pneumonia, when  strong  inspiratory  efforts  have  been  made,  the  lungs  are  larga 
in  volume  and  the  air-cells  much  distended.  Clinically,  this  condition  may 
occur  rapidly  in  cardiac  dyspnoea  and  angina  pectoris.  The  area  of  pulmo- 
nary resonance  is  much  increased,  and  piping  rales  and  prolonged  expiration 
are  heard  everywhere.     A  similar  condition  may  follow  pressure  on  the  vagi. 

V.     INTERSTITIAL    EMPHYSEMA 

Beads  of  air  are  seen  in  the  interlobular  and  subpleural  tissue,  sometimes 
forming  large  bull^  beneath  the  pleura.  A  rare  event  is  rupture  close  to  the 
root  of  the  lung,  and  the  passage  of  air  along  the  trachea  into  the  subcuta- 
neous tissues  of  the  neck.  After  tracheotomy  just  the  reverse  may  occur  and 
the  air  may  pass  from  the  tracheotomy  wound  along  the  windpipe  and  bronchi 
and  appear  beneath  the  surface  of  the  pleura.  From  this  inte^~stitial  emphy- 
sema spontaneous  pneumothorax  may  arise  in  healthy  persons. 


V.     GANGRENE  OF  THE  LUNG 

Etiolo^. — Gangrene  of  the  lung  is  not  an  affection  per  se,  but  occurs  in 
a  variety  of  conditions  when  necrotic  areas  undergo  putrefaction.  It  is  not 
easy  to  say  why  gangrene  should  occur  in  one  case  and  not  in  another,  as  the 


644  DISEASES  OF  THE  RESPIEATOEY  SYSTEM 

germs  of  putrefaction  are  always  in  tlie  air-passages^,  and  yet  necrotic  territories 
larely  become  gangrenous.  Total  obstruction  of  a  pulmonary  artery,  as  a  rule, 
causes  infarction,  and  the  area  shut  off  does  not  often,  though  it  may,  slough. 
Another  factor  would  seem  to  be  necessary — probably  a  lowered  tissue  resist- 
ance, the  result  of  general  or  local  causes.  It  is  met  with  (1)  as  a  sequence  of 
lobar  pneumonia.  This  rarely  occurs  in  a  previously  healthy  person — more 
commonly  in  the  debilitated  or  in  the  diabetic  subject.  (2)  Gangrene  is  very 
prone  to  follow  aspiration  pneumonia,  since  the  foreign  particles  rapidly  un- 
dergo putrefactive  changes.  Of  a  similar  nature  are  the  cases  of  gangrene  due 
to  perforation  of  cancer  of  the  cesoi)hagus  into  the  lung  or  into  the  bronchus. 
(3)  The  putrid  contents  of  a  bronchiectatic,  more  commonly  of  a  tuberculous, 
cavity  may  excite  gangrene  in  the  neighboring  tissues.  The  pressure  bron- 
chiectasis following  aneurism  or  tumor  may  lead  to  extensive  sloughing.  (4) 
Gangrene  may  folloAV  simple  embolism  of  the  pulmonary  artery.  More  com- 
monly, however,  the  embolus  is  derived  from  a  part  which  is  mortified  or  comes 
from  a  focus  of  bone  disease.  In  typhus  and  in  typhoid  fever  gangrene  of 
the  lung  may  follow  thrombosis  of  one  of  the  larger  branches  of  the  pulmonary 
artery.  Lastly,  gangrene  of  the  lung  may  occur  in  conditions  of  debility  dur- 
ing convalescence  from  protracted  fever — occasionally,  indeed,  without  our 
being  able  to  assign  any  reasonable  cause. 

Morbid  Anatomy. — Laennec,  who  first  accurately  described  pulmonary 
gangrene,  recognized  a  diffuse  and  a  circumscribed  form.  The  former,  though 
rare,  is  sometimes  seen  in  connection  with  pneumonia,  more  rarely  after  ob- 
literation of  a  large  branch  of  the  pulmonary  artery.  It  may  involve  the  greater 
part  of  a  lobe,  and  the  lung  tissue  is  converted  into  a  horribly  offensive  green- 
ish-black mass,  torn  and  ragged  in  the  centre.  In  the  circumscribed  form  there 
is  well-marked  limitation  between  the  gangrenous  area  and  the  surrounding 
tissue.  The  focus  may  be  single  or  there  may  be  two  or  more.  The  lower 
lobe  is  more  commonly  affected  than  the  upper,  and  the  peripheral  more  than 
the  central  portion  of  the  lung.  A  gangrenous  area  is  at  first  uniformly  green- 
ish brown  in  color;  but  softening  rapidly  takes  place  with  the  formation  of  a 
cavity  with  shreddy,  irregular  walls  and  a  greenish,  offensive  fluid.  The  lung 
tissue  in  the  immediate  neighborhood  shows  a  zone  of  deep  congestion,  often 
consolidation,  and  outside  this  an  intense  oedema.  In  the  embolic  cases  the 
plugged  artery  can  sometimes  be  found.  AAlien  rapidly  extending,  vessels  may 
be  opened  and  a  copious  haemorrhage  ensue.  Perforation  of  the  pleura  is  not 
uncommon.  The  irritating  decomposing  material  usually  excites  the  most 
intense  bronchitis.  Embolic  processes  are  not  infrequent.  There  is  a  remark- 
able association  in  some  cases  between  circumscribed  gangrene  of  the  lung  and 
abscess  of  the  brain. 

Symptoms  and  Course. — Usually  definite  symptoms  of  local  pulmonary 
disease  precede  the  characteristic  features  of  gangrene.  These,  of  course,  are 
very  varied,  depending  on  the  primary  disease.  The  sputum  is  very  character- 
istic. It  is  intensely  fetid — usually  profuse — and,  if  expectorated  into  a  conical 
glass,  separates  into  three  layers — a  greenish  brown,  heavy  sediment ;  an  inter- 
vening thin  liquid,  which  sometimes  has  a  greenish  or  a  broA\TLish  tint;  and,  on 
top,  a  thick,  frothy  layer.  Spread  on  a  glass  plate,  the  shreddy  debris  of  lung 
tissue  can  readily  be  picked  out.  Even  large  fragments  of  lung  may  be  coughed 
up.    Eobertson,  of  Onancock,  Va.,  sent  one  several  centimetres  in  length,  which 


ABSCESS  OF  THE  LUNG  645 

had  been  expectorated  by  a  lad  of  eighteen,  who  had  severe  gangrene  and  re- 
covered. Microscopically,  elastic  fibres  are  found  in  abundance,  with  granular 
matter,  pigment  grains,  fatty  crystals,  bacteria,  and  leptothrix.  It  is  stated 
that  elastic  tissue  is  sometimes  absent.  The  peculiar  plugs  of  sputum  which 
occur  in  bronchiectasis  are  not  found.  Blood  is  often  present,  and,  as  a  rule,  is 
much  altered.  The  sputum  has,  in  a  majority  of  the  cases,  an  intensely  fetid 
odor,  which  is  communicated  to  the  breath  and  may  permeate  the  entire  room. 
It  is  much  more  offensive  than  in  fetid  bronchitis  or  in  abscess  of  the  lung. 
The  fetor  is  particularly  marked  when  there  is  free  communication  between 
the  gangrenous  cavities  and  the  bronchi.  Localized  gangrene,  unsuspected 
during  life  and  in  which  there  had  been  no  fetor  of  the  breath,  may  be  found 
post  mortem. 

The  physical  signs,  when  extensive  destruction  has  occurred,  are  those  of 
cavity,  but  the  limited  circumscribed  areas  may  be  difficult  to  detect.  Bron- 
chitis is  always  present.     The  X-ray  examination  aids  in  diagnosis. 

Among  the  general  symptoms  may  be  mentioned  fever,  usually  of  moder- 
ate grade;  the  pulse  is  rapid,  and  very  often  the  constitutional  depression  is 
severe.  But  the  only  special  features  indicative  of  gangrene  are  the  sputum 
and  the  fetor  of  the  breath.  The  patient  generally  sinks  from  exhaustion. 
Fatal  hsemorrhage  may  ensue. 

Treatment. — This  is  very  unsatisfactory.  The  indication  is  to  disinfect 
the  gangrenous  area,  but  this  is  often  impossible.  An  antiseptic  spray  of 
carbolic  acid  may  be  employed.  A  good  plan  is  for  the  patient  to  use  over  the 
mouth  and  nose  an  inhaler,  which  may  be  charged  with  a  solution  of  carbolic 
acid  or  guaiacol ;  the  latte'r  drug  has  also  been  used  hypodermically,  with,  it  is 
said,  happy  results  in  removing  the  odor.  If  the  signs  of  cavity  are  distinct 
an  attempt  should  be  made  to  cleanse  it  by  direct  injections  of  an  antiseptic 
solution.  If  the  patient's  condition  is  good  and  the  gangrenous  region  can  be 
localized,  surgical  interference  is,  indicated.  The  general  condition  of  the 
patient  is  always  such  as  to  demand  the  greatest  care  in  the  matter  of  diet  and 
nursing. 

VI.     ABSCESS  OF  THE  LUNG 

Etiology. — Suppuration  occurs  in  the  lung  under  the  following  condi- 
tions: (1)  As  a  sequence  of  inflammation,  either  lobar  or  lobular.  Apart 
from  the  purulent  infiltration  this  is  rare,  and  even  in  lobar  pneumonia  the 
abscesses  are  of  small  size  and  usually  involve,  as  Addison  remarked,  several 
pointi?  at  the  same  time.  On  the  other  hand,  abscess  formation  is  frequent  in 
the  deglutition  and  aspiration  forms  of  broncho-pneumonia.  After  wounds  of 
the  neck  or  operations  uJ3on  the  throat,  particularly  the  tonsils,  in  suppurative 
disease  of  the  nose  or  larynx,  occasionally  even  of  the  ear  (Yolkmann),  in- 
fective particles  reach  the  bronchi  by  aspiration  and  excite  an  intense  inflam- 
mation which  often  ends  in  abscess.  Cancer  of  the  oesophagus,  perforating  the 
root  of  the  lung  or  into  the  bronchi,  may  produce  extensive  suppuration.  The 
abscesses  vary  in  size  from  a  walnut  to  an  orange,  have  ragged  and  irregular 
walls,  and  purulent,  sometimes  necrotic,  contents. 

(2)  Embolic,  so-called  metastatic,  abscesses,  the  result  of  infective  emboli, 
are  extremely  common  in  pyaemia.     They  may  be  numerous  and  present  very 


646  DISEASES  OF  THE  EESPIEATOEY  SYSTEM 

definite  diaracters.  As  a  rule  they  are  superficial,  beneath  the  pleura,  and 
often  wedge-shaped.  At  first  firm,  grayish  red  in  color,  and  surrounded  by  a 
zone  of  intense  hypergemia,  suppuration  soon  follows  with  the  formation  of  a 
definite  abscess.  The  pleura  is  usually  covered  with  greenish  lymph,  and  per- 
foration sometimes  takes  place  with  the  production  of  pneumothorax. 

(3)  Perforation  of  the  lung  from  without,  lodgment  of  foreign  bodies, 
and,  in  the  right  lung,  perforation  from  abscess  of  the  liver  or  a  suppurating 
echinococcus  cyst  are  occasionally  causes  of  pulmonary  abscess. 

(4)  Suppurative  processes  play  an  important  part  in  chronic  pulmonary 
tuberculosis,  many  of  the  symptoms  of  which  are  due  to  them. 

Symptoms. — Abscess  following  pneumonia  is  easily  recognized  by  an  aggra- 
vation of  the  general  symptoms  and  by  the  physical  signs  of  cavity  and  the 
character  of  the  expectoration.  Embolic  abscesses  can  not  often  be  recognized, 
and  the  local  symptoms  are  generally  masked  in  the  general  pyasmic  manifesta- 
tions. The  character  of  the  sputum  is  of  great  importance  in  determining  the 
presence  of  abscess.  The  odor  is  offensive,  yet  it  rarely  has  the  horrible  fetor 
of  gangrene  or  of  putrid  bronchitis.  Fragments  of  lung  tissue  and  elastic 
tissue  with  alveolar  arrangement  may  be  found.  The  presence  of  this  with  the 
physical  signs  and  the  X-ray  examination  rarely  leave  any  question  as  to  the 
diagnosis.  Embolic  cases  usually  run  a  fatal  course.  Eecovery  occasionally 
occurs  after  pneumonia.  In  a  case  following  typhoid  fever  Kerr  removed  two 
ribs  and  found  free  in  the  pus  of  a  localized  empyema  a  sequestered  piece  of 
lung,  the  size  of  the  palm  of  the  hand,  which  had  sloughed  off  from  the  lower 
lobe.     The  patient  made  a  good  recovery. 

Treatment. — The  patient  should  lie  with  the  affected  side  uppermost  as 
much  as  possible.  The  X-ray  picture  is  sometimes  a  guide  as  to  the  best  po- 
sition to- favor  drainage.  The  foot  of  the  bed  should  be  elevated  and  the  pa- 
tient lie  without  a  pillow.  The  head  should  be  lowered  over  the  side  of  the 
bed  during  paroxysms  of  coughing.  When  the  abscess  is  well-defined  and  su- 
perficial, an  attempt  .may  be  made  to  open  and  drain  it.  Artificial  pneumo- 
thorax has  been  suggested  when  the  abscess  is  connected  with  a  bronchus.  The 
patient  should  be  kept  in  the  open  air  if  possible  and  given  a  liberal  diet. 


VII.    NEW  GROWTHS  IN  THE  LUNGS 

Etiology  and  Morbid  Anatomy. — While  primary  tumors  are  rare,  second- 
arv  growths  are  not  uncommon.  Carcinoma  is  the  most  common  primary 
form.  Endothelium  and  sarcoma  are  less  frequent.  Hypernephroma  often 
has  metastases  in  the  lungs. 

Varieties. — The  following  groups  may  be  recognized : 

(a)  Acute  pleuro-pneumonic  form,  with  a  very  rapid  course — dyspnoea, 
cough,  asphyxia,  rapid  emaciation  and  death  in  from  six  to  twelve  weeks.  Most 
of  these  cases  are  secondary,  sometimes  to  unrecognized  disease  elsewhere,  but 
there  are  instances  of  primary  disease  of  this  type.  It  is  a  remarkable  fact 
that  cobalt  miners  of  Schneeberg  are  very  liable  to  a  primary  carcinoma  of  the 
lung  which  may  run  this  acute  course. 

(b)  CiTRONTc  PLEURO-PULMONARY  CARCINOMA,  of  which  there  are  several 
types:     (1)  Broncho-pulmonary  Form. — This,  the  most  typical  variety,  begins 


ACUTE  PLEURISY  647 

vith  bronchial  symptoms,  bloody  sputum,  loss  of  weight  and  strength,  and 
uJuTmia.  The  physical  signs  may  be  suggestive  of  tuberculosis,  but  the  earliest 
indications  are  usually  at  the  root  of  the  lung.  Later  there  may  be  cavity  for- 
mation, with  a  bronchiectatic  type  of  sputum.  Tubercle  bacilli  are  absent  and 
there  may  be  very  large  round  cells  with  many  fatty  granules,  representing 
degenerate  cancer  cells.  The  X-ray  picture  is  not  distinctive  and  the  cases  are 
usually  taken  for  tuberculosis. 

(2)  Mediastinal  Type. — Quite  early  in  this  form  the  glands  become  in- 
volved, increase  rapidly,  compress  the  adjoining  structures  and  the  type  of  the 
disease  is  that  of  a  mediastinal  tumor  with  its  dominant  pressure  symptoms. 

(3)  Pleuritic  Type. — Many  of  the  cases  are  primary  endothelioma  of  the 
pleura  of  which  Keilty  found  9  in  5,000  autopsies.  The  earliest  and  dominant 
symptoms  are  at  the  back  with  pleuritic  pain,  cough,  friction,  progressive  ef- 
fusion, and  shortness  of  breath.  On  tapping,  the  effusion  is  usually  bloody, 
though  at  first  it  may  be  clear.  In  other  instances  the  pleura  is  early  involved 
with  rapid  extension,  but  no  effusion.  There  may  be  little  or  no  cough,  and 
very  slight  dyspnoea,  with  progressive  weakness,  emaciation,  and  anaemia  as 
the  chief  features.  Subcutaneous  nodules  may  occur  along  the  ribs,  with 
widespread  metastases  in  the  lymph  glands  and  internal  organs. 

From  the  standpoint  of  treatment  not  much  is  to  be  expected.  The  new 
surgical  technique  has  made  the  thoracic  cavity  accessible,  and  it  is  possible 
that  early  explorations  may  become  common  in  doubtful  cases.  In  a  few  in- 
stances operation  has  been  done ;  in  Lenhartz'  case  the  patient  remained  well 
for  a  year,  and  died  two  and  a  half  years  after  operation. 


E.    DISEASES  OF  THE  PLEURA 

I.     ACUTE  PLEURISY 

Anatomically,  the  cases  may  be  divided  into  dry  or  adhesive  pleurisy  and 
pleurisy  with  effusion.  Another  classification  is  into  primary  or  secondary 
forms.  According  to  the  course,  a  division  may  be  made  into  ncvte  and  clironic 
pleurisy,  and  as  it  is  impossible,  at  present,  to  group  the  various  forms  etio- 
logically,  this  is  perhaps  the  most  satisfactory  division. 

I.     FIBEINOUS   OR  PLASTIC  PLEURISY 

In  this  the  pleural  membrane  is  covered  by  a  sheeting  of  lymph  of  variable 
thickness,  which  gives  it  a  turbid,  granular  appearance,  or  the  fibrin  may  exist 
in  distinct  layers.  It  occurs  (1)  as  an  independent  affection,  following  cold 
or  exposure.  This  form  of  acute  plastic  i^leurisy  without  fluid  exudate  is  not 
common  in  perfectly  healthy  individuals.  Cases  are  met  with,  however,  in 
which  the  disease  sets  in  with  the  usual  symptoms  of  pain  in  the  side  and 
slight  fever,  and  there  are  the  physical  signs  of  fibrinous  pleurisy.  After  per- 
sisting for  a  few  days,  the  friction  murmur  disappears  and  no  exudation  oc- 
curs.    Union  takes  place  between  the  membranes,  and  possibly  the  pleuritic 


648  DISEASES  OF  THE  EESPIEATOEY  SYSTEM 

adhesions  which  are  found  in  such  a  large  percentage  of  all  bodies  examined 
after  death  originate  in  these  slight  fibrinous  pleurisies. 

Fibrinous  pleurisy  occurs  (2)  as  a  secondary  process  in  acute  diseases  of 
the  lung,  such  as  pneumonia,  which  is  always  accompanied  by  a  certain  amount 
of  pleurisy,  usually  of  this  form.  Cancer,  abscess,  and  gangrene  also  cause 
plastic  pleurisy  when  the  surface  of  the  lung  becomes  involved.  This  condi- 
tion is  speciall}"  associated  in  a  large  number  of  cases  with  tuberculosis.  Pleu- 
ral pain,  stitch  in  the  side,  and  a  dry  cough,  with  marked  friction  sounds  on 
auscultation,  are  the  initial  phenomena  in 'many  instances  of  pulmonary  tu- 
berculosis.    The  pleural  signs  are  usually  basic. 

II.     SERO-FIBEIXOUS   PLEUEISY 

In  a  majority  of  cases  there  is,  with  the  fibrin,  a  variable  amount  of  fluid 
exudate,  which  produces  the  condition  known  as  pleurisy  with  effusion. 

Etiology. — Of  19-i  cases  in  fifteen  years  in  the  Hopkins  Hospital,  there 
were  161  males  and  33  females.  Under  twenty  years  of  age  there  were  20 
patients;  18  were  over  sixty  years  of  age.  The  greatest  number  was  in  the  fifth 
decade,  59.  Cold  acts  as  a  predisposing  agent,  which  permits  the  action  of 
various  micro-organisms.  A  majority  of  the  cases  are  tuberculous.  This  view 
is  based  upon:  (1)  Post  mortem  evidence.  Tubercles  have  been  found  in 
acute  cases,  thought  to  have  been  "rheumatic"  or  due  to  cold.  (2)  The  not 
infrequent  presence  of  tuberculous  lesions,  often  latent,  in  the  lung  or  else- 
where. (3)  The  character  of  the  exudate.  If  coagulated  and  the  coagulum 
digested  and  centrifugalized,  tubercle  bacilli  are  frequently  found.  Injected 
into  a  guinea  pig,  in  amounts  of  15  c.  c.  or  more,  tuberculosis  followed  in  62 
per  cent.  (Eichhorst).  The  cytodiagnosis  shows  that  as  in  other  tuberculous 
exudates  the  mono-nuclear  leucocytes  predominate.  (1)  The  tuberculin  re- 
action is  given  in  a  considerable  percentage  of  the  cases.  (5)  The  subsequent 
history.  Of  90  cases  of  acute  pleurisy  which  had  been  under  the  observation 
of  H.  I.  Bovrditch  between  1849  and  1879,  32  died  of  or  had  pulmonary  tu- 
berculosis. Among  130  patients  with  primary  joleurisy  with  eft'usion,  followed 
for  a  period  of  seven  years  by  Hedges,  40  per  cent,  became  tuberculous. 

Of  300  uncomplicated  cases  of  pleural  effusion  in  the  Massachusetts  Gen- 
eral Hospital,  folloAved  by  E.  C.  Cabot,  the  subsequent  history  was  ascertained 
in  221;  followed  five  years  until  death  or  pulmonary  tuberculosis,  117;  well 
after  five  years^  96.  In  172  of  the  cases  of  pleurisy  with  effusion  in  the  Johns 
Hopkins  Hospital  Hamman  got  reports  from  88;  of  these  4S  were  living  and 
well,  30  later  became  tuberculous,  in  2  the  result  was  questionable,  and  8 
died  of  other  diseases.  Twelve  of  the  88  had  tubercle  bacilli  in  the  sputum 
while  in  the  hospital  without  discoverable  pulmonary  lesion ;  3  of  the  13  were 
living  and  well;  in  8  the  signs  became  well  marked;  one  died  of  unknown 
cause.  Hamman  collected  562  cases  (including  the  above)  in  which  the  sub- 
sequent history  was  sought;  of  these  167,  29.7  per  cent,  became  tuberculous. 

Bacteriolo^  of  Acute  Pleurisy. — From  a  bacteriological  standpoint  we 
may  recognize  three  groups  of  cases,  caused  by  the  tubercle  bacillus,  the  pneu- 
mococcus,  and  the  streptococcus,  respectively. 

Bacillus  tuberculosis  is  present  in  a  very  large  proportion  of  all  cases  of 
primary  or  so-called  idiopathic  pleurisy.     The  exudate  is  usually  sterile  on 


ACUTE  PLEURISY  649 

cover  slips  or  in  the  culture  and  inoculation  tests  made  in  the  ordinar}'  way, 
as  the  bacilli  are  very  scanty.  It  has  been  demonstrated  clearly  that  a  large 
amount  of  the  exudate  must  be  taken  to  make  the  test  complete,  either  in  cul- 
tures or  in  the  inoculation  of  animals.  Eichhorst  found  that  more  than  63 
per  cent,  were  demonstrated  as  tuberculous  when  as  much  as  15  c.  c.  of  the 
exudate  was  inoculated  into  test  animals,  while  less  than  10  per  cent,  of  the 
cases  showed  tuberculosis  when  only  1  c.  c.  of  the  exudate  was  used.  This  is  a 
point  to  which  observers  should  pay  very  special  attention.  Le  Damany  has 
demonstrated  the  tuberculous  character  of  all  but  4  in  55  primary  pleurisies. 
He  used  large  quantities  of  the  fluid  for  his  inoculation  experiments. 

The  pneumococcus  pleurisy  is  almost  always  secondary  to  a  focus  of  in- 
flammation in  the  lung.  It  may,  however,  be  primary.  The  exudate  is  usually 
purulent  and  the  outlook  is  favorable. 

The  streptococcus  pleurisy  is  the  typical  septic  form  which  may  occur 
either  from  direct  infection  of  the  pleura  through  the  lung  in  broncho-pneu- 
monia, or  in  cases  of  streptococcus  pneumonia;  in  other  instances  it  follows 
infection  of  more  distant  parts.  The  acute  streptococcus  pleurisy  is  the  most 
serious  and  fatal  of  all  forms. 

Among  other  bacteria  which  have  been  found  are  the  staphylococcus, 
Friedlander's  bacillus,  the  typhoid  bacillus,  and  the  diphtheria  bacillus. 

Morbid  Anatomy. — In  sero-fibrinous  pleurisy  the  serous  exudate  is  abun- 
dant and  the  fibrin  is  found  on  the  pleural  surfaces  and  scattered  through  the 
fluid  in  the  form  of  flocculi.  The  proportions  of  these  constituents  vary  a 
great  deal.  In  some  instances  there  is  very  little  membranous  fibrin ;  in  others 
it  forms  thick,  creamy  layers  and  exists  in  the  dependent  part  of  the  fluid  as 
whitish,  curd-like  masses.  The  fluid  is  of  a  lemon  color,  either  clear  or  slightly 
turbid,  depending  on  the  number  of  formed  elements.  In  some  instances  it 
has  a  dark  brown  color.  The  microscopic  examination  shows  leucocytes,  oc- 
casional swollen  cells,  which  may  be  derived  from  the  pleural  endothelium, 
shreds  of  fibrillated  fibrin,  and  a  variable  number  of  red  blood-corpuscles.  A 
large  number  of  cells  undergoing  mitotic  division  is  diagnostic  of  malignant 
disease.  The  fluid  is  rich  in  albumin  and  sometimes  coagulates  spontaneously. 
Its  composition  closely  resembles  that  of  blood  serum.  Cholesterin,  uric  acid, 
and  sugar  are  occasionally  found.  The  amount  of  the  efl'usion  varies  from  i/^ 
to  4  litres.  Enormous  amounts  are  sometimes  removed,  188  ounces  in  one  case 
(E.  C.  Carter).  The  lung  in  serofibrinous  pleurisy  is  more  or  less  compressed. 
If  the  exudation  is  limited  the  lower  lobe  alone  is  atelectatic:  but  in  an  ex- 
tensive efl'usion  which  reaches  to  the  clavicle  the  entire  lung  will  be  found 
lying  close  to  the  spine,  dark  and  airless,  or  even  bloodless — i.  e.,  carnified. 

In  large  exudations  the  adjacent  organs  are  displaced;  the  liver  is  de- 
pressed and  the  heart  dislocated.  With  reference  to  the  position  of  the  heart, 
the  following  statements  may  be  made:  (1)  Even  in  the  most  extensive  left 
sided  exudation  there  is  no  rotation  of  the  apex  of  the  heart,  which  in  no  case 
was  to  the  right  of  the  mid-sternal  line;  (2)  the  relative  position  of  the  apex 
and  base  is  usually  maintained ;  in  some  instances  the  apex  is  lifted,  in  others 
the  whole  heart  lies  more  transversely;  (3)  the  right  chambers  of  the  heart 
occupy  the  greater  portion  of  the  front,  so  that  the  displacement  is  rather  a 
definite  dislocation  of- the  mediastinum,  with  the  pericardium,  to  the  rio-Jit 


650  DISEASES  OF  THE  EESPIRATOEY  SYSTEM 

than  any  special  twisting  of  the  heart  itself;  (4)  the  kink  or  twist  in  the  in- 
ferior vena  cava  described  by  Bartels  may  be  present. 

Symptoms. — Prodromes  are  not  uncommon,  but  the  disease  may  set  in 
abruptly  with  a  chill,  followed  by  fever  and  a  severe  pain  in  the  side.  In  very 
many  cases,  however,  the  onset  is  insidious,  particularly  in  children  and  in 
elderly  persons.  A  little  dyspnoea  on  exertion  and  an  increasing  pallor  may 
be  the  only  features.  Washbourn  has  called  attention  to  the  frequency  with 
which  the  pneumococcus  pleurisy  sets  in  with  the  features  of  pneumonia.  The 
pain  in  the  side  is  the  most  distressing  symptom,  and  is  usually  referred  to 
the  nipple  or  axillary  regions.  It  must  be  remembered,  however,  that  pleuritic 
pain  may  be  felt  in  the  abdomen  or  low  down  in  the  back,  particularly  when 
the  diaphragmatic  surface  of  the  pleura  is  involved.  It  is  lancinating,  sharp, 
and  severe,  and  is  aggravated  by  cough.  At  this  early  stage,  on  auscultation, 
sometimes  indeed  on  palpation,  a  dry  friction  rub  can  be  detected.  The  fever 
rarely  rises  so  rapidly  as  in  pneumonia,  and  does  not  reach  the  same  grade.  A 
temperature  of  from  102°  to  103°  F.  is  an  average  pyrexia.  It  may  drop  to 
normal  at  the  end  of  a  week  or  ten  days  without  any  definite  change  in  the 
physical  signs,  or  may  persist  for  several  weeks.  The  temperature  of  the  af- 
fected is  higher  than  that  of  the  sound  side.  Cough  is  an  early  symptom  in 
acute  pleurisy,  but  is  rarely  so  distressing  or  frequent  as  in  pneumonia.  There 
are  instances  in  which  it  is  absent.  The  expectoration  is  usually  slight  in 
amount,  mucoid,  and  occasionally  streaked  with  blood. 

At  the  outset  there  may  be  dyspnoea,  due  partly  to  the  fever  and  partly  to 
the  pain  in  the  side.  Later  it  results  from  the  compression  of  the  lung,  par- 
ticularly if  the  exudation  has  taken  place  rapidly.  In  the  cases  with  very 
rapid  effusion  the  dyspnoea  may  be  marked.  When,  however,  the  fluid  is 
effused  slowly,  one  lung  may  be  entirely  compressed  without  inducing  short- 
ness of  breath,  except  on  exertion,  and  the  patient  will  lie  quietly  in  bed  with- 
out evincing'the  slightest  respiratory  distress.  When  the  effusion  is  large  the 
patient  usually  prefers  to  lie  upon  the  affected  side. 

Physical  Signs.— Inspection  shows  some  degree  of  immobility  on  the  af- 
fected side,  depending  upon  the  amount  of  exudation ;  and  in  large  effusions 
an  increase  in  volume,  which  may  appear  to  be  much  more  than  it  really  is  as 
determined  by  mensuration.  The  intercostal  depressions  are  obliterated.  In 
right  sided  effusions  the  apex  beat  may  be  lifted  to  the  fourth  interspace,  be 
pushed  beyond  the  left  nipple,  or  even  be  seen  in  the  axilla.  When  the  exuda- 
tion is  on  the  left  side,  the  heart  impulse  may  not  be  visible ;  but  if  the  effusion 
is  large  it  is  seen  in  the  third  and  fourth  spaces  on  the  right  side,  and  some- 
times'as  far  out  as  the  nipple,  or  even  beyond  it.  In  massive  effusion  on  the  left 
side  there  may  be  a  prominence  below  the  left  costal  margm. 

Palpation  enables  us  to  determine  the  deficient  movements  on  the  affected 
side,  the  obliteration  of  the  intercostal  spaces,  and  more  accurately  to  define 
the  position  of  the  heart's  impulse.  In  simple  .serofibrinous  effusion  there  is 
rarely  any  oedema  of  the  chest  walls.  It  is  scarcely  ever  possible  to  obtain  fluc- 
tuation. Tactile  fremitus  is  greatly  diminished  or  abolished.  If  the  effusion 
is  slight  there  may  be  only  enfeeblement.  The  absence  of  the  voice  vibrations  in 
effusions  of  any  size  is  the  most  valuable  physical  sign.  In  children  and  oc- 
casionally in  adults  there  may  be  much  effusion  with  retention  of  fremitus. 


ACUTE  PLEUEISY  651 

In  rare  cases  the  vibrations  may  be  communicated  to  the  chest  walls  through 
localized  pleural  adhesions. 

Mensuration. — With  the  cyrtometer,  if  the  effusion  is  excessive,  a  differ- 
ence of  from  half  an  inch  to  an  inch,  or  even,  in  large  effusions,  an  inch  and 
a  half,  may  be  found  between  the  two  sides.  Allowance  must  be  made  for  the 
fact  that  the  right  side  is  naturally  larger  than  the  left. 

Percussion. — Early  in  the  disease  there  may  be  no  alteration,  but  with  the 
gradual  accumulation  of  the  fluid  the  resonance  becomes  defective,  and  finally 
gives  place  to  flatness.  Erom  day  to  day  the  gradual  increase  in  height  of  the 
fluid  may  be  studied.  In  a  pleuritic  effusion  rising  to  the  fourth  rib  in  front 
the  percussion  signs  are  usually  very  suggestive.  In  the  subclavicular  region 
the  attention  is  often  aroused  at  once  by  a  tympanitic  note,  the  so-called 
Skoda's  resonance,  which  is  heard  perhaps  more  commonly  in  this  situation 
with  pleural  eft'usion  than  in  any  other  condition.  It  shades  into  a  flat  note 
in  the  lower  mammary  and  axillary  regions.  Tympany  may  be  obtained  also 
behind,  just  above  the  limit  of  effusion.  The  dulness  has  a  peculiarly  resist- 
ant, wooden  quality,  differing  from  that  of  pneumonia  and  readily  recognized 
by  skilled  fingers.  When  the  patient  is  in  the  erect  posture  the  upper  line  of 
dulness  is  not  horizontal,  but  is  higher  behind  than  in  front,  forming  a  para- 
bola. The  curve  marking  the  intersection  of  the  plane  of  contact  of  lung  and 
fluid  with  the  chest  wall  is  known  as  "Ellis's  line''  which  Garland  verified 
clinically  and  by  animal  experiments.  With  medium-sized  effusions  this  line 
begins  lowest  behind,  advances  upward  and  forward  in  a  letter-S  curve  to  the 
axillary  region,  whence  it  proceeds  in  a  straight  decline  to  the  sternum.  This 
curve  is  demonstrable  only  when  the  patient  is  in  the  erect  position.  Grocco, 
in  1903,  called  attention  to  the  existence  in  pleural  effusion  of  a  triangular 
area  of  relative  dulness,  along  the  spine,  on  the  side  opposite  to  the  pleurisy,  in 
width  from  2  to  5  cm.,  and  with  the  apex  upward.  It  can  be  demonstrated  in 
a  large  majority  of  all  case's,  particularly  in  young  and  thin  persons.  It  is  pos- 
sibly due  to  the  bulging  of  the  mediastinum,  by  the  fluid,  across  the  middle 
line,  the  anatomical  possibility  of  which  has  been  pointed  out  by  Calvert. 

On  the  right  side  the  dulness  passes  without  change  into  that  of  the  liver. 
On  the  left  side  in  the  nipple  line  it  extends  to  and  may  obliterate  Traube's 
semilunar  space.  If  the  effusion  is  moderate,  the  phenomenon  of  movable  dul- 
ness may  be  obtained  by  marking  carefully,  in  the  sitting  posture,  the  upper 
limit  in  the  mammary  region,  and  then  in  the  recumbent  posture,  noting  the 
change  in  the  height  of  dulness.  This  sign  of  fluid  can  not  always  be  obtained. 
In  very  copious  exudation  the  dulness  may  reach  the  clavicle  and  even  extend 
beyond  the  sternal  margin  of  the  opposite  side. 

Auscultation. — Early  in  the  disease  a  friction  rub  may  be  heard,  which 
disappears  as  the  fluid  accumulates.  It  is  a  to-and-fro  dry  rub,  close  to  the 
car,  and  has  a  leathery,  creaking  character.  There  is  another  pleural  friction 
sound  which  closely  resembles,  and  is  scarcely  to  be  distinguished  from,  the 
fine  crackling  crepitus  of  pneumonia.  This  may  be  heard  at  the  commence- 
ment of  the  disease,  and  also,  as  pointed  out  in  1841  by  MacDonnell,  Sr.,  of 
Montreal,  when  the  effusion  has  receded  and  the  pleural  layers  come  together 
again. 

With  even  a  slight  exudation  there  is  weakened  or  distant  breathing.  Often 
inspiration  and  expiration  are  distinctly  audible,  though  distant,  and  have  a 


652  DISEASES  OF  THE  EESPIEATOEY  SYSTEM 

tubular  quality.  Sometimes  only  a  puflBng  tubular  expiration  is  heard,  which 
may  have  a  metallic  or  amphoric  quality.  Loud  resonant  rales  accompanying 
this  may  forcibly  suggest  a  cavity.  These  pseudo-cavernous  signs  are  met 
with  more  frequently  in  children,  and  often  lead  to  error  in  diagnosis.  Above 
the  line  of  dulness  the  breath  sounds  are  usually  harsh  and  exaggerated,  and 
may  have  a  tubular  quality. 

The  vocal  resonance  is  usually  diminished  or  absent.  The  whispered  voice 
is  said  to  be  transmitted  through  a  serous  and  not  through  a  purulent  exudate 
(Baccelli's  sign),  but  this  is  not  always  true.  This  author  advises  direct  aus- 
cultation in  the  antero-lateral  region  of  the  chest.  There  may,  however,  be 
intensification — bronchophony.  The  voice  sometimes  has  a  curious  nasal, 
squeaking  character,  which  was  termed  by  Laennec  cegophony,  from  its  supposed 
resemblance  to  the  bleating  of  a  goat.  In  t3^pical  form  this  is  not  common, 
but  it  is  by  no  means  rare  to  hear  a  curious  twang-like  quality  in  the  voice, 
particularly  at  the  outer  angle  of  the  scapula. 

In  the  examination  of  the  heart  it  is  well  to  bear  in  mind  that  when  the 
apex  of  the  heart  lies  beneath  the  sternum  there  may  be  no  impulse.  The 
determination  of  the  situation  of  the  organ  may  rest  with  the  position  of 
maximum  loudness  of  the  sounds.  Over  the  displaced  organ  a  systolic  murmur 
may  be  heard.  When  the  lappet  of  lung  over  the  pericardium  is  involved  on 
either  side  there  may  be  a  pleuro-pericardial  friction. 

Blood  Count. — Emerson  studied  the  histories  of  89  cases  of  acute  pleurisy 
with  effusion  in  which  blood  counts  were  made  before  the  temperature  reached 
normal.  Only  26  had  a  leucocytosis  between  10,000  and  15,000;  one  only 
above  15,000.    In  12  of  the  cases  the  count  was  below  5,000. 

The  X-RAY  PICTURES  are  of  great  interest  and  of  much  value  in  diagnosis. 
They  show  that  the  effusion  is  not  always  in  the  lower  portion  of  the  chest 
with  the  patient  in  the  upright  position,  but  that  it  may  represent  a  vertical 
column  in  the  lateral  aspect  of  the  chest,  compressing  the  lung  toward  the 
spine.  The  effusion  is  not  always  mobile,  but  may  be  fixed  by  adhesions  in  one 
position. 

Course. — The  course  of  acute  sero-fibrinous  pleurisy  is  very  variable.  After 
persisting  for  a  week  or  ten  days  the  fever  subsides,  the  cough  and  pain  dis- 
appear, and  a  slight  effusion  may  be  quickly  absorbed.  In  cases  in  which  the 
effusion  reaches  as  high  as  the  fourth  rib  recovery  is  usually  slower.  Many  in- 
stances come  under  observation  for  the  first  time,  after  two  or  three  weeks'  in- 
disposition, with  the  fluid  at  a  level  with  the  clavicle.  The  fever  may  last  from 
ten  to  twenty  days  without  exciting  anxiety,  though,  as  a  rule,  in  ordinary 
l^leurisy,  the  temperature  in  cases  of  moderate  severity  is  normal  within  eight 
or  ten  days.  Left  to  itself,  the  natural  tendency  is  to  resorption  ;  but  this  may 
take  place  very  slowly.  With  the  absorption  of  the  fluid  there  is  a  redux-fric- 
tion  crepitus,  either  leathery  and  creaking  or  crackling  and  rale-like,  and  for 
months,  or  even  longer,  the  defective  resonance  and  feeble  breathing  are  heard 
at  the  base.  Eare  modes  of  termination  are  perforation  and  discharge  through 
the  lung,  and  externally  through  the  chest  wall,  examples  of  which  have  been 
recorded  by  Sahli. 

The  immediate  irrogtiosis  in  pleurisy  with  effusion  is  good.  Of  320  cases 
at  St.  Bartholomew's  Hospital,  only  6.1  per  cent,  died  before  leaving  the  hos- 
pital   (Hedges).     A  sero-fibrinous  exudate  may  persist  for  months  Avithout 


ACUTE  PLEFTJTSY  653 

change,  particularly  in  tuberculous  cases,  and  will  sometimes  reaccumulato 
after  aspiration  and  resist  all  treatment.  After  persistence  for  more  than 
twelve  months^  in  spite  of  repeated  tapping,  a  serous  effusion  Avas  cured  by 
incision  without  deformity  of  the  chest  (S.  West).  "When  one  pleura  is  full 
and  the  heart  is  greatly  dislocated,  the  condition,  although  in  a  majority  of 
cases  producing  remarkably  little  disturbance,  is  not  without  risk. 

III.     PUEULENT  PLEURISY 

{Empyema) 

Etiology. — Pus  in  the  pleura  is  due  to  (a)  infection  from  within,  as  a 
rule  directly  from  a  patch  of  pneumonia  or  a  septic  focus  in  the  lung,  or  in 
some  cases  a  tuberculous  broncho-pneumonia;  (6)  involvement  from  without, 
as  in  fracture  of  a  rib,  penetrating  wound,  disease  of  oesophagus,  etc.  It  fre- 
quently follows  the  infectious  diseases,  particularly  scarlet  fever.  It  is  very 
often  latent,  and  due  to  undiscovered  pneumonia.  It  is  common  in  children, 
more  in  boys  than  in  girls,  and  between  the  ages  of  one  and  five  and  eight  and 
nine. 

The  pneumococcus  is  the  most  common  organism,  then  the  ordinary  pus 
organisms  and  tubercle  bacilli;  in  rare  cases  the  influenza  bacillus,  and  even 
psorosperms,  have  been  found. 

Morbid  Anatomy. — On  opening  an  empyema  post  mortem  Ave  usually  find 
that  the  effusion  has  separated  into  a  clear,  greenish  yellow  serum  above  and 
the  thick,  cream-like  pus  below.  The  fluid  may  be  scarcely  more  than  turbid, 
with  flocculi  of  fibrin  through  it.  In  the  pneumococcus  empyema  the  pus  is 
usually  thick  and  creamy.  It  usually  has  a  heavy,  sweetish  odor,  but  in  some 
instances — particularly  those  following  wounds — it  is  fetid.  In  cases  of  gan- 
grene of  the  lung  or  pleura  the  pus  has  a  horribly  stinking  odor.  Microscop- 
ically it  has  the  characters  of  ordinary  pus.  The  pleural  membranes  are  greatly 
thickened,  and  present  a  grayish  Avhite  layer  from  1  to  2  mm.  in  thickness. 
On  the  costal  pleura  there  may  be  erosions,  and  in  old  cases  fistulous  com- 
munications are  common.  The  lung  may  be  compressed  to  a  very  small  limit, 
and  the  visceral  pleura  also  may  show  perforations. 

Symptoms. — Purulent  pleurisy  may  begin  abruptly,  with  the  symptoms 
already  described;  More  frequently  it  comes  on  insidiously  in  the  course  of 
other  diseases  or  follows  an  ordinary  sero-fibrinous  pleurisy.  There  may  be  no 
pain  in  the  chest,  very  little  cough,  and  no  dyspnoea,  unless  the  side  is  very 
full.  Symptoms  of  septic  infection  are  rarely  wanting.  If  in  a  child,  there 
is  a  gradually  developing  pallor  and  weakness;  sAveats  occur,  and  there  is  ir- 
regular fever.  A  cough  is  by  no  means  constant.  The  leucocytes  are  usually 
much  increased;  in  one  fatal  case  they  numbered  115,000  per  c.  mm. 

Physical  Signs. — Practically  they  are  those  already  considered  in  pleurisy 
with  effusion  but  there  are  one  or  tAA^o  additional  points  to  be  mentioned.  In 
empyema,  particularly  in  children,  the  disproportion  between  the  sides  may  be 
extreme.  The  intercostal  spaces  may  not  only  bo  obliterated,  but  may  bulge. 
Not  infrequently  there  is  oedema  of  the  chest  Avails.  The  netAvork  of  sub- 
cutaneous veins  may  be  very  distinct.  It  must  not  be  forgotten  that  in  children 
the  breath-sounds  may  be  loud  and  tubular  over  a  purulent  effusion  of  con- 


654  DISEASES  OF  THE  RESPIEATOEY  SYSTEM 

eiderable  size.  The  dislocation  of  the  heart  and  displacement  of  the  liver  are 
more  marked  in  empyema  than  in  serous  effusion — probably,  as  Senator  sug- 
gests, owing  to  the  greater  weight  of  the  fluid. 

A  curious  phenomenon  associated  generally  with  empyema,  but  sometimes 
occurring  in  the  sero-fibrinous  exudate,  is  pulsating  pleurisy,  first  described 
by  MacDonnell,  Sr.,  of  Montreal.  In  95  cases  collected  by  Sailer  it  was  much 
more  frequent  in  males  than  in  females.  In  38  there  was  a  tumor;  that  is, 
empyema  necessitatis.  In  all  but  one  case  the  fluid  was  purulent.  Pneumo- 
thorax may  be  present.  There  are  two  groups  of  cases,  the  intrapleural  pul- 
sating pleurisy  and  the  pulsating  empyema  necessitatis,  in  which  there  is  an 
external  pulsating  tumor.  'No  satisfactory  explanation  has  been  offered  how 
the  heart  impulse  is  thus  forcibly  communicated  through  the  effusion. 

Empyema  is  a  chronic  affection,  which  in  a  few  instances  terminates 
naturally  in  recover}^,  but  a  majority  of  cases,  if  left  alone,  end  in  death. 
The  following  are  some  modes  of  natural  cure:  (a)  By  absorption  of  the 
fluid.  In  small  effusions  this  may  take  place  gradually.  The  chest  wall  sinks. 
The  pleural  layers  become  greatly  thickened  and  enclose  between  them  the 
inspissated  pus,  in  which  lime  salts  are  gradually  deposited.  Such  a  condition 
may  be  seen  once  or  twice  a  year  in  the  post  mortem  room  of  any  large  hos- 
pital, (h)  By  perforation  of  the  lung.  Although  in  this  event  death  may 
take  place  rapidly,  by  suffocation,  as  Aretseus  says,  yet  in  cases  in  which  it 
occurs  gradually  recovery  may  follow.  Empyema  may  discharge  either  by 
ojsening  into  the  bronchus  and  forming  a  fistula,  or,  as  Traube  pointed  out, 
by  producing  necrosis  of  the  pulmonary  pleura,  sufficient  to  allow  the  soaking 
of  the  pus  through' the  spongy  lung  tissue  into  the  bronchi.  In  the  first  way 
pneumothorax  usually,  though  not  always,  develops.  In  the  second  way  the 
pus  is  discharged,  without  formation  of  pneumothorax.  Even  with  a  bron- 
chial fistula  recovery  is  possible,  (c)  By  perforation  of  the  chest  wall — 
empyema  necessitatis.  This  is  by  no  means  an  unfavorable  method,  as  many 
cases  recover.  The  perforation  may  occur  anywhere  in  the  chest  wall,  but  is, 
as  Cruveilhier  remarked,  more  common  in  front.  It  may  be  anywhere  from 
the  third  to  the  sixth  interspace,  usually,  according  to  Marshall,  in  the  fifth. 
It  may  perforate  in  more  than  one  place,  and  there  may  be  a  fistulous  com- 
munication which  opens  into  the  pleura  at  some  distance  from  the  exteraal 
orifice.  The  tumor,  when  near  the  heart,  may  pulsate.  The  discharge  may 
persist  for  years.  In  Copeland's  Dictionary  is  mentioned  an  instance  of  a 
Bavarian  physician  who  had  a  pleural  fistula  for  thirteen  years  and  enjoyed 
fairly  good  health. 

An  empyema  may  perforate  the  neighboring  organs,  the  oesophagus,  peri- 
toneum, pericardium,  or  the  stomach.  A  remarkable  sequel  is  a  pleuro- 
oesophageal  fistula,  of  which  cases  have  been  reported  by  Voelcker,  Thursfield, 
and  Osier.  In  one  case  there  was  a  fistulous  communication  through  the 
chest  wall.  Very  remarkable  cases  are  those  which  pass  down  the  spine  and 
along  the  psoas  into  the  iliac  fossa,  and  simulate  a  psoas  or  lumbar  abscess. 

Encapsulated  Empyema. — In  lobar  or  broncho-pneumonia,  pockets  of 
pus  from  the  size  of  an  egg  to  an  orange  may  form.  A  good  many  cases 
were  met  with  in  the  streptococcus  empyema  during  the  War,  and  H.  M. 
Thomas,  Jr.,  calls  attention  to  the  frequency  of  abdominal  pain  and  meteor- 


ACUTE  PLEUEISY  655 

ism,  the  early  prostration,  the  high  leukocytosis,  and  the  danger  of  rupture 
into  the  pleura.     The  condition  may  be  revealed  only  by  the  X-ray  picture.  • 

IV.     TUBEECULOSIS  PLEUEISY 

This  has  already  been  considered  (p.  178),  and  the  symptoms  and  physical 
signs  do  not  require  any  description  other  than  that  already  given  in  connec- 
tion with  the  sero-fibrinous  and  purulent  forms. 

V.     OTHEE  VAEIETIES  OF  PLEUEISY 

Haemorrhagic  Pleurisy. — A  bloody  effusion  is  met  with  under  the  follow- 
ing conditions:  (a)  In  the  pleurisy  of  asthenic  states,  such  as  cancer,  nephri- 
tis, and  occasionally  in  the  malignant  fevers.  It  is  interesting  to  note  the 
frequency  with  which  hgemorrhagic  pleurisy  is  found  in  cirrhosis  of  the  liver. 
It  occurred  in  the  very  patient  in  whom  Laennec  first  accurately  described 
this  disease.  While  this  may  be  a  simple  hemorrhagic  pleurisy,  in  a  majority 
of  the  cases  it  has  been  tuberculous,  (h)  Tuberculous  pleurisy,  in  which 
the  bloody  effusion  may  result  from  the  rupture  of  newly  formed  vessels 
in  the  soft  exudate  accompanying  the  eruption  of  miliary  tubercles,  or  it  may 
come  from  more  slowly  formed  tubercles  in  a  pleurisy  secondary  to  extensive 
pulmonary  disease,  (c)  Cancerous  pleurisy,  whether  primary  or  secondary,  is 
frequently  hEemorrhagic.  (d)  Occasionally  hgemorrhagic  exudation  is  met 
with  in  perfectly  healthy  individuals,  in  whom  there  is  not  the  slightest 
suspicion  of  tuberculosis  or  cancer.  In  one  such  case,  a  large,  able-bodied 
man,  the  patient  was  healthy  and  strong  eight  years  afterward.  And,  lastly, 
it  must  be  remembered  that  during  aspiration  the  lung  may  be  wounded 
and  blood  in  this  way  be  mixed  with  the  sero-fibrinous  exudate.  The  condi- 
tion of  hgemorrhagic  pleurisy  is  to  be  distinguished  from  hsemothorax. 

Diaphragmatic  Pleurisy. — The  inflammation  may  be  limited  partly  or 
chiefly  to  the  diaphragmatic  surface.  This  is  often  a  dry  pleuris}^,  but  there 
may  be  effusion,  either  sero-fibrinous  or  purulent,  which  is  circumscribed  on 
the  diaphragmatic  surface.  In  these  cases  the  pain  is  low  in  the  zone  of  the 
diaphragm  and  may  simulate  that  of  acute  abdominal  disease.  It  may  be 
intensified  by  pressure  at  the  point  of  insertion  of  the  diaphragm  at  the  tenth 
rib.  The  diaphragm  is  fixed  and  the  respiration  is  thoracic  and  short. 
Andral  noted  severe  dyspnoea  and  attacks  simulating  angina  in  some  cases. 
The  effusion  is  usually  plastic,  not  serous.  Serous  or  purulent  effusions  of 
any  size  limited  to  the  diaphragmatic  surface  are  extremely  rare.  Intense 
subjective  with  trifling  objective  features  are  suggestive  of  diaphragmatic 
pleurisy. 

Encysted  Pleurisy. — The  effusion  may  be  circumscribed  by  adhesions  or 
separated  into  tw^o  or  more  pockets  or  loculi,  which  communicate  with  each 
other.  This  is  most  common  in  empyema.  In  these  cases  there  have  usu- 
ally been,  at  different  parts  of  the  pleura,  multiple  adhesions  by  which  the 
fluid  is  limited.  In  other  instances  the  recent  false  membranes  may  encapsu- 
late the  exudation  on  the  diaphragmatic  surface,  for  example,  or  the  part  of 
the  pleura  posterior  to  the  mid-axillary  line.  In  some  cases  the  tactile  fremitus 
is  retained  along  certain  lines  of  adhesion.     The  condition  may  be  very  puz- 


656  DISEASES  OF  THE  EESPIEATOEY  SYSTEM 

zling  and  present  special  difficulties  in  diagnosis.  The  exploratory  needle 
should  be  freely  used  and  the  X-rays  employed. 

Interlobar  pleurisy  forms  an  interesting  and  not  uncommon  variety.  In 
nearly  every  instance  of  acute  pleurisy  the  interlobar  serous  surfaces  are  also 
involved  and  closely  agglutinated  together,  and  sometimes  the  fluid  is  encysted 
between  them.  In  this  position  tubercles  are  to  be  carefully  looked  for.  In 
a  case  of  this  kind  following  pneumonia  there  was  an  enormous  purulent 
collection  between  the  lower  and  upper  and  middle  lobes  of  the  right  side 
which  looked  at  first  like  a  large  abscess  of  the  lung.  These  collections  may 
perforate  the  bronchi,  and  the  cases  present  special  difficulties  in  diagnosis. 

Chylothorax. — This  is  a  rare  condition  first  described  by  Bartolet  in  1633. 
E.  H,  Funk  found  only  54  cases  of  chylous  effusion  reported  (1918).  Three 
forms  of  milk-like  effusion  occur ;  (1)  chylous,  (2)  chyliform,  and  (3)  pseudo- 
chylous. The  cause  of  the  chylous  effusion  is  trauma,  in  which  the  thoracic 
duct  is  ruptured,  or  pressure  causing  a  backward  flow  along  the  pulmonary 
and  pleural  lymphatics.  The  fluid  accumulates  rapidly.  The  signs  are  those 
of  a  serous  effusion  and  the  diagnosis  is  made  only  by  aspiration.  The  fluid 
is  milky  in  appearance  and  contains  fat  in  minute  globules.  The  fat  may  be 
as  high  as  4  per  cent.  The  specific  gravity  exceeds  1.012.  The  chyliform 
effusion  is  usually  associated  with  tuberculosis  or  neoplasm  and  accumulates 
slowly.  The  milky  appearance  is  regarded  as  due  to  fat  liberated  by  the  break- 
ing down  of  leucoc3'tes  and  endothelial  cells  which  have  undergone  fatty  de- 
generation. The  pseudo-chylous  fluid  has  a  specific  gravity  below  1.012  and 
is  poor  in  solids.  It  occurs  in  heart  disease,  amyloid  disease,  and  nephritis 
(syphilitic?). 

Treatment. — Injury  to  the  thoracic  duct  during  operation  may  require 
ligation.  For  the  effusion  tapping  is  indicated  if  pressure  symptoms  are  pres- 
ent but  a  large  amount  should  not  be  removed  at  one  time.  Any  underlying 
condition  should  receive  proper  treatment. 

Diagnosis  of  Pleurisy 
Acute  plastic  pleurisy  is  readily  recognized.  In  the  diagnosis  of  pleuritic 
effusion  the  first  question  is.  Does  a  fluid  exudate  exist?  the  second,  What 
is  its  nature?  In  large  effusions  the  increase  in  the  size  of  the  affected  side, 
the  immobility,  the  absence  of  tactile  fremitus^  together  with  the  displace- 
ment of  organs,  give  infallible  indications  of  the  presence  of  fluid.  The  chief 
difficulty  arises  in  effusions  of  moderate  extent,  when  the  dulness,  the  pres- 
ence of  bronchophony,  and,  perhaps,  tubular  breathing  may  simvilate  pneu- 
monia. The  chief  points  to  be  borne  in  mind  are:  (a)  Differences  in  the 
onset  and  in  the  general  characters  of  the  two  affections,  more  particularly 
the  initial  chill,  the  higher  fever,  more  urgent  dyspncea,  and  the  rusty  expecto- 
ration, which  characterize  pneumonia.  As  already  mentioned,  some  of  the 
cases  of  pneumococcus  pleurisy  set  in  like  pneumonia.  (&)  Certain  physical 
signs — the  more  wooden  character  of  the  dulness,  the  greater  resistance,  and 
the  marked  diminution  or  the  absence  of  tactile  fremitus  in  pleurisy.  The 
auscultatory  signs  may  be  deceptive.  It  is  usually,  indeed,  the  persistence  of 
tubular  breathing,  particularly  the  high-pitched,  even  amphoric  expiration, 
heard  in  some  cases  of  pleurisy,  which  has  raised  the  doubt.  The  intercostal 
spaces  are  more  commonly  obliterated  in  pleuritic  effusion  than  in  pneumonia. 


ACUTE  PLEURISY  657 

The  displacement  of  organs  is  a  very  valuable  sign.  Xowadays  with  an 
exploring  needle  the  question  is  easily  settled.  In  cases  of  doubt  the  explora- 
tory puncture  should  be  made  without  hesitation.  Pus  is  sometimes  not 
obtained  if  too  small  a  needle  is  used.  Pneumothorax  is  an  occasional  se- 
quence. .The  needle  is  especially  useful  in  those  cases  in  which  there  are 
pseudo-cavernous  signs  at  the  base.  In  cases,  too,  of  massive  pneumonia,  in 
which  the  bronchi  are  plugged  with  fibrin,  if  the  patient  has  not  been  seen 
from  the   outset,  the   diagnosis  may  be   impossible   without  it. 

On  the  left  side  it  may  be  difficult  to  differentiate  a  very  large  pericardial 
from  a  pleural  effusion.  The  retention  of  resonance  at  the  base,  the  presence 
of  tympany  toward  the  axilla,  the  absence  of  dislocation  of  the  heart-beat 
to  the  right  of  the  sternum,  the  feebleness  of  the  pulse  and  of  the  heart- 
sounds,  and  the  urgency  of  the  dyspnoea,  out  of  all  proportion  to  the  extent 
of  the  effusion,  are  the  chief  points  to  be  considered.  Hydrothorax,  which  is 
not  uncommon  in  heart-disease,  presents  signs  identical  with  those  of  sero- 
fibrinous effusion.  Certain  tumors  within  the  chest  may  simulate  pleural 
effusion.  It  should  be  remembered  that  many  intrathoracic  growths  are 
accompanied  by  exudation.  Malignant  disease  of  the  lung  and  of  the  pleura 
and  hydatids  of  the  pleura  produce  extensive  dulness,  with  suppression  of  the 
breath-sounds,  simulating  closely  effusion. 

On  the  right  side,  abscess  of  the  liver,  subdiaphragmatic  abscess,  and  hy- 
datid cysts  may  rise  high  into  the  pleura  and  produce  dulness  and  enfeebled 
breathing.  Often  in  these  cases  there  is  a  friction  sound,  which  should  excite 
suspicion,  and  the  upper  outline  of  the  dulness  is  sometimes  plainly  convex. 
In  a  case  of  cancer  of  the  kidney  the  growth  involved  the  diaphragm  very 
early,  and  for  months  there  were  signs  of  pleurisy  before  our  attention  was 
directed  to  the  kidney.  In  all  cases  of  doubt  the  X-ray  examination  is  a  great 
aid ;  exploratory  puncture  should  be  done  without  hesitation. 

The  second  question,  as  to  the  nature  of  the  fluid,  is  quickly  decided  by 
the  use  of  the  needle.  The  persistent  fever,  the  occurrence  of  sweats,  a  leuco- 
cytosis,  and  the  increase  in  the  pallor  suggest  the  presence  of  pus.  In  chil- 
dren the  complexion  is  often  sallow  and  earthy.  In  protracted  cases,  even  in 
children,  when  the  general  symptoms  and  the  appearance  of  the  patient  have 
been  most  strongly  suggestive  of  pus,  the  syringe  has  withdrawn  clear  fluid. 
On  the  other  hand,  effusions  of  short  duration  may  be  purulent,  even  when  the 
general  symptoms  do  not  suggest  it.  In  pneumonia  the  practitioner  should  be 
on  the  alert  if  the  crisis  is  clelayed  or  the  temperature  rises  after  the  crisis,  if 
chills  and  sweats  follow,  or  if  the  cough  changes  to  one  of  paroxysmal  type  of 
great  intensity.  There  are -three  groups:  {a)  The  presence  of  the  empyema 
is  readily  detected.  (&)  It  is  suspected,  but  it  is  not  possible  to  locate  the  pus 
by  the  ordinary  physical  means.  The  exploratory  needle  should  be  freely  used. 
{c)  In  a  few  instances  small  interlobar  collections,  small  mural  abscesses,  and 
the  diaphragmatic  form  may  escape  detection  until  an  exploratory  operation  is 
performed.  The  prognostic  import  of  the  bacteriological  examination  of  the 
aspirated  fluid  is  as  follows:  The  pneumococcus  is  of  favorable  significance, 
as  such  cases  usually  get  well  rapidly,  even  with  a  single  aspiration.  The 
streptococcus  empyema  is  the  most  serious  form,  and  even  after  a  free  drainage 
the  patient  may  succumb  to  a  general  septicaemia.  A  sterile  fluid  indicates  in 
a  majority  of  instances  a  tuberculous  origin.     In  the  distinction  between  an 


658  DISEASES  OF  THE  EESPIRATOEY  SYSTEM 

exudate  (pleurisy)  and  a  transudate  (hydrothorax)  from  the  fluid,  the  points 
are:  Specific  gravity  above  1.020  in  exudate,  below  1.015  in  transudate;  al- 
bumin 30  to  65  gms.  per  litre  and  fibrinogen  1  in  exudate,  and  in  transudate 
10  to  30  gms.  albumin  and  fibrinogen  0.1  gm.  per  litre. 

Treatment 

Acute  Fibrinous  Plewisy. — The  patient  should  be  in  bed.  At  the  onset 
the  severe  pain  may  be'  relieved  by  hot  or  cold  applications,  but  a  hypodermic 
of  morphia  is  more  effective.  The  Paquelin  cautery  may  be  lightly  applied.  It 
is  well  to  administer  a  mercurial  or  saline  purge.  Fixing  the  side  by  strapping 
with  adhesive  plaster,  which  should  pass  well  over  the  middle  line,  applied 
tightly  and  evenly  at  full  expiration,  gives  great  relief.  Dry  cupping  may  be 
employed.  Blisters  are  of  no  special  service  in  the  acute  stages,  although  they 
relieve  the  pain.  The  ice-bag  may  be  used  as  in  pneumonia.  The  open-air 
treatment  should  be  begun  early,  as  a  majority  of  the  cases  are  tuberculous. 
Medicines  are  rarely  required  and  mercurials  are  not  indicated.  Dover's 
powder  or  codein  may  be  given  at  night. 

When  effusion  has  taken  place,  mustard  plasters  or  iodine,  producing  slight 
counter-irritation,  appear  useful,  particularly  in  the  later  stages.  Iodide  of 
potassium  is  of  doubtful  benefit.  By  some  the  salicylates  are  believed  to  be 
of  special  efficacy ;  but  drug  treatment  of  the  disease  is  unsatisfactory.  A  dry 
diet  and  frequent  saline  purges  (in  concentrated  form  before  breakfast)  may 
be  tried  and  it  has  been  advised  to  use  a  salt-free  diet,  but  these  measures  are 
disappointing. 

Early  and  if  necessary  repeated  aspiration  is  the  most  satisfactory  treat- 
ment. The  results  obtained  by  Delafield  in  200  cases  treated  by  early  aspira- 
tion have- never  been  equalled  by  any  other  method.  The  credit  of  introducing 
aspiration  in  pleuritic  effusions  is  due  to  Morrill  Wyman,  of  Cambridge,  Mass., 
and  Henry  I.  Bowditch,  of  Boston.  Years  prior  to  Dieulafoy's  work,  aspira- 
tion was  in  constant  use  at  the  Massachusetts  General  Hospital  and  advocated 
repeatedly  by  Bowditch.  As  the  question  is  one  of  some  historical  interest,  we 
give  Bowditch's  conclusions  concerning  aspiration,  expressed  more  than  sixty 
years  ago,  and  which  practically  represent  the  opinion  of  to-day:  "(1)  The 
operation  is  perfectly  simple,  but  slightly  painful,  and  can  be  done  with  ease 
upon  any  patient  in  however  advanced  a  stage  of  the  disease.  (2)  It  should 
be  performed  forthwith  in  all  cases  in  M^hich  there  is  complete  filling  up  of 
one  side  of  the  chest.  (3)  He  had  determined  to  use  it  in  any  case  of  even 
moderate  effusion  lasting  more  than  a  few  weeks  and  in  which  there  should 
seem  to  be  a  disposition  to  resist  ordinary  modes  of  treatment.  (4)  He  urgel 
this  practice  upon  the  profession  as  a  very  important  measure  in  practical 
medicine;  believing  that  by  this  method  death  may  frequently  be  prevented 
from  ensuing  either  by  sudden  attack  of  dyspnoea  or  subsequent  phthisis,  and. 
finally,  from  the  gradual  wearing  out  of  the  powers  of  life  or  inability  to  ab- 
sorb the  fluid."  Vhen  the  fluid  reaches  to  the  clavicle  the  indication  for  as- 
piration is  imperative.  Fever  is  not  a  contra-indication ;  indeed,  sometimes 
with  serous  exudates  the  temperature  falls  after  aspiration. 

The  operation  is  simple  and  practically  without  risk.  The  spot  selected  for 
puncture  should  be  either  in  the  sixth  intercostal  space  in  the  mid-axilla  or  at 
the  outer  angle  of  the  scapula  in  the  eighth  space.     The  arm  of  the  patient 


ACUTE  PLEUEISY  659 

should  be  brought  forward  with  the  hand  on  the  opposite  shoulder,  so  as  to 
widen  the  spaces.  The  needle  should  be  thrust  in  close  to  the  upper  margin 
of  the  rib,  so  as  to  avoid  the  intercostal  artery,  the  wounding  of  which,  how- 
ever, is  exceedingly  rare.  The  fluid  should  be  Avithdrawn  slowly.  The  amount 
will  depend  on  the  size  of  the  exudate.  If  the  fluid  reaches  to  the  clavicle  a 
litre  or  more  may  be  withdrawn  with  safety.  As  the  fluid  is  withdrawn  it  may 
be  replaced  by  oxygen,  run  in  under  a  pressure  of  4  mm.  Hg.  In  chronic 
cases  of  serous  pleurisy  after  the  failure  of  repeated  tappings  S.  West  showed 
the  value  of  free  incision  and  drainage.  He  reiDorted  cases  of  recovery  after 
effusions  of  fifteen  and  eighteen  months'  standing. 

Repeated  tapping  may  be  required  in  some  cases.  In  the  chronic  cases  the 
injection  of  epinephrin  (20  to  30  drojDs  of  a  1  to  1,000  solution)  into  the 
pleural  cavity  after  aspiration  has  proved  of  value. 

Symptoms  and  Accidents  during  Paracentesis. — Pain  is  usually  com- 
plained of  after  a  certain  amount  of  fluid  has  been  withdrawn;  it  is  sharp  and 
cutting  in  character.  Coughing  occurs  toward  the  close,  and  may  be  severe  and 
paroxysmal.  Pneumotliorax  may  follow  an  exploratory  puncture  or  aspiration. 
Subcutaneous  emphysema  may  develop  from  the  point  of  puncture,  without  the 
production  of  pneumothorax.  Cerebral  symptoms. — Faintness  is  not  uncom- 
mon. Convulsions  may  occur  during  the  withdrawal  or  while  irrigating  the 
pleura.  These  symptoms  are  regarded  by  most  authors  as  of  reflex  origin. 
Hemiplegia  may  follow.  And  lastly  sudden  death  may  occur  either  from 
syncope  or  during  the  convulsions. 

As  A.  E.  Eussell  has  pointed  out,  these  serious  and  even  fatal  events  may 
follow  exploratory  puncture  of  the  lung.  Such  accidents  of  paracentesis  and 
of  washing  out  the  pleura  are  explained  by  the  studies  of  Capps  and  Lewis, 
who  have  shown  that  a  sudden  and  sometimes  fatal  fall  in  blood  pressure  may 
follow  the  experimental  irrigation  of  the  pleura  in  dogs.  Occasionally  toxic 
symptoms  arise  resembling  those  of  the  "serum  illness'"' — pains  in  the  joints, 
albumin  in  the  urine,  and  oedema — suggestive  of  the  absorption  of  toxins  that 
act  like  a  heterogeneous  serum.  Expectoration  of  a  large  quantity  of  albumin- 
ous fluid  may  occur  suddenly  after  the  tapping,  associated  with  dyspnoea. 
Some  cases  have  proved  rapidly  fatal,  with  the  features  of  an  acute  oedema  of 
the  lungs.     It  occurs  usually  after  large  amounts  are  removed. 

The  after-treatment  of  pleurisy  is  important  and  the  patients  should  be 
handled  exactly  as  if  they  had  an  early  tuberculous  lung  lesion. 

Empyema. — A  majority  of  the  cases  get  well,  provided  that  free  drainage 
is  obtained,  and  it  makes  no  difference  practically  what  measures  are  followed 
so  long  as  this  indication  is  met.  In  a  few  cases  with  turbid  fluid,  between 
sero-fibrinous  and  purulent,  recovery  follows  aspiration.  The  good  results  in 
any  method  depend  upon  the  thoroughness  with  which  the  cavity  is  drained. 
Irrigation  of  the  cavity  is  rarely  necessary  unless  the  contents  are  fetid.  In 
the  subsequent  treatment  a  point  of  great  importance  in  facilitating  the  closure 
of  the  cavity  is  the  distention  of  the  lung  on  the  affected  side.  This  may  be 
accomplished  by  the  method  advised  by  Ralston  James,  which  has  been  practised 
with  great  success,  especially  in  children.  The  patient  daily,  for  a  certain 
length  of  time,  increasing  gradually  with  the  increase  of  his  strength,  trans- 
fers by  air-pressure  water  from  one  bottle  to  another.  The  bottles  should  be 
large,  holding  at  least  a  gallon  each,  and  by  the  arrangement  of  tubes,  as  in 


660  DISEASES  OF  THE  EESPIRATOEY  SYSTEM 

the  Wolff's  bottle,  an  expiratory  effort  of  the  patient  forces  the  water  from 
one  bottle  into  the  other.  Equally  efficacious  is  the  plan  advised  by  Naunyn. 
The  patient  sits  in  an  arm-chair  grasping  strongly  one  of  the  rungs  with  the 
hand  and  forcibly  compressing  the  sound  side  against  the  arm  of  the  chair; 
then  forcible  inspiratory  efforts  are  made  which  act  chiefly  on  the  compressed 
lung,  as  the  sound  side  is  fixed.  The  abscess  cavity  is  gradually  closed,  partly 
by  the  falling  in  of  the  chest  wall  and  partly  by  the  expansion  of  the  lung.  In 
some  instances  it  is  necessary  to  resect  portions  of  one  or  more  ribs.^ 

Until  recently  efficient  drainage  has  been  regarded  as  the  most  important 
consideration,  and  both  operative  and  drainage  proceedings  have  been  directed 
toward  making  the  chest  wall  conform  to  the  lung.  While  thoracotomy  and 
free  drainage  have  done  a  great  deal,  it  must  be  confessed  tbat  in  a  not  mcon- 
siderable  number  of  cases  the  obliteration  of  the  pus  cavity  has  been  a^  long 
and  sometimes  hopeless  matter.  In  its  place  continuous  drainage  and  inter- 
mittent siphonage  have  been  used. 

The  physician  is  often  asked,  in  cases  of  empyema  with  emaciation,  fever 
and  feeble,  rapid  pulse,  whether  the  patient  can  stand  the  operation.  Even 
in  the  most  desperate  cases  one  should  never  hesitate  to  make  a  free  incision. 


II.     CHRONIC  PLEURISY 

This  affection  occurs  in  two  forms : 

Chronic  pleurisy  with  effusion  in  which  the  disease  may  set  in  insidi- 
ously or  may  follow  an  acute  sero-fibrinous  pleurisy.  There  are  casos  in  which 
the  fluid  persists  for  months  or  even  years  without  undergoing  any  special  al- 
teration and  without  becoming  purulent.  Such  cases  have  the  characters  which 
we  have  described  under  pleurisy  with  effusion. 

Chronic  Dry  Pleurisy. — The  cases  are  met  with  (a)  as  a  sequence  of 
ordinary  pleural  effusion.  When  the  exudate  is  absorbed  and  the  layers  of  the 
pleura  come  together  there  is  left  between  them  a  variable  amount  of  fibrinous 
material  which  gradually  undergoes  organization,  and  is  converted  into  a  layer 
of  firm  connective  tissue.  This  process  goes  on  at  the  base,  and  is  represented 
clinically  by  a  slight  grade  of  flattening,  deficient  expansion,  defective  reso- 
nance on  percussion,  and  enfeebled  breathing.  After  recovery  from  empyema 
the  flattening  and  retraction  may  be  still  more  marked.  In  both  cases  it  is  a 
condition  which  can  be  greatly  benefited  by  pulmonary  gymnastics.  In  these 
firm,  fibrous  membranes  calcification  may  occur,  particularly  after  empyema. 
It  is  not  very  uncommon  to  find  between  the  false  membranes  a  small  pocket 
of  fluid  forming  a  sort  of  pleural  cyst.  In  the  great  majority  of  these  cases 
the  condition  need  not  cause  anxiety.  There  may  be  an  occasional  dragging 
pain  at  the  base  of  the  lung  or  a  stitch  in  the  side,  but  patients  may  remain  in 
perfectly  good  health  for  years.  The  most  advanced  grade  of  this  secondary 
dry  pleurisy  is  seen  in  those  cases  of  empyema  which  have  been  left  to  them- 
selves and  have  perforated  and  ultimately  healed  by  a  gradual  absorption  or 
discharge  of  the  pus,  with  retraction  of  the  side  of  the  chest  and  permanent 
carnification  of  the  lung.  Traumatic  lesions,  such  as  gunshot  wounds,  may  be 
followed  by  an  identical  condition.  Post  mortem,  it  is  quite  impossible  to  sep- 
arate the  layers  of  the  pleura,  which  are  greatly  thickened,  particularly  at  the 


HYDEOTHOEAX  661 

base,  aijcl  surround  a  compressed,  airless,  fibroid  lung.  Bronchiectasis  may 
gradually  ensue,  sometimes  not  only  on  the  affected  side,  but  also  in  the  lower 
lobe  of  the  other  lung. 

(b)  Primitive  dry  pleurisy. — This  condition  may  directly  follow  the  acute 
plastic  pleurisy  already  described ;  but  it  may  set  in  without  any  acute  symp- 
toms whatever,  and  the  patient's  attention  may  be  called  to  it  by  feeling  the 
pleural  friction.  A  constant  effect  of  this  primitive  dry  pleurisy  is  the  adhe- 
sion of  the  layers.  This  is  probably  an  invariable  result,  whether  the  pleurisy 
is  primary  or  secondary.  The  organization  of  the  thin  layer  of  exudation  in  a 
pneumonia  will  unite  the  two  surfaces  by  delicate  bands.  Pleural  adhesions 
are  extremely  common,  and  it  is  rare  to  examine  a  body  entirely  free  from 
them.  They  may  be  limited  in  extent  or  universal.  Thin  fibrous  adhesions 
do  not  produce  any  alteration  in  the  percussion  characters,  and,  if  limited, 
there  is  no  special  change  heard  on  auscultation.  When,  however,  there  is  gen- 
eral synechia  on  both  sides  the  expansile  movement  of  the  lung  is  considerably 
impaired.  We  should  naturally  think  that  universal  adhesions  would  interfere 
materially  with  the  function  of  the  lungs,  but  practically  we  see  many  in- 
stances in  which  there  has  not  been  the  slightest  disturbance.  The  physical 
signs  of  total  adhesion  are  by  no  means  constant.  It  has  been  stated  that  there 
is  a  marked  disproportion  between  the  degree  of  expansion  of  the  chest  walls 
and  the  intensity  of  the  vesicular  murmur,  but  the  latter  is  a  very  variable 
factor,  and  under  perfectly  normal  conditions  the  breath-sounds,  with  very  full 
chest  expansion,  may  be  extremely  feeble.  The  diaphragm  phenomenon — 
Litten's  sign — is  absent. 

It  is  probable  that  a  primitive  dry  pleurisy  may  lead  to  great  thickening 
of  the  membranes,  and  ultimate  invasion  of  the  lung,  causing  a  cirrhosis. 

Lastly,  there  is  a  primitive  dry  pleurisy  of  tuberculous  origin.  In  it  both 
parietal  and  costal  layers  are  greatly  thickened — perhaps  from  2  to  3  mm. 
each — and  present  firm  fibroid,  caseous  masses  and  small  tubercles,  while 
uniting  these  two  greatly  thickened  layers  is  a  reddish-gray  fibroid  tissue, 
sometimes  infiltrated  with  serum.  This  may  be  a  local  process  confined  to  one 
pleura,  or  it  may  be  in  both.  These  cases  are  sometimes  associated  with  a 
similar  condition  in  the  pericardium  and  peritoneum. 

Occasionally  remarkable  vaso-motor  phenomena  occur  in  chronic  pleurisy, 
whether  simple  or  in  connection  with  tuberculosis  of  an  apex.  Flushing  or 
sweating  of  one  cheek  or  dilatation  of  the  pupil  are  the  common  manifesta- 
tions. They  appear  to  be  due  to  involvement  of  the  first  thoracic  ganglion  at 
the  top  of  the  pleural  cavity. 

Treatment. — It  is  well  to  carry  out  the  general  treatment  for  tuberculosis. 
In  some  cases  the  use  of  exercises  may  be  of  value,  but  the  chances  of  helping 
the  local  condition  materially  by  any  treatment  are  not  good. 


III.     HYDROTHORAX 

Hydrothorax  is  a  transudation  of  simple  non-inflammatory  fluid  into  the 
pleural  cavities,  and  occurs  as  a  secondary  process  in  many  affections.  The 
fluid  is  clear,  without  any  flocculi  of  fibrin,  and  the  membranes  are  smooth. 
It  is  met  with  more  particularly  in  connection  with  general  dropsy,  either 


663  DISEASES  OF  THE  EESPIEATOEY  SYSTEM 

renal,  cardiac,  or  hsemic.  It  may,  however,  occur  alone,  or  with  only  slight 
oedema  of  the  feet.  A  child  was  admitted  to  the  Montreal  General  Hospital 
with  urgent  dyspnoea  and  cyanosis,  and  died  the  night  after  admission.  She 
had  extensive  bilateral  hydrothorax,  which  had  come  on  early  in  the  nephritis 
of  scarlet  fever.  In  renal  disease  hydrothorax  is  almost  always  bilateral,  but 
in  heart  affections  one  pleura  is  more  commonly  involved.  The  physical  signs 
are  those  of  pleural  effusion,  but  the  exudation  is  rarely  excessive.  In  kidney 
and  heart-disease,  even  when  there  is  no  general  dropsy,  the  occurrence  of 
dyspnoea  should  at  once  direct  attention  to  the  pleura,  since  many  patients  are 
carried  off  by  a  rapid  effusion.  In  chronic  valvular  disease  the  effusion  is 
usually  on  the  right  side,  and  may  recur  for  months.  The  greater  frequency 
of  the  dextral  effusion  has  been  attributed  to  compression  of  the  azygos  vein, 
but  compression  of  the  pulmonary  veins  by  the  dilated  right  auricle  seems 
more  probable.  Post  mortem  records  show  the  frequency  with  which  this  con- 
dition is  overlooked.  The  saline  purges  will  in  many  cases  rapidly  reduce 
the  effusion,  but,  if  necessary,  aspiration  should  be  practised  repeatedly. 


IV.     HEMOTHORAX 

This  is  a  common  sequence  of  wounds  of  the  chest  by  bullets,  shrapnel  or 
bayonet ;  thousands  of  cases  occurred  in  the  recent  war.  A  high  velocity  bullet 
may  pass  through  the  chest  and  lung  without  causing  serious  damage  and  the 
man  may  be  walking  about  within  a  week.  The  blood  usually  comes  from  the 
lung.  The  amount  varies  from  a  few  ounces  to  four  or  five  pints.  When  with- 
drawn the  blood  forms  a  scanty  clot.  The  fluid  is  not  all  blood,  but  mixed 
Avith  serous  exudate  with  many  leucocytes,  endothelial  and  eosinophile  cells. 
Even  when  large  amounts  are  present  there  may  be  no  signs  of  anaemia.  The 
pleural  surfaces  are  covered  with  a  thin  film  of  fibrin.  Pneumothorax  and 
pneumo-hsemothorax  are  rare,  8  cases  of  the  latter  and  4  of  the  former  in  328 
cases  of  gunshot  wounds  of  the  chest  (Bradford  and  Elliott). 

Symptoms. — Shock,  cough,  dyspnoea,  and  spitting  of  blood  are  present  in 
a  majority  of  the  cases.  Slight  fever  is  frequent  and  the  pulse  is  quickened. 
If  not  infected  the  progress  is  uneventful.  The  cough  lessens,  slight  fever 
persists,  but  with  moderate  exudates  the  absorption  is  rapid.  A  slight  icteric 
tinge  of  the  skin  may  be  present. 

The  physical  signs  vary  with  the  amount  of  fluid.  With  a  massive  exudate 
there  is  a  flat  or  Skodaic  note  on  percussion,  absence  of  fremitus,  and  distant 
or  feeble  tubular  breathing.  The  signs  are  often  less  distinctive  than  with 
simple  effusion.  With  the  fluorosc6pe  the  diaphragm  is  seen  to  be  high.  A 
remarkable  phenomenon,  not  seen  in  ordinary  effusion,  is  the  early  flattening 
and  immobility  of  the  side,  which  with  the  high  level  of  the  diaphragm  speaks 
for  massive  collapse  of  the  lung,  with  displacement  of  the  heart  towards  the 
•affected  side.  This  may  take  place  with  nioderate  effusion  and  may  disappear 
rapidly.  Contralateral  collapse  of  the  unaffected  lung  is  met  with  not  infre- 
quently, indicated  by  flatness  at  the  opposite  base  with  tubular  breathing  and 
increased  fremitus. 

Complications. — Septic  infection  is  indicated  by  increasing  fever  and  pulse 
rate,  persistence  of  cough,  increase  of  the  exudate,  sweats,  etc.     Secondary 


PNEUMOTHOEAX  663 

ha?morrhage  is   rare.      Pneumonia,   pericarditis,   purulent  bronchitis,   abscess 
and  gangrene,  and  general  streptococcus  infection  may  occur. 

Treatment. — Without  infection  a  majority  of  the  cases  get  well  with  rest 
in  bed,  but  increase  of  the  dyspnoea  may  demand  aspiration.  Oxygen  replace- 
ment is  useful  in  large  effusions.    Infection  calls  for  free  drainage. 


V.  PNEUMOTHORAX 

(Hydro-Pneumothorax  and  Pyo-Pneumotliorax) 

Air  alone  in  the  pleural  cavity,  to  which  the  term  pneumothorax  is  strictly 
applicable,  is  an  extremely  rare  condition.  It  is  almost  invariably  associated 
with  a  serous  fluid — hydro-pneuniothorax,  or  with  pus — pyo-pneumothorax. 

Etiology. — There  exists  normally  within  the  pleural  cavity  of  an  adult 
a  negative  pressure  of  several  (3  to  5)  millimetres  of  mercury,  due  to  the  recoil 
of  the  distended,  perfectly  elastic  lung.  Hence,  through  any  opening  connect- 
ing the  pleural  cavity  Math  the  external  air  we  should  expect  air  to  rush  in 
until  this  negative  pressure  is  relieved.  To  explain  the  absence  of  pneumo- 
thorax in  a  few  cases  of  injury  laying  the  pleura  bare,  in  which  it  would  be  ex- 
pected, S.  West  assumed  the  existence  of  a  cohesion  between  the  pleurse,  but 
this  force  has  not  as  yet  been  satisfactorily  demonstrated. 

If  the  opening  causing  the  pneumothorax  remains  patent,  which  occurs 
in  some  external  wounds  and  in  perforations  through  consolidated  areas  of  the 
lung,  the  intrathoracic  pressure  will  be  that  of  the  atmosphere.  The  lung 
will  be  found  to  have  collapsed  as  much  as  possible  by  virtue  of  its  own  elastic 
tension,  the  intercostal  grooves  are  obliterated,  the  heart  is  displaced,  and  the 
diaphragm  depressed,  because  the  negative  pressure  by  which  these  organs  are 
partly  retained  in  their  ordinary  position  has  been  relieved.  If  the  opening 
becomes  closed  the  intrathoracic  pressure  may  rise  above  the  atmospheric  and 
the  displacements  be  much  increased.  But  most  perforations  through  the 
lung  are  valvular,  a  property  of  lung  tissue,  and  the  intrapleural  pressure  is 
soon  about  7  mm.  of  mercury.  If  there  be  a  fluid  exudate  the  pressure  may 
be  higher,  b^it  the  high  pressures  supposed  are  more  apparent  than  real,  and 
that  measured  at  the  autopsy  table  is  quite  surely  not  that  during  life.  It  is 
more  a  question  of  the  amount  of  distention  than  the  actual  pressure  which  de- 
termines the  discomfort  of  the  patient. 

Pneumothorax  arises:  (1)  In  perforating  wounds  of  the  chest,  in  which 
case  it  is  sometimes  associated  with  extensive  cutaneous  emphysema.  It  may 
follow  exploratory  puncture  either  with  a  small  needle  or  an  aspirator.  Pneu- 
mothorax rarely  follows  fracture  of  the  rib,  even  though  the  lung  may  be  torn. 
(2)  In  perforation  of  the  pleura  through  the  diaphragm,  usually  by  malignant 
disease  of  the  stomach  or  colon,  or  abscess  of  tlie  liver.  The  pleura  may  also 
be  perforated  in  cases  of  cancer  of  the  oesophagus.  (3)  When  the  lung  is  per- 
forated, by  far  the  most  common  cause :  (a)  In  the  normal  lung  from  rupture 
of  the  air-vesicles  during  straining  or  even  when  at  rest.  The  air  may  be 
absorbed  and  no  ill  effect  follow.  It  does  not  necessarily  excite  pleurisy,  as 
pointed  out  many  years  ago  by  Gairdner,  but  inflammation  and  effusion  are 
the  usual  result,     (&)   From  perforation  due  to  local  disease  of  the  lung,  either 


6^4  DISEASES  OF  THE  EESPIEATOEY  SYSTEM 

the  softening  of  a  caseous  focus  or  the  breaking  of  a  tuberculous  cavity.  Ac- 
cording to  S.  "West,  90  per  cent,  of  all  the  cases  are  due  to  this  cause.  Less 
common  are  the  cases  due  to  septic  broncho-pneumonia  and  to  gangrene.  A 
rare  cause  is  the  breaking  of  a  hasmorrhagic  infarct  in  chronic  heart-disease, 
(c)  Perforation  of  the  lung  from  the  pleura,  -which  arises  in  certain  cases  of 
empyema  and  produces  a  pleuro-bronchial  fistula.  (4)  Spontaneously,  by  the 
development  in  pleural  exudates  of  the  gas  bacillus  (B.  aerogenes  capsulatus 
Welch).  Of  48  cases,  the  basis  of  Emerson^s  monograph  (J.  H,  H.  Reports, 
vol.  xi),  22  were  tuberculous,  6  were  the  result  of  trauma,  10  of  aspiration, 
2  were  spontaneous,  2  followed  bronchiectasis,  2  abscess  of  the  lung,  1  gan- 
grene, 2  an  empyema,  and  1  abscess  of  the  liver  perforating  through  the  lung. 

Pneumothorax  occurs  chiefly  in  adults,  is  rare  in  young  children  and  more 
frequent  in  males  than  in  females. 

A  remarkable  recurrent  variety  has  been  described  by  S.  West,  Goodhart, 
and  Furney.  In  -Goodhart's  case  the  pneumothorax  developed  first  in  one 
side  and  then  in  the  other. 

Morbid  Anatomy. — If  the  trocar  or  blow-pipe  is  inserted  between  the  ribs, 
there  may  be  a  jet  of  air  of  sufficient  strength  to  blow  out  a  lighted  match. 
On  opening  the  thorax  the  mediastinum  and  pericardium  are  seen  to  be  dis- 
placed to  the  opposite  side ;  but  the  heart  is  not  rotated,  and  the  relation  of  its 
parts  is  maintained  much  as  in  the  normal  condition.  A  serous  or  purulent 
fluid  is  usually  present,  and  the  membranes  are  inflamed.  The  cause  of  the 
pneumothorax  can  usually  be  found  without  difficulty.  In  the  great  majority 
of  instances  it  is  the  perforation  of  a  tuberculous  cavity  or  a,  breaking  of  a 
superficial  caseous  focus.  The  orifice  of  rupture  may  be  extremely  small.  In 
chronic  ca^es  there  may  be  a  fistula  of  considerable  size  communicating  with 
the  bronchi.     The  lung  is  usually  compressed  and  carnified. 

Symptoms. — Pain  on  the  affected  side  and  dyspnoea  are  the  usual  symptoms 
of  onset.  The  rupture  may  be  felt  or  even  heard  by  the  patient.  The  cough 
may  be  aggravated  with  an  inc'rease  in  the  amount  of  sputum.  In  severe  cases 
the  color  becomes  livid,  the  pulse  feeble  and  rapid,  there  is  sweating  with  signs 
of  great  respiratory  distress — the  pneumothorax  acutissimus  of  Unverricht. 
The  patient  may  become  unconscious  and  die  within  twenty-four  hours.  In  23 
per  cent,  of  385  cases  the  onset  was  insidious  (0.  H.  P.  Pepper) .  The  "splash" 
may  be  the  first  indication  to  the  patient  of  any  change. 

Physical  Signs. — Inspection  shows  marked  enlargement  of  the  affected 
side  with  immobility.  The  patient  usually  lies  on  the  affected  side.  The  heart 
impulse  is  usually  much  displaced.  On  palpation  the  fremitus  is  greatly 
diminished  or  more  commonly  abolished.  It  may  be  increased  in  front  due 
possibly  to  bands  of  adhesions  or  a  lung  pressed  up  against  the  chest  wall.  On 
percussion  the  resonance  has  a  tympanitic  or  an  amphoric  quality.  This,  how- 
ever, is  not  always  the  case.  It  may  be  a  dull  tympany,  resembling  Skoda's 
resonance.  In  some  instances'  it  may  be  a  full,  hyperresonant  note,  like  em- 
physema; while  in  others  there  is  dulness'.  These  extreme  variations  depend 
doubtless  upon  the  degree  of  intrapleural  tension.  Error  in  diagnosis  may 
result  from  ignorance  of  the  fact  that  the  percussion  note  may  be  "muffled, 
toneless,  almost  dull"  (Walshe).  There  is  usually  dulness  at  the  base  from 
effused  fluid,  which  can  readily  be  made  to  change  by  altering  the  position  of 
the  patient.     When  recumbent  the  t}-mpanitic  "note   on   the  right   side  may 


PNEUMOTHOEAX  665 

reach  the  costal  border,  when  erect  the  dulness  may  be  at  the  third  rib.  The 
liver  iiatness  may  be  obliterated.  On  auscultation  the  breath-sounds  are  sup- 
pressed. Sometimes  there  is  only  a  distant  feeble  inspiratory  murmur  of 
marked  amphoric  quality.  The  contrast  between  the  loud  exaggerated  breath- 
sounds  on  the  normal  side  and  the  absence  of  the  breath-sounds  on  the  other  is 
very  suggestive.  The  rales  have  a  peculiar  metallic  quality,  and  on  coughing 
or  deep  inspiration  there  may  be  what  Laennec  termed  the  metallic  tinkle. 
This  sound,  like  striking  a  glass  vessel  with  a  pin,  may  even  be  heard  some 
distance  from  the  patient  or  in  all  parts  of  the  room  (Allbutt).  A  gurgling 
sound  may  be  heard  during  inspiration,  the  so-called  "water  whistle  noise.'" 
The  voice  has  a  curious  metallic  echo.  The  coin-sound,  termed  by  Trousseau 
the  hruit  d'airain,  is  very  characteristic.  To  obtain  it  the  auscultator  should 
place  one  ear  on  the  back  of  the  chest  wall  while  the  assistant  taps  one  coin 
on  another  on  the  front  of  the  chest.  The  metallic  echoing  sound  which  is  pro- 
duced in  this  way  is  one  of  the  most  constant  and  characteristic  signs  of 
pneumothorax.  The  Hippocratic  succussion  splash  may  be  obtained  when  the 
auscultator's  head  is  placed  upon  the  chest  while  the  patient's  body  is  shaken. 
A  splashing  sound  is  produced,  which  may  be  audible  at  a  distance.  A  patient 
may  himself  notice  it  in  making  abrupt  changes  in  posture.  The  metallic 
phenomena  are  best  heard  in  cases  with  a  consolidated  lung  and  thickened 
pleura,  as  in  tuberculosis.  The  movable  dulness  and  splash  depend  on  fluid. 
Of  other  physical  signs  displacement  of  organs  is  most  constant.  The  heart 
may  be  "drawn  over"  to  the  opposite  side,  and  the  liver  greatly  displaced,  so 
that  its  upper  surface  is  below  the  level  of  the  costal  margin,  a  degree  of  dis- 
location rarely  seen  in  simple  effusion. 

Gas  analysis. — Emerson  determined  experimentally  that  of  the  air  intro- 
duced, the  oxygen  rapidly  diminishes,  but  the  nitrogen  remains  very  constant. 
An  increasing  amount  of  oxygen  suggests  an  open  fistula.  Air  is  absorbed 
rapidly  from  the  normal  pleura  and  in  spontaneous  cases  the  signs  may  dis- 
appear within  a  week;  in  other  instances  weeks  or  months  may  elapse. 

Diagnosis. — In  cases  in  which  the  percussion  note  is  dull  the  condition 
may  be  mistaken  for  effusion.  Diaphragmatic  or  congenital  hernia  following 
a  crush  or  other  accident  may  closely  simulate  it.  Pneumothorax  in  a  patient 
with  emphysema  may  cause  difficulty.  Percussion  of  the  lower  border  of  the 
lung  on  the  affected  side  shows  that  the  resonance  in  pneumothorax  extends 
to  the  lowest  part  of  the  pleural  cavity  and  is  fixed,  not  changing  with  in-  and 
expiration. 

Very  large  cavities  with  tympanitic  percussion  resonance  and  rales  of  an 
amphoric,  metallic  quality,  may  simulate  pneumothorax.  In  total  excavation 
of  one  lung  the  amphoric  and  metallic  phenomena  may  be  intense,  but  the 
absence  of  dislocation  of  the  organs,  of  the  succussion  splash,  and  of  the  coin- 
sound  suffices  to  differentiate  this  condition.  While  this  is  true  in  the  great 
majority  of  cases,  the  coin  sound  may  be  heard  over  a  large  cavity  in  the  right 
upper  lobe.  The  condition  of  pyo-pneumothorax  subphrenicus  may  simulate 
closely  true  pneumothorax. 

X-ray  Examination. — The  characteristic  features  are  an  abnormally  clear 
zone  without  the  normal  lung  markings,  the  shadow  of  the  collapsed  lung  not 
always  easy  to  see,  and  the  visceral  displacements.  The  fluid  shows  as  an 
■opaque  shadow  and  with  the  fluoroscope  a  wavy  outline  of  the  fluid  may  be  seen 


666  DISEASES  OF  THE  EESPIEATORY  SYSTEM 

in  shaking  the  patient.  An  aneurism  pressing  on  one  bronchus  may  cause 
great  inflation  of  the  lung  and  a  condition  wliich  gives  clinical  and  X-ray  fea- 
tures suggestive  of  pneumothorax. 

Progpiosis. — This  depends  largely  upon  the  cause.  S.  West  gives  a  mor- 
tality of  70  per  cent.  The  tuberculous  cases  usually  die  within  a  few  weeks. 
Of  22  tuberculous  cases  20  died,  and  5  of  the  10  cases  following  aspiration 
(J.  H.  H.  Series).  There  are  tuberculous  cases  in  which  the  pneumothorax, 
if  occurring  early,  seems  to  arrest  the  progress  of  the  tuberculosis.  There  is 
a  chronic  pneumothorax  which  may  last  between  three  and  four  years.  The 
outlook  in  spontaneous  pneumothorax  is  good.  It  may  recur  or  it  may  appear 
later  in  the  other  side.  Though  usually  not  tubercvilous  and  due  to  a  ruptured 
bleb  or  a  tear,  it  may  be  followed  years  later  by  tuberculosis  of  the  lung 
( Hamman ) . 

Treatment. — The  patient  should  be  kept  as  quiet  as  possible  and  morphia 
given  to  secure  this  if  necessary.  He  should  be  encouraged  to  suppress  cough 
and  avoid  deep  respirations.  Strapping  the  affected  side  and  the  giving  of 
sedatives,  such  as  codein  and  heroin,  may  lessen  cough.  With  fluid  present 
it  may  be  necessary  to  remove  some  if  there  are  pressure  symptoms,  but  it  is 
better  left  alone  if  possible  for  two  weeks  or  until  the  fistula  is  closed.  There 
are  three  groups  of  cases :  First,  in  the  pneumothorax  acutissimus,  with  ur- 
gent dyspnoea,  great  displacement  of  the  heart,  cyanosis,  and  low  blood  pres- 
sure, an  opening  should  be  made  in  the  pleura  and  kept  open,  converting  a 
valvular  into  an  open  variety.  Immediate  aspiration  with  a  trocar  has  saved 
life.  Secondly,  the  spontaneous  cases  which  usually  do  well,  as  the  air  is 
quickly  absorbed;' so  also  with  the  traumatic  variety.  Very  many  of  the  tu- 
berculous cases  are  best  let  alone,  if  the  patient  is  doing  well,  or  if  the  disease 
in  the  other  lung  is  advanced.  Thirdly,  when  there  is  pus,  and  the  patient  is 
not  doing  well,  or  in  the  tuberculous  variety  if  the  other  lung  is  not  involved, 
pleurotomy,  or  resection  of  one  or  two  ribs,  may  be  done.  Of  nine  cases  in  our 
series  two  recovered.    Eepeated  aspiration  may  result  in  marked  improvement. 


VI.     AFFECTIONS  OF  THE  MEDIASTINUM 

Lymphadenitis. — The  greater  number  of  glands  are  on  the  right  side,  and 
the  right  bronchus  passes  off  at  a  higher  level  (fifth  dorsal  vertebra)  than  the 
'  left.  The  glands  are  constantly  enlarged  in  all  inflammatory  affections  of  the 
lungs.  In  all  the  acute  affections  of  childhood  they  are  found  swollen.  They 
are  almost  constantly  involved  in  tuberculosis  of  the  lungs  and  they  are  not 
infrequently  the  only  organs  found  tuberculous.  Often  in  children  the  glands 
on  the  lung  root  become  enlarged  and  caseous  and  penetrate  deeply  into  the 
hilus  and  into  the  lung  itself. 

The  symptoms  of  enlarged  mediastinal  glands  are  very  uncertain  in  the 
simple  and  tuberculous  forms.  On  the  'other  hand  in  Hodgkin's  disease  and 
in  sarcoma  pressure  symptoms  are  the  rule. 

Much  attention  has  been  paid  to  the  diagnosis  of  this  condition  and  authors 
speak  lightly  of  the  possibility  of  recognizing  by  percussion  various  grades  of 
enlargement.  It  is  claimed  that  the  pressure  of  the  glands  on  the  right  bron- 
chus may  cause  a  dulness  in  the  right  lung  apex  due  to  slight  collapse.    Ex- 


AFFECTIONS  OF  THE  MEDIASTINUM  667 

amined  by  the  X-rays,  the  percentage  of  children  with  enlarged  mediastinal 
glands  is  very  high,  50  to  60  in  some  series.  D'Espine  says  there  is  a  change 
in  the  whispered  voice  which  h^s  a  bronchial  ring  at  the  level  of  the  seventh 
cervical  and  last  dorsal,  and  the  respiratory  murmur  may  be  rougher  and 
harsher. 

Suppurative  Lympliadeiiitis. — Occasionally  abscess  in  the  bronchial  or 
tracheal  lymph-glands  is  found.  It  may  follow  the  simple  adenitis,  but  is 
most  frequently  associated  with  tubercle.  The  liquid  portion  may  gradually 
be  absorbed  and  the  inspissated  contents  undergo  calcification.  Serious  acci- 
dents occasionally  occur,  as  perforation  into  the  oesophagus  or  into  a  bronchus, 
or  in  rare  instances,  as  in  the  case  reported  by  Sidney  Phillips,  perforation  of 
the  aorta,  as  well  as  a  bronchus,  which  did  not  prove  fatal  rapidly,  but  caused 
repeated  attacks  of  hsemoptysis  during  a  period  of  sixteen  months. 

Tumors. — Sarcoma  is  by  far  the  most  frequent  tumor.  Ross,  in  a  study  of 
60  cases,  found  -i-i  cases  of  sarcoma  and  10  of  carcinoma.  The  lung  was  usually 
involved.  In  nearly  70  per  cent,  the  anterior  glands  were  affected.  There  are 
three  chief  points  of  origin,  the  thymus,  the  lymph-glands,  and  the  pleura  and 
lung.  Males  are  more  frequently  affected  than  females.  The  age  is  most 
commonly  between  thirty  and  fifty. 

Symptoms. — The  signs  of  mediastinal  tumor  are  those  of  intrathoracic 
pressure.  In  some  cases  almost  the  entire  chest  is  filled  with  the  masses.  The 
heart  and  lungs  are  pushed  back  and  it  is  marvelous  how  life  can  be  maintained 
with  such  dislocation  and  compression  of  the  organs.  Dyspncea  is  one  of  the 
earliest  and  most  constant  symptoms,  and  may  be  due  either  to  pressure  on 
the  trachea  or  on  the  recurrent  laryngeal  nerves.  It  may,  indeed,  be  cardiac, 
due  to  pressure  upon  the  heart  or  its  vessels.  In  a  few  cases  it  results  from 
the  pleural  effusion  which  so  frequently  accompanies  intrathoracic  growths. 
Associated  with  the  dyspncea  is  a  cough,  often  severe  and  paroxysmal  in  char- 
acter, with  the  brazen  quality  of  the  so-called  aneurismal  cough  when  a  re- 
current nerve  is  involved.  The  voice  may  also  be  affected  from  a  similar  cause. 
Haemoptysis  may  occur  and  the  picture  suggest  pulmonary  tuberculosis.  Pres- 
sure on  the  vessels  is  common.  The  superior  vena  cava  may  be  compressed  and 
obliterated,  and  when  the  process  goes  on  slowly  the  collateral  circulation  may 
be  completely  established.  Less  commonly  the  inferior  vena  cava  or  one  or 
other  of  the  subclavian  veins  is  compressed.  The  arteries  are  much  more 
rarely  obstructed.  There  may  be  dysphagia,  due  to  compression  of  the  oesopha- 
gus. There  may  be  pupillary  changes,  usually  contraction.  Expectoration  of 
blood,  pus,  and  hair  is  characteristic  of  the  dermoid  cyst,  of  which  Christian 
noted  64  cases  in  1914. 

Physical  Signs. — On  inspection  there  may  be  orthopnoea  and  marked 
cyanosis  of  the  upper-  part  of  the  body.  In  such  instances,  if  of  long  dura- 
tion, there  are  signs  of  collateral  circulation  and  the  superficial  mammary  and 
epigastric  veins  are  enlarged.  In  these  cases  of  chronic  obstruction  the  finger- 
tips may  be  clubbed.  There  may  be  bulging  of  the  sternum  or  the  tumor  may 
erode  the  bone  and  form  a  prominent  subcutaneous  growth.  The  rapidly  grow- 
ing lymphoid  tumors  more  commonly  than  others  perforate  the  chest  wall. 
In  4  of  13  cases  of  Hodgkin's  disease  there  was  mediastinal  growth,  and  in  3 
instances  the  sternum  was  eroded  and  perforated.  The  perforation  may  be  on 
one  side  of  the  breast-bone.    The  projecting  tumor  may  pulsate;  the  heart  may 


668  DISEASES  OF  THE  EESPIEATOEY  SYSTEM 

be  dislocated  and  its  impulse  much  out  of  place.  Contraction  of  one  side  of 
the  thorax  has  been  noted  in  a  few  instances.  On  palpation  the  fremitus  is 
absent  wherever  the  tumor  reaches  the  chest  wall.  If  pulsating,  it  rarely  has 
the  forcible,  heaving  impulse  of  an  aneurismal  sac.  On  auscultation  there  is 
usually  silence  over  the  dull  region.  The  heart-sounds  are  not  transmitted  and 
the  respiratory  murmur  is  feeble  or  inaudible,  rarely  bronchial.  Vocal  reso- 
nance is,  as  a  rule,  absent.  Signs  of  pleural  effusion  occur  in  a  great  many  in- 
stances of  mediastinal  growth,  and  in  doubtful  cases  the  aspirator  needle 
should  be  used. 

Tumors  of  the  anterior  mediastinum  originate  usiially  in  the  thymus,  or 
its  remnants,  or  in  the  connective  tissue;  the  sternum  is  pushed  forward  and 
often  eroded.  The  growth  may  be  felt  in  the  suprasternal  fossa;  the  cervical 
glands  are  usually  involved.  The  pressure  symptoms  are  chiefly  upon  the  ve- 
nous trunks.    Dyspnoea  is  a  prominent  feature. 

Intrathoracic  tumors  in  t]}e  middle  and  post-erior  mediastinum  originate 
most  commonly  in  the  lymph-glands.  The  symptoms  are  out  of  all  proportion 
to  the  signs ;  there  is  urgent  dyspncea  and  cough,  which  is  sometimes  loud  and 
ringing.  The  pressure  symptoms  are  chiefly  upon  the  gullet,  the  recurrent 
laryngeal,  and  sometimes  upon  the  azygos  vein. 

In  a  third  group,  tumors  originating  in  the  pleura  and  the  lunff,  the  pres- 
sure symptoms  are  not  so  marked.  Pleural  exudate  is  very  much  more  com- 
mon; the  patient  becomes  anaemic  and  emaciation  is  rapid.  There  may  be 
secondary  involvement  of  the  lymph-glands  in  the  neck. 

Diagnosis. — The  diagnosis  of  mediastinal  tumor  from  aneurism  is  some- 
times extremely  difficiilt.  An  interesting  case  reported  and  figured  by  Soko- 
losski,  in  Bd.  19  of  the  Deutsches  Archiv  fiir  klinische  Medicin,  in  which 
Oppolzer  diagnosed  aneurism  and  Skoda  mediastinal  tumor,  illustrates  how  in 
some  instances  the  most  skillful  of  observers  may  be  unable  to  agree.  Scarcely 
a  sign  is  found  in  aneurism  which  may  not  be  duplicated  in  mediastinal  tumor. 
This  is  not  strange,  since  the  symptoms  in  both  are  largely  due  to  pressure. 
The  cyanosis,  the  venous  engorgement,  the  signs  of  collateral  circulation  are 
as  a  rule,  much  more  marked  in  tumor.  The  time  element  is  important.  If 
a  case  has  persisted  for  more  than  eighteen  months  the  disease  is  probably 
aneurism.  There  are,  however,  exceptions  to  this.  By  far  the  most  valuable 
sign  of  aneurism  is  the  diastolic  shock  so  often  to  be  felt,  and  in  a  majority  of 
cases  to  be  heard,  over  the  sac.  This  is  rarely,  if  ever,  present  in  mediastinal 
growths,  even  when  they  perforate  the  sternum  and  have  communicated  pulsa- 
tion. Tracheal  tugging  is  rarely  present  in  tumor.  Another  point  of  impor- 
tance is  that  a  tumor,  advancing  from  the  mediastinum,  eroding  the  sternum, 
and  appearing  externally,  if  aneurismal,  has  forcible,  heaving,  and  distinctly 
expansile  pulsations.  The  radiating  pain  in  the  back  and  arms  and  neck  is 
rather  in  favor  of  aneurism,  as  is  also  a  beneficial  influence  on  it  of  iodide  of 
potassium.  The  remarkable  traumatic  cyanosis  of  the  upper  half  of  the  body 
which  follows  compression  injuries  of  the  thorax  could,  scarcely  be  mistaken 
for  the  effect  of  tumor.  The  X-ray  picture  is  rarely  at  fault  in  differentiating 
aneurism  and  tumor. 

The  frequency  of  pleural  effusion  in  connection  with'  mediastinal  tumor 
is  to  be  constantly  borne  in  mind.     It  may  give  curiously  complex  characters 


APFECTIONS  OF  THE  MEDIASTINUM  669 

to  the  physical  signs — characters  which  are  profoundly  modified  after  aspira- 
tion of  the  liquid.    Occasionally  a  tumor  of  the  mediastiuum  is  operable. 

Abscess  of  the  Mediastinum. — Hare  collected  115  cases  of  mediastinal 
abscess,  in  77  of  which  there  were  details  su.Ticient  to  permit  the  analysis.  Of 
these  cases  the  great  majority  occurred  in  males.  Forty-fear  were  instances  of 
acute  abscess.  The  anterior  mediastinum  is  most  commonly  .the  seat  of  the 
suppuration.  The  cases  are  most  frequently  associated  with  trauma.  Some 
have  followed  erysipelas  or  occurred  in  association  with  eruptive  fevers.  Many 
cases,  particularly  the  chronic  abscesses,  are  of  tuberculous  origin.  Of  symp- 
toms, pain  behind  the  sternum  is  the  most  common.  It  may  be  of  a  throbbing 
character,  and  in  the  acute  cases  is  associated  with  fever,  sometimes  with  chills 
and  sweats.  If  the  abscess  is  large  there  may  be  dyspnoea.  The  pus  may  bur- 
roAV  into  the  abdomen,  perforate  through  an  intercostal  space,  or  erode  the  ster- 
num. Instances  are  on  record  in  which  the  abscess  has  discharged  into  the 
trachea  or  oesophagus.  In  chronic  abscess  the  pus  becomes  inspissated  and 
produces  no  ill  effect.  The  physical  signs  are  indefinite.  A  pulsating  and 
fluctuating  tumor  may  appear  at  the  border  of  the  sternum  or  at  the  sternal 
notch.  The  absence  of  hruit,  of  the  diastolic  shock,  and  of  the  expansile  pul- 
sation usually  enables  a  correct  diagnosis  to  be  made.  When  in  doiibt  a  needle 
may  be  inserted. 

Mediastinitis,  Acute  and  Indurative. — The  acute  form  occurs  in  pericardi- 
tis and  pleurisy,  sometimes  as  a  primary  disease  in  the  infections,  particularly 
pneumonia  and  S3q3hilis.  The  symptoms  are  indefinite  and  it  is  rarely  recog- 
nized clinically.  Pain  behind  the  sternum  and  pressure  signs  ma)^  be  present 
and  a  well  marked  creaking  friction  with  dulling  of  the  percussion  note  on  the 
sternum  (C.  P.  Howard).  It  may  pass  on  to  abscess  formation  or  more  com- 
monly to  the  indurative  form,  in  which  there  is  great  increase  in  the  fibrous 
tissues  in  the  mediastinum,  usually  with  adherent  pericarditis.  The  process 
may  extend  and  seriously  compress  or  even  obliterate  the  vessels.  Certain  of 
the  cases  of  fibroid  obliteration  of  the  superior  vena  cava  originate  in  this  way. 
It  is  sometimes  associated  with  chronic  fibroid  polyserositis.  The  process  may 
begin  about  the  aorta  and  is  then  usually  syphilitic.  Cyanosis,  dyspnoea  and 
cough  are  the  prominent  symptoms.  The  superficial  veins  are  enlarged,  the 
sternal  note  is  flat,  the  X-ray  picture  shows  a  broad  mediastinal  shadow,  there 
may  be  visible  pulsation  of  the  larynx  and  trachea  and  sometimes  a  loud  creak- 
ing friction  is  heard.  Swelling  of  the  feet  and  ascites  may  be  present,  and 
Avhen  the  thoracic  duct  is  involved  the  ascitic  fluid  may  be  chylous.  The  heart 
may  be  enlarged  with  an  associated  adherent  pericardium  and  the  clinical  pic- 
ture at  the  end  may  be  that  of  cardiac  dropsy. 

Miscellaneous  Affections. — In  Hare's  study  of  520  cases  there  were  7 
instances  of  fibroma,  11  cases  of  dermoid  cyst,  8  cases  of  hydatid  cyst,  and  cases 
of  lipoma  and  gumma. 

Emphysema  of  the  Mediastinum. — Air  in  the  cellular  tissues  of  the  me- 
diastinum is  met  with  in  cases  of  trauma,  and  occasionally  in  fatal  cases  of 
diphtheria  and  in  whooping-cough.  It  may  extend  to  the  subcutaneous  tissues. 
Champneys  called  attention  to  its  frequency  after  tracheotomy,  in  which,  he 
says,  the  conditions  faA'oring  the  production  are  division  of  the  deep  fascia, 
obstruction  in  the  air-passages,  and  inspiratory  efforts.  The  deep  fascia,  he 
says,  should  not  be  raised  from  the  trachea.    It  is  often  associated  with  pneu- 


670  DISEASES  OF  THE  EESPIEATOEY  SYSTEM 

mothorax^  and  more  often  in  rupture  of  the  lung  without  pneumothorax,  tlie 
pleura  remaining  intact  and  the  air  dissecting  its  way  along  the  bronchi  into 
the  mediastinum  and  into  the  neck.  The  condition  seems  by  no  means  un- 
common. Angel  Money  found  it  in  16  of  28  cases  of  tracheotomy,  and  in  2 
of  these  pneumothorax  also  was  present. 


F.    DISEASES  OF  THE  DIAPHRAGM 

From  its  importance  in  respiration  any  disturbance  of  the  function  of  the 
diaphragm  may  result  in  marlved  symptoms,  especially  in  respiration.  With 
inflammation  of  either  surface  the  proper  contraction  is  affected.  Paralysis 
may  occur  with  central  lesions  or  injury  or  disease  of  the  phrenic  nerves.  It 
is  seen  with  diphtheria  and  acute  polio-myelitis.  The  arch  of  the  diaphragm 
is  high  and  there  may  be  massive  collapse  of  the  lower  lobe  on  the  affected  side. 
Bilateral  paralysis  is  always  serious.  There  is  severe  dyspnoea,  the  movements 
of  the  epigastrium  and  hypochondria  are  reversed,  the  lower  thorax  expands 
horizontally  to  a  marked  extent  and  with  the  fluoroscope  the  high  position  of 
the  arches  and  absence  of  movement  can  be  seen.  Clonic  spasm  is  present  with 
hiccough,  which,  in  acute  illness,  is  a  sign  of  gravity.  Tonic  spasm  is  some- 
times seen  in  patients  with  emphysema  and  severe  bronchitis.  Diaphragmatic 
hernia  has  to  be  distinguished  from  pneumothorax.  In  case  of  doubt  the  X-ray 
study  renders  the  diagnosis  clear.  l7iflammatio7i  is  common  and  usually  sec- 
ondary to  some  process  in  the  thorax  or  abdomen.  The  lymphatic  supply  fa- 
vors infection.  The  best  example  of  an  acute  process  is  seen  in  diaphragmatic 
pleurisy.  The  most  important  causes  of  more  chronic  inflammation  are  pleu- 
ritis  and  tuberculosis.  As  a  result  of  an  acute  process  changes  in  the  muscle 
and  adhesions  are  common  with  resulting  restriction  of  motion.  This  causes 
dyspnoea  and  possibly  the  pain  and  soreness  in  the  lower  thorax  so  common 
after  pleurisy.  Diminished  expansion  of  the  lower  thorax,  absence  of  Litten's 
sign,  dulness  and  feeble  breath  sounds  are  found,  due  in  part  to  thickened 
pleura.  The  X-ray  study  confirms  the  diagnosis  and  by  it  tlie  exact  condition 
can  be  determined.  The  extent  of  deformity  of  the  diaphragm  and  restric- 
tion of  motion  are  often  striking.  In  pulmonary  tuberculosis  there  may  be 
decreased  movement  of  the  diaphragm  even  when  the  lung  lesion  is  apical.  In 
pneumoconiosis,  in  some  cases  of  emphysema  and  of  fibroid  change,  the  de- 
formity of  the  diaphragm  and  its  restricted  function  ar?  marked.  In  advanced 
stages  of  all  these  diseases  this  plays  a  considerable  part  in  causing  the  symp- 
toms, especially  dyspnoea. 


SECTION  VIII 
DISEASES  OF  THE  KIDNEYS 

I.     MALFORMATIONS 

Newman  classifies  them  as  follows:  A.  Displacements  without  mobility — 
(1)  congenital  displacement  without  deformity;  (2)  congenital  displacement 
with  deformity;  (3)  acquired  displacements.  B.  Malformations  of  the  kid- 
ney. I.  Variations  in  number — (a)  supernumerary  kidney ;  (b)  single  kidney, 
congenital  absence  of  one  kidney,  atrophy  of  one  kidney;  (c)  absence  of  both 
kidneys.  II.  Variations  in  form  and  size — (a)  general  variations  in  form, 
lobulation,  etc. ;  (h)  hypertrophy  of  one  kidney ;  ( c)  fusion  of  two  kidneys — < 
horseshoe  kidney,  sigmoid  kidney,  disk-shaped  kidney.  In  the  horseshoe  kid- 
ney, the  commonest  form  of  fusion,  the  lower  poles  are  usually  joined.  The 
condition  sometimes  may  be  recognized  during  life  by  palpation.  C.  Varia- 
tions in  pelvis,  ureters,  and  blood-vessels. 

The  fused  kidneys  may  form  a  large  mass,  which  is  often  displaced,  be- 
ing either  in  an  iliac  fossa,  in  the  mid  line  of  the  abdomen,  or  even  in  the  pel- 
vis. Under  these  circumstances  it  may  be  mistaken  for  a  new  growth.  The 
organ  has  been  removed  under  the  belief  that  it  was  a  floating  kidney.  One 
patient  lived  eleven  days  with  complete  anuria. 

Congenital  Hydro-Ureter  and  Hydronephrosis. — In  this  rare  condition  one 
kidney  may  be  involved  or  one  kidney  with  the  ureters.  A  man  aged  21  under 
the  care  of  Halsted  had  from  his  second  year  severe  attacks  of  abdominal  pain 
in  which  a  swelling  would  appear  betAveen  the  hip  and  costal  margin  and  sub- 
side with  the  passage  of  a  large  amount  of  urine;  a  huge  hydronephrotic  sac 
was  opened  and  drained.  Of  the  bilateral  congenital  form  there  are  two 
varieties.  (1)  A  remarkable  hypertrophy  and  dilatation  of  the  bladder  and 
ureters,  associated  with  congenital  defect  of  the  abdominal  muscles.  The 
bladder  may  form  a  large  abdominal  tumor,  and  the  ureters  may  be  visi- 
ble through  the  thin  abdominal  walls  as  coils  resembling  the  small  intes- 
tine. (2)  There  is  a  form  of  dilatation  of  the  bladder,  enlargement  of  the 
ureters  and  pelvis,  With  a  clinical  picture  of  chronic  pyelonephritis  and  re- 
tention of  the  urine,  resembling  obstruction,  but  in  which,  post  mortem,  there 
is  no  demonstrable  organic  obstruction.  There  appears  to  be  a  congenital  mal- 
clevelopment  of  the  musculature  of  the  pelves,  ureters  and  bladder  wall,  or 
"an  acquired  vesical  paresis,  so  that  efforts  of  micturition  become  weaker  and 
weaker  as  time  goes  on."  The  bladder  distends,  the  ureteral  meatuses  become 
insufficient,  secondary  infection  follows,  and  the  child  from  three  to  six  years 
of  age  comes  under  observation  with  all  the  signs  of  an  extensi\'e  pyelonephritis. 

671 


672  DISEASES  OF  THE  KIDNEYS 


II.     MOVABLE  KIDNEY 

{Floating  Kidney  J  Palpable  Kidney;  Ben  mohilis;  Nepliroptosis) 

Known  to  Eiolan  in  the  17th  century  and  to  Matthew  Baillie  and  to 
Eayer  in  the  first  half  of  the  19th  century,  it  is  only  in  the  past  forty  years 
that  the  condition  has  attracted  widespread  attention. 

The  kidney  is  held  in  position  by  its  fatty  capsule,  by  the  peritoneum  which 
passes  in  front  of  it,  and  by  the  blood-vessels.  Usually  fixed,  under  certain 
circumstances  one  or  the  other  organ,  more  rarely  both,  becomes  movable.  In 
very  rare  cases  the  kidney  is  surrounded,  to  some  extent,  by  the  peritoneum, 
and  is  anchored  at  the  hilus  by  a  mesonephron.  Some  would  limit  the  term 
floating  kidney  to  this  condition. 

Movable  kidney  is  almost  always  acquired.  It  is  more  common  in  women. 
Of  the  667  cases  collected  by  Kuttner,  584  were  in  women  and  only  83  in  men. 
It  is  more  common  on  the  right  than  on  the  left  side.  Of  727  cases  analyzed 
by  this  author,  it  occurred  on  the  right  in  553  cases,  on  the  left  in  81,  and  on 
both  sides  in  93.  The  greater  frequency  in  women  may  be  attributed  to  com- 
pression of  the  lower  thoracic  zone  by  tight  lacing,  and,  more  important  still, 
to  the  relaxation  of  the  abdominal  walls  which  follows  repeated  pregnancies. 
Movable  kidney,  however,  is  by  no  means  uncommon  in  nulliparse.  There  may 
be  a  congenitally  relaxed  condition  of  the  peritoneal  attachments  as  the  condi- 
tion has  been  met  with  in  infants  and  children.  Wasting  of  the  fat  about  the 
kidney ;,  trauma  and  the  lifting  of  heavy  weights  are  occasionally  factors.  The 
kidney  is  sometimes  dragged  down  by  tumors.  The  greater  frequency  on  the 
right  side  is  probably  associated  with  the  position  of  the  kidney  just  beneath 
the  liver,  and  the  depression  to  which  the  organ  is  subjected  with  each  descent 
of  the  diaphragm  in  inspiration. 

Many  cases  present  that  combination  of  neurasthenia  with  gastro-intestinal 
disturbance  which  has  been  described  by  Glenard  as  enteroptosis  (see  p.  538). 

To  determine  the  presence  of  a  movable  kidney  the  patient  should  be  in 
the  dorsal  position,  with  the  head  moderately  Ioav  and  the  abdominal  walls 
relaxed.  The  left  hand  is  placed  in  the  lumbar  region  behind  the  eleventh  and 
twelfth  ribs;  the  right  hand  in  the  hypochondriac  region,  in  the  nipple  line, 
just  under  the  edge  of  the  liver.  Bimanual  palpation  may  detect  the  presence 
of  a  firm,  rounded  body  just  below  the  edge  of  the  ribs.  If  nothing  is  felt, 
the  patient  should  be  asked  to  draw  a  deep  breath,  when,  if  the  organ  is  pal- 
pable, it  is  touched  by  the  fingers  of  the  right  hand.  Tarious  grades  of  mo- 
bility may  be  recognized.  It  may  be  possible  barely  to  feel  the  lower  edge  on 
deep  palpation — palpahle  kidney — or  the  organ  may  be  so  far  displaced  that 
on  drawing  the  deepest  breath  the  fingers  of  the  right  hand  may  be,  in  a  thin 
person,  slipped  above  the  upper  end  of  the  organ,  which-  can  be  readily  held 
down,  but  can  net  be  pushed  beloAV  the  level  of  the  navel — movable  kidney.  In 
a  third  group  the  organ  is  freely  movable,  and  may  even  be  felt  just  above 
Poupart's  ligament,  or  in  the  mid  line  of  the  abdomen,  or  can  even  be  pushed 
over  beyond  this  point.    To  this  the  term  floating  kidney  is  appropriate. 

The  movable  kidney  may  be  tender  on  pressure,  especially  when  it  is  grasped 
very  firmly,  when  there  is  a  dull  pain,  or  sometimes  a  sickening  sensation.    Ex- 


MOVABLE  KIDNEY  673 

aminatioii  of  the  patient  from  behind  may  show  a  distinct  flattening  in  the 
lumbar  region  on  the  side  in  which  the  kidney  is  mobile. 

Symptoms. — In  a  large  majority  of  cases  there  are  no  symptoms,  and  if 
detected  accidentally  it  is  well  not  to  let  the  patient  know  of  its  presence.  Too 
much  stress  may  be  laid  upon  the  condition.  Pain  in  the  lumbar  region  or  a 
sense  of  dragging  and  discomfort  may  be  present  or  there  may  be  intercostal 
neuralgia.  In  a  large  group  the  symptoms  are  those  of  neurasthenia  with 
dyspepsia.  In  women  the  hysterical  symptoms  may  be  marked,  and  in  men 
various  grades  of  hypochondriasis ;  and  various  forms  of  insanity  have  been  at- 
tributed to  it !  Dilatation  of  the  stomach  has  been  observed,  due  to  pressure 
of  the  dislocated  kidney  upon  the  duodenum.  The  association  with  a  depressed 
stomach  is  common  in  women.  Constipation  is  not  infrequent.  Some  writers 
have  described  pressure  upon  the  gall-ducts,  with  jaundice,  but  this  is  very 
rare.  Egecal  accumulation  and  even  obstruction  may  be  associated  with  the 
displaced  organ. 

Dietl's  Crises. — In  connection  with  movable  kidney,  nearly  always  in 
Avomen,  and  on  the  right  side,  there  are  remarkable  attacks  characterized  by 
pain,  chill,  nausea,  vomiting,  fever,  and  collapse.  They  were  described  first 
by  Dietl,  in  1864,  and  attributed  to  twist  or  kink  of  the  renal  vessels  or  of 
the  ureter.  In  the  subject  of  movable  kidney  they  may  recur  at  intervals  for 
months  or  years.  A  sudden  exertion,  an  error  in  diet,  or  standing  for  a  long 
time  may  bring  on  an  attack.  The  pain  is  in  the  renal  region,  of  great  in- 
tensity, simulating  colic,  and  radiates  down  to  the  ureter  and  through  to  the 
back.  The  patient  feels  nauseated  and  cold,  or  there  may  be  a  severe  chill; 
vomiting  is  common.  The  urine  is  scanty  and  contains  an  excess  of  urate  and 
oxalates ;  sometimes  it  is  bloody.  The  affected  side  is  tender,  the  muscular 
tension  increases,  and  the  kidney  may  be  felt  enlarged,  sensitive  to  pressure 
and  less  movable ;  but  there  is  no  positive  tumor.  In  other  cases  a  tumor  rap- 
idly forms  from  dilatation  of  the  pelvis  of  the  kidney.  Appearing,  first  an- 
teriorly, at  the  edge  of  the  epigastric  region,  it  may  gradually  reach  the  size 
of  a  large  orange  or  a  cocoanut  and  fills  the  entire  renal  region.  This  may 
happen  within  thirty-six  or  forty-eight  hours.  The  nausea  persists,  there  is 
fever,  the  patient  looks  ill,  and  the  urine  may  be  scanty  or  bloody.  The  gen- 
eral symptoms  abate,  the  local  tenderness  lessens,  the  amount  of  urine  may  in- 
crease rapidly,  and  in  ten  or  twelve  hours  the  tumor  may  disappear.  In  a 
month  or  two  with  a  return  of  the  symptoms  the  tumor  reappears,  and  again 
subsides.  This  is  the  condition  of  intermittent  hydronephrosis,  one  of  the  most 
serious  and  distressing  of  the  sequels  of  movable  kidney. 

Dia^osis. — The  diagnosis  of  movable  kidney  is  rarely  doubtful.  Tumors 
of  the  gall-bladder,  ovarian  growths,  and  tumors  of  the  bowels  may  in  rare  in- 
stances be  confounded  with  it. 

Treatment. — In  many  instances  the  greatest  relief  is  experienced  from 
a  bandage  and  pad.  It  should  be  applied  in  the  morning,  with  the  patient  in 
the  dorsal  or  knee-breast  position,  and  she  should  be  taught  how  to  push  up 
the  kidney.  An  air  pad  may  be  used  if  the  organ  is  sensitive.  In  other  cases 
a  support  in  the  lower  abdominal  zone  has  the  same  effect.  In  the  attacks  of 
severe  colic  morphia  may  be  required.  The  intermittent  hydronephrosis  may  be 
relieved  by  the  pad  and  bandage.  It  rarely  demands  immediate  operation.  The 
kidney  may  have  to  be  fixed  in  position.     This  is  a  suitable  procedure  for  se- 


674  DISEASES  OF  THE  KIDXEYS 

vere  cases^  and  relief  is  afforded  in  many  instances  by  the  operation,  though 
not  in  alL  Treatment  designed  to  increase  fat-formation  often  helps  to  hold  the 
kidney  in  place.  Attention  should  always  be  given  to  the  state  of  the  nervous 
system  and  in  some  cases  a  prolonged  rest  treatment  is  indicated. 


III.  CIRCULATORY  DISTURBANCES 

The  secretion  of  urine  is  accomplished  by  the  maintenance  of  a 
certain  blood  pressure  within  the  glomeruli  and  by  the  activity  of  the  renal 
epithelium.  The  watery  elements  are  filtered  from  the  glomeruli,  the  amount 
depending  on  the  rapidity  and  the  pressure  of  the  blood  current;  the  quality, 
whether  normal  or  abnormal,  depending  upon  the  condition  of  the  capillary 
and  glomerular  epithelium;  while  the  greater  portion  of  the  solid  ingredients 
are  excreted  by  the  epithelium  of  the  convoluted  tubules.  The  integrity  of  the 
epithelium  covering  the  capillary  tufts  within  Bowman's  capsule  is  essential 
to  the  production  of  a  normal  urine.  If  under  any  circumstances  their  nutri- 
tion fails,  as  when,  for  example,  the  rapidity  of  the  blood  ciirrent  is  lowered, 
so  that  they  are  deprived  of  the  necessar}^  amount  of  oxygen,  the  material  which 
filters  through  is  no  longer  normal,  but  contains  serum  albumin.  The  renal 
epithelium  is  extremely  sensitive  to  circulatory  changes,  and  compression  of 
the  renal  artery  for  only  a  few  minutes  causes  serious  disturbance. 

The  circulation  of  the  kidney  is  influenced  by  reflex  stimuli  coming  from 
the  skin.  Exposure  to  cold  causes  heightened  blood  pressure  within  the  kid- 
ne3'S  and  increased  secretion  of  urine.  Bradford  has  shown  that  after  excision 
of  portions  of  the  kidne}^,  to  as  much  as  one-third  of  the  total  weight,  there 
is  a  remarkable  increase  in  the  flow  of  urine. 

Congestion  of  the  Kidneys. — (1)  Active  CoNGESTiOiSr ;  Htper.emia. — 
Acute  congestion  of  the  kidney  is  met  with  in  the  early  stage  of  nephritis, 
whether  due  to  cold  or  to  the  action  of  poisons  and  severe  irritants.  Turpen- 
tine, cubebs,  cantharides,  and  copaiba  cause  extreme  hyperemia  of  the  organ. 
The  most  tyj)ical  congestion  of  the  kidney  which  we  see  post  mortem  is  that 
in  the  early  stage  of  acute  nephritis,  when  the  organ  may  be  large,  soft,  of  a 
dark  color,  and  on  section  blood  drips  from  it  freely. 

It  has  been  held  that  in  all  the  acute  fevers  the  kidneys  are  congested,  and 
that  this  explained  the  scanty,  high  colored,  and  often  albuminous  urine.  On 
the  other  hand,  the  kidney  in  acute  fever  may  be  small,  pale,  and  bloodless; 
this  anemia,  increasing  with  the  pyrexia  and  interfering  with  the  nutrition  of 
the  glomerular  epithelium,  may  account  for  the  scanty,  dark-colored  urine  and 
the  presence  of  albumin.  In  the  prolonged  fevers,  however,  it  is  probable  that 
relaxation  of  the  arteries  again  takes  place.  Certainly  it  is  rare  to  find  post 
mortem  marked  anaemia;  on  the  contrary,  the  kidney  of  fever  is  commonly 
swollen,  the  blood-vessels  are  congested,  and  the  cortex  freqiiently  shows  traces 
of  cloudy  swelling.  The  circulatory  disturbances  in  acute  fevers  are  probably 
less  important  than  the  irritative  effects  of  the  specific  agents  of  the  disease 
or  the  products  produced  in  their  growth  or  by  the  altered  metabolism.  The 
urine  is  diminished  in  amount,  and  may  contain  albumin  and  tube-casts,  some- 
times much  of  the  former  and  few  of  the  latter. 

(2)   Passive  Congestion;  Meqhafical  HTPER.ffiMiA, — This  is  found  in 


ANOMALIES  OF  THE  UEINAEY  SECEETIOX  675 

cases  of  chronic  disease  of  the  heart  or  lung,  with  impeded  circulation,  and  as 
a  result  of  pressure  upon  the  renal  veins  by  tumors,  the  pregnant  uterus,  or 
ascitic  fluid.  In  the  cardiac  kidney,  as  it  is  called,  the  cyanotic  induration 
associated  with  chronic  heart  disease,  the  organs  are  enlarged  and  firm,  the 
capsule  strips  otf,  as  a  rule,  readily,  the  cortex  is  of  a  deep  red  color,  and  the 
pyramids  of  a  purple  red.  The  section  is  coarse  looking,  the  substance  is  very 
firm,  and  resists  cutting  and  tearing.  The  interstitial  tissue  is  increased,  and 
there  is  a  small-celled  infiltration  between  the  tubules.  Here  and  there  the 
Malpighian  tufts  have  become  sclerosed.  The  blood-vessels  are  usually  thick- 
ened, and  there  may  be  more  or  less  granular,  fatty,  or  hyaline  changes  in  the 
epithelium  of  the  tubules.  The  condition  is  indeed  a  diffuse  nephritis.  The 
urine  is  usually  reduced,  is  of  high  specific  gravity,  and  contains  more  or  less 
albumin.  Hyaline  tube  casts  and  blood  corpuscles  are  not  uncommon.  In 
some  cases  (over  half)  with  maeroscopically  no  signs  of  chronic  or  acute  ne- 
phritis the  urinary  features  lead  to  the  diagnosis  of  acute  nephritis  (Emer- 
son). In  uncomplicated  cases  of  the  cyanotic  induration  uraemia  is  rare.  In 
the  cardiac  cases  with  extensive  arterio-sclerosis,  the  kidneys  are  more  involved 
and  the  renal  function  is  likely  to  be  disturbed. 


IV.    ANOMALIES  OF  THE  URINARY  SECRETION 

I.     ANUEIA 

Total  suppression  of  urine  occurs  under  the  following  conditions: 

(a)  As  an  event  in  the  intense  congestion  of  acute  nephritis.  For  a  time 
no  urine  may  be  formed ;  more  often  the  amount  is  greatly  reduced. 

(b)  More  commonly  complete  anuria  is  seen  in  subjects  of  renal  stone, 
fragments  of  which  block  both  ureters;  or  the  calculus  blocks  the  only  kidney, 
the  other  being  represented  by  a  shell  of  tissue.  In  this  "obstructive  sup- 
pression," as  it  is  called,  there  is  a  condition  which  has  been  called  latent 
uraemia.  There  may  be  very  little  discomfort,  and  the  symptoms  are  very 
unlike  those  of  ordinary  uraemia.  Convulsions  occurred  in  only  5  of  -il  cases 
(Herter)  ;  headache  in  only  6;  vomiting  in  only  12.  Consciousness  is  retained; 
the  pupils  are  usually  contracted;  the  temperature  may  be  low;  there  are 
twitchings  and  perhaps  occasional  vomiting.  Of  41  cases,  35  occurred  in 
males.  Of  36  cases  in  which  there  was  absolute  anuria,  in  11  the  condition 
lasted  more  than  four  days,  in  18  cases  from  seven  to  fourteen  days,  and  in  7 
cases  longer  than  fourteen  days  (Herter).  Obstructive  suppression  is  met  with 
also  when  cancer  compresses  both  ureters  and  involves  their  orifices  in  the 
bladder. 

(c)  Cases  occur  occasionally  in  which  the  cause  is  prerenal.  The  follow- 
ing are  among  the  more  important  conditions  with  which  this  form  of  anuria 
may  be  associated :  Fevers  and  inflammations ;  acute  poisoning  by  phosphorus, 
mercury,  lead,  and  turpentine;  aortic  thrombosis  involving  the  renal  arteries; 
in  the  collapse  after  severe  injuries  or  after  operations,  or,  indeed,  after  the 
passing  of  a  catheter;  in  the  collapse  stage  of  cholera  and  yellow  fever;  and, 
lastly,  there  is  an  hysterical  anuria,  of  which  Charcot  reported  a  case  in  which 
the  suppression  lasted  for  eleven  days.    Bailey  reports  the  case  of  a  young  girl. 


676  DISEASES  OF  THE  KIDNEYS 

aged  eleven,  inmate  of  an  orphan  asylum,  who  passed  no  urine  from  October 
10th  to  December  12th  (when  8  ounces  were  withdrawn),  and  again  from  this 
date  to  March  1st !  The  question  of  hysterical  deception  was  considered  in  the 
case. 

A  patient  may  live  for  from  ten  days  to  two  weeks  with  complete  suppres- 
sion. In  Polk's  case,  in  which  the  only  kidney  was  removed,  the  patient  lived 
eleven  days.  It  is  reniarkable  that  in  many  instances  there  are  no  toxic  fea- 
tures.   Adams  reports  a  case  of  recovery  after  nineteen  days  of  suppression. 

Treatment. — In  the  obstructive  cases  surgical  interference  should  be  re- 
sorted to.  In  the  non-obstructive  cases,  particularly  when  due  to  extreme  con- 
gestion of  the  kidney,  cupping  over  the  loins,  hot  applications,  free  purging, 
and  sweating  with  pilocarpine  and  hot  air  are  indicated.  When  the  secretion 
is  once  started  diuretin  often  acts  well.  Large  hot  irrigations,  with  normal 
salt  solution,  with  Kemp's  double-current  rectal  tubes,  are  stated  to  stimulate 
the  activity  of  the  kidneys  in  a  remarkable  way. 

II.     H^MATUEIA 

Etiology. — The  following  division  may  be  made  of  the  conditions  in  which 
hsematuria  occurs : 

(1)  Essential  Hematuria. — How  much  basis  there  is  for  this  group  is 
a  question  and  it  seems  doubtful  whether  the  term  should  be  retained.  To 
make  this  diagnosis  is  to  confess  our  inability  to  find  any  positive  cause. 
There  are  some  cases,  usually  in  young  adults,  in  which  no  cause  can  be 
found  and  in  which  operation  gives  no  clue  to  the  cause  of  the  hemorrhage. 
Some  are  due  to  varicosity  of  vessels  in  the  papillae.  The  subjects  are  usually 
under  the  age  of  thirty.  The  bleeding  is  spontaneous,  often  associated  witli 
pain,  though  in  many  cases  the  attacks  are  painless.  The  X-ray  picture  is 
negative,  the  haemorrhage  ceases  of  itself,  and  only  in  a  few  cases  do  the  at- 
tacks recur  with  such  frequency  that  the  patient  becomes  anaemic.  The  con- 
dition has  been  referred  to  under  Gull's  name  of  "renal  epistaxis"  in  previous 
editions.  It  is  rarely  serious,  and  many  cases  recover  spontaneously,  in  others 
nephrotomy  stops  the  tendency  to  bleeding,  though  why  it  should  do  so  is 
diilicult  to  say.    The  outlook  is  good  (see  Hale  White,  Q.  J.  M.,  1911). 

(2)  General  Diseases. — In  the  malignant  specific  fevers,  in  purpura, 
and  occasionally  in  leukaemia.     It  may  be  caused  by  malaria. 

(3)  Eenal  Causes. — Acute  congestion  and  inflammation,  as  in  nephritis 
or  pyelonephritis,  or  due  to  the  effect  of  toxic  agents,  such  as  turpentine,  car- 
bolic acid,  and  cantharides.  When  the  carbolic  spray  was  in  use  many  surgeons 
suffered  from  haematuria  in  consequence  of  this  poison.  Eenal  infarction,  as 
in  ulcerative  endocarditis.  New  growths,  in  which  the  bleeding  is  usually 
profuse.  In  tuberculosis  at  the  onset,  when  the  papillae  are  involved,  there 
may  be  bleeding.  Stone  in  the  kidney  is  a  frequent  cause.  Parasites:  The 
Filaria  hancrofti  and  Bilharzia  cause  a  form  of  haematuria  met  with  in  the 
tropics.  The  echinococcus  is  rarely  associated  with  haemorrhage.  It  is  some- 
times met  with  in  floating  kidney  and  hydronephrosis.  An  unusual  cause  is 
the  painful,  villous  tumor  of  the  renal  pelvis,  of  which  Savory  and  Nash  report 
a  remarkable  case  and  collected  -±9  others  from  the  literature.  It  would  be 
difficult  to  distinguish  the  condition  from  stone.  Angioma  and  capillary  neevi 
of  the  papillae  may  cause  bleeding. 


ANOMALIES  OF  THE  UEINAEY  SECEETION  677 

(4)  Affections  of  the  Urinary  Passages. — Stone  in  the  ureter,  tu- 
mors, polypi,  tuberculosis,  diverticula,  or  ulceration  of  the  bladder,  the  pres- 
ence of  a  calculus,  parasites,  and,  very  rarely,  ruptured  veins  in  the  bladder. 
Sleeding  from  the  urethra  occasionally  occurs  in  gonorrhoea  and  as  a  result 
of  the  lodgment  of  a  calculus.  In  females  it  may  be  due  to  prolapse  or  tumor 
of  the  urethra.  Recurring  hsematuria  may  be  an  early  symptom  in  malignant 
disease  of  or  an  enlarged  prostate. 

(5)  Traumatism. — Injuries  may  produce  bleeding  from  any  part  of  the 
urinary  passages.  By  a  fall  or  blow  on  the  back  the  kidney  may  be  ruptured, 
and  this  may  be  followed  by  very  free  bleeding;  less  commonly  the  blood 
comes  from  injury  of  the  bladder  or  of  the  prostate.  Blood  from  the  urethra 
is  frequently  due  to  injury  by  the  passage  of  a  catheter,  or  sometimes  to  falls. 
Transient  hfematuria  follows  all  operations  on  the  kidney. 

(6)  Exercise. — After  strenuous  exercise  or  exposure  to  cold  temporary 
hsematuria  may  occur  with  blood  casts,  followed  by  transient  albuminuria,  in 
individiials  who  show  no  signs  of  nephritis. 

Diagnosis. — This  is  usually  easy.  The  color  of  the  urine  varies  from  a 
light  smoky  to  a  bright  red,  or  it  may  have  a  dark  porter  color.  The  blood- 
corpuscles  are  readily  recognized  microscopically,  either  plainly  visible  and 
retaining  their  color,  in  which  case  they  are  usually  crenated,  or  simply  as 
shadows.  In  ammoniacal  urine  or  urines  of  low  specific  gravity  the  haemo- 
globin is  rapidly  dissolved  from  the  corpuscles. 

It  is  important  to  distinguish  between  blood  coming  from  the  bladder  and 
from  the  kidneys.  From  the  bladder  the  blood  may  be  found  only  with  the 
last  portions  of  urine,  or  only  at  the  termination  of  micturition.  In  hgemor- 
rhage  from  the  kidneys  the  blood  and  urine  are  intimately  mixed.  Clots  are 
more  commonly  found  in  the  blood  from  the  kidneys,  and  may  form  moulds 
of  the  pelvis  or  of  the  ureter.  When  the  seat  of  the  bleeding  is  in  the  bladder, 
on  washing  out  this  organ,  the  water  is  more  or  less  blood-tinged;  but  if  the 
source  of  the  bleeding  is  higher,  the  water  comes  away  clear.  In  many  in- 
stances it  is  difficult  to  settle  the  question  by  the  examination  of  the  urine 
alone,  and  the  symptoms  and  the  physical  signs  must  also  be  taken  into  ac- 
count. Cystoscopic  examination  of  the  bladder  and  catheterization  of  the 
ureters  are  aids  in  the  diagnosis  of  doubtful  cases.  The  recognition  of  the 
cause  may  be  difficult.  New  growth,  tuberculosis  and  calculus  should  always 
be  considered. 

III.     HEMOGLOBINURIA 

This  is  characterized  by  the  presence  of  blood-pigment  in  the  urine.  The 
blood-cells  are  absent  or  in  insignificant  numbers.  The  coloring  matter  is  not 
hsematin,  as  indicated  by  the  old  name,  hcpmatinuria,  nor  in  reality  always 
haemoglobin,  but  most  frequently  methsemoglobin.  The  urine  has  a  red  or 
brownish-red,  sometimes  quite  black,  color,  and  usually  deposits  a  very  heavy 
brownish  sediment.  When  the  haemoglobin  occurs  only  in  small  quantities, 
it  may  give  a  lake  or  smoky  color  to  the  urine.  Microscopic  examination 
shows  the  presence  of  granular  pigment,  sometimes  fragments  of  blood  disks, 
epithelium,  and  very  often  darkly  pigmented  urates.  The  urine  is  also  al- 
buminous. The  number  of  red  blood  corpuscles  bears  no  proportion  to  the 
intensity  of  the  color  of  the  urine.     Examined  spectroscopically,  there  are 


678  DISEASES  OF  THE  KIDNEYS 

either  the  two  absorption  bands  of  oxyhgemoglobin,  which  is  rare^  or  more  com- 
monly, there  are  the  three  absorption  bands  of  metha^moglobin,  of  which  the 
one  in  the  red  near  C  is  characteristic.     There  are  two  clinical  groups. 

Toxic  Haemoglo'binuria, — This  is  caused  by  poisons  which  produce  rapid> 
dissolution  of  the  blood  corpuscles,  such  as  potassium  chlorate  in  large  doses, 
pyrogallic  acid,  carbolic  acid,  arseniuretted  hydrogen,  carbon  monoxide,  naph- 
thol,  and  muscarine;  also  the  poisons  of  scarlet  fever,  yellow  fever,  typhoid 
fever,  malaria,  and  syphilis.  It  has  also  followed  severe  -burns.  Exposure  to 
excessive  cold  and  violent  muscular  exertion  are  stated  to  produce  hgemo- 
globinuria.  A  most  remarkable  toxic  form  occurs  in  horses,  coming  on  with 
great  suddenness  and  associated  with  paresis  of  the  hind  legs.  Death  may 
occur  in  a  few  hours  or  a  few  days.  The  animals  are  attacked  only  after  being 
stalled  for  some  days  and  then  taken  out  and  driven,  particularly  in  cold 
weather.  The  form  of  hsemoglobinuria  from  cold  and  exertion  is  extremely 
rare.  jSTo  instance  of  it,  even  in  association  with  frost-bites,  came  under  our 
observation  in  Canada.  Blood  transfused  from  one  mammal  into  another 
causes  dissolution  of  the  corpuscles  with  the  production  of  hemoglobinuria; 
and,  lastly,  there  is  the  epidemic  hcemoglohinuria  of  the  newborn,  associated 
with  jaundice,  cyanosis,  and  nervous  symptoms. 

Paroxysmal  Hsemoglobinuria. — This  rare  disease  is  characterized  by  the 
occasional  passage  of  bloody  urine,  in  which  the  coloring  matter  only  is  pres- 
ent. It  is  more  frequent  in  males  than  in  females,  and  occurs  chiefly  in 
adults.  It  seems  specially  associated  Math  cold  and  exertion,  and  has  often 
been  brought  on,  in  a  susceptible  person,  by  the  use  of  a  cold  foot-bath.  It 
occurs  in  persons  subject  to  Ea3maud's  disease,  and  the  relation  between  these 
two  affections  is  extremely  close;  some  hold  that  they  are  manifestations  of 
one  and  the  same  disorder.  Druitt,  the  author  of  the  well-known  Surgical 
Vade-mecum,  has  given  a  graphic  description  of  his  sufferings,  which  lasted 
for  many  years,  and  were  accompanied  with  local  asphyxia  and  local  syncope. 
The  connection,  however,  is  not  very  common.  The  relation  of  hfemoglobinuria 
to  malaria  has  been  considered.  Syphilis  is  present  in  some  cases.  In  a  case 
reported  by  Br  em  after  fifteen  injections  of  arsphenamine,  the  hsemoglobinuria 
disappeared. 

The  attacks  may  come  on  suddenly  after  exposure  to  cold  or  as  a  result 
of  mental  or  bodily  exhaustion.  They  may  be  preceded  by  chills  and  pyrexia. 
In  other  instances  the  temperature  is  subnormal.  There  may  be  vomiting  and 
diarrhoea.  Pain  in  the.  lumbar  region  is  not  uncommon.  The  hsemoglobinuria 
rarely  persists  for  more  than  a  day  or  two — sometimes,  indeed,  not  for  a  day. 
There  are  instances  in  which,  even  in  a  single  day,  there  have  been  two  or 
three  paroxysms,  and  in  the  intervals  clear  urine  has  been  passed.  Jaundice 
has  been  present  in  a  number  of  cases.    The  disease  is  rarely  if  ever  fatal. 

Much  has  been  done  to  clear  up  the  nature  of  this  remarkable  disease  by 
the  studies  of  Eason,  Donath,  Landsteiner,  Hoover  and  Stone,  and  Moss. 
Briefly,  the  blood  serum  of  these  patients  contains  a  complex  haeniolysin,  a 
potential  toxin,  capable  of  dissolving  the  patient's  own  corpuscles  and  those  of 
other  individuals.  It  is  an  amboceptor  component  of  the  hfemolysin,  not  the 
complement,  that  is  peculiar,  and  this  amboceptor  differs  "from  other  known 
h{emol5''tic  amboceptors  in  that  it  will  unite  with  the  red  blood-corpuscles  only 
at  a  low  temperature  in  the  presence  of  complement,   and   furthermore  in 


AN0MALI:ES  of  the  UEINAEY  SECEETIOI^^  679 

that  it  is  capable  of  bringiug  about  the  solution  of  the  patient's  own  cells 
(auto-hcPmolytic  action),  and  those  of  other  members  of  the  group  to  which 
the  patient  belongs,  as  well  as  the  cells  of  members  of  other  groups"  (Moss). 
Atmospheric  cold  and  congestion  of  the  peripheral  vessels,  as  in  Eaynaud's 
disease,  will  reduce  the  temperature  of  the  blood  sufficiently  to  permit  of  the 
union  of  the  amboceptor  and  corpuscles,  and  haemolysis  occurs  when  the  blood 
passes  to  the  internal  organs. 

Treatment. — The  essential  treatment  must  depend  on  the  cause.  In  all 
forms  of  ha^maturia  rest  is  essential.  In  that  produced  by  renal  calculi  the 
recumbent  posture  may  suffice  to  cheek  the  bleeding.  Full  doses  of  acetate 
of  lead  and  opium  should  be  tried,  then  calcium  lactate  and  epinephrin.  Cold 
may  be  applied  to  the  loins  or  dry  cups  in  the  lumbar  region.  Incision  of  the 
kidney  has  cured  the  so-called  essential  hsematuria. 

The  treatment  of  paroxysmal  hsemoglobinuria  is  unsatisfactory.  Amyl 
nitrite  will  sometimes  cut  short  or  prevent  an  attack  (Chvostek).  During 
the  paroxysm  the  patient  should  be  kept  warm  and  given  hot  drinks.  If  there 
is  a  syphilitic  history  active  treatment  should  be  given.  In  a  warm  climate 
the  attacks  are  much  less  frequent.  It  is  possible  that  an  antitoxin  may  be 
obtained  to  neutralize  the  haemolytic  amboceptor  of  the  disease. 

IV.     ALBUMINUEIA 

"Reasons  drawn  from  the  urine  are  as  brittle  as  the  urinal"  is  a  dictum 
of  Thomas  Fuller  peculiarly  appropriate  in  connection  with  this  subject. 

The  presence  of  albumin  in  the  urine,  formerly  regarded  as  indicative  of 
nephritis,  is  now  recognized  as  occurring  under  many  circumstances  without 
the  existence  of  serious  organic  change  in  the  kidney.  Two  groups  of  cases 
may  be  recognized — those  in  which  the  kidneys  show  no  coarse  lesions,  and 
those  in  which  there  are  evident  anatomical  changes. 

Albuminuria  without  Coarse  Renal  Lesions. —  (a)  FuNCTio:NrAL^  so-called 
Physiological  Albumixupja. — In  a  normal  condition  of  the  kidney  only 
the  water  and  the  salts  are  allovv'ed  to  pass  from  the  blood.  When  albumi- 
nous substances  transude  there  is  probably  disturbance  in  the  nutrition  of 
the  epithelium  of  the  capillaries  of  the  tuft,  or  of  the  cells  surrounding  the 
glomerulus.  This  statement  is  still  in  dispute,  and  many  hold  that  there  is  a 
physiological  albuminuria  which  may  follow  muscular  work,  the  ingestion  of 
food  rich  in  albumin,  violent  emotions,  cold  bathing,  and  dyspepsia.  On  one 
point  all  agree,  that  the  cause  must  be  something  unusual  and  excessive,  as  a 
very  hard  tramp,  a  football  match,  a  race,  etc.  The  presence  of  albumin  in 
the  urine,  in  any  form  and  under  any  circumstance,  maj^  be  regarded  as  in- 
dicative of  change  in  the  renal  or  glomerular  epithelium,  a  change,  however, 
which  may  be  transient,  slight,  and  unimportant,  depending  upon  variations 
in  the  circulation  or  upon  the  irritating  effects  of  substances  taken  with  the 
food  or  temporarily  present,  as  in  febrile  states. 

Albuminuria  of  adolescence  and  cyclic  albuminuria,  in  which  the  all)umin 
is  present  only  at  certain  times  during  the  day — ortlioslaiic  albuminuria — 
are  interesting  forms.  A  majority  of  the  cases  occur  in  young  persons — 
boys  more  commonly  than  girls — and  the  condition  is  often  discovered  acci- 
dentally.    These  are  often  the  children  of  neurotic  parents,  and  have  well- 


680  DISEASES  OF  THE  KIDXEYS 

marked  vasomotor  instability.  Some  cases  last  only  during  puberty,  some 
throughout  life.  The  condition  is  very  common,  particularly  in  young  men  in 
training — the  athletic  albuminuria  to  which  Collier  has  called  attention.  Of 
156  men  in  training  130  had  albumin  in  the  urine.  Erlanger  and  Hooker 
have  shown  that  the  albumin  is  excret-ed  only  during  periods  with  low  pulse 
pressure.  The  urine,  as  a  rule,  contains  only  a  very  small  amount  of  albumin, 
but  in  some  instances  large  quantities  are  present.  The  most  striking  fea- 
ture is  the  variability.  It  may  be  absent  in  the  morning  and  present  only 
after  exertion:  or  it  may  be  greatly  increased  after  taking  food,  particularly 
proteins.  Even  the  change  to  the  upright  position  (orthostatic)  may  suffice 
to  cause  it,  and  in  such  cases  there  may  be  tension  on  the  renal  veins  by  in- 
crease of  the  lumbar  curve,  since  it  has  been  shown  that  a  spinal  jacket  will 
prevent  the  appearance  of  the  albumin.  Support  of  a  movable  kidney  may 
stop  it.  The  quantity  of  urine  may  be  but  little,  if  at  all,  increased,  the 
specific  gravity  is  usually  normal,  and  the  color  may  be  high.  Occasionally 
hyaline  casts  may  be  found,  and  in  some  instances  there  has  been  transient 
glycosuria.  As  a  rule,  the  pulse  is  not  of  high  tension  and  the  second  aortic 
sound  is  not  accentuated. 

Various  forms  of  this  afEection  have  been  recognized  by  writers,  such  as 
neurotic,  dietetic,  cyclic,  intermittent,  and  paroxysmal — ^names  which  indi- 
cate the  characters  of  the  different  varieties. 

Goodhart,  from  a  study  of  the  after  history  of  more  than  2.50  cases,  holds 
that  albuminuria  of  the  adolescent  has  no  sinister  effect  on  health  or  upon 
duration  of  life,  and  that  with  due  circumspection  such  cases  ought  not  to  be 
excluded  from  the  advantages  of  life  insurance.  This  is  a  very  important 
statement  from  a  man  who  has  made  a  special  study  of  the  subject. 

In  a  few  cases  the  albumin  is  persistent,  the  amount  is  larger,  though  it 
may  vary  from  day  to  day,  the  pulse  tension  is  increased,  and  these  are  prob- 
ably indications  of  organic  changes  in  the  kidney. 

(b)  Febrile  Albumixuria. — Pyrexia,  by  whatever  cause  produced,  may 
cause  slight  albuminuria.  The  presence  of  the  albumin  is  due  to  slight 
changes  in  the  glomeruli  induced  by  the  fever,  such  as  cloudy  swelling,  which 
can  not  be  regarded  as  an  organic  lesion.  It  is  extremely  common,  occurring 
in  pneumonia  (in  about  70  per  cent,  of  our  cases),  diphtheria,  typhoid  fever 
(about  60  per  cent,  of  our  cases),  malaria,  especially  the  eestivo-autumnal  type, 
and  even  in  the  fever  of  acute  tonsillitis.  The  amount  of  albumin  is  slight, 
and  it  usually  disappears  from  the  urine  with  the  cessation  of  the  fever. 
Hyaline  and  even  epithelial  casts  accompany  the  condition. 

(c)  'Ejemic  Chaxges. — Purpura,  scurvy,  chronic  poisoning  by  lead  or 
mercury,  syphilis,  leukgemia,  and  profound  anaemia  may  be  associated  with 
slight  albuminuria.  Abnormal  ingredients  in  the  blood,  such  as  bile  pigment, 
may  cause  the  passage  of  small  amounts  of  albumin. 

The  transient  albuminuria  of  pregnancy  may  belong  to  this  h»mic  group, 
although  in  a  majority  of  such  cases  there  are  changes  in  the  renal  tissue. 
Albumin  may  be  found  sometimes  after  the  inhalation  of  ether  or  chloroform. 

(d)  Keevous  System. — In  many  morbid  conditions  of  the  nervous  sys- 
tem, albumin  may  be  present  in  the  urine,  and  there  are  instances  in  young 
nervous  persons  which  are  not  easy  to  separate  from  the  so-called  orthostatic 
forms.      In  brain   tumors,   following   epileptic   attacks,   in   various   types   of 


ANOMALIES  OF  THE  UEIXAKY  SECRETIOX  081 

meningitis,  albumin  has  been  present.  In  meningeal  haemorrhage,  as  pointed 
out  by  Guillaiu,  the  albumin  may  be  very  abundant,  5  to  20  grams  in  the  litre. 

Albuminuria  with  Definite  Lesions  of  the  Urinary  Organs. —  (a)  Conges- 
tion of  the  kidney,  either  active,  such  as  follows  exposure  to  cold  and  is  as- 
sociated with  the  early  stages  of  nephritis,  or  passive,  due  to  obstructed  out- 
flow in  disease  of  the  heart  or  lungs,  or  to  pressure  on  the  renal  veins  by  the 
pregnant  uterus  or  tumors. 

(h)  Organic  disease  of  the  kidneys — acute  and  chronic,  nephritis,  amyloid 
and  fatty  degeneration,  suppurative  nephritis,  and  tumors. 

(c)  Affections  of  the  pelvis,  ureters,  bladder,  and  prostate,  when  associated 
with  the  formation  of  pus  or  haematuria. 

(d)  Hereditary  Familial  Alhuminuria  and  Hcemorrhagic  Nephritis. — 
Families  have  been  described  by  Guthrie,  and  by  Kendell  and  Hurst,  in  which 
through  two  and  three  generations  members  of  the  family  have  had  albu- 
minuria, high  blood  pressure,  occasional  haematuria  or  sometimes  only  micro- 
scopic blood,  from  early  childhood.  Some  of  the  patients  died  early  from 
uraemia ;  others  lived  to  adult  life.  Hypertension  and  cardio-vascular  fea- 
tures ha^e  been  present  in  some  cases. 

Albumosuria. — Albumose,  peptone,  and  globulin  are  occasionally  found  in 
the  urine,  but  are  of  very  slight  clinical  significance.  They  are  found  in  many 
febrile  diseases,  in  chronic  suppuration,  and  whenever  protein  materials  are 
undergoing  autolysis,  as  in  pneumonia,  acute  yellow  atrophy,  and  during  the 
involution  of  the  uterus. 

Myelopathic  albumosuria,  "Kaliler's  disease,"  is  characterized  by  multiple 
myelomata  Avith  persistent  excretion  of  what  is  known  as  the  Bence-Jones 
body,  a  protein  discovered  by  him  in  1848.  Some  believe  that  it  is  not  a  pro- 
teose but  a  higher  protein  of  endogenous  origin  derived  either  from  the  tumor 
cells  of  a  myeloma  or  from  the  abnormal  synthesis  of  a  body  protein.  Males 
above  forty  years  of  age  are  usually  affected.  The  Bence-Jones  body  appears 
rarely  with  other  tumors  of  the  bones.  The  myeloma  is  a  true  tumor,  the  cells 
of  which  resemble  the  plasma  rather  than  the  myelocytes  of  the  bone  marrow 
(Christian).  In  a  case  seen  with  Hamburger  the  persistent  albumosuria  led 
to  the  diagnosis  of  multiple  myelomata  before  any  bone  tumors  could  be  felt. 
The  disease  runs  a  fatal  course.  The  simplest  reaction  is  the  white  precipi- 
tate formed  on  adding  nitric  acid  to  the  urine;  when  boiled  it  disappears, 
to  reappear  on  cooling.  As  in  one  of  Bradshaw's  cases,  the  urine  may  be  of 
a  milky  white  color  when  passed. 

Prognosis. — Febrile  albuminuria  is  transient,  and  in  a  majority  of  the 
cases  depending  upon  ha^mic  causes  the  condition  disappears  and  leaves  the 
kidneys  intact.  A  trace  of  albumin  in  a  man  over  forty,  with  or  without  a 
few  hyaline  casts,  is  not  of  much  significance,  except  as  an  indication  that  his 
kidneys,  like  his  hair,  are  beginning  to  turn  '^gray"  with  age.  In  many  in- 
stances the  discovery  is  a  positive  advantage,  as  the  man  is  made  to  realize, 
perhaps  for  the  first  time,  that  he  has  been  living  carelessly.  The  question  was 
discussed  from  this  standpoint  in  a  paper  with  the  paradoxical  title  "On  the 
Advantages  of  a  Trace  of  Albumin  and  a  Few  Tube-casts  in  the  Urine  of 
Men  over  Fifty  Years  of  Age"  {N.  Y.  Med.  Jour.,  vol.  Ixxiv).  The  persistence 
of  a  slight  amount  of  albumin  in  young  men  without  increased  arterial  tension 


682  DISEASES  OF  THE  KIDXEYS 

is  less  serious^  as  even  after  continiiing  for  3'ears  it  may  disappear.  The  out- 
look in  the  so-called  cyclic  albnminnria  has  been  discussed. 

Practically  in  all  cases  the  presence  of  albumin  indicates  a  change  of 
some  sort  in  the  glomeruli,  the  nature,  extent,  and  gravity  of  which  it  is 
difficult  to  estimate;  so  that  other  considerations,  such  as  the  presence  of  tube- 
casts,  increased  tension,  the  general  condition  of  the  patient,  and  the  influ- 
ence of  digestion  upon  the  albumin,  must  be  carefully  considered. 

The  physician  is  often  consulted  as  to  the  relation  of  albuminuria  and 
life  assurance.  As  his  function  is  to  protect  the  interests  of  the  company, 
he  should  reject  all  cases  in  which  albumin  occurs  in  the  urine,  except  in 
young  persons  with  transient  albuminuria.  Naturally,  companies  lay  great 
stress  upon  the  presence  of  albumin,  but  in  the  most  fatal  malady  with  which 
they  have  to  deal — chronic  interstitial  nephritis — the  albumin  is  often  absent 
or  transient,  even  when  the  disease  is  well  developed.  After  the  fortieth  year, 
from  a  standpoint  of  life  insurance,  the  state  of  the  arteries  and  the  blood 
pressure  are  more  important  than  the  condition  of  the  urine. 

V.     BACTEEIUEIA 

Described  first  by  Roberts  in  1881,  much  attention  has  been  paid  to  it 
and  its  importance  recognized  both  as  a  secondary  and  a  primary  affection. 
The  secondary  form  is  best  illustrated  by  the  common  bacilluria  of  typhoid 
fever.  In  the  cases  in  which  there  is  no  recognizable  cause  or  primary  focus, 
the  colon  bacillus,  streptococci,  and  the  gonococcus  are  the  commonest  organ- 
isms. The  bacilli  may  come  directly  from  the  blood,  as  in  typhoid  fever,  and 
probably  multiply  in  the  urinary  passages,  or  they  may  come  from  a  focus  of 
infection  anywhere  from  Bowman's  capsule  to  the  prostate. 

Clinically  there  are  two  groups  of  cases,  the  bacilluria  pure  and  simple 
and  the  bacilluric  cystitis  or  pyelitis.  In  the  former  there  may  be  no  symp- 
toms; the  urine  may  have  a  slight  haziness  due  to  the  enormous  number  of 
organisms,  but  there  is  no  pus.  In  the  other  there  are  signs  of  inflammatory 
reaction  in  the  urinary  passages  and  there  is  pus.  Usually  with  the  Bacillus 
coli  infection  the  urine  is  acid,  with  the  staphylococcus  alkaline  and  often 
with  marked  phosphaturia.  The  cases  are  often  very  intractable.  Without 
cystitis  or  pyelitis  there  may  be  no  symptoms,  but  in  too  many  instances 
there  are  all  the  aggravated  phenomena  of  these  two  affections.  Many  cases 
clear  up  rapidly  with  hexamine.  Vaccine  therapy  has  been  extensively  used 
but  not  with  very  good  results. 

VI.     PYUEIA 
{Pus  in  the  Urine) 

Causes. —  (a)  Pyelitis  and  Pyelonephritis. — In  large  abscesses  of  the 
kidney,  pyonephrosis,  the  pus  may  be  intermittent,  while  in  calculus  and  tu- 
berculous pyelitis  the  pyuria  is  usually  continuous,  though  varying  in  in- 
tensity. In  cases  due  to  the  colon  or  tubercle  bacillus  the  urine  is  acid,  in 
those  due  to  the  proteus  bacillus  alkaline,  while  in  the  staphylococcus  cases 
the  urine  is  either  less  acid  than  normal,  or  alkaline.  In  the  pyelitis  and 
pyelonephritis  following  cystitis  the  urine  is  alkaline  or  acid,  depending  upon 


ANOMALIES  OF  THE  URINAEY  SECRETION  683 

the  infecting  micro-organism;  more  mucus,  frequent  micturition,  and  a  pre- 
vious bladder  history  are  aids  in  diagnosis.  H.  Cabot  points  out  that  if  the 
fresh  urine  shows  cocci  in  abundance,  with  a.  small  amount  of  albumin,  few 
red  blood  cells,  many  leucocytes  or  a  little  pus,  and  the  renal  function  near 
normal,  it  is  probably  a  coccus  infection  and  mostly  in  the  cortex.  If  there 
are  many  bacilli,  little  albumin,  much  pus  and  greatly  decreased  renal  func- 
tion it  is  probably  a  colon  bacillus  infection  with  the  first  effect  on  the  con- 
voluted tubes  and  the  lesion  of  the  pelvis  secondary. 

(b)  Cystitis. — The  urine  is  usually  acid,  especially  in  women,  since  the 
colon  bacillus  is  a  very  common  cause  of  these  infections.  The  pus  and  mucus 
are  more  rop}^,  and  triple  phosphate  crystals  are  found  in  the  freshly  passed 
urine  in  the  alkaline  infections.     Pus  may  come  from  the  prostate. 

(c)  Ueetpieitis,  particularly  gonorrhoea.  The  pus  appears  first,  is  in 
small  quantities,  and  there  are  signs  of  local  inflammation. 

(d)  In  LEUCOKRHCEA  the  quantity  of  pus  is  usually  small,  and  large  flakes 
of  vaginal  epithelium  are  numerous.  In  doubtful  cases,  when  leucorrhoea  is 
present,  the  urine  should  be  withdrawn  through  a  catheter. 

(e)  Rupture  of  Abscesses  into  the  Urinary  Passages. — In  such  cases 
as  pelvic  or  perityphlitic  abscess  there  have  been  previous  symptoms  of  pus 
formation.  A  large  amount  is  passed  within  a  short  time,  then  the  discharge 
stops  abruptly  or  rapidly  diminishes  within  a  few  days. 

Pus  gives  to  the  urine  a  white  or  yellowish-white  appearance.  On  settling, 
the  sediment  is  sometimes  ropy,  the  supernatant  fluid  usually  turbid.  In 
cases  due  to  urea-decomposing  microbes  (proteus  bacillus,  various  staphylo- 
cocci) the  odor  may  be  ammoniacal  even  in  fresh  urine.  The  pus  cells  are 
usually  well  formed  when  the  pus  comes  from  the  bladder ;  the  protoplasm  is 
granular,  and  often  shows  many  translucent  processes. 

The  only  sediment  likely  to  be  confounded  with  pus  is  that  of  the  phos- 
phates; but  it  is  whiter  and  less  dense,  and  is  distinguished  immediately  by 
microscopic  examination  or  by  the  addition  of  acid.  With  the  pus  there  is 
always  more  or  less  epithelium  from  the  bladder  and  pelves  of  the  kidneys, 
but  since  in  these  situations  the  forms  of  cells  are  practically  identical,  they 
afford  no  information  as  to  the  locality  from  which  the  pus  has  come. 

The  treatment  is  considered  under  the  conditions  in  which  pyuria  occurs. 

VII.     CHYLURIA— NON-PARASITIC 

This  is  a  rare  affection,  occurring  in  temperate  regions  and  unassociated 
with  the  Filaria  hancrofti.  The  urine  is  of  an  opaque  white  color;  it  resem- 
bles milk  closely,  is  occasionally  mixed  with  blood  (hsematochyluria),  and 
sometimes  coagulates  into  a  firm.  Jelly-like  mass.  In  other  instances  there  is 
at  the  bottom  of  the  vessel  a  loose  clot  which  may  be  distinctly  blood  tinged. 
The  turbidity  seems  to  be  caused  l)y  numerous  minute  granules — more  rarely 
oil  droplets  similar  to  those  of  milk.  In  Montreal  a  dissection  in  a  case  of 
thirteen  years'  duration  showed  no  trace  of  parasites.  The  urine  may  be  much 
more  milky  shortly  after  taking  food,  and  the  recumbent  posture  increases  the 
milkiness.  In  one  case  the  urine  only  became  chylous  in  the  bladder,  and 
Hertz  foujid  obstnictioji  of  the  thoracic  duct  and  a  communicating  ruptured 
lymphatic  vessel  in  the  ])ladflcr. 


684  DISEASES  OF  THE  KIDNEYS 


VIII.    LITHUEIA 


The  general  relations  of  uric  acid  have  been  considered  under  gout. 

Occurrence  in  the  ITrine. — The  uric  acid  occurs  in  combination  chiefly 
with  ammonium  and  sodium,  forming  the  acid  urates.  In  smaller  quantities 
are  the  potassium,  calcium,  and  lithium  salts.  The  uric  acid  may  be  separated 
from  its  bases  and  crystallizes  in  rhombs  or  prisms,  which  are  usually  of  a 
deep  red  color,  owing  to  the  staining  of  the  urinary  pigments.  The  sediment 
is  granular  and  the  crystals  look  like  grains  of  Cayenne  pepper.  It  is  very  im- 
portant not  to  mistake  a  deposit  of  uric  acid  for  an  excess.  The  deposition  of 
numerous  grains  in  the  urine  within  a  few  hours  after  passing  is  more  likely 
to  be  due  to  conditions  which  diminish  the  solvent  power  than  to  increase  in 
the  quantity.  Of  the  conditions  which  cause  precipitation  of  the  uric  acid 
Eoberts  gives  the  following:  "(1)  High  acidity;  (2)  poverty  in  mineral 
salts;  (3)  low  pigmentation;  and  (4)  high  percentage  of  uric  acid."  The 
grade  of  acidity  is  probably  the  most  important  element. 

In  health  the  amount  of  uric  acid  excreted  bears  a  fairly  constant  ratio  to 
the  urea  eliminated.  According  to  von  Noorclen,  the  average  ratio  is  1  to  50, 
while  the  average  ratio  of  the  nitrogen  of  uric  acid  to  the  total  nitrogen 
eliminated  in  the  urine  is  1  to  70.  In  several  cases  of  gout  Futcher  found 
that  in  the  intervals  between  acute  attacks  the  uric  acid  was  reduced  to  a 
much  greater  extent  than  the  urea,  so  that  the  ratio  of  the  former  to  the  latter 
often  varied  between  1  to  300  up  to  (in  one  case)  1  to  1,500,  a  return  to  about 
the  normal  proportions  occurring  during  the  acute  attacks. 

,;  More  common  is  the  precipitation  of  amorphous  urates,  forming  the  so- 
called  brick-dust  deposit,  which  has  a  pinkish  color,  due  to  urinary  pigment. 
It  is  Composed  chiefly  of  the  acid  sodium  urates.  It  occurs  particularly  in  very 
acid  urine  of  a  high  specific  gravity.  As  the  urates  are  more  soluble  in  warm 
solutions,  they  frequently  deposit  as  the  urine  cools.  Here,  too,  the  deposition 
does  not  necessarily,  indeed  usually  does  not,  mean  an  excessive  excretion,  but 
the  existence  of  conditions  favoring  the  deposit. 

Treatment. — Meat,  fish,  tea  and  coffee  should  be  excluded  from  the  diet 
and  the  patient  should  drink  water  freely.  Alkalies  and  salicylic  acid  may  be 
given. 

IX.     OXALUEIA 

The  discovery  of  calcium  oxalate  crystals  in  the  urine  by  Donne  in  1838 
led  to  the  description  of  the  so-called  oxalic-acid  diathesis.  It  is  claimed  that 
all  the  oxalic  acid  found  in  the  urine  is  taken  into  the  body  with  the  food 
(Dunlop).  In  health  none,  or  only  a  trace,  is  formed  in  the  body.  The 
amount  fluctuates  with  the  quantity  of  food  taken,  and  is  usually  below  10 
milligrams  daily  (H.  Baldwin).  It  seems  to  be  formed  in  the  body  when 
there  is  an  absence  of  free  hydrochloric,  acid  in  the  gastric  juice,  and  in  con- 
nection with  excessive  fermentation  in  the  intestines.  It  never  forms  a 
heavy  deposit,  but  the  crystals — usually  octahedral,  rarely  dumb-bell-shaped — 
collect  in  the  mucous  cloud  and  on  the  sides  of  the  vessel. 

When  in  excess  and  present  for  any  considerable  time,  the  condition  is 
known  as  o^alwia,  the  chief  interest  of  which  is  in  the  fact  that  the  crystals 


ANOMALIES  OF  THE  URINARY  SECRETION  685 

may  be  deposited  before  the  urine  is  voided,  and  form  a  calculus.  It  is  held 
by  many  that  there  is  a  special  diathesis  associated  with  its  presence  in  ex- 
cess and  manifested  clinically  by  dyspepsia,  particularly  the  nervous  form, 
irritability,  depression  of  spirits,  lassitude,  and  sometimes  marked  hypochon- 
driasis. There  may  be  in  addition  neuralgic  pains  and  the  general  symptoms 
of-  neurasthenia.  The  local  and  general  symptoms  are  probably  dependent 
upon  some  disturbance  of  metabolism  of  which  the  oxaluria  is  one  of  the  mani- 
festations. It  is  a  feature  also  in  many  gouty  persons,  and  in  the  condition 
called  lithsmia. 

Treatment. — Water  should  be  taken  freely.  In  the  diet  the  following 
should  be  avoided:  spinach,  rhubarb,  cranberries,  asparagus,  radish,  horse- 
radish, grapes  and  currants. 

X.    CYSTINUEIA 

This  rare  condition,  a  sort  of  chemical  malformation  (Garrod),  is  of  clini- 
cal importance  because  cystin  is  very  sparingly  soluble  and  calculi  may  be 
formed,  renal  or  vesical.  It  is  strongly  hereditary  and  has  been  traced  through 
three  generations.  The  quantity  excreted  is  about  0,5  gram  per  diem,  and  the 
excretion  persists  for  years,  or  even  for  life,  without  causing  disturbance  of 
health.  Cystin  is  one  of  the  amino-acid  fragments  of  the  protein  molecule, 
and  its  excretion  is  one  of  the  unexplained  errors  of  protein  metabolism.  In 
the  urinary  sediment  the  colorless  hexagonal  crystals  of  cystin  are  readily  de- 
tected. 

Treatment. — This  involves  a  decreased  production  of  cystin  by  reducing 
the  amount  of  protein  in  the  diet  or  an  increased  solubility  in  the  urine  by 
giving  sodium  bicarbonate  (90  to  150  grains,  6  to  10  gms.  a  day). 

XI.     PHOSPHATUEIA 

The  phosphoric  acid  is  excreted  from  the  body  in  combination  with  potas- 
sium, sodium,  calcium,  and  magnesium,  forming  two  classes,  the  alkaline 
phosphates  of  sodium  and  potassium  and  the  earthy  phosphates  of  lime  and 
magnesia.  The  amount  of  phosphoric  acid  (PgOg)  excreted  in  the  twenty- 
four  hours  varies,  according  to  Hammarsten,  between  1  and  5  grams,  with  an 
average  of  2.5  grams.  It  is  derived  mainly  from  the  phosphoric  acid  taken 
in  the  food,  but  also  in  part  as  a  decomposition  product  from  nuclein,  pro- 
tagon,  and  lecithin.  Of  the  alkaline  phosphates,  those  in  combination  with 
sodium  are  the  most  abundant.  The  alkaline  phosphates  of  the  urine  are 
more  abundant  than  the  earthy  phosphates. 

Of  the  earthy  phosphates^  those  of  lime  are  abundant,  of  magnesium  scanty. 
In  urine  which  has  undergone  ammoniacal  fermentation,  either  in-  or  outside 
the  body,  there  is  in  addition  the  ammonio-magnesium  or  triple  phosphate, 
which  occurs  in  triangular  prisms  or  in  feathery  or  stellate  crystals.  The 
earthy  phosphates  occur  as  a  sediment  in  the  urine  when  the  alkalinity  is  due 
to  a  fixed  alkali,  or  under  certain  circumstances  the  deposit  may  take  place 
within  the  bladder,  and  then  the  phosphates  are  passed  at  the  end  of  micturi- 
tion as  a  whitish  fluid,  popularly  confounded  with  spermatorrhoea.  Study  of 
the  cases  with  symptoms  of  neurasthenia  and  a  phosphate  sediment  in  the 


686  DISEASES  OF  THE  KIDNEYS 

fresh  urine  indicates  an  abnormality  in  the  calcium  metabolism,  an  absolute 
increase  of  this  with  a  decrease  of  the  phosphoric  acid.  The  calcium  phos- 
phate may  be  precipitated  by  heat  and  produce  a  cloudiness  which  may  be 
mistaken  for  albumia,  but  is  dissolved  upon  making  the  urine  acid.  This 
is  frequent  m  persons  suffering  frojn  dyspepsia  or  debility  of  any  kind.  The 
phosphates  may  be  in  great  e:scess,  rising  in  the  twenty-four  hours  to  from 
7  to  9  grams  (Teissier),  whereas  the  normal  amount  is  not  more  than  2.5 
grams.  Lastl)',  the  phosphates  may  be  deposited  in  urine  which  has  under- 
gone decomposition,  in  which  the  carbonate  of  ammonia  from  the  urea  com- 
bines with  the  magnesium  phosphates,  forming  the  triple  salt.  This  is  seen 
in  cystitis,  due  to  a  urea  decomposing  microbe. 

The  clinical  significance  of  an  excess  of  phosphates,  to  which  the  term 
pliosphaturia  is  applied,  has  been  much  discussed.  A  deposit  does  not  neces- 
sarily mean  an  excess,  to  determine  which  a  careful  analysis  of  the  twenty- 
four  hours'  secretion  should  be  made.  It  has  long  been  thought  that  there 
is  a  relation  between  the  activity  of  the  nerve  tissues  and  the  output  of  phos- 
phoric acid;  but  the  question  can  not  yet  be  considered  settled.  The  amount 
is  increased  in  wasting  diseases,  such  as  tuberculosis,  acute  yellow  atrophy  of 
the  liver,  leukemia,  and  severe  anaemia,  whereas  it  is  diminished  in  acute  dis- 
eases and  during  pregnancy. 

Teissier,  of  Lyons,  in  1876,  described  a  condition  to  which  he  gave  the 
name  of  "essential  phosphaturia,"  and  it  has  been  called  "phosphatic  dia- 
betes," the  symptoms  of  which  are  polyuria,  thirst,  emaciation,  and  a  great 
increase  in  the  excretion  of  phosphates,  which  rise  to  as  much  as  7  to  9  grams 
a  day.  The  condition  sometimes  simulates  true  diabetes  very  closely,  even 
to  the  pruritus  and  dry  skin.  In  a  remarkable  case  of  this  kind,  under  ob- 
servation for  several  years.  Barker  studied  the  metabolism  and  found  it  nor- 
mal for  carbohydrates,  but  the  organic  phosphorus  percentage  was  high;  the 
chief  abnormality  was  an  abnormally  large  amount  of  organic  acids,  so  that 
chemically  the  condition  was  suggestive  of  an  acidosis. 

XII.     INDICANUEIA 

The  substance  in  the  urine  which  has  received  this  name  is  the  indoxyl- 
sulphate  of  potassium,  in  which  form  it  appears  in  the  urine  and  is  colorless. 
When  concentrated  acids  or  strong  oxidizing  agents  are  added  to  the  urine, 
this  substance  is  decomposed  and  the  indigo  set  free.  It  is  present  only  in 
small  quantities  in  healthy  urine.  It  is  derived  from  the  indol,  a  product 
formed  in  the  intestine  by  the  decomposition  of  the  albumin  under  the  influence 
of  bacteria.  When  absorbed,  this  is  oxidized  in  the  tissues  to  indoxyl,  which 
combines  with  the  potassium  sulphate,  forming  indican. 

It  is  a  common  condition  met  with  accidentally  in  persons  of  good  health 
or  with  slight  digestive  complaints.  It  is  not  specially  associated  with  con- 
stipation (Allen  Jones).  In  gall-stone  attacks,  in  hyperchlorhydria,  in  recur- 
ring appendicitis,  in  wasting  diseases,  in  peritonitis,  and  in  empyema  it  is 
usually  present.  In  a  few  cases  it  is  constantly  present  and  in  excess.  Barr 
found  only  32  such  cases  among  2,092  patients,  and  in  these  the  symptoms 
did  not  suggest  an  "intestinal  auto-intoxication,"  nor  did  lacto-bacillary 
treatment  have  the  slightest  influence  on  the  condition. 


ANOMALIES  OF  THE  UEINAEY  SECRETION  687 

Indican  has  occasionally  been  found  in  calculi.  Though,  as  a  rule,  the 
urine  is  colorless  when  passed,  there  are  instances  in  which  decomposition  has 
taken  place  within  the  body,  and  a  blue  color  has  been  noticed  immediately 
after  the  urine  was  voided.  Sometimes,  too,  in  alkaline  urine  on  exposure 
there  is  a  bluish  film  on  the  surface.  Methylene  blue,  a  coloring  matter  for 
candy,  etc.,  must  be  excluded. 

XIII.     MELANUEIA 

Black  urine  may  be  dark  when  passed  or  may  become  so  later.  In  the 
following  conditions  melanuria  may  occur:  (1)  Jaundice.  Only  in  very 
chronic  cases  of  deeply  bronzed  icterus  do  we  see  the  urine  quite  dark,  due  to 
the  presence  of  large  quantities  of  biliverdin.  (3)  Hsematuria  and  hasmo- 
globinuria.  Here  it  is  an  exaggeration  of  the  smoky  tint  due  to  the  presence 
of  blood.  (3)  Hsematoporphyrinuria,  to  be  considered  later.  (4)  Melanuria, 
in  which  the  urine  has,  as  a  rule,  the  normal  color  when  passed,  and  on  stand- 
ing becomes  black  as  ink.  In  some  instances  it  is  black  when  passed.  Melan- 
uria of  this  type  only  occurs  with  the  presence  of  melanotic  tumors.  (5) 
Alkaptonuria.  (6)  Indicanuria.  When  rich  in  indoxyl  sulphate  the  urine  is 
brown  in  color,  or  becomes  so  after  standing,  due  to  the  oxidation  products  of 
indol.  This  is  by  far  the  most  common  cause  of  black  urine,  and  in  any  disease 
leading  to  an  abundant  secretion  of  indican,  as  in  intestinal  obstruction,  etc., 
black  urine  may  be  passed.  As  Garrod  suggests,  it  is  probable  that  the  black 
urine  in  cases  of  tuberculosis  is  of  an  allied  nature.  (7)  After  certain  articles 
of  diet  and  drugs.  Some  dark  colored  vegetable  pigments,  as  in  black  cherries, 
plums  and  bilberries,  cause  darkening  of  the  urine.  Besorcin  may  do  the  same. 
Carboluria  is  by  no  means  uncommon,  and  was  frequently  seen  in  the  days 
of  the  antiseptic  spray.  It  has  been  ascribed  to  hydrochinone  formed  from 
phenol.  Naphthalene,  creosote,  and  the  salicylates  may  cause  darkening  of 
the  urine,  or  even  blackness. 

XIV.     ALKAPTONURIA 

"Alkaptonuria  is  not  the  manifestation  of  a  disease,  but  is  rather  of  the 
nature  of  an  alternative  course  of  metabolism,  harmless  and  usually  congenital 
and  lifelong"  (Garrod).  Of  40  known  examples,  19  occurred  in  seven  fam- 
ilies, and  several  were  the  offspring  of  first  cousins  (Garrod).  There  are  two 
points  of  clinical  interest.  The  alkapton  urine  reduces  Fehling's  solution, 
and  diabetes  may  be  suggested,  but  it  does  not  ferment,  and  it  is  optically 
inactive.  The  linen  may  be  stained  by  the  urine,  which  in  some  cases  is  dark 
when  passed.  In  1866  Virchow  recorded  a  case  of  blackening  of  the  carti- 
lages and  ligaments — ochronosis,  which  is  considered  elsewhere. 

XV.     PNEUMATURIA 

Gas  may  be  passed  with  the  urine — 1.  After  mechanical  introduction  of 
air  in  vesical  irrigation  or  cystoscopic  examination  in  the  knee-elbow  position. 
2.  As  a  result  of  the  introduction  of  gas  forming  organisms  in  catheterization 
or  other  operation.     Glycosuria  lias  been  present  in  a  majority  of  the  cases. 


688  DISEASES  OF  THE  KIDNEYS 

The  yeast  fungus,  the  colon  bacillus,  and  the  Bacilltis  aerogenes  capsulatu^ 
have  been  found.    3.  In  cases  of  vesico-enteric  fistula. 

In  gas  production  within  the  bladder  the  symptoms  are  those  of  a  mild 
cystitis,  with  the  passage  of  gas  at  the  end  of  micturition,  sometimes  with  a 
loud  sound.  The  diagnosis  is  readily  made  by  causing  the  patient  to  urinate 
in  a  bath  or  by  plunging  the  end  of  the  catheter  under  water. 

XVI.     OTHER  SUBSTANCES 

Lipuria. — Fat  in  the  urine,  or  lipuria,  occurs,  first,  without  disease  of  the 
kidneys,  as  in  excess  of  fat  in  the  food,  after  the  administration  of  cod  liver 
oil,  in  fat  embolism  occurring  after  fractures,  in  the  fatty  degeneration  in 
phosphorus  poisoning,  in  prolonged  suppuration,  as  in  tuberculosis  and  pyae- 
mia, in  the  lipgemia  of  diabetes  mellitus;  secondly,  with  disease  of  the  kid- 
neys, as  in  the  fatty  stage  of  chronic  nephritis,  in  which  fat  casts  are  some- 
times present,  and,  according  to  Ebstein,  in  pyonephrosis ;  and,  thirdly,  in  the 
affection  known  as  chyluria.  The  urine  is  usually  turbid,  but  there  may  be 
fat  drops  as  well,  and  ;fatty  crystals  have  been  found.  In  a  few  rare  instances 
calculi  composed  of  fat  and  coated  with  phosphates  have  been  found. 

Lipaciduria  is  applied  to  the  condition  in  which  there  are  volatile  fatty 
acids  in  the  urine,  such  as  acetic,  butyric,  formic,  and  propionic  acid. 

Ketonuria. — The  occurrence  of  acetone,  diacetic  acid,  and  /3-oxyhutyric 
acid  has  been  considered  under  Diabetes. 

Choluria  and  glycosuria  are  considered  under  jaundice  and  diabetes. 

Haematoporphyrin  occasionally  occurs  in  the  urine.  It  was  first  recog- 
nized by  Hoppe-Seyler.  Xencki  and  Sieler  determined  its  exact  formula,  and 
the  former  demonstrated  that  the  only  chemical  difference  between  hsematin 
and  haematoporphyrin  is  that  the  latter  is  simply  haematin  free  from  iron.  It 
has  been  found  in  the  urine  in  pulmonary  tuberculosis,  pleurisy  with  effusion, 
rheumatic  fever,  lead  poisoning,  and  intestinal  haemorrhages.  This  pigment 
has  been  found  very  frequently  after  the  administration  of  sulphonal,  and 
sometimes  imparts  a  very  dark  color  to  the  urine. 


V.     UREMIA 

Definition. — A  toxaemia  from  renal  insufficiency  developing  in  the  course 
of  nephritis  or  in  conditions  associated  with  anuria.  The  nature  of  the  poison 
is  in  doubt. 

Theories  of  TJraemia. — The  chief  views  are:  (a)  That  it  is  due  to  the 
accumulation  in  the  blood  of  body  poisons  which  should  be  excreted  by  the 
kidney.  (&)  That  it  is  a  disturbance  of  the  normal  kidney  metabolism. 
Brown-Sequard  suggested  that  the  kidney  had  an  internal  secretion,  to  the 
disturbance  of  which  it  is  thought  that  .the  symptoms  of  ursemia  may  be  due. 
Eose  Bradford's  experiments  show  how  profoundly  the  kidneys  influence  the 
body  metabolism,  particularly  that  of  the  muscles.  If  more  than  two-thirds 
of  the  total  kidney  weight  is  removed,  there  is  an  extraordinary  increase  in 
the  production  of  urea  and  of  the  nitrogenous  bodies  of  the  creatin  class,  (c) 
TJrremia  has  been  attributed  to  nephrolvsins  but  the  evidence  is  not  convincing. 


UE^MIA  689 

(d)  The  old  view  of  Traube  that  the  symptoms  of  uraemia,  particularly  tlie 
coma  and  convulsions,  are  due  to  localized  oedema  of  the  brain,  (e)  Acidosis 
has  been  suggested  but  while  it  may  be  associated,  it  is  not  an  important 
cause  and  not  always  present.  It  seems  probable  that  the  causes  vary  in  dif- 
ferent patients. 

Foster  describes  three  forms  of  ursmia,  but  the  majority  of  cases  are  not 
uncomplicated.  1.  Eetention  type.  In  this  there  is  a  simple  retention  of 
urinary  nitrogenous  waste — a  urinary  poisoning.  3,  Cerebral  cedema  type. 
In  this  there  is  defective  water  and  salt  excretion  with  a  resulting  cerebral 
cedema.  3.  Toxic  or  epileptiform  type.  In  this  toxaemia  is  a  marked  feature, 
the  result  of  abnormal  metabolism.  The  first  two  represent  a  failure  of  excre- 
tion of  water,  salt  and  nitrogenous  material.  The  third  may  show  these  but 
also  an  element  foreign  to  normal  metabolism,  which  causes  toxaemia,  and 
Foster  has  isolated  a  toxic  base  which  causes  convulsive  seizures  in  animals.  As 
regards  the  effect  of  urea  itself  Hewlett  has  shown  that  urea  in  the  blood  in 
amounts  over  150  mg.  per  100  c.  c.  produces  symptoms  like  some  of  those  seen 
in  uraemia. 

Symptoms. — Clinically,  we  may  recognize  latent,  acute,  and  chronic  forms. 
The  latent  form  has  been  considered  under  the  section  on  anuria.  Acute 
uraemia  may  arise  in  any  form  of  nephritis.  It  is  more  common  in  the  post- 
febrile varieties.  Bradford  thinks  that  it  is  specially  associated  with  a  form 
of  contracted  white  kidney  in  young  subjects.  Chronic  forms  of  uraemia  are 
more  frequent  in  the  arterio-sclerotic  and  granular  kidney.  For  convenience 
the  symptoms  of  uraemia  may  be  described  under  cerebral,  dyspnoeic,  and  gas- 
tro-intestinal  manifestations. 

Among  the  cerebral  symptoms  of  uraemia  may  be  described : 

(a)  Mania. — This  may  come  on  abruptly  in  an  individual  who  has  shown 
no  previous  indications  of  mental  trouble,  and  who  may  not  be  known  to  have 
nephritis.  In  one  case  of  this  kind  the  patient  became  suddenly  maniacal  and 
died  in  six  days.  More  commonly  the  delirium  is  less  violent,  but  the  patient 
is  noisy,  talkative,  restless,  and  sleepless. 

(b)  Delusional  Insanity  (Folie  BrigJitique) . — Cases  are  by  no  means  un- 
common, and  excellent  clinical  reports  have  been  issued  on  the  subject  from 
several  of  the  asylums,  particularly  by  Bremer,  Christian,  and  Alice  Bennett. 
Delusions  of  persecution  are  common  and  the  patients  may  commit  suicide. 
The  condition  is  of  interest  medico-legally  because  of  its  bearing  on  testamen- 
tary capacity.    Profound  melancholia  may  also  supervene. 

(c)  Convulsions. — These  may  come  on  unexpectedly  or  be  preceded  by 
pain  in  the  head  and  restlessness.  The  attacks  may  be  general  and  identical 
with  those  of  ordinary  epilepsy,  though  the  initial  cry  may  not  be  present. 
The  fits  may  recur  rapidly,  and  in  the  interval  the  patient  is  usually  uncon- 
scious. Sometimes  the  temperature  is  elevated,  but  more  frequently  it  is  de- 
pressed, and  may  sink  rapidly  after  the  attack.  Local  convulsions  may  occur 
in  most  characteristic  form  in  uraemia.  A  remarkable  sequence  of  the  convul- 
sions is  blindness — urwmic  amaurosis — which  may  persist  for  several  days. 
This,  however,  may  occur  apart  from  the  convulsions.  It  usually  passes  off 
in  a  day  or  two.  There  are,  as  a  rule,  no  ophthalmoscopic  changes.  Some- 
times urpemic  deafness  supervenes,  and  is  probably  also  a  cerebral. manifesta- 


690  DISEASES  OF  THE  KIDNEYS 

tion.     It  may  also  occur  in  connection  with  persistent  headache,  nausea,  and 
other  gastric  symptoms. 

(d)  Coma. — Unconsciousness  invariably  accompanies  the  general  convul- 
sions, but  a  coma  maj  develop  gradually  without  any  convulsive  seizures. 
Frequently  it  is  preceded  by  headache,  and  the  patient  gradually  becomes  dull 
and  apathetic.  In  these  cases  there  may  have  been  no  previous  indications  of 
renal  disease,  and  unless  the  urine  is  examined  the  nature  of  the  case*  may  be 
overlooked.  Twitchings  of  the  muscles  occur,  particularly  in  the  face  and 
hands,  but  there  are  many  cases  of  coma  in  which  the  muscles  are  not  in- 
volved. In  some  of  theSe  cases  a  condition  of  torpor  persists  for  weeks  or 
even  months.  The  tongue  is  usually  furred  and  the  breath  very  foul  and 
heavy. 

(e)  Local  Palsies. — In  the  course  of  chronic  nephritis  hemiplegia,  aphasia 
or  monoplegia  may  come  on  spontaneously  or  follow  a  convulsion,  and  post 
mortem  no  gross  lesions  of  the  brain  be  found,  but  only  a  localized  or  dif- 
fused oedema.  These  cases,  which  are  not  very  uncomnion,  may  simulate  al- 
most every  form  of  organic  paralysis  of  cerebral  origin. 

(/)  Of  other  cerebral  symptoms,  headache  is  important.  It  is  most 
often  occipital  and  extends  to  the  neck.  It  may  be  an  early  feature  and  asso- 
ciated with  giddiness.  Other  nervous  symptoms  of  uraemia  are  intense  itch- 
ing of  the  skin,  numbness  and  tingling  in  the  fingers,  and  cramps  in  the 
muscles  of  the  calves,  particularly  at  night.     An  erythema  may  be  present. 

Uremic  dyspncea  is  classified  by  Palmer  Howard  as  follows:  (a)  Con- 
tinuous dyspnoea;  (h)  paroxysmal  dyspnoea;  (c)  both  types  alternating;  and 
(d)  Cheyne- Stokes  breathing.  The  attacks  of  dyspnoea  are  most  commonly 
nocturnal;  the  patient  may  sit  up,  gasp  for  breath,  and  show  great  distress. 
Acidosis  plays  a  part  in  some  cases.  Occasionally  the  breathing  is  noisy  and 
stridulous.  The  Cheyne-Stokes  type  may  persist  for  weeks  or  months.  One 
patient,  up  and  about,  could  feed  himself  only  in  the  apnoea  period.  Though 
usually  of  serious  omen  and  occurring  with  coma  and  other  symptoms,  re- 
covery may  follow  even  after  persistence  for  a  long  period. 

The  GASTEO-iNTESTiNAL  manifestations  often  set  in  with  abruptness.  Un- 
controllable vomiting  may  come  on  and  its  cause  be  quite  unrecognized.  The 
attacks  may  be  preceded  by  nausea  and  associated  with  diarrhoea.  The  diar- 
rhoea may  come  on  without  the  vomiting;  sometimes  it  is  profuse  and  asso- 
ciated with  a  catarrhal  or  diphtheritic  inflammation  of  the  colon. 

A  special  uremic  stomatitis  has  been  described  in  which  the  mucosa  of 
the  lips,  gums,  and  tongue  is  swollen  and  erythematous.  The  saliva  may 
be  decreased,  and  there  is  difficulty  in  swallowing  and  in  mastication.  The 
tongue  is  usually  very  foul  and  the  breath  heavy  and  fetid.  A  cutaneous 
erythema  may  occur  and  a  remarkable  urea  "frost"  on  the  skin. 

Fever  is  not  uncommon  in  uraemic  states,  and  may  occur  with  the  acute 
nephritis,  with  the  complications,  and  as  a  manifestation  of  the  uraemia  itself. 

Very  many  patients  with  chronic  uraemia  succumb  to  terminal  infections — 
acute  peritonitis,  pericarditis,  pleurisy,  meningitis,  or  endocarditis. 

Diagnosis. — Blood  analyses  are  of  great  value,  both  for  diagnosis  and. 
prognosis.  Non-protein  nitrogen  above  120  mgms.,  urea  nitrogen  above. 80 
mgms.,  uric  acid  above  4  mgms.,  and  creatinine  above  4  mgms.  for  100  c.  c. 
of  blood  point  to  the  retention  type.     In  the. "oedema  form"  there  may  not  be 


UEyEMIA  691 

any  increase.  The  test  of  the  functional  capacity  of  the  kidney  by  the  use  of 
phenol-sulphonephthalein  is  of  value  both  in  differential  diagnosis  and  in 
giving  warning  of  impending  uraemia.  In  uraemia  the  elimination  of  phthal- 
ein  is  nil  or  only  a  faint  trace  in  two  hours.  In  patients  with  chronic  nephri- 
tis in  whom  the  elimination  in  two  hours  is  below  10  per  cent,  there  is  grave 
danger  of  uraemia. 

Uraemia  may  be  confounded  with: 

(a)  Cerebral  lesions,  such  as  haemorrhage,  meningitis,  or  even  tumor.  In 
apoplexy,  so  commonly  associated  with  nephritis  and  hypertension,  the  sudden 
loss  of  consciousness,  particularly  if  with  convulsions,  may  simulate  uraemia; 
but  the  mode  of  onset,  the  existence  of  complete  hemiplegia,  with  conjugate 
deviation  of  the  eyes,  suggest  hsemorrhage.  There  are  cases  of  uraemic  hemi- 
plegia or  monoplegia  which  can  not  be  separated  from  those  of  organic  lesion 
and  which  post  mortem  show  no  trace  of  coarse  disease  of  the  brain.  In  some 
of  these  cases  it  is  quite  impossible  to  distinguish  between  the  two  conditions. 
So,  too,  cases  of  meningitis,  in  a  condition  of  deep  coma,  with  slight  fever, 
furred  tongue,  but  without  localizing  symptoms,  may  readily  be  confounded 
with  uraemia. 

(h)  With  certain  infectious  diseases.  Uraemia  may  persist  for  weeks  or 
months  and  the  patient  lies  in  a  condition  of  torpor  or  even  unconsciousness, 
with  a  heavily  coated,  perhaps  dry,  tongue,  muscular  twitchings,  a  rapid 
feeble  pulse,  with  slight  fever.  This  not  unnaturally  suggests  the  existence  of 
one  of  the  infectious  diseases.  Cases  of  the  kind  are  not  uncommon,  and  have 
been  mistaken  for  typhoid  fever  and  miliary  tuberculosis., 

(c)  Uremic  coma  may  be  confounded  with  poisoning  by  alcohol  or  opium. 
In  opium  poisoning  the  respiration  is  slow  and  the  pupils  contracted;  in 
alcoholism  they  are  more  commonly  dilated.  In  uraemia  they  are  not  con- 
stant; they  may  be  either  widely  dilated  or  of  medium  size.  The  examination 
of  the  eye  grounds  should  be  made  to  determine  the  presence  or  absence  of 
albuminuric  retinitis.  The  urine  should  be  examined.  The  odor  of  the 
breath  sometimes  gives  an  important  hint.  The  condition  of  the  heart  and 
arteries  should  also  be  taken  into  account.  Sudden  uraemic  coma  is  more 
common  in  chronic  interstitial  nephritis.  The  character  of  the  delirium  in 
alcoholism  is  sometimes  important,  and  the  coma  is  not  so  deep  as  in  uraemia 
or  opium  poisoning.  It  may  for  a  time  be  impossible  to  determine  whether 
the  condition  is  due  to  uraemia,  profound  alcoholism,  or  haemorrhage  into  the 
pons  Varolii. 

And,  lastly,  in  connection  with  sudden  coma,  it  is  to  be  remembered  that 
insensibility  may  occur  after  prolonged  muscular  exerti'on,  as  after  running 
a  ten-mile  race.  In  some  instances  unconsciousness  has  come  on  rapidly  vdth 
stertorous  breathing  and  dilated  pupils.  Cases  have  occurred  under  condi- 
tions in  which  sun-stroke  could  be  excluded ;  and  Poore  considers  that  the  con- 
dition is  due  to  the  too  rapid  accumulation  of  waste  products  in  the  blood, 
and  to  hyperpyrexia  from  suspension  of  sweating. 

The  treatment  will  be  considered  under  Chronic  Nephritis. 


693  DISEASES  OF  THE  KIDNEYS 


VI.     ACUTE  NEPHRITIS 

Definition. — Acute  diffuse  nephritis,  due  to  infection  or  to  the  action  of 
toxic  agents  upon  the  kidneys.  In  all  instances  changes  exist  in  the  epithelial, 
vascular,  and  intertubiilar  tissues,  which  vary  in  intensity  in  different  forms: 
hence  writers  have  described  a  tubular,  a  glomerular,  and  an  acute  interstitial 
nephritis. 

Etiology. — The  following  are  the  principal  causes  of  acute  nephritis: 

(1)  Cold.  Exposure  to  cold  and  wet  is  a  common  cause  and  determines, 
in  all  probability,  an  acute  infection. 

(2)  The  toxins  of  the  acute  infections,  particularly  scarlet  fever.  Many 
cases  are  due  to  streptococcus  infection,  secondary  to  some  form  of  infec- 
tion, as  in  the  tonsils.  An  acute  hsematogenous  infection  may  cause  a  very 
severe  nephritis.  It  is  evident  that  all  grades  of  severity  may  occur.  Syphilis 
is  a  factor  in  some  cases.  In  exudative  erythema  and  purpuric  affections 
acute  nephritis  is  not  uncommon. 

(3)  Epidemic  nephritis. — Described  first  during  the  American  Civil  War 
and  noted  by  Italian  observers,  it  prevailed  widely  during  the  recent  war 
(Trench  nephritis). 

(4)  Toxic  agents,  such  as  turpentine,  mercury,  potassium  chlorate,  and 
carbolic  acid,  may  cause  an  acute  congestion  which  sometimes  terminates  in 
nephritis.     Alcohol  probably  never  excites  an  acute  nephritis. 

(5)  Pregnancy,  in  which  the  condition  is  probably  due  to  toxic  products 
as  yet  undetermined. 

(6)  Acute  nephritis  occurs  occasionally  in  connection  with  extensive  le- 
sions of  the  skin,  as  in  burns  or  in  chronic  skin-diseases,  and  also  after  trauma. 
It  may  follow  operations  on  the  kidney. 

Poisons  damage  different  portions  of  the  kidney,  corrosive  sublimate  the 
epithelium  of  the  capsules  and  of  the  convoluted  tubules  of  the  adjacent  first 
division,  uranium  chiefly  the  spiral  portion  of  the  convoluted  tubes  and  Henle's 
loops,  chromium  the  proximal  and  middle  division  of  the  convoluted  and  col- 
lecting tubules.  It  is  not  easy  to  correlate  the  experimental  nephritis  with  the 
types  of  spontaneous  nephritis  in  man.  The  experimental  form  has  been 
studied  with  a  view  to  determine  the  action  of  diuretics  but  without  very 
positive  results,  except  that  in  animals  with  experimental  nephritis  certain 
diuretics  seem  to  shorten  the  duration  of  life. 

Morbid  Anatomy, — The  kidneys  may  present  to  the  naked  eye  in  mild 
cases  no  evident  alterations.  When  seen  early  in  more  severe  forms  the  or- 
gans are  congested,  swollen,  dark,  and  on  section  may  drip  blood.  Bright's 
original  description  is  as  follows: 

"The  kidneys,  .  .  .  stripped  easily  out  of  their  investing  membrane,  were 
large  and  less  firm  than  they  often  are,  of  the  darkest  chocolate  color,  inter- 
spersed with  a  few  white  points,  and  a  great  number  nearly  black ;  and  this, 
with  a  little  tinge  of  red  in  parts,  gave  the  appearance  of  a  polished  fine- 
grained porphyry  or  greenstone.  ...  On  (section)  tliese  colors  were  found 
to  pervade  the  whole  cortical  part;  but  the  natural  striated  appearance  was 
not  lost,  and  the  external  part  of  each  mass  of  tubnli  was  particularly  dark 


ACUTE  XEPHEITTS  693 

...  a  very  considerable  quantity  of  l)lood  oozed  from  tlie  kidney,  showing  a 
most  unusual  accumulation  in  the  organ." 

In  other  instances  the  surface  is  pale  and  mottled,  the  capsule  strips  off 
readily,  and  the  cortex  is  swollen,  turbid,  and  of  a  grayish  red  color,  while 
the  pyramids  have  an  intense  beefy  red  tint.  The  glomeruli  in  some  instances 
stand  out  plainly,  being  deeply  swollen  and  congested ;  in  other  instances  they 
are  pale. 

The  histology  may  be  thus  summarized:  (a)  Glomerular  changes.  The 
tufts  suffer  first,  and  there  is  either  an  acute  intracapillary  glomerulitis,  in 
which  the  capillaries  become  filled  with  cells  and  thrombi,  or  involvement  of 
the  epithelium  of  the  tuft  and  of  Bowman's  capsule,  the  cavity  of  which  con- 
tains leucocytes  and  red  blood-corpuscles. 

(&)  The  alterations  in  the  tvhular  epithelium  consist  in  cloudy  swelling, 
fatty  change,  and  hyaline  degeneration.  In  the  convoluted  tubules,  the  ac- 
cumulation of  altered  cells  with  leucocytes  and  blood-corpiiscles  causes  the  en- 
largement and  swelling  of  the  organ. 

(c)  Interstitial  changes.  In  the  milder  forms  a  simple  inflammatory 
exudate — serum  mixed  with  leucocytes  and  red  blood-corpuscles — exists  be- 
tween the  tubules.  In  severer  cases  areas  of  small  celled  infiltration  occur 
about  the  capsules  and  between  the  convoluted  tubes. 

Symptoms. — The  onset  is  usually  sudden,  and,  when  the  nephritis  follows 
cold,  dropsy  may  be  noticed  within  twenty-four  hours.  After  fevers  the  on- 
set is  less  abrupt,  but  the  patient  gradually  becomes  pale  and  a  puffiness  of 
the  face  or  swelling  of  the  ankles  is  first  noticed.  In  children  there  may  be 
convulsions  at  the  outset.  Chilliness  or  rigors  initiate  the  attack  in  a  limited 
number  of  cases.  Pain  in  the  back,  nausea,  and  vomiting  may  be  present. 
The  fever  is  variable.  Many  cases  in  adults  have  no  rise  in  temperature.  In 
young  children  with  nephritis  from  cold  or  scarlet  fever  the  temperature  may, 
for  a  few  days,  range  from  101°  to  103°. 

The  most  characteristic  symptoms  are  the  urinary  changes.  There  may 
at  first  be  suppression;  more  commonly  the  urine  is  scanty,  highly  colored, 
and  contains  blood,  albumin,  and  tube  casts.  The  quantity  is  reduced  and 
only  4  or  5  ounces  may  be  passed  in  twenty-four  hours;  the  specific  gravity 
is  high — 1.025,  or  more ;  the  color  varies  from  a  smoky  to  a  deep  porter  color, 
but  is  seldom  bright  red.  On  standing  there  is  a  heavy  deposit;  microscopic- 
ally there  are  blood  corpuscles,  epithelium  from  the  urinary  passages,  and 
hyaline,  blood,  and  epithelial  tube  casts.  The  albimiin  is  abundant,  forming  a 
curdy,  thick  precipitate.  The  largest  amounts  of  albumin  are  seen  in  the 
early  acute  nephritis  of  syphilis,  in  which  it  may  reach  8.5  per  cent.  The 
total  excretion  of  urea  is  reduced,  though  the  percentage  is  high. 

(Edema  is  an  early  and  marked  symptom.  In  cases  of  extensive  dropsy 
effusion  may  take  place  into  the  pleurae  and  peritoneum.  There  are  cases  of 
scarlatinal  nephritis  in  which  the  dropsy  of  the  extremities  is  trivial  and  ef- 
fusion into  the  pleurae  extensive.  The  lungs  may  become  oedematous.  In 
rare  cases  there  is  oedema  of  the  glottis.  Epistaxis  may  occur  or  cutaneous 
ccchymoses  may  develop  in  the  course  of  the  disease. 

The  pulse  may  be  hard,  the  tension  increased,  and  the  second  sound  in  the 
aortic   area   accentuated.      The   blood   pressure   may   be   very   variable.      Oc- 


694  DISEASES  OF  THE  KIDNEYS 

casionally  dilatation  of  the  heart  comes  on  rapidly  and  may  cause  sudden 
death.     The  skin  is  dry  and.  it  may  be  difficult  to  induce  sweating. 

Urcemic  symptoms  occur  in  a  limited  number  of  cases,  either  at  the  onset 
with  suppression,  more  commonly  later  in  the  disease.  Ocular  changes  are 
not  so  common  in  acute  as  in  chronic  nephritis,  but  hemorrhagic  retinitis  may 
occur  and  occasionally  papillitis. 

The  course  varies  considerably.  The  description  just  given  is  of  the  form 
which  most  commonly  follows  cold  or  scarlet  fever.  In  many  of  the  febrile 
cases  dropsy  is  not  a  prominent  symptom,  and  the  diagnosis  rests  rather  with 
the  examination  of  the  urine.  Moreover,  the  condition  may  be  transient  and 
less  serious.  In  other  cases  there  may  be  hsematuria  and  pronounced  signs  of 
interference  with  the  renal  function.  The  most  intense  acute  nephritis  may 
exist  without  anasarca.  In  scarlatinal  nephritis,  in  which  the  glomeruli  are 
most  seriously  affected,  suppression  of  the  urine  may  be  an  early  symptom,  the 
dropsy  is  apt  to  be  extreme,  and  ursemic  manifestations  are  common.  Acute 
nephritis  in  children,  however,  may  set  in  very  insidiously  and  be  associated 
with  transient  or  slight  oedema,  and  the  symptoms  may  point  rather  to  affec- 
tion of  the  digestive  system  or  to  brain  disease. 

Diagnosis. — It  is  very  important  to  l^ear  in  mind  that  the  most  serious 
involvement  of  the  kidneys  may  be  manifested  only  by  slight  oedema  of  the 
feet  or  puffiness  of  the  eyelids,  without  impairment  of  the  general  health.  On 
the  other  hand,  from  the  urine  alone  a  diagnosis  can  not  be  made  with  cer- 
tainty, since  simple  cloudy  swelling  and  circulatory  changes  may  cause  a  sim- 
ilar condition  of  urine.  The  first  indication  of  trouble  may  be  a  ursemic  con- 
vulsion. This  is  particularly  the  case  in  the  acute  nephritis  of  pregnancy,  and 
it  is  a  good  rule  for  the  practitioner  invariably  to  ask  that  during  pregnancy 
the  urine  should  be  sent  regularly  for  examination. 

In  nephritis  from  cold  and  in  scarlet  fever  the  symptoms  are  usually 
marked  and  the  diagnosis  is  rarely  in  doubt.  As  already  mentioned,  every 
case  in  which  albumin  is  present  should  not  be  called  acute  nephritis,  not  even 
if  tube  casts  be  present.  Thus  the  common  febrile  albuminuria,  although  it 
represents  the  first  link  in  the  chain  of  events  leading  to  acute  nephritis, 
should  not  be  placed  in  the  same  category.  The  most  frequent  error'  is  to 
regard  acute  exacerbations  in  chronic  nephritis  as  primary  acute  attacks. 
The  history,  the  condition  of  the  heart  and  vessels,  the  blood  pressure,  and 
the  eye  grounds  are  important  points  in  recognizing  the  existence  of  former 
nephritis. 

There  are  occasional  cases  of  acute  nephritis  with  anasarca,  in  which  al- 
bumin is  either  absent  or  present  only  as  a  trace,  but  these  are  rare.  Tube  casts 
are  usually  found,  and  the  absence  of  albumin  is  rarely  permanent.  The  urine 
may  be  reduced  in  amount. 

The  character  of  the  casts  is  of  use  in  the  diagnosis  of  the  form  of  ne- 
phritis, but  scarcely  of  such  value  as  has  been  stated.  The  hyaline  and  granu- 
lar casts  are  common  to  all  varieties.  -The  blood  and  epithelial  casts,  par- 
ticularly those  made  up  of  leucocytes,  are  most  common  in  the  acute  cases. 

Pro^osis. — The  outlook  varies  somewhat  with  the  cause.  Eecoveries  in 
the  form  following  exposure  to  cold  are  much  more  frequent  than  after  scar- 
latinal nephritis.  In  younger  children  the  mortality  is  high,  amounting  to  at 
least  one-third  of  the  cases.     Serious  symptoms  are  low  arterial  tension,  the 


ACUTE  NEPHEITIS  695 

occurrence  of  uraemia,  and  effusion  into  the  serous  sacs.  The  persistence  of 
the  dropsy  after  the  first  month,  intense  pallor,  and  a  large  amount  of  al- 
bumin indicate  the  possibility  of  the  disease  becoming  chronic.  For  some 
months  after  the  disappearance  of  the  dropsy  there  may  be  traces  of  albumin 
and  a  few  tube  casts.  If  the  nephritis  is  due  to  a  focus  of  infection  which 
can  be  removed  the  outlook  is  naturally  better. 

In  scarlatinal  nephritis,  if  the  progress  is  favorable,  the  dropsy  diminishes 
in  a  week  or  ten  days,  the  urine  increases,  the  albumin  lessens,  and  by  the 
end  of  a  month  the  dropsy  has  disappeared  and  the  urine  is  nearly  free.  In 
very  young  children  the  course  may  be  rapid,  and  the  urine  may  be  free  from 
albumin  in  the  fourth  week.  Other  cases  are  more  insidious,  and  though  the 
dropsy  may  disappear,  the  albumin  persists  in  the  urine,  the  anasmia  is 
marked,  and  the  condition  becomes  chronic,  or,  after  several  recurrences  of 
the  dropsy,  improves  and  complete  recovery  takes  place. 

Prophylaxis. — Care  in  the  infectious  diseases  which  may  be  complicated 
by  nephritis  is  important.  Proper  treatment  of  foci  of  infection,  especially 
the  tonsils,  is  of  value.  Care  should  be  taken  not  to  give  any  drugs  which 
may  irritate  the  kidney. 

Treatment. — The  patient  should  be  in  bed  and  remain  there  until  all 
traces  of  the  disease  have  disappeared  or  until  there  is  no  hope  of  complete 
recovery.  A  period  of  three  months  should  be  allowed  for  this.  The  presence 
of  red  blood  cells  in  the  urine  is  an  indication  for  absolute  rest.  As  sweating 
plays  such  an  important  part  in  the  treatment,  it  is  well,  if  possible,  to  ac- 
custom the  patient  to  blankets.    He  should  also  be  clad  in  thin  Canton  flannel. 

The  diet  should  consist  of  milk  or  butter-milk,  gruels  made  of  arrow-root 
or  oat-meal,  barley  water,  and  fruit  juices.  It  is  sometimes  better  to  confine 
the  patient  to  a  strictly  milk  diet  for  a  few  days.  Cream  and  lactose  may 
be  added.  As  convalescence  is  established,  bread  and  butter,  lettuce,  water 
cress,  grapes,  oranges,  and  other  fruits  may  be  given.  Meats  should  be  used 
very  sparingly.  As  there  is  marked  retention  of  the  chlorides,  which  seem  to 
bear  a  relation  to  the  dropsy,  salt  should  be  withheld. 

The  fluid  intake  must  be  governed  by  the  condition.  With  oedema  it  is 
well  to  restrict  the  total  intake  to  1000  or  1500  c.  c.  Otherwise  the  patient 
may  drink  freely  of  alkaline  mineral  waters,  ordinary  water,  or  lemonade.  A 
useful  drink  is  a  dram  of  cream  of  tartar  in  a  pint  of  boiling  water,  to  which 
may  be  added  the  juice  of  half  a  lemon  and  a  little  sugar.  Taken  when 
cold,  this  is  a  pleasant  diluent  drink.  Alkaline  drinks  are  useful  if  there  is 
acidosis.  Fluid  may  be  given  by  the  bowel  or  by  saline  infusion  if  it  is  not 
well  taken  by  mouth. 

Xo  remedies,  so  far  as  known,  control  directly  the  changes  going  on  in 
the  kidneys.  The  indications  are:  (1)  To  give  the  excretory  function  of 
the  kidney  rest  by  utilizing  the  skin  and  the  bowels,  in  the  hope  that  the 
natural  processes  may  effect  a  cure;  (2)  to  meet  symptoms  as  they  arise. 

In  a  case  of  scarlet  fever  it  may  occasionally  be  possible  to  avert  an  attack, 
the  premonitory  symptoms  of  which  are  marked  increase  in  the  arterial  ten- 
sion and  the  presence  of  blood  coloring  matter  in  the  urine  (Mahomed).  An 
active  saline  cathartic  may  completely  relieve  this  condition. 

At  the  onset,  when  there  is  pain  in  the  back  or  hfematuria,  the  Paquelin 
cautery  or  the  dry  cups  give  relief.     Warm  poultices  are  often  grateful.     In 


696  DISEASES  OF  THE  KIDNEYS 

cases  which  set  in  with  suppression  of  urine  these  measures  should  be  adopted, 
and  in  addition  the  hot  bath  with  subsequent  pack,  copious  diluents,  and  a 
free  purge.  The  dropsy  is  best  treated  by  hydrotherapy — either  the  hot  bath, 
the  wet  pack,  or  the  hot-air  bath.  In  children  the  wet  pack  is  usually  satis- 
factory. It  is  applied  by  wringing  a  blanket  out  of  hot  water,  wrapping  the 
child  in  it,  covering  this  with  a  dry  blanket,  and  then  with  a  rubber  cloth. 
In  this  the  child  may  remain  for  an  hour.  It  may  be  repeated  daily.  In  the 
case  of  adults,  the  hot  air  bath  or  the  vapor  bath  may  be  conveniently  given 
by  allowing  the  vapor  or  air  to  pass  from  a  funnel  beneath  the  bed  clothes, 
which  are  raised  on  a  low  cradle.  More  efficient,  as  a  rule,  is  a  hot  bath  of 
from  fifteen  or  twenty  minutes,  after  which  the  patient  is  wrapped  in  blankets. 
The  sweating  produced  by  these  measures  is  usually  profuse,  rarely  exhaust- 
ing, and  in  a  majority  of  cases  the  dropsy  can  be  relieved  in  this  way.  There 
are  some  cases  in  which  the  skin  does  not  respond  to  the  baths,  and  if  the 
symptoms  are  serious,  particularly  if  ursemia  supervenes,  pilocarpine  may  be 
used.  The  latter  may  be  given  hypodermically,  in  doses  of  from  a  sixth  to 
an  eighth  of  a  grain  (0.01  to  0.008  gm.)  in  adults,  and  from  a  twentieth  to 
a  twelfth  of  a  grain  (0.003  to  0.005  gm.)  in  children  of  from  two  to  ten 
years. 

The  hoivels  should  be  kept  open  by  a  morning  saline  purge;  in  children 
the  fluid  magnesia  is  readily  taken;  in  adults  the  sulphate  of  magnesia  may 
be  given  by  Hay's  method,  in  concentrated  form,  in  the  morning,  before  any- 
thing is  taken  into  the  stomach.  In  nephritis  it  not  infrequently  causes 
vomiting.  The  compound  powder  of  jalap  (gr.  xx,  1.3  gm.)  or,  if  necessary, 
elaterin  (gr.  1/20,  0.003  gm.)  may  be  used.  If  the  dropsy  is  not  extreme,  the 
urine  not  very  concentrated,  and  ursemic  symptoms  are  not  present,  the  bowels 
should  be  kept  loose  without  active  purgation.  If  these  measures  fail  to  re- 
duce the  dropsy  and  it  has  become  extreme,  the  skin  may  be  punctured  with  a 
lancet  or  drained  by  a  fine  aspirator  needle  and  the  fluid  allowed  to  flow 
through  rubber  tubing  into  a  vessel  beneath  the  bed.  If  the  dyspnoea  is 
marked,  owing  to  pressure  of  fluid  in  the  pleurae,  aspiration  should  be  per- 
formed. In  some  instances  the  ascites  is  extreme  and  may  require  paracente- 
sis. If  uremic  convulsions  occur,  the  intensity  of  the  paroxysms  may  be 
limited  by  the  use  of  chloroform;  to  an  adult  a  pilocarpine  injection  should 
be  at  once  given,  and  from  a  robust,  strong  man  20  ounces  of  blood  may  be 
withdrawn.  In  children  the  loins  may  be  dry  cupped,  the  wet  pack  used,  and 
a  brisk  purgative  given.  Bromide  of  potassium  and  chloral  sometimes  prove 
useful.  Vomiting  may  be  relieved  by  ice  and  by  restricting  the  amount  of 
food. 

As  to  the  use  of  diuretics  in  acute  nephritis  the  best  diuretic  is  water, 
which  may  be  taken  freely  with  citrate  of  potash,  if  the  kidneys  can  excrete  it. 
Digitalis  should  be  given  only  when  the  myocardial  condition  requires  it. 

For  the  persistent  albuminuria,  we  have  no  remedy  of  the  slightest  value. 
Nothing  indicates  more  clearly  our  helplessness  in  controlling  kidney  me- 
tabolism than  inability  to  meet  this  common  symptom. 

For  the  ancemia  associated  with  acute  nephritis  iron  should  be  employed 
but  not  until  the  acute  symptoms  have  subsided.  In  the  adult  it  may  be  used 
in  the  form  of  the  perchloride  in  increasing  doses,  as  convalescence  proceeds. 
In  children,  the  syrup  of  the  iodide  of  iron  or  the  syrup  of  the  phosphate  of 


CHEOXIC  NEPHRITIS  697 

iron  are  useful  preparations.  Tyson  urged  caution  in  the  too  free  use  of  iron 
in  kidney  disease.  In  convalescence  care  should  be  taken  to  guard  the  patient 
against  cold.  The  diet  should  still  consist  chiefly  of  milk  and  a  return  to 
mixed  food  should  be  gradual.  A  change  of  air  is  often  beneficial,  particularly 
a  residence  in  a  warm,  equable  climate. 


VII.     CHRONIC  NEPHRITIS 

In  nephritis  there  are  two  principal  departures  from  normal:  (1)  The 
kidney  lets  out  material  wliich  should  be  kept  in  (e.  g.  albumin)  and  (2) 
keeps  in  material  Avhich  should  be  passed  out.  The  first  represents  the  signifi- 
cant urinary  findings,  the  second  the  changes  in  the  blood  and  body  fluids. 

A  clinical  classification  of  chronic  nephritis  offers  many  difficulties.  A 
pathological  classification  deals  with  end  results  and  can  not  be  applied  at  the 
bedside.  In  all  forms  we  deal  with  a  diffuse  process,  involving  epithelial,  in- 
terstitial and  glomerular  tissue.  A  functional  diagnosis  is  of  great  value  but 
the  function  of  the  kidney  may  be  influenced  by  factors  outside  the  kidney 
itself.  As  regards  an  etiological  classification  there  is  more  opportunity  for 
this  in  acute  nephritis  than  in  the  chronic  forms  in  which  it  is  only  possible 
in  a  small  proportion  of  cases  and  does  not  take  us  very  far  in  estimating  the 
present  condition.  Two  main  forms  may  be  recognized.  (1)  Those  termed 
chronic  interstitial — the  "dry"  form,  in  which  there  is  a  retention  of  nitrog- 
enous products  in  the  blood,  often  ending  in  uraemia,  and  (2)  the  chronic 
parenchymatous — the  "wet"  form,  in  which  there  is  retention  of  water  and 
salt  with  resulting  oedema.  There  are  many  intermediate  forms  and  the 
terms  mentioned  may  be  regarded  as  describing  the  cases  at  each  end  of  a 
series  with  every  grade  of  variation  between.  The  tendency  is  to  consider  the 
occurrence  of  hypertension  and  oedema  with  the  result  of  the  functional  tests 
as  designating  a  symptom-complex  rather  than  a  distinct  disease.  The  most 
useful  tests  in  estimating  the  kidney  function  are:  (1)  The  phthalein  test.  (2) 
The  determination  of  the  urea  nitrogen,  uric  acid  and  creatinine  content  of 
the  blood  with  the  estimation  of  the  index  of  urea  excretion  (Ambard,  Mc- 
Lean). (3)  The  two-hour  test  in  which  the  patient  is  given  full  diet  with 
fluid  at  mealtime  only.  The  urine  is  collected  every  two  hours  from  8  a.  m. 
to  10  p.  m.  and  from  10  p.  m.  to  8  a.  m.  The  important  points  are  the 
lowering  of  the  maximum  specific  gravity,  the  fixation  of  specific  gravity  and 
an  increase  in  the  night  urine.     (4)  The  response  to  the  action  of  a  diuretic. 

The  amyloid  kidney  is  usually  spoken  of  as  a  variety  of  nephritis,  but  in 
reality  it  is  a  degeneration  which  may  accompany  any  form  of  nephritis. 

I.    CHRONIC  PARENCHYMATOUS  NEPHRITIS 

Etiologyi. — In  many  cases  the  disease  follows  an  acute  nephritis,  but  more 
frequently  than  is  usually  stated  the  disease  has  an  insidious  onset  and  occurs 
independently  of  any  acute  attack.  Continued  bacterial  septicaemia,  secondary 
to  a  focal  infection,  is  probably  the  most  important  cause.  The  fevers  may 
play  an  important  role  in  certain  cases.  Eosenstein,  Bartels,  I.  E.  Atkinson, 
and  Thayer  have  laid  stress  upon  malaria  as  a  cause.     The  use  of  alcohol  is 


698  DISEASES  OF  THE  KIDNEYS 

believed  to  lead  to  this  form  of  nephritis.  In  chronic  suppuration,  syphilis, 
and  tuberculosis  a  diffuse  nephritis  is  not  uncommon,  sometimes  associated 
with  amyloid  disease.  Males  are  rather  more  subject  to  the  affection  than 
females.  It  is  met  with  most  commonly  in  young  adults,  and  is  by  no  means 
infrequent  in  children  as  a  sequence  of  scarlatinal  nephritis. 

Morbid  Anatomy. — Several  varieties  have  been  recognized.  The  large 
white  hidney  of  Wilks,  in  which  the  organ  is  enlarged,  the  capsule  is  thin,  and 
the  surface  white  with  the  stellate  veins  injected,  is  not  common  in  America. 
On  section  the  cortex  is  swollen  and  yellowish  white  in  color,  and  often 
presents  opaque  areas.  The  pyramids  may  be  deeply  congested.  On  micro- 
scopic examination  the  epithelium  is  granular  and  fatty,  and  the  tubules  of 
the  cortex  are  distended,  and  contain  tube  casts.  Hyaline  changes  are  present 
in  the  epithelial  cells.  The  glomeruli  are  large,  the  capsules  thickened,  the 
capillaries  show  hyaline  changes,  and  the  epithelium  of  the  tuft  and  of  the 
capsule  is  extensively  altered.  The  interstitial  tissue  is  everywhere  increased^ 
though  not  to  an  extreme  degree. 

The  second  variety  results  from  gradual  increase  in  the  connective  tissue 
and  subsequent  shrinkage,  forming  what  is  called  the  small  ivhite  kidney 
or  the  pale  granular  kidney.  It  is  doubtf iil  Avhether  this  is  always  preceded 
by  the  large  white  kidney.  Some  observers  hold  that  it  may  be  a  primary  in- 
dependent form.  The  capsule  is  thickened  and  the  surface  rough  and  granu- 
lar. On  section  the  resistance  is  greatly  increased,  the  cortex  is  reduced  and 
presents  numerous  opaque  white  or  whitish  yellow  foci,  consisting  of  accumu- 
lations of  fatty  epithelium  in  the  convoluted  tubules.  This  combination  of 
contracted  kidney  with  areas  of  marked  fatty  degeneration  has  been  given  the 
name  of  §mall  granular  fatty  kidney.  The  interstitial  changes  are  marked, 
many  glomeruli  are  destroyed,  the  degeneration  of  epithelium  in  the  convo- 
luted tubules  is  widespread,  and  the  arteries  are  greatly  thickened. 

Belonging  to  this  chronic  tubal  nephritis  is  a  variety  known  as  the  clii^onic 
licemorrhagic  nepliritis,  in  which  the  organs  are  enlarged,  yellowish  white  in 
color,  and  in  the  cortex  are  many  brownish  red  areas,  due  to  hgemorrhage  into 
and  about  the  tubes.  In  other  respects  the  changes  are  identical  with  those 
in  the  large  white  kidney. 

Symptoms. — Following  an  acute  nephritis,  the  disease  may  present,  in  a 
modified  way,  the  symptoms  of  that  affection.  In  many  cases  it  sets  in  in- 
sidiously, and  after  an  attack  of  dyspepsia  or  a  period  of  failing  health  and 
loss  of  strength  the  patient  becomes  pale,  and  puffiness  of  the  eyelids  or  swol- 
len feet  are  noticed  in  the  morning. 

The  symptoms  are  as  follows :  The  urine  is,  as  a  rule,  diminished  in 
quantity,  averaging  500  c.  c.  It  has  a  dirty  yellow,  sometimes  smoky,  color, 
and  is  turbid  from  the  presence  of  urates.  On  standing,  a  heavy  sediment 
falls,  in  which  are  found  numerous  tube  casts  of  various  fornis  and  sizes, 
hyaline,  both  large  and  small,  epithelial,  granular,  and  fatty  casts.  Leucocytes 
are  abundant;  red  blood  cells  are  frequently  met  with,  and  epithelium  from 
the  kidneys  and  pelves.  The  albumin  is  abundant  and  may  be  from  -1  to  6 
per  cent.  It  is  more  abundant  in  the  urine  passed  during  the  day.  The 
specific  gravity  may  be  high  in  the  early  stages — from  1.020  to  1.025,  even 
1.040 — though  in  the  later  stages  it  is  lower.     The  urea  is  always  reduced  in 


CHEONIC  NEPHKITIS  699 

quantity.  As  the  patient  improves  from  5  to  6  litres  of  urine  a  day  may  be 
voided. 

Dropsy  is  a  marked  and  obstinate  symptom  of  this  form.  The  face  is  pale 
and  puffy,  and  in  the  morning  the  eyelids  are  oedematous.  The  anasarca  is 
general,  and  there  may  be  involvement  of  the  serous  sacs.  In  these  chronic 
cases  associated  with  large  white  kidney  there  is  often  a  distinctive  appear- 
ance in  the  face;  the  complexion  is  pasty,  the  pallor  marked,  and  the  eyelids 
are  oedematous.  The  dropsy  is  peculiarly  obstinate.  Epstein  suggests  that 
"the  loss  of  protein  incurred  by  the  blood  serum  through  the  continuous  al- 
buminuria causes  a  decrease  in  the  osmotic  pressure  of  the  blood,  which  favors 
the  absorption  or  inhibition  and  retention  of  fluid  by  the  tissues."  With  this 
there  is  a  great  increase  in  the  lipoid  content  of  the  blood — lipoidgemia. 
Uremic  symptoms  are  common,  though  convulsions  are  perhaps  less  frequent 
than  in  inierstitial  nephritis. 

The  tension  of  the  pulse  may  be  increased;  the  vessels  ultimately  become 
stiff  and  the  heart  hypertrophied,  though  there  are  instances  of  this  form 
in  which  the  heart  is  not  enlarged.  The  aortic  second  sound  may  be  ac- 
centuated. Eetinal  changes,  though  less  frequent  than  in  the  chronic  in- 
terstitial nephritis,  occur  in  a  considerable  number  of  cases. 

Gastro-intestinal  symptoms  are  common.  Vomiting  is  frequently  a  dis- 
tressing and  serious  symptom,  and  diarrhoea  may  be  profuse.  Ulceration  of 
the  colon  may  prove  fatal  and  is  common  in  the  tropics  in  association  with 
malarial  and  other  forms  of  nephritis. 

The  functional  tests  may  show  great  variations.  In  many  cases  the  great- 
est change  is  in  the  ability  to  secrete  water  and  salt,  in  others  the  reduction  in 
function  is  more  general  and  the  phthalein  excretion  may  be  much  reduced. 
In  some  cases  there  is  hyperpermeability. 

It  is  sometimes  impossible  to  determine,  even  by  the  most  careful  exami- 
nation of  the  urine  or  by  analysis  of  the  symptoms,  whether  the  condition  of 
the  kidney  is  that  of  the  large  white  or  of  the  small  white  form.  In  cases, 
however,  which  have  lasted  for  several  years,  with  th3  progressive  increase  in 
the  renal  connective  tissue  and  the  cardio-vascular  changes,  the  clinical  picture 
may  approach,  in  certain  respects,  that  of  the  contracted  kidney.  The  urine 
is  increased,  with  low  specific  gravity.  It  is  often  turbid,  may  contain  traces 
of  blood,  the  tube  casts  are  numerous  and  of  every  variety  of  form  and  size, 
and  the  albumin  is  abundant.  Dropsy  is  usually  present,  though  not  so  ex- 
tensive as  in  the  early  stages. 

Pro^Oisis. — This  is  extremely  grave.  In  a  case  which  has  persisted  for 
more  than  a  year  recovery  rarely  takes  place.  Death  is  caused  either  by  great 
effusion  with  oedema  of  the  lungs,  by  ursemia,  or  by  secondary  inflammation 
of  the  serous  membranes.  Occasionally  in  children,  even  when  the  disease  has 
persisted  for  two  years,  the  symptoms  disappear  and  recovery  takes  place. 
The  frequency  of  acute  exacerbations  adds  to  the  uncertainty  of  prognosis.  A 
marked  decrease  in  the  kidney  function  is  of  grave  omen. 

Treatment. — Much  the  same  treatment  should  be  carried  out  as  in  acute 
nephritis.  Eest  need  not  be  absolute  if  the  general  condition  permits  of  some 
exertion.  The  dropsy  should  be  treated  by  hot  baths  and  a  salt-free  diet. 
Iron  preparations  should  be  given  when  there  is  marked  anaemia  but  the 
pallor  of  the  face  may  not  be  a  good  index  of  the  blood  condition.    The  acetate 


700  DISEASES  OF  THE  KIDNEYS 

of  potash,  digitalis,  and  diuretin  are  useful  in  increasing  the  flow  of  urine. 
Basham's  mixture  given  in  plenty  of  water  is  often  beneficial. 

Diet. — In  line  with  the  views  held  by  Epstein  the  effort  should  be  to  in- 
crease the  protein  content  of  the  blood  and  reduce  the  excessive  amount  of 
lipoid.  This  must  be  done  largely  by  a  high  protein  and  fat  poor  diet,  with 
a  moderate  amount  of  carbohydrates.  He  gives  120  to  240  gm.  of  protein, 
20  to  40  gm.  of  fat  and  150  to  300  gm.  of  carbohydrate.  The  fluid  intake  is 
from  1200  to  1500  c.  c.  and  the  amount  of  salt  is  reduced  to  a  minimum. 
The  foods  are  lean  veal  and  ham,  egg  white,  oysters,  gelatine,  lima  beans,  split 
and  green  peas,  rice,  oatmeal,  mushrooms,  bananas,  skimmed  milk,  coffee, 
tea  and  cocoa.  The  amount  of  fluid  intake  must  in  many  cases  be  decided 
by  results.  The  Karrell  diet  consists  in  giving  200  c.  c.  of  milk  at  8  a.  m., 
12  noon,  and  4  and  8  p.  m.,  and  nothing  more.  After  a  week,  a  soft  egg 
with  bread  may  be  added  and  the  diet  gradually  increased  but  the  intake  of 
fluid  should  be  kept  at  800  c.  c.  a  day  for  some  time.  Some  patients  with 
marked  dropsy  do  well  with  this,  but  in  others  it  is  advisable  to  increase  the 
amount  of  fluid. 

II.     CHEONIC  INTERSTITIAL  NEPHRITIS 

[Contracted  Kidney;  Arteriosclerotic  Kidney;  Senile  Kidney) 

Etiology  and  Morbid  Anatomy. — Sclerosis  of  the  kidney  is  met  with 
{a)  as  a  sequence  of  the  large  Avhite  kidney,  forming  the  secondary  contracted 
kidney;  (6)  as  a  primary  independent  affection,  the  red  granular  kidney;  (c) 
as  a  sequence  of  arterio-sclerosis ;  and   {d)  as  a  senile  change. 

{a)  Secondary  Form. — The  small  white  kidney,  as  it  is  called,  has  al- 
ready been  described  as  a  sequel  to  chronic  parenchymatous  nephritis. 

(6)  In  the  primary  form,  known  also  as  the  red  granular  kidney,  the 
organ  is  smaller  than  in  the  secondary  interstitial  nephritis,  the  capsule  is 
very  adherent,  the  granulations  small,  the  organ  of  a  reddish  brown  color, 
the  cysts  numerous,  the  arteries  very  sclerotic,  and  the  cortex  greatly  reduced 
in  volume.  The  chief  reason  for  calling  this  primary  is  that  one  can  find  no 
history  of  previous  renal  disease.  Some  families  show  the  disease  in  many 
members  for  several  generations.  Syphilis,  alcohol,  and  overeating  are  men- 
tioned as  contributory  causes.  Lead  is  a  rare  cause  in  America  but  a  more 
common  cause  in  parts  of  England.  It  is  by  no  means  always  easy  to  differ- 
entiate between  the  secondary  and  the  primary  forms.  As  a  rule,  the  former 
is  paler  and  not  so  small.  Of  174  cases  of  this  form  which  came  to  autopsy, 
in  79  the  combined  weight  of  the  kidneys  was  about  300  grams,  in  57  cases 
200  to  300  grams,  in  30  cases  150  to  200  grams,  and  below  150  grams  in  8 
cases  (Emerson).  Unilateral  nephritis  is  extremely  rare,  not  occurring 
once  in  the  series. 

(c)  Arterio-sclerotic  Kidney. — This  is  not  necessarily  a  contracted 
kidney.  The  organ  is  very  hard,  red,  and  often  heavier  than  normal.  Of 
the  cases,  studied  by  Emerson,  in  61  per  cent,  the  combined  weight  was  above 
300  grams,  and  in  only  6  per  cent,  was  it  below  200  grams.  The  surface  may 
be  smooth  or  the  capsule  only  slightly  thickened  and  adherent,  tearing  the 
substance  very  little  as  it  is  stripped  off.     In  other  cases  the  atrophy  is  in 


CHRONIC  NEPHRITIS  701 

spots,  affecting  certain  vascular  districts,  so  that  there  is  a  large,  sunken,  deep 
red  patch  on  the  surface,  or  one  pole  of  the  kidney  is  shrunken,  or  the  process 
is  general  in  both  kidneys,  but  the  resulting  contraction  gives  a  warty  rather 
than  a  granular  surface. 

(d)  In  the  senile  form,  met  with  in  the  aged,  the  organs  are  reduced 
in  size,  the  capsules  thickened  and  adherent,  the  pelvic  fat  much  increased, 
both  cortical  and  pyramidal  portions  uniformly  wasted,  and  the  arteries  of  the 
kidney  substance  very  prominent. 

Almost  invariably  associated  with  chronic  interstitial  nephritis  are  gen- 
eral arterio-sclerosis  and  hypertrophy  of  the  heart.  The  changes  in  the  ar- 
teries will  be  described  elsewhere.  In  the  red  granular  kidney  the  left  ven- 
tricle is  specially  hypertrophied,  but  in  all  forms  the  heart  is  greatly  enlarged. 
In  many  cases  the  disease  is  latent,  and  the  patients  die  of  apoplexy  or  of  acute 
uraemia.  In  the  arterio-sclerotic  form  death  is  more  commonly  cardiac,  and 
the  condition  of  the  kidneys  may  be  entirely  overlooked. 

The  disease  is  really  one  which  involves  the  cardiovascular-renal  system. 
Much  discussion  has  taken  place  as  to  the  association  of  hypertrophy  of  the 
heart  and  sclerosis  of  the  blood-vessels  with  the  renal  changes.  A  complete 
solution  of  the  problems  has  scarcely  yet  been  offered.  Briefly,  there  are  two 
views — the  mechanical  and  the  chemical.  Dating  from  the  time  of  Bright  it 
was  thought  that  the  heart  had  greater  difficulty  in  driving  the  blood  through 
the  capillary  system.  Traube  held  that  tlie  obliteration  of  a  large  number 
of  capillary  territories  in  the  kidney  raised  the  arterial  pressure  and  in  this 
way  led  to  hypertrophy  of  the  heart.  In  explanation  of  the  muscular  hyper- 
trophy of  the  walls  of  the  smaller  arteries  George  Johnson  introduced  the  view 
of  a  stop-cock  action  of  these  vessels  under  the  influence  of  irritating  ingredi- 
ents in  the  blood.  The  mechanical  view  was  thus  put  by  Cohnheim.  The 
activity  of  the  circulation  through  the  kidneys  at  any  moment  does  not  depend 
upon  the  need  of  these  organs  for  blood,  but  solely  upon  the  amount  of  ma- 
terial for  the  urinary  secretion  existing  in  the  blood.  When  parts  of  both 
kidneys  have  undergone  atrophy,  the  blood  flow  in  the  parts  remaining  must 
be  as  great  as  it  would  have  been  to  the  whole  of  the  organs,  had  they  been 
intact;  but  in  order  that  such  a  quantity  of  blood  should  pass  through  the 
restricted  capillary  area  now  open  to  it  an  excessive  pressure  is  necessary. 
This  can  be  brought  to  bear  only  by  the  exertion  of  an  increased  force  on  the 
part  of  the  left  ventricle  with  the  maintenance  of  a  corresponding  resistance 
in  all  other  arterial  territories.  In  this  way  both  the  high  arterial  pressure 
and  the  cardio-vascular  changes  are  explained. 

The  chemical  view  supposes  the  production  (a)  by  the  kidneys,  (&)  by 
the  supra-renal  glands,  of  certain  pressor  substances.  So  far  as  the  kidney  is 
concerned,  the  observations  are  by  no  means  in  accord.  In  chronic  interstitial 
nephritis  there  is  often  hyperplasia  of  the  cortical  substance  of  the  suprarenals, 
and  some  have  claimed  to  have  discovered  in  the  blood  of  chronic  nephritics  an 
increase  in  the  pressor  substances,  an  adrenal infemia.  Through  their  influ- 
ence, from  one  or  both  of  these  sources,  the  blood-pressure  is  raised,  with  the 
sequence  of  hypertrophy  of  the  heart  and  sclerosis  of  the  arteries. 

Symptoms. — Many  cases  are  latent,  and  are  not  recognized  until  the  oc- 
currence of  one  of  the  serious  or  fatal  complications.  Even  an  advanced  grade 
of  contracted  kidney  may  bo  compatible  with  great  mental  and  bodily  activity. 


702  DISEASES  OF  THE  KIDXEYS 

There  may  have  been  no  symptoms  whatever  to  suggest  to  the  patient  the 
existence  of  a  serious  malady.  In  other  cases  the  general  health  is  disturbed. 
The  patient  complains  of  lassitude,  is  sleepless,  has  to  get  up  at  night  to  mic- 
turate ;  the  digestion  is  disordered,  the  tongue  is  furred ;  there  are  complaints 
of  headache,  failing  vision,  and  breathlessness  on  exertion. 

So  complex  and  varied  is  the  clinical  picture  that  it  will  be  best  to  con- 
sider the  symptoms  under  the  various  systems. 

Ueinaey  System. — In  the  small  contracted  kidney  polyuria  is  common. 
Frequently  the  patient  has  to  get  up  two  or  three  times  during  the  night  to 
empty  the  bladder,  and  there  is  increased  thirst.  It  is  for  these  symptoms 
occasionally  that  relief  is  sought.  And  yet  in  many  cases  with  very  small 
kidneys  this  feature  has  not  been  present.  A  careful  study  of  the  urine  and 
the  anatomical  condition  showed  that  no  close  parallelism  could  be  made 
between  the  weight  of  the  kidney,  its  appearance,  and  the  urine  it  secreted 
before  death.  Of  174:  cases  with  autopsy,  in  almost  a  third  the  renal  changes 
were  so  slight  that  the  nephritis  was  not  mentioned  as  a  part  of  the  clinical 
diagnosis  (Emerson).  The  color  of  the  urine  is  a  light  yellow,  and  the  spe- 
cific gravity  ranges  from  1.005  to  1.012.  Persistent  low  specific  gravity  is 
one  of  the  most  constant  and  important  features.  Traces  of  albumin  are 
found,  but  may  be  absent  at  times,  particularly  in  the  early  morning  urine. 
It  may  be  apparent  only  with  the  more  delicate  tests.  The  sediment  is  scanty, 
and  in  it  a  few  hyaline  or  granular  casts  are  found.  The  quantity  of  the  solid 
constituents  of  the  urine  is,  as  a  rule,  diminished,  though  in  some  instances 
the  urea  may  be  excreted  in  full  amount.  In  attacks  of  dyspepsia  or  bron- 
chitis, or  in  the  later  stages  when  the  heart  fails,  the  quantity  of  albumin  may 
be  greatly  increased  and  the  urine  diminished.  Occasionally  blood  occurs  in 
the  urine,  and  there  may  be  hematuria  (S.  West),  Slight  leakage,  represented 
by  the  constant  presence  of  a  few  red  cells,  may  be  present  early  in  the  disease 
and  persist  for  years.  In  the  arteriosclerotic  form  the  quantity  of  urine  is 
normal,  or  reduced  rather  than  increased;  the  specific  gravity  is  normal  or 
high,  the  color  of  the  urine  is  good,  and  there  are  hyaline  and  finely  granular 
casts.  The  amount  of  albumin  varies  with  the  food  and  exercise,  and  is  usu- 
ally much  in  excess  of  that  seen  with  the  contracted  kidneys,  and  does  not 
show  so  often  the  albumin  free  intervals  of  that  form,  also  it  is  more  common 
to  find  albumin  without  casts,  while  in  the  contracted  kidney  casts  may  occur 
without  albumin. 

The  functional  findings  are  very  variable  in  different  stages.  They  are  of 
value  in  determining  the  approach  of  ursemia.  As  the  studies  of  Janeway 
showed,  in  the  majority  of  cases  death  is  not  from  renal  insufficiency  but 
from  cardiac  failure  ;or  cerebral  vascular  disease.  Functional  tests  are  of 
value  in  deciding  whether  myocardial  or  renal  insufficiency  is  the  more  im- 
portant factor. 

CiRCULATOEY  SYSTEM. — The  pulse  is  hard,  the  tension  increased,  and  the 
vessel  wall,  as  a  rule,  thickened.  A.  distinction  must  be  made  between  in- 
creased tension  and  thickening  of  the  arterial  wall.  The  tension  may  be  plus 
in  a  normal  vessel,  but  in  chronic  nephritis  it  is  more  common  to  have  in- 
creased tension  in  a  stiff  artery. 

A  pulse  of  increased  tension  has  the  following  characters :  It  is  hard  and 
incompressible,  requiring  a  good  deal  of  force  to  overcome  it;  it  is  persistent. 


CHEONIC  NEPHRITIS  703 

and  in  the  intervals  between  the  beats  the  vessel  feels  fnll  and  can  be  rolled 
beneath  the  finger.  These  characters  may  be  present  in  a  vessel  the  walls  of 
which  are  little^,  if  at  all,  increased  in  thickness.  To  estimate  the  latter  the 
pulse  wave  should  be  obliterated  in  the  radial,  and  the  vessel  wall  felt  be- 
yond it.  In  a  perfectly  normal  vessel  the  arterial  coats,  under  these  circum- 
stances, can  not  be  differentiated  from  the  surrounding  tissue;  whereas,  if 
thickened,  the  vessel  can  be  rolled  beneath  the  finger.  Persistent  high  blood 
pressure  is  one  of  the  earliest  and  most  important  symptoms  of  interstitial 
nephritis.  During  the  disease  the  pressure  may  rise  to  250  mm.  or  300  mm. 
With  dropsy  and  cardiac  dilatation  the  pressure  may  fall,  but  not  necessarily. 
The  cardiac  features  are  equally  important,  though  often  less  obvious.  Hyper- 
trophy of  the  left  ventricle  occurs  to  overcome  the  resistance  offered  in  the 
arteries.  The  enlargement  of  the  heart  ultimately  becomes  more  general.  The 
apex  is  displaced  downward  and  to  the  left ;  the  impulse  is  forcible  and  may  be 
heaving.  In  elderly  persons  with  emphysema  the  displacement  of  the  apex 
may  not  be  evident.  The  first  sound  at  the  apex  may  be  duplicated ;  more  com- 
monly the  second  sound  at  the  aortic  cartilage  is  accentuated.  The  sound  In 
extreme  cases  may  have  a  bell-like  quality.  In  ma^iy  cases  a  systolic  murmur 
develops  at  the  apex,  as  a  result  of  relative  insufficiency.  It  may  be  loud  and 
transmitted  to  the  axilla.  Finally  the  hypertrophy  fails,  the  heart  becomes 
dilated,  gallop  rhythm  is  present,  and  the  general  condition  is  that  of  chronic 
myocardial  failure.  In  the  arterio-sclerotic  form  the  picture  may  be  cardiac 
from  beginning  to  close- — dyspnoea  and  signs  of  dilated  heart. 

Blood, — The  estimation  of  the  urea  N,  uric  acid  and  creatinin  is  particu- 
larly important,  an  increase  meaning  retention.  The  urea  IST  (normal  12-15 
mg,  per  100  c,  c.)  is  increased  to  15-50  mgs.  in  chronic  nephritis  and  80-300 
in  uremia.  Uric  acid  (normal  1-2.5)  is  increased  to  4  in  chronic  nephritis 
and  4-15  in  uraemia.  Creatinin  (normal  1-2.5)  is  increased  to  3  in  chronic 
nephritis  and  from  3  to  5  in  urasmia.  These  findings  are  important  in  diag- 
nosis and  prognosis.  It  is  a  question  which  of  these  is  the  most  useful.  Per- 
sistent loM^  urea  content  in  the  blood,  in  the  absence  of  oedema,  is  evidence 
against  renal  disease.  As  the  uric  acid  is  the  most  difficult  to  excrete  some 
regard  its  estimation  as  particularly  useful  in  the  absence  of  gout.  In  the 
immediate  prognosis  the  creatinin  estimation  is  important.  Amounts  from 
3  to  5  mg,  per  100  c,  c.  of  blood  are  unfavorable  and  if  above  5  mg.  an  early 
termination  may  be  expected, 

Eespiratoey  System, — Sudden  oedema  of  the  glottis  may  occur.  Effu- 
sion into  the  pleurge  or  sudden  oedema  of  the  lungs  may  prove  fatal.  Acute 
pleurisy  and  pneumonia  are  not  uncommon.  Bronchitis  is  a  frequent  accom- 
paniment, particularly  in  the  winter.  Sudden  attacks  of  dyspnoea,  particu- 
larly at  night,  are  not  infrequent.  This  is  often  a  urasmic  symptom  or  due 
to  acidosis  but  is  sometimes  cardiac,  Cheyne-Stokes  breathing  may  be  pres- 
ent, most  commonly  toward  the  close,  but  the  patient  may  be  walking  about 
and  even  attending  to  his  occupation. 

Acidosis. — The  majority  of  advanced  cases  show  some  degree  of  acidosis, 
which  is  often  severe  and  hastens  a  fatal  issue. 

Digestive  System, — Dyspepsia  and  loss  of  appetite  are  common.  Severe 
and  uncontrollable  vomiting  may  be  the  first  symptom.  This  is  usually  re- 
garded as  a  manifestation  of  ursemia,  but  it  may  occur  without  any  other  in- 


yo.4  DISEASES  OF  THE  KIDNEYS 

dications,,  and  may  prove  fatal  without  any  suspicion  that  chronic  nephritis 
was  present.  Severe  and  even  fatal  diarrhoea  may  develop.  The  tongue  may 
be  coated  and  the  breath  hea^^  and  urinous. 

Nervous  System. — Various  cerebral  manifestations  have  been  mentioned 
under  uraemia.  Headache,  sometimes  of  the  migraine  type,  may  be  an  early 
and  persistent  feature  of  chronic  nephritis.  A  morning  headache  which  wakes 
the  patient  early  and  lasts  until  midday  is  not  uncommon.  In  hypertension 
mental  work  often  causes  headache.  Cerebral  hemorrhage  is  closely  related 
to  interstitial  nephritis  and  may  take  place  into  the  meninges  or  the  cere- 
brum. It  is  usually  associated  with  marked  changes  in  the  vessels.  Neural- 
gias, in  various  regions,  are  not  uncommon. 

Special  Sexses. — Troubles  in  vision  may  be  the  first  symptom.  It  is 
remarkable  in  how  many  cases  the  condition  is  diagnosed  first  by  the  ophthal- 
mic surgeon.  The  flame  shaped  retinal  haemorrhages  are  the  most  common. 
Less  frequent  is  diffuse  retinitis  or  papillitis.  Sudden  blindness  may  super- 
vene without  retinal  changes — urgemic  amaurosis.  Diplopia  is  a  rare  event. 
Eecurring  conjunctival  and  palpebral  haemorrhages  are  fairly  common,  par- 
ticularly in  the  arterio-sclerotic  form.  Auditory  troubles  are  by  no  means 
infrequent  and  ringing  in  the  ears,  with  dizziness,  is  not  uncommon.  Various 
forms  of  deafness  may  occur. 

Skin. — (Edema  is  not  common  in  interstitial  nephritis.  Slight  puffiness 
of  the  ankles  may  be  present,  but  in  a  majority  of  the  cases  dropsy  does  not 
supervene.  When  extensive,  it  is  almost  always  the  result  of  gradual  failure 
of  the  hypertrophied  heart.  The  skin  is  often  dry  and  pale,  and  sweats  are 
not  common.  In  some  instances  the  sweat  may  deposit  a  white  frost  of  urea 
on  the  surface  of  the  skin.  Eczema  is  a  common  accompaniment  of  chronic 
interstitial  nephritis.  Tingling  of  the  fingers  or  numbness  and  pallor — the 
dead  fingers — are  not,  as  some  suppose,  in  any  way  peculiar  to  nephritis. 
Intolerable  itching  of  the  skin  may  be  present,  and  cramps  in  the  muscles  are 
by  no  means  rare. 

Haemorrhages  are  not  infrequent,  particularly  epistaxis.  Severe  and  wide- 
spread purpura  is  a  not  uncommon  terminal  event  and  the  primary  disease 
may  not  be  recognized.  Broncho-pulmonary  haemorrhages  may  occur.  Ascites 
is  rare  except  in  association  with  cirrhosis  of  the  liver. 

Diagnosis. — The  autopsy  often  discloses  the  true  nature  of  the  disease,  one 
of  the  many  intercurrent  affections  of  which  may  have  proved  fatal.  The 
early  stages  of  interstitial  nephritis  are  difficult  to  recognize.  In  a  patient 
with  increased  pulse  tension  (particularly  if  the  vessel  wall  is  sclerotic),  with 
the  apex  beat  of  the  heart  dislocated  to  the  left,  the  second  aortic  sound  ring- 
ing and  accentuated,  the  urine  abundant  and  of  low  specific  gravity,  with  a 
trace  of  albumin  and  an  occasional  hyaline  or  granular  cast,  the  dignosis  of 
interstitial  nephritis  may  be  safely  made.  Of  all  the  indications,  that  offered  by 
the  pulse  is  the  most  important.  Persistent  high  tension  with  thickening  of 
the  arterial  wall  in  a  man  under  fifty  means  that  serious  mischief  has  already 
taken  place,  that  cardio-vascular  changes  are  certainly,  and  renal  most  probably, 
present.  In  the  arterio-sclerotic  cases  the  history  is  of  the  "strenuous  life'' — 
work,  alcohol,  tobacco,  Venus — and  not  of  an  infection  or  of  lead  or  gout. 
The  urine  is  not  of  persistently  low  specific  gravity,  there  may  be  little  or 
no.  albumin  except  in  interciirrent  attacks;  the  s5^mptoms  are  cardiac  rather 


CHROmC  NEPHRITIS  705 

than  renal  or  cerebral;  the  ocular  changes  are  hemorrhagic,  not  the  true 
albuminuric  retinitis.  Primary  hypertension  should  be  distinguished  and  in 
this  the  functional  tests  are  of  value. 

Prognosis. — Chronic  nephritis  is  an  incurable  affection,  and  the  anatomical 
conditions  on  which  it  depends  are  quite  as  much  beyond  the  reach  of  medi- 
cines as  vv'rinkled  skin  or  gray  hair.  However,  it  is  compatible  with  the  en- 
joyment of  life  for  many  years,  and  it  is  now  recognized  that  increased  ten- 
sion, thickening  of  the  arterial  walls,  and  polyuria  with  a  small  quantity  of 
albumin,  neither  doom  a  man  to  death  within  a  short  time  nor  necessarily 
interfere  with  the  pursuits  of  an  active  life  so  long  as  proper  care  be  taken. 
Patients  with  high  tension  and  a  little  albumin  in  the  urine  with  hyaline 
casts  may  live  for  ten,  twelve,  or  even  fifteen  years.  Serious  indications  are 
the  occurrence  of  ursemic  symptoms,  dilatation  of  the  heart,  the  onset  of  serous 
effusions,  the  onset  of  Cheyne-Stokes  breathing,  marked  acidosis,  persistent 
vomiting,  and  diarrhoea.  The  functional  tests  and  blood  analysis  give  valu- 
able information  and  are  material  aids  in  prognosis. 

Treatment. — Patients  without  local  indications  or  in  whom  the  condi- 
tion has  been  accidentally  discovered  should  so  regulate  their  lives  as  to 
throw  the  least  possible  strain  upon  heart,  arteries,  and  kidneys.  A  quiet  life 
without  mental  worry,  with  gentle  but  not  excessive  exercise,  and  residence  in 
an  equable  climate,  should  be  recommended.  In  addition  they  should  be 
told  to  keep  the  bowels  open,  the  skin  active  by  a  daily  tepid  bath  with  fric- 
tion, and  the  urinary  secretion  free  by  drinking  daily  a  definite  amount  of 
either  distilled  water  or  some  pleasant  mineral  water.  Alcohol  should  be 
strictly  prohibited.    Tea  and  coffee  are  allowable. 

The  diet  should  be  light  and  nourishing,  and  the  patient  should  be  warned 
not  to  eat  excessively,  and  not  to  take  meat  more  than  once  a  day.  Care  in 
food  and  drink  is  probably  the  most  important  element  in  the  treatment  of 
early  cases.  A  patient  in  good  circumstances  may  be  urged  to  go  away  during 
the  winter  months,  or,  if  necessary,  to  move  altogether  to  a  warm  equable  cli- 
mate, like  that  of  Southern  California.  There  is  no  doubt  of  the  value  in 
these  cases  of  removal  from  the  changeable,  irregular  weather  which  prevails 
in  the  temperate  regions  from  November  until  April. 

At  this  period  medicines  are  not  required  unless  for  certain  special  symp- 
toms. Patients  derive  much  benefit  from  an  annual  visit  to  certain  mineral 
springs,  such  as  Poland,  Bedford,  Saratoga,  in  America,  and  Vichy  and  others 
in  Europe.  Mineral  waters  have  no  curative  influence  upon  chronic  nephritis ; 
they  simply  help  the  interstitial  circulation  and  keep  the  drains  flushed.  In 
this  early  stage,  when  the  patient's  condition  is  good,  the  tension  not  higli. 
and  the  quantity  of  albumin  small,  medicines  are  not  indicated,  since  no 
remedies  are  known  to  have  the  slightest  influence  upon  the  progress  of  the 
disease.  Sooner  or  later  symptoms  arise  which  demand  treatment.  Of  these 
the  following  are  the  most  important : 

(a)  Hypertension. — It  is  to  be  remembered  that  a  certain  increase  of  ten- 
sion is  not  only  necessary  but  unavoidable  in  chronic  nephritis,  and  probably 
the  most  serious  danger  is  too  great  lowering  of  the  tension.  The  happy 
medium  must  be  sought  between  such  heightened  tension  as  throws  a  serious 
strain  upon  the  heart  and  risks  rupture  of  the  vessels  and  the  low  tension 
Avhich,  under  these  circumstances,  is  specially  liable  to  be  associated  with 


706  DISEASES  OF  THE  KIDXEYS 

serous  effusions.  In  cases  with  persistent  high  tension  the  diet  should  be 
light,  an  occasional  saline  purge  should  be  given,  and  sweating  promoted  by 
means  of  hot  air  or  the  hot  bath.  A  few  days  in  bed  on  milk  diet  is  some- 
times useful.    An  occasional  venesection  helps  some  patients. 

(6)  More  or  less  ancemia  is  present  in  advanced  cases,  and  is  best  met  by 
the  use  of  iron. 

(c)  Myocardial  insufficiency. — The  patient  should  be  allowed  to  assume 
the  most  comfortable  position  but  rest  should  be  as  complete  as  possible.  The 
diet  should  be  greatly  restricted  and  it  is  often  wise  to  give  no  food  for  a  day. 
Then  milk  (750  to  1000  c,  c.  a  day)  may  be  allowed.  Later  it  is  well  to  give 
food  in  small  amounts  with  frequent  feedings.  The  total  intake  of  fluids 
must  depend  somewhat  on  the  presence  of  oedema.  With  this  the  amount  of 
fluid  should  not  be  over  1500  c,  c.  and  salt  withheld  as  far  as  possible.  Free 
purgation  is  indicated,  for  which  calomel  or  elaterin  (gr.  l/?0,  0.003  gm.) 
and  salines  may  be  used.  With  marked  dilatation  of  the  heart,  venesection  is 
advisable  unless  the  patient  is  anaemic.  Digitalis  is  indicated  and  a  high 
blood  pressure  is  not  a  contraindication  to  its  use.  Full  doses  should  be  em- 
ployed and  with  a  good  preparation  it  matters  little  in  which  form  it  is  given. 
In  severe  cases  it  is  well  to  give  it  intramuscularly  or  administer  one  dose  of 
strophanthin  and  follow  this  with  digitalis.  Of  other  preparations,  theo- 
bromine (gr.  V,  0.3  gm.),  diuretin  (gr.  xv,  1  gm.),  and  theocin  (gr.  iii,  0.2 
gm.)  may  be  tried.    Xone  has  an  effect  equal  to  digitalis. 

(d)  Vaso-dilators. — The  giving  of  these  is  not  indicated  for  the  purpose  of 
reducing  pressure  but  they  are  often  of  service  in  relieving  symptoms,  especially 
headache,  dizziness  and  dyspnoea.  Nitroglycerine  may  be  given  beginning 
with  gr.  1/100  (0.00065  gm.)  and  increasing  till  an  effect  is  produced.  So- 
dium nitrite  is  often  more  useful  in  doses  of  gr.  %-ii  (0.03-0.12  gm.).  Ery- 
throl  tetranitrate  has  a  more  prolonged  effect.  The  dose  of  the  vasodilator 
should  be  that  which  produces  an  effect. 

(e)  Urcemic  Symptoms. — Even  before  marked  manifestations  are  present 
there  may  be  extreme  restlessness,  mental  wandering,  a  heavy,  foul  breath, 
and  a  coated  tongue.  Headache  is  not  often  complained  of,  though  intense 
frontal  headache  may  be  an  early  symptom  of  ursemia.  In  this  condition,  too, 
the  patient  may  complain  of  palpitation,  feelings  of  numbness,  and  sometimes 
nocturnal  cramps.  For  these  symptoms  the  saline  purgatives  should  be  or- 
dered, and  hot  baths,  so  as  to  induce  copious  sweating.  Water  should  be  given 
freely,  by  mouth,  by  the  drop  method  by  the  bowel,  and  by  subcutaneous  injec- 
tion if  necessary.  Grandin  states  that  irrigation  of  the  bowel  with  hot  water 
is  most  useful.  If  signs  of  acidosis  are  present,  sodium  bicarbonate  (3  i,  4 
gm.,  a  day)  should  be  given.  For  the  ursemic  convulsions,  if  severe,  inhala- 
tions of  chloroform  may  be  used.  If  the  patient  is  robust  and  full-blooded, 
from  12  to  20  ounces  of  blood  should  be  removed.  Lumbar  puncture  is  often 
useful  and  can  be  done  without  hesitation.  The  patient  should  be  freely 
sweated,  and  if  the  convulsions  tend  to  recur  chloral  may  be  given,  either  by 
the  mouth  or  per  rectum,  or,  better  still,  morphia.  ITrsmic  coma  must  be 
treated  by  active  purgation,  and  sweating  should  be  promoted  by  the  use  of 
pilocarpine  or  the  hot  bath.  For  the  restlessness  and  delirium  morphia  is  in- 
dispensable. Since  its  recommendation  in  urcemic  states  by  Stephen  Mac- 
Kenzie,  this  remedy  has  been  used  extensively  and  is  of  great  value  in  these 


AMYLOID  DISEASE  707 

cases.     It  is  of  special  value  in  the  dyspncea  and  Cheyne-Stokes  breathing  of 
advanced  arterio-sclerosis  with  chronic  ursemia. 

SuEGlCAL  TREAIMENT.—Edebohls  introduced  the  operation  of  decapsu- 
lation of  the  kidneys  iu  order  to  establish  new  vascular  connections,  and  so 
influence  the  nutrition  of  the  organs.  There  is  probably  a  small  group  of 
suitable  cases — the  subacute  and  chronic  forms  which  follow  acute  infections 
— in  which  the  outlook  is  hopeless  from  medical  treatment. 


VIII.     AMYLOID  DISEASE 

Amyloid  (lardaceous  or  waxy)  degeneration  of  the  kidneys  is  simply  an 
event  in  the  process  of  chronic  nephritis,  most  commonly  in  the  chronic  paren- 
chymatous nephritis  following  fevers,  or  of  cachectic  states.  It  has  no  claim 
to  be  regarded  as  one  of  the  varieties  of  nephritis.  The  affection  of  the  kid- 
neys is  generally  a  part  of  a  widespread  amyloid  degeneration  occurring  in  pro- 
longed suppuration,  as  in  disease  of  the  bone,  in  syphilis,  tuberculosis,  and 
occasionally  leukaemia,  lead  poisoning,  and  gout.  It  varies  curiously  in  fre- 
quency in  different  localities. 

The  amyloid  kidney  is  large  and  pale,  the  surface  smooth,  and  the  venae 
stellatae  well  marked.  On  section  the  cortex  is  large  and  may  show  a  peculiar 
glistening,  infiltrated  appearance,  and  the  glomeruli  are  very  distinct.  The 
pyramids,  in  striking  contrast  to  the  cortex,  are  of  a  deep  red  color.  A  sec- 
tion soaked  in  dilute  tincture  of  iodine  shows  spots  of  a  walnut  or  mahogany 
brown  color.  The  Malpighian  tufts  and  the  straight  vessels  may  be  most 
affected.  In  lardaceous  disease  the  kidneys  are  not  always  enlarged  but  may 
be  normal  in  size  or  small,  pale,  and  granular.  The  amyloid  change  is  first 
seen  in  the  Malpighian  tufts,  and  then  involves  the  afferent  and  efferent  ves- 
sels and  the  straight  vessels.  It  may  be  confined  entirely  to  them.  In  later 
stages  the  tubules  are  affected,  chiefly  the  membrane,  rarely,  if  ever,  the  cells 
themselves. 

Symptoms. — The  renal  features  alone  may  not  indicate  the  presence  of 
this  degeneration.  Usually  the  associated  condition  gives  a  hint  of  the  nature 
of  the  process.  The  urine,  as  a  rule,  shows  important  changes;  the  quantity 
is  increased,  and  it  is  pale,  clear,  and  of  low  specific  gravity.  The  albumin  is 
usually  abundant,  but  it  may  be  scanty,  and  in  rare  instances  absent.  Pos- 
sibly the  variations  in  the  situation  of  the  amyloid  changes  may  account  for 
this,  since  albumin  is  less  likely  to  be  present  when  the  change  is  confined  to 
the  vasa  recta.  In  addition  to  ordinary  albumin  globulin  may  be  present. 
The  tube  casts  are  variable,  usually  hyaline,  often  fatty  or  finely  granular. 
Occasionally  the  amyloid  reaction  can  be  detected  in  the  hyaline  casts.  Dropsy 
is  present  in  many  instances,  particularly  when  there  is  much  anaemia  or 
profound  cachexia.  It  is  not  an  invariable  symptom,  and  there  are  cases  in 
which  it  does  not  develop.     Diarrhoea  is  a  common  accompaniment. 

Increased  arterial  tension  and  cardiac  hypertrophy  are  not  usually  pres- 
ent, except  in  those  cases  in  which  amyloid  degeneration  occurs  in  the  secon- 
dary contracted  kidney ;  under  which  circumstances  there  may  be  uraemia  and 
retinal  changes,  which,  as  a  rule,  are  not  met  with  in  other  forms. 

Diagnosis. — By  the  condition  of  the  urine  alone  it  is  not  possible  to  rec- 


708  DISEASES  OF  THE  KIDNEYS 

ognize  amyloid  changes  iu  the  kidney.  Usually,  however,  there  is  no  diflB- 
culty,  since  the  disease  comes  on  in  association  with  syphilis,  prolonged  sup- 
puration, disease  of  the  bone,  or  tuberculosis,  and  there  is  evidence  of  enlarge- 
ment of  the  liver  and  spleen.  A  suspicious  circumstance  is  the  existence  of 
polyuria  Avith  a  large  amount  of  albumin  in  the  urine  and  few  casts,  or 
when,  in  these  constitutional  affections,  a  large  quantity  of  clear,  pale  urine 
is  passed,  even  without  the  presence  of  albumin. 

The  prognosis  depends  rather  on  the  condition  with  wliich  the  nephritis  is 
associated.     As  a  rule  it  is  s^rave. 


IX.     PYELITIS 

(Consecutive  Nephritis;  Pyelonephritis;  Pyonephrosis) 

Definition. — Inflammation  of  the  pelvis  of  the  kidney  and  the  conditions 
which  result  from  it. 

Etiology. — Pyelitis  in  almost  all  cases  is  induced  by  bacterial  invasion 
and  multiplication,  rarely  by  the  irritation  of  various  substances  such  as  tur- 
pentine. Xormally  the  kidney  can  eliminate  without  harm  to  itself,  appar- 
ently, various  bacteria  carried  to  it  by  the  blood-current  from  some  focus  of 
infection;  and  it  probably  becomes  infected  only  when  its  resistance  is  low- 
ered, as  a  result  of  some  general  cause,  as  anaemia,  malnutrition,  or  intercur- 
rent disease,  or  of  some  local  cause,  as  nephritis,  displacement,  congestion  due 
to  pressure  of  neoplasms  upon  the  ureter,  twisted  ureter  (Dietl's  crisis),  or  of 
operation,  or  when  the  number  or  virulence  of  the  micro-organisms  is  in- 
creased. These  same  factors  probably  play  an  important  role  also  in  the  other 
common  causes  of  pyelitis,  ascending  infection  from  an  infected  bladder 
(cystitis),  and  tuberculous  infection.  Other  causes  described  are  various 
fevers,  cancer,  hydatids,  the  ova  of  certain  parasites,  cold,  and  overexertion. 
Calculus  seems  not  to  be  a  common  cause.  It  is  a  not  uncommon  complication 
of  pregnancy  (French). 

Morbid  Anatomy. — In  the  early  stages  of  pyelitis  the  mucous  membrane 
is  turbid,  somewhat  swollen,  and  may  show  ecchymoses  or  a  grayish  pseudo- 
membrane.  The  urine  in  the  pelvis  is  cloudy,  and,  on  examination,  numbers 
of  epithelial  cells  are  seen. 

In  the  calculous  pyelitis  there  may  be  only  slight  turbidity  of  the  mem- 
brane, which  has  been  called  by  some  catarrhal  pyelitis.  More  commonly  the 
mucosa  is  roughened,  grayish  in  color,  and  thick.  Under  these  circumstances 
there  is  almost  always  more  or  less  dilatation  of  the  calyces  and  flattening  of 
the  papillte.  Following  this  condition  there  may  be  {a)  extension  of  the  sup- 
purative process  to  the  kidney  itself,  forming  a  pyelonephritis;  (&)  a  gradual 
dilatation  of  the  calyces  with  atrophy  of  the  kidney  substance,  and  finally  the 
production  of  the  condition  of  pyonephrosis,  in  which  the  entire  organ  is 
represented  by  a  sac  of  pus  with  or  without  a  thin  shell  of  renal  tissue,  (c) 
After  the  kidney  structure  has  been  destroyed  by  suppuration,  if  the  obstruc- 
tion at  the  orifice  of  the  pelvis  persists,  the  fluid  portions  may  be  absorbed 
and  the  pus  become  inspissated,  so  that  the  organ  is  represented  by  a  series 


PYELITIS  709 

of  sacculi  containing-  grayish,  putty  like  masses,  which  may  become  impreg- 
nated with  lime  salts. 

Tuberculous  pyelitis  usually  starts  upon  the  apices  of  the  pyramids,  and 
may  at  first  be  limited  in  extent.  Ultimately  the  condition  produced  may  be 
similar  to  that  of  calculous  pyelitis.  Pyonephrosis  is  quite  as  frequent  a  se- 
quence, while  the  transformation  of  the  pus  into  a  putty-like  material  im- 
pregnated with  salts,  forming  the  so-called  scrofulous  kidney,  is  even  com- 
moner. 

The  pyelitis  consecutive  to  cystitis  is  generally  bilateral,  and  the  kidneys 
are  sometimes  involved,  forming  the  so-called  surgical  kidneys — acute  sup- 
purative nephritis.  There  are  lines  of  suppuration  extending  along  the  pyra- 
mids, or  small  abscesses  in  the  cortex,  often  Just  beneath  the  capsule;  or  there 
may  be  wedge  shaped  abscesses.  The  pus  organisms  either  pass  up  the  tu- 
bules or,  as  Steven  has  shown,  through  the  lymphatics. 

Symptoms. — The  forms  associated  with  the  fevers  rarely  cause  any  symp- 
toms, even  when  the  process  is  extensive.  In  mild  grades  there  is  pain  in  the 
back  or  there  may  be  tenderness  on  deep  pressure  over  the  kidney.  The  urine, 
turbid  and  containing  pus  cells,  some  mucus,  and  occasional  red  blood-cells, 
is  acid  or  alkaline,  depending  on  the  infecting  microbe;  usually  the  albumi- 
nuria is  of  higher  grade  comparatively  than  the  pyuria. 

Before  the  condition  of  pyuria  is  established  there  may  be  attacks  of  pain 
on  the  affected  side  (not  reaching  the  severe  agony  of  renal  colic),  rigors, 
high  fever,  and  sweats.  Under  these  circumstances  the  urine,  which  may 
have  been  clear,  becomes  turbid  or  smoky  from  the  presence  of  blood,  and  may 
contain  large  numbers  of  mucous  cells  and  transitional  epithelium. 

The  statement  is  not  infrequently  made  that  the  epithelium  in  the  urine 
in  pyelitis  is  distinctive  and  characteristic.  This  is  erroneous,  as  may  be  read- 
ily demonstrated  by  comparing  scrapings  of  the  mucosa  of  the  renal  pelvis  and 
of  the  bladder.  In  both  the  epithelium  belongs  to  what  is  called  the  transi- 
tional variety,  and  in  both  regions  the  same  conical,  fusiform,  and  irregular 
cells  with  long  tails  are  found,  and  yet  in  pyelitis  more  of  these  tailed  cells 
occur,  for  in  cystitis  one  must  often  search  long  for  them. 

When  the  pyelitis,  whether  calculous  or  tuberculous,  has  become  chronic 
and  discharges,  the  symptoms  are : 

{a)  Pyuria. — The  pus  is  in  variable  amount,  and  may  be  intermittent. 
Thus,  as  is  often  the  case  when  only  one  kidney  is  involved,  the  ureter  may  be 
temporarily  blocked,  and  normal  urine  is  passed  for  a  time;  then  there  is  a 
sudden  outflow  of  the  pent  up  pus  and  the  urine  becomes  purulent.  Coinci- 
dent with  this  retention,  a  tumor  mass  may  be  felt  on  the  side  aft'ected.  The 
pus  has  the  ordinary  characters,  but  the  transitional  epithelium  is  not  so 
abundant  at  this  stage  and  comes  from  the  bladder  or  from  the  pelvis  of  the 
healthy  side.  Occasionally,  in  rapidly  advancing  pyelonephritis,  portions  of 
the  kidney  tissue,  particularly  of  the  apices  of  the  pyramids,  may  slough  away 
and  appear  in  the  urine;  or  solid  cheesy  moulds  of  the  calyces  are  passed. 
Casts  from  the  kidney  tubules  are  sometimes  present.  The  reaction  of  the 
urine  depends  upon  the  infecting  microbe,  whether  the  condition  is  unilateral 
or  bilateral,  and  whether  the  bladder  is  also  infected,  when  vesical  irritability 
and  frequent  micturition  may  be  present,  Polyuria  is  visually  present  in  tlie 
chronic  cases. 


no  DISEASES  OF  THE  KIDNEYS 

(6)  Intermittent  fever  associated  with  rigors  is  usually  present  in  cases 
of  suppurative  pyelitis.  The  chills  may  recur  at  regular  intervals,  and  the 
cases  are  often  mistaken  for  malaria.  Owen-Eees  called  attention  to  the  fre- 
quent occurrence  of  these  rigors,  which  form  a  characteristic  feature  of  both 
calculous  and  tuberculous  pyelitis.  Ultimately  the  fever  assumes  a  hectic 
type  and  the  rigors  may  cease. 

(c)  The  general  condition  of  the  patient  often  indicates  prolonged  sup- 
puration. There  is  more  or  less  wasting  with  anaemia  and  a  progressive  fail- 
ure of  health.  Secondary  abscesses  may  develop  and  the  clinical  picture  be- 
comes that  of  pyaemia.  In  some  instances,  particularly  of  tuberculous  pyelitis, 
the  clinical  course  may  resemble  that  of  typhoid  fever.  There  are  instances 
of  pyuria  recurring,  at  intervals,  for  many  years  without  impairment  of  the 
bodily  vigor.     Some  of  the  chronic  cases  have  practically  no  discomfort. 

(d)  Physical  examination  usually  reveals  tenderness  or  a  definite  swelling 
on  the  affected  side,  which  may  vary  much  in  size  and  attain  large  dimensions 
if  the  kidney  becomes  enormously  distended,  as  in  pyonephrosis. 

(e)  Occasionally  nervous  symptoms,  which  may  be  associated  with  dysp- 
noea, supervene,  or  the  termination  may  be  in  a  curious  toxaemia  or  by  coma, 
not  unlike  that  of  diabetes.  These  have  been  attributed  to  the  absorption  of 
the  decomposing  materials  in  the  urine,  whence  the  so-called  ammonifemia.  A 
form  of  paraplegia  has  been  described  in  connection  with  some  cases  of  abscess 
of  the  kidney,  but  whether  due  to  a  myelitis  or  to  a  peripheral  neuritis  has 
not  been  determined. 

In  suppurative  nephritis  following  cystitis,  the  patient  complains  of  pain 
in  the  back,  the  fever  becomes  high,  irregular,  and  associated  with  chills,  and 
in  acute  cases  a  typhoid  state  may  precede  the  fatal  event. 

Diagnosis. — Between  the  tuberculous  and  the  calculous  forms  of  pyelitis 
it  may  be  diffic^ilt  or  impossible  to  distinguish,  except  by  the  detection  of 
tubercle  bacilli  in  the  pus.  The  examination  for  bacilli  should  be  made  sys- 
tematically, and  in  suspicious  cases  intraperitoneal  injections  of  guinea-pigs 
should  also  be  made.  From  perinephric  abscess  pyonephrosis  is  distinguished 
by  the  more  definite  character  of  the  tumor,  the  absence  of  oedematous  swell- 
ing in  the  lumbar  region,  and,  most  important  of  all,  the  history.  The  urine, 
too,  in  perinephric  abscess  may  be  free  from  pus.  There  are  cases,  however, 
in  which  it  is  difficult  indeed  to  make  a  satisfactory  diagnosis. 

Suppurative  pyelitis  and  cystitis  are  apt  to  be  confounded.  The  two  con- 
ditions may  coexist  and  prove  puzzling,  but  the  history,  the  higher  relative 
grade  of  albuminuria  in  pyelitis,  the  polyuria,  the  mode  of  development,  the 
local  signs  in  one  lumbar  region,  and  the  absence  of  pain  in  the  bladder  should 
be  sufficient  to  differentiate  the  affections.  By  the  cystoscope,  it  may  be  defi- 
nitely determined  whether  the  pus  comes  from  the  kidneys  or  from  the 
bladder. 

In  the  diagnosis  of  pyelitis  from  pyelonepliritis,  tlie  functional  test  is  im- 
portant; this  is  normal  in  pyelitis  and  reduced  in  pyelonephritis. 

Much  may  be  done  with  X-ray  examinations  to  determine  the  condition 
of  the  pelves^  of  the  kidneys.  When  an  opaque  solution  is  injected  by  the 
ureteral  catheter  a  shadow  is  cast  giving  a  very  accurate  outline  of  the  pelvis 

of  the  organ. 

Prognosis, — Cases  coming  on  during  the  fevers  usually  recover.     In  the 


HYDEONEPHROSIS  711 

chronic  cases  the  appearance  of  toxaemia  is  of  grave  omen.  Tuberculous  pye- 
litis may  terminate  favorably  by  inspissation  of  the  pus  and  conversion  into 
a  putty-like  substance  with  deposition  of  lime  salts.  With  pyonephrosis  the 
dangers  are  increased.  Perforation  may  occur  into  the  peritoneum,  the  pa- 
tient may  be  worn  out  by  the  hectic  fever,  or  amyloid  disease  may  develop. 
!  Treatment. — Fluids  should  be  taken  freely,  particularly  the  alkaline  min- 
eral waters,  to  which  potassium  citrate  may  be  added. 

The  treatment  of  the  calculous  form  will  be  considered  later.  Practically 
there  are  no  remedies  which  have  much  influence  upon  the  pyuria.  Some  of 
the  urinary  antiseptics  seem  to  be  of  value,  especially  in  the  acute  cases. 
Hexamine  should  be  given  in  full  doses  (gr.  xv^  1  gm.,  three  or  four  times  a 
day) ;  watch  should  be  kept  for  signs  of  irritation  and  the  dose  reduced  if  they 
appear.  Lavage  of  the  pelvis  of  the  kidney  has  been  much  employed.  Vac- 
cine therapy  is  sometimes  of  value.  Tonics  should  be  given,  a  nourishing 
diet,  and  milk  and  butter-milk  may  be  taken  freely.  When  the  tumor  has 
formed  or  even  before  it  is  perceptible,  if  the  symptoms  are  serious  and  severe, 
the  kidney  should  be  explored,  and,  if  necessary,  nephrotomy  or  nephrectomy 
should  be  performed. 

X.     HYDRONEPHROSIS 

Definition. — Dilatation  of  the  pelvis  and  calyx  of  the  kidney  with  atrophy 
of  its  substance,  caused  by  the  accumulation  of  non-purulent  fluids,  the  re- 
sult of  obstruction. 

Etiology. — The  condition  may  be  congenital,  owing  to  some  abnormality 
in  the  ureter  or  urethra.  The  tumor  produced  may  be  large  enough  to  retard 
labor.  Sometimes  it  is  associated  with  other  malformations.  There  is  a  con- 
dition of  moderate  dilatation,  apparently  congenital,  which  is  not  connected 
with  any  obstruction  in  the  ducts.  In  some  instances  there  has  been  contrac- 
tion or  twisting  of  the  ureter,  or  it  is  inserted  into  the  kidney  at  an  acute 
angle  or  at  a  high  level.  In  adult  life  the  condition  may  be  due  to  lodgment  of 
a  calculus,  or  to  a  cicatricial  stricture  following  ulcer. 

New  growths,  such  as  tubercle  or  cancer,  may  induce  hydronephrosis ;  more 
commonly  by  pressure  upon  the  ureter  from  without,  particularly  tumors  of 
the  ovaries  and  uterus.  Occasionally  cicatricial  bands  compress  the  ureter. 
Obstruction  within  the  bladder  may  result  from  cancer,  hypertrophy  of  the 
prostate,  and  in  the  urethra  from  stricture.  It  is  stated  that  slight  grades  of 
hydronephrosis  have  been  found  in  patients  with  excessive  polyuria. 

In  whatever  way  produced,  when  the  ureter  is  blocked  the  secretion  accu- 
mulates in  the  pelvis  and  infundibula.  Sometimes  acute  inflammation  fol- 
lows, but  more  commonly  the  slow,  gradual  pressure  causes  atrophy  of  the 
papillae  with  gradual  distention  and  wasting  of  the  organ.  In  acquired  cases 
from  pressure,  even  when  dilatation  is  extreme,  there  may  usually  be  seen  a 
thin  layer  of  renal  structure.  In  the  most  extreme  stages  the  kidney  is  repre- 
sented by  a  large  cyst,  which  may  perhaps  show  on  its  inner  surface  imperfect 
septa.  The  fluid  is  thin  and  yellowish  in  color,  and  contains  traces  of  urinary 
salts,  urea,  uric  acid,  and  sometimes  albumin.  The  secretion  may  be  turbid 
from  admixture  with  small  quantities  of  pus. 

Total  occlusion  does  not  always  iead  to  a  hydronephrosis,  but  may  be  fol- 


712  DISEASES  OF  THE  KIDNEYS 

lowed  by  atrophy  of  the  kidney.  It  appears  that  when  the  obstruction  is  in- 
termittent or  not  complete  the  greatest  dilatation  is  apt  to  follow.  The  sac 
may  be  enormous,  and  cause  a  large  abdominal  tumor.  The  condition  has  even 
been  mistaken  for  ascites.  Enlargement  of  the  other  kidney  may  compensate 
for  the  defect.    Hypertrophy  of  the  left  side  of  the  heart  usually  follows. 

Symptoms. — When  small,  it  may  not  be  noticed.  The  congenital  cases 
when  bilateral  usually  prove  fatal  within  a  few  days;  when  unilateral,  the  tu- 
2iior  may  not  be  noticed  for  some  time.  It  increases  progressively  and  has  all 
the  characters  of  a  tumor  in  the  renal  region.  In  adult  life  many  of  the 
cases,  due  to  pressure  by  tumors,  as  in  cancer  of  the  uterus  and  enlargement 
of  the  prostate,  etc.,  give  rise  to  no  symptoms. 

In  intermittent  hydronephrosis  the  tumor  suddenly  disappears  with  the 
discharge  of  a  large  quantity  of  clear  fluid;  the  sac  gradually  refills,  and  the 
process  may  be  repeated  for  years.  In  these  cases  the  obstruction  is  unilateral ; 
a  cicatricial  stricture  exists,  or  a  valve  is  present  in  the  ureter,  or  the  ureter 
enters  the  upper  part  of  the  pelvis.  Many  of  the  cases  are  in  women  and  as- 
sociated with  movable  kidney. 

The  examination  of  the  abdomen  shows,  in  unilateral  hydronephrosis,  a 
tumor  occupying  the  renal  region.  When  of  moderate  size  it  is  readily  recog- 
nized, but  when  large  it  may  be  confounded  with  ovarian  or  other  tumors. 
In  young  children  it  may  be  mistaken  for  sarcoma  of  the  kidney  or  of  the 
retroperitoneal  glands,  the  common  cause  of  abdominal  tumor  in  early  life. 
The  large  hydronephrotic  sac.  is  frequently  mistaken  for  ovarian  tumor.  The 
latter  is,  as  a  rule,  more  mobile,  and  rarely  fills  the  deeper  portion  of  the 
lumbar  region  so  thoroughly.  The  ascending  colon  can  often  be  detected  pass- 
ing over  the  renal  tumor,  and  examination  per  vaginam,  particularly  under 
ether,  will  give  important  indications  as  to  the  condition  of  the  ovaries.  The 
fluid  of  the  renal  cyst  is  clear,  or  turbid  from  the  presence  of  cell  elements, 
rarely  colloid  in  character;  the  specific  gravity  is  low;  albumin  and  traces  of 
urea  and  uric  acid  are  usually  present;  and  the  epithelial  elements  in  it  may 
be  similar  to  those  found  in  the  pelvis  of  the  kidney.  In  old  sacs,  however,  the 
fluid  may  not  be  characteristic,  since  the  urinary  salts  disappear,  but  in  one 
case  of  several  years'  duration  oxalates  of  lime  and  urea  were  found. 

Perhaps  the  greatest  difficulty  is  offered  by  the  condition  of  hydrone- 
phrosis in  a  movable  kidney.  Here,  the  history  of  sudden  disappearance  of 
the  tumor  with  the  passage  of  a  large  quantity  of  clear  fluid  is  a  point  of  great 
importance  in  the  diagnosis.  In  those  rare  instances  of  an  enormous  sac  fill- 
ing the  entire  abdomen,  and  sometimes  mistaken  for  ascites,  the  character  of 
the  fluid  might  be  the  only  point  of  difference.  The  tumor  of  pyonephrosis 
may  be  practically  the  same  in  physical  characteristics.  Fever  is  usually  pres- 
ent, and  pus  is  often  found  in  the  urine.  In  these  cases,  when  in  doubt,  an 
exploratory  operation  should  be  done. 

The  outlook  depends  much  upon  the  cause.  AVhen  single,  the  condition 
may  never  produce  serious  trouble,  and  the  intermittent  cases  may  persist 
for  years,  and  finally  disappear.  Occasionally  the  cyst  ruptures  into  the  peri- 
toneum, more  rarely  through  ^ihe  diaphragm  into  the  lung.  The  sac  may 
discharge  spontaneously  through  the  ureter  and  the  fluid  never  reaccumulate. 
In  bilateral  hydronephrosis  there  is  danger  of  uraemia  and  blocking  of  the 
ureter  on  the  sound  side  by  calculus  has  been  followed  by  uraemia.     And, 


NEPHROLITHIASIS  713 

lastly,  the  sac  may  suppurate,  and  the  condition  change  to  one  of  i^yonephrosis. 
Treatment. — Cases  of  intermittent  hydronephrosis  which  do  not  cause 
serious  symptoms  should  be  let  alone.  It  is  stated  that,  in  sacs  of  moderate 
size,  the  obstruction  has  been  overcome  by  massage,  but,  if  practised,  it  should 
be  done  with  great  care.  When  the  sac  reaches  a  large  size  aspiration  may  be 
performed  and  repeated  if  necessary.  Puncture  should  be  made  in  the  flank, 
midway  between  the  ilium  and  the  last  rib.  If  the  fluid  reaccumulates  and 
the  sac  becomes  large,  it  may  be  incised  and  drained,  or,  as  a  last  resort,  the 
kidney  may  be  removed.  In  women  a  carefully  adapted  pad  and  bandage  will 
sometimes  prevent  the  recurrence  of  an  intermittent  hydronephrosis. 


XI.     NEPHROLITHIASIS 

{Renal  Calculus) 

Definition. — The  formation  in  the  kidney  or  in  its  pelvis  of  concretlcins, 
by  the  deposition  of  certain  of  the  solid  constituents  of  the  urine. 

Etiology  and  Pathology. — In  the  kidney  substance  itself  the  separation 
of  the  urinary  salts  produces  a  condition  to  which,  unfortunately,  the  term 
infarct  has  been  applied.  Three  varieties  may  be  recognized:  (1)  The  uric 
acid  infarct,  usually  met  with  at  the  apices  of  the  pyramids  in  new  born  chil- 
dren and  during  the  first  weeks  of  life.  The  priapism  and  attacks  of  crying 
in  the  new-born  have  been  attributed  to  the  passage  of  these  infarcts;  (3) 
the  sodium  urate  infarct,  sometimes  associated  with  ammonium  urate,  which 
forms  whitish  lines  at  the  apices  of  the  pyramids  and  is  met  with  chiefly, 
but  not  always,  in  gouty  persons;  and  (3)  the  lime  infarcts,  forming  very 
opaque  white  lines  in  the  pyramids,  usually  in  old  people. 

In  the  pelvis  and  calyces  concretions  of  the  following  forms  occur:  (a) 
Small  gritty  particles,  renal  sand,  ranging  in  size  from  the  individual  grains 
of  the  uric  acid  sediment  to  bodies  1  or  2  mm.  in  diameter.  These  may  be 
passed  in  the  urine  for  long  periods  without  producing  any  symptoms,  since 
they  are  too  fine  to  be  arrested  in  their  downward  passage. 

(b)  Larger  concretions,  ranging  in  size  from  a  small  pea  to  a  bean,  and 
either  solitary  or  multiple  in  the  calyces  and  pelvis.  It  is  the  smaller  of 
these  calculi  which,  in  their  passage,  produce  the  attacks  of  renal  colic.  They 
may  be'  rounded  and  smooth,  or  present  numerous  irregular  projections. 

(c)  The  dendritic  form  of  calculus.  The  orifice  of  the  ureter  may  be 
blocked  by  a  Y-shaped  stone.  The  pelvis  itself  may  be  occupied  by  the  con- 
cretion, which  forms  a  more  or  less  distinct  mould.  These  are  the  remark- 
able coral  calculi,  which  form  in  the  pelvis  complete  moulds  of  infundibula 
and  calyces,  the  latter  even  presenting  cup-like  depressions  corresponding  to 
the  apices  of  the  papillae.  Some  of  these  casts  in  stone  of  the  renal  pelvis  are 
as  beautifully  moulded  as  Hyrtl's  corrosion  preparations. 

Chemically  the  varieties  of  calculi  are:  (1)  Uric  acid  and  urates,  form- 
ing the  renal  sand,  the  small  solitary,  or  the  large  dendritic  stones.  They 
are  very  hard,  the  surface  is  smooth,  and  the  color  reddish.  The  larger 
stones  are  usually  stratified  and  very  dense.     Usually  the  uric  acid  and  the 


714  DISEASES  OF  THE  KIDNEYS 

urates  are  mixed,  but  in  children  stones  composed  of  urates  alone  may  occur. 
Uric  acid  calculi  are  rare. 

(2)  Oxalate  of  lime,  which  forms  mulberry-shaped  calculi,  studded  with 
points  and  spines.  They  are  often  very  dark  in  color,  intensely  hard,  and 
are  a  mixture  of  oxalate  of  lime  and  uric  acid.  These  comprise  the  great 
majority  of  renal  calculi. 

(3)  Phosphatic  calculi  are  composed  of  the  calcium  phosphate  and  the 
ammonio-magnesium  phosphate,  sometimes  mixed  with  a  small  amount  of 
calcium  carbonate.  The  phosphatic  salts  are  often  deposited  about  the  uric 
acid  or  calcium  oxalate  stones. 

(4)  Eare  forms  of  calculi  are  made  up  of  cystine,  xanthine,  carbonate  of 
lime,  indigo,  and  urostealith. 

The  mode  of  formation  of  calculi  has  been  much  discussed.  They  may 
be  produced  by  an  excess  of  a  sparingly  soluble  abnormal  ingredient,  such  as 
cystine  or  xanthine.  Ord  suggests  that  albumin,  mucus,  blood,  and  epithelial 
threads  may  be  the  starting  point  of  stone.  The  demonstration  of  organisms 
in  the  centre  of  renal  calculi  renders  it  probable  that  in  many  cases  the  nucleus 
of  the  stone  is  an  agglutinated  mass  of  bacteria. 

Eenal  calculi  are  most  common  in  the  early  and  later  periods  of  life. 
They  are  moderately  frequent  in  the  United  States,  but  there  do  not  appear 
to  be  special  districts,  corresponding  to  the  "stone  counties"  in  England. 
Men  are  more  often  affected  than  women.  Sedentary  occupations  seem  to 
predispose  to  stone. 

The  effects  are  varied.  It  is  by  no  means  uncommon  to  find  a  dozen  or 
more  stones  of  various  sizes  in  the  calyces  without  any  destruction  of  the 
mucous  membrane  or  dilatation  of  the  pelvis.  A  turbid  urine  fills  the  pelvis, 
in  which  there  are  numerous  cells  from  the  epithelial  lining.  There  are  cases 
of  this  sort  in  which,  apparently,  the  stones  may  go  on  forming  and  are  passed 
for  years  without  seriously  impairing  the  health  and  without  inconvenience, 
except  the  attacks  of  renal  colic.  Still  more  remarkable  are  the  cases  of  coral 
like  calculi,  which  may  occupy  the  entire  pelvis  and  calyces  without  causing 
pyelitis,  but  which  gradually  lead  to  more  or  less  induration  of  the  kidney. 
The  most  serious  effects  are  when  the  stone  excites  a  suppurative  pyelitis  and 
pyonephrosis.  Of  140  kidneys  containing  stones  removed  at  the  Mayo 
clinic,  9  were  cancerous  (Correll). 

Symptoms. — Patients  may  pass  gravel  for  years  without  having  an  attack 
of  renal  colic,  and  a  stone  may  never  lodge  in  the  ureter.  In  other  instances, 
the  formation  of  calculi  goes  on  year  by  year  and  the  patient  has  recurring 
attacks  such  as  have  been  so  graphically  described  by  Montaigne  in  his  own 
case.  A  patient  may  pass  enormous  numbers  of  calculi.  A  patient  may  pass 
a  single  calculus,  and  never  be  troubled  again.  The  large  coral  calculi  may 
excite  no  symptoms.  In  a  remarkable  specimen  of  the  kind,  presented  to  the 
McGill  Medical  Museum  by  J.  A.  Macdonald,  the  patient,  a.  middle-aged 
woman,  died  suddenly  with  urgemic  symptoms.  There  was  no  pyelitis,  but 
the  kidneys  were  sclerotic. 

Renal  colic  ensues  when  a  stone  enters  the  ureter,  or  follows  an  acute  py- 
elitis. An  attack  may  set  in  abruptly  without  apparent  cause,  or  may  follow 
a  strain  in  lifting.  It  is  characterized  by  agonizing  pain,  which  starts  in  the 
flank  of  the  affected  side,  passes  down  the  ureter,  and  is  felt  in  the  testicle 


NEPHROLITHIASIS  715 

and  along  the  inner  side  of  the  thigh.  The  pain  may  also  radiate  through 
the  abdomen  and  chest,  and  be  very  intense  in  the  back.  In  severe  attacks 
nausea  and  vomiting  follow  and  the  patient  is  collapsed.  Perspiration 
breaks  out  upon  the  face  and  the  pulse  is  feeble  and  quick.  A  chill  may  pre- 
cede the  outbreak^  and  the  temperature  may  rise  as  high  as  103°.  No  one 
has  more  graphically  described  an  attack  of  "the  stone"  than  Montaigne, 
who  was  a  sufferer  for  many  years :  "Thou  art  seen  to  sweat  with  pain,  to 
look  pale  and  red,  to  tremble,  to  vomit  well-nigh  to  blood,  to  suffer  strange 
contortions  and  convulsions,  by  starts  to  let  tears  drop  from  thine  eyes,  to 
urine  thick,  black,  and  frightful  water,  or  to  have  it  suppressed  by  some  sharp 
and  craggy  stone,  that  cruelly  pricks  and  tears  thee."  From  personal  experi- 
ence the  senior  author  can  describe  three  sorts  of  pain  in  an  attack  of  renal 
colic :  (a)  A  constant  localized,  dull  pain,  the  area  of  which  could  be  cov- 
ered on  the  skin  of  the  back  in  the  renal  region  by  a  penny  piece,  and  which 
could  be  imitated  exactly  by  deep  firm  pressure  on  a  superficial  bone.  (&) 
Paroxysms  of  pain  radiating  in  the  course  of  the  ureter  or  into  the  flank,  and 
as  they  increase  accompanied  by  sweating,  fainting,  and  nausea,  (c)  Flushes 
or  rushes  of  hot  pain  at  intervals,  often  momentary,  usually  passing  to  the 
back,  less  often  toward  the  groin.  Dozens  of  these  flushes  relieved  the  monot- 
ony of  (&).  The  symptoms  persist  for  a  variable  period.  In  short  attacks 
they  do  not  last  longer  than  an  hour;  in  other  instances  they  continue  for  a 
day  or  more,  with  temporary  relief.  Micturition  is  frequent,  occasionally 
painful,  and  the  urine,  as  a  rule,  is  bloody.  There  are  instances  in  which  a 
large  amount  of  clear  urine  is  passed,  probably  from  the  other  kidney.  In 
rare  cases  the  secretion  of  urine  is  completely  suppressed,  even  when  the  kid- 
ney on  the  opposite  side  is  normal,  and  death  may  occur  from  uraemia.  This 
most  frequently  happens  when  the  second  kidney  is  extensively  diseased,  or 
when  only  a  single  kidney  exists.     Orchitis  may  follow  an  attack. 

After  the  attack  of  colic  has  passed  there  is  more  or  less  aching  on  the 
affected  side,  and  the  patient  can  usually  tell  from  which  kidney  the  stone 
has  come.  Examination  during  the  attack  is  usually  negative.  Very  rarely 
the  kidney  becomes  palpable.  Tenderness  on  the  affected  side  is  common. 
In  very  thin  persons  it  may  be  possible,  on  examination  of  the  abdomen,  to 
feel  the  stone  in  the  ureter;  or  the  patient  may  complain  of  a  grating  sensa- 
tion. 

When  the  calculi  remain  in  the  kidney  they  may  produce  very  definite  and 
characteristic  symptoms,  of  which  the  following  are  the  most  important : 

(a)  Pain,  usually  in  the  back,  which  is  often  no  more  than  a  dull  sore- 
ness, but  which  may  be  severe  and  come  on  in  paroxysms.  It  is  usually  on  the 
side,  affected,  but  may  be  referred  to  the  opposite  kidney,  and  there  are  in- 
stances in  which  the  pain  has  been  confined  to  the  sound  side.  It  radiates 
in  the  direction  of  the  ureter,  and  may  be  felt  in  the  scrotum  or  even  in  the 
penis.  Vesical  irritability  is  common.  Pains  of  a  similar  nature  may  occur 
in  movable  kidneys  or  be  referred  in  prostatic  disease,  and  surgeons  have  in- 
cised the  kidney  for  stone  and  found  none.  In  an  instance  in  which  pain  was 
present  for  a  couple  of  years  the  exploration  revealed  only  a  contracted  kidney. 

(6)  Hci'maturm. — Although  this  occurs  most  frequently  when  the  stone 
becomes  enjgaged  in  the  ureter,  it  may  also  come  on  when  the  stones  are  in  the 
pelvis-     Th'o.  Ibleeding  is  seldom  profuse,  as  in  cancer,  but  in  some  instances 


716  DISEASES  OF  THE  KIDNEYS 

may  persist  for  a  long  time.  It  is  aggravated  by  exertion  and  lessened  by 
rest.  Frequently  it  only  gives  to  the  urine  a  smoky  hue.  The  urine  may  be 
free  for  days,  and  then  a  sudden  exertion  or  a  prolonged  ride  may  cause 
smokiness,  or  blood  may  be  passed  in  considerable  quantities. 

(c)  Pyelitis. —  (1)  There  may  be  attacks  of  severe  pain  in  the  back,  not 
amounting  to  actual  colic,  which  are  initiated  by  a  heavy  chill  followed  by 
fever,  in  which  the  temperature  may  reach  104°  or  105°,  followed  by  profuse 
sweating.  The  urine,  which  has  been  clear,  may  become  turbid  and  smoky 
and  contain  blood  and  abundant  epithelium  from  the  pelvis.  Attacks  of  this 
description  may  recur  at  intervals  for  months  or  years,  and  be  mistaken  for 
malaria,  unless  special  attention  is  paid  to  the  urine  and  to  the  existence  of 
the  pain  in  the  back.  This  renal  intermittent  fever,  due  to  the  presence  of 
calculi,  is  analogous  to  the  hepatic  intermittent  fever,  due  to  gall-stones,  and 
in  both  it  is  important  to  remember  that  the  most  intense  paroxysms  may 
occur  without  any  evidence  of  suppuration. 

(2)  More  frequently  the  symptoms  of  purulent  pyelitis,  which  have  al- 
ready been  described,  are  present;  pain  in  the  renal  region,  recurring  chills, 
and  pus  in  the  urine,  with  or  without  indications  of  pyonephrosis. 

(d)  Pyuria. — There  are  instances  of  stone  in  the  kidney  in  which  pus 
occurs  continuously  or  intermittently  in  the  urine  for  many  years. 

Patients  with  stone  in  the  kidney  are  often  robust,  high  livers,  and  gouty. 
Attacks  of  dyspepsia  are  not  uncommon,  or  they  may  have  severe  headaches. 

Diag^nosis. — The  X-ray  picture  is  rarely  at  fault,  and  specialists  in  this 
department  are  becoming  more  and  more  skillful,  so  that  mistakes  are  now 
rare.  Eenal  may  be  mistaken  for  intestinal  colic,  particularly  if  the  disten- 
tion of  the  bowels  is  marked,  or  for  biliary  colic.  The  situation  and  direction 
of  the  pain,  the  retraction  and  tenderness  of  the  testicle,  the  occurrence  of 
hematuria,  the  vesical  irritability  and  the  altered  character  of  the  urine  are 
distinctive  features.  Attention  may  again  be  called  to  the  fact  that  attacks 
simulating  renal  colic  are  associated  with  movable  kidney  and  disease  'of  the 
prostate  or  even,  it  has  been  supposed,  with  the  accumulation  of  the  oxalates  or 
uric  acid  in  the  pelvis  of  the  kidney.  The  diagnosis  between  a  stone  in  the 
kidney  and  stone  in  the  bladder  is  not  always  easy,  though  in  the  latter  the 
pain  is  particularly  about  the  neck  of  the  bladder,  and  not  limited  to  one 
side.  It  is  stated  that  differences  occur  in  the  symptoms  produced  by  differ- 
ent sorts  of  calculi.  The  large  uric  acid  calculi  less  frequently  produce  severe 
symptoms.  On  the  other  hand,  as  the  oxalate  of  lime  is  a  rougher  calculus,  it 
is  apt  to  produce  more  pain  (often  of  a  radiating  character)  and  to  cause 
haemorrhage,  hi  both  these  forms  the  urine  is  acid.  The  phosphatic  calculi 
are  stated  to  produce  the  most  intense  pain,  and  the  urine  is  commonly  al- 
kaline. 

Treatment. — In  the  attacks  of  renal  colic  great  relief  is  experienced  by 
the  hot  bath,  which  is  sometimes  sufficient  to  relax  the  spasm.  When  the  pain 
is  very  intense  morphia  should  be  given  "hypodermically  and  inhalations  of 
chloroform  may  be  necessary  until  the  effects  of  the  anodyne  are  manifest. 
Local  applications  are  sometimes  grateful — hot  poultices,  or  cloths  wrung  out 
of  hot  water.  The  patient  may  drink  freely  of  hot  lemonade,  soda  water,  or 
barley  water.      Occasionally  change  in  posture  or  inversion  will  give  great 


TUMOES  OF  THE  KIDNEY  717 

relief.  Surgical  interference  should  be  considered  in  all  cases,  especially 
when  the  stone  is  large  or  the  associated  pyelitis  severe. 

In  the  intervals  the  patient  should,  as  far  as  possible,  live  a  quiet  life, 
avoiding  sudden  exertion  of  all  sorts.  The  essential  feature  in  the  treatment 
is  to  keep  the  urine  abundant  and,  in  the  uric  acid  or  uratic  cases,  alkaline. 
The  patient  should  drink  daily  a  large  quantity  of  mineral  water*  or  dis- 
tilled water,  which  is  just  as  satisfactory.  The  aching  pains  in  the  back  are 
often  greatly  relieved  by  this  treatment.  Many  patients  find  benefit  from  a 
stay  at  Saratoga,  Bedford,  Poland,  or  other  mineral  springs  in  the  United 
States,  or  at  Vichy  or  Ems  in  Europe. 

If  a  stone  has  been  passed  its  composition  should  be  determined  so  that 
proper  treatment  can  be  carried  out  to  prevent  the  further  formation  of 
stones  if  possible.  For  the  uric  acid  stones,  which  are  rare,  an  alkaline  urine 
is  advisable,  but  for  the  oxalate  and  phosphatic  stones  an  acid  reaction  should 
be  maintained.  In  case  of  oxalate  calculi  foods  containing  oxalic  acid  should 
be  avoided.  The  most  important  are  tea,  coffee,  cocoa,  pepper,  rhubarb,  spinach, 
beetroot,  beans,  currants  and  figs.  For  the  uric  acid  calculi  the  diet  is  that 
indicated  in  gout. 


XII.     TUMORS  OF  THE  KIDNEY 

These  are  benign  and  malignant.  Of  the  benign  tumors,  the  most  com- 
mon are  the  small  nodular  fibromata  which  occur  frequently  in  the  pyramids, 
and  occasionally  lipoma,  angioma,  or  hjmpliadenoma.  The  adenomata  may 
be  congenital ;  small  nodules  of  aberrant  adrenal  tissue  are  not  uncommon. 

Malignant  growths — cancer  or  sarcoma — may  be  either  primary  or  secon- 
dary. The  sarcomata  are  either  alveolar  sarcoma  or  the  remarkable  form  con- 
taining striped  muscular  fibres — rhabdomyoma.  The  most  common  and  im- 
portant renal  tumor  is  the  liyperneplwoma,  growing  in  or  upon  the  organ  from 
the  adrenal  tissue — the  aberrant  "rests"  of  Grawitz.  Of  163  cases  only  6 
were  extra-renal  (Ellis).  They  may  be  small  and  in  the  renal  cortex  or 
form  large  tumors  with  extensive  metastases,  particularly  in  the  lungs.  Most 
of  the  so-called  carcinomas  and  alveolar  sarcomas  of  the  kidney  are  really 
hypernephromata.  About  6  per  cent,  of  cases  of  ncAv  groAvth  are  associated 
with  calculi. 

The  tumors  attain  a  very  large  size,  and  almost  fill  the  abdomen.  In  chil- 
dren they  may  be  enormous.  They  grow  rapidly,  are  often  soft,  and  hemor- 
rhage frequently  takes  place  into  them.  In  the  sarcomata,  invasion  of  the 
pelvis  or  of  the  renal  vein  is  common.  The  rhabdomyomata  rarely  form  very 
large  tumors,  and  death  occurs  shortly  after  birth.  In  one  case  a  child  at  the 
age  of  three  years  and  a  half  died  suddenly  of  embolism  of  the  pulmonary 
artery  and  tricuspid  orifice  by  a  fragment  of  the  tumor,  which  had  grown 
into  the  renal  vein. 

In  association  with  hypernephroma  of  the  adrenal  cortex  precocious  de- 
velopment of  the  external  genitals  has  been  noted,  with  in  many  instances 
overgrowth  of  the  body,  growth  of  hair  on  the  face,  and  development  of  the 

*  Some  of  these,  if  we  judge  by  the  laudatory  reports,  are  as  potent  as  the  waters 
of  Corsena.  declared  by  Montaigne  to  be  "powerful  enoutrh  to  break  stones." 


718  DISEASES  OF  THE  KIDXEYS 

breasts,,  with  menstruation  in  girls.  It  seems  probable  that  the  tumor  of 
the  adrenal  cortex  stimulates  the  secretion  and  has  indirect  effects  upon  the 
other  glands  controlling  metabohsm. 

Symptoms. — The  following  are  the  most  important:  (a)  HcBmaturia  in 
one-half  the  cases,  which  may  be  the  first  indication.  The  blood  is  fluid  or 
clotted,  and  there  may  be  very  characteristic  moulds  of  the  pelvis  of  the  kid- 
ney and  of  the  ureter,  which  are  rare  except  in  cancer.  Cancer  elements  may 
sometimes  be  recognized  in  the  urine. 

(&)  Pain  is  an  uncertain  symptom.  In  several  of  the  largest  tumors 
which  have  come  under  our  observation  there  has  been  no  discomfort  from 
beginning  to  close.  When  present,  it  is  of  a  dragging,  dull  character,  situated 
in  the  flank  and  radiating  down  the  thigh.  The  passage  of  the  clots  may 
cause  great  pain.  In  one  case  the  growth  was  at  first  upward,  and  the  symp- 
toms for  some  months  were  those  of  pleurisy. 

(c)  Progressive  emaciation.  The  loss  of  flesh  is  usually  marked  and  ad- 
vances rapidly.  There  may,  however,  be  a  very  large  tumor  without  emacia- 
tion. 

Physical  Sigxs. — In  almost  all  instances  tumor  is  present.  When  small 
and  on  the  right  side,  it  may  be  very  movable;  in  some  instances,  occupying  a 
position  in  the  iliac  fossa,  it  has  been  mistaken  for  ovarian  tumor.  The  large 
growths  fill  the  flank  and  gradually  extend  toward  the  middle  line,  occupying 
the  right  or  left  half  of  the  abdomen.  Inspection  may  show  two  or  three 
hemispherical  projections  corresponding  to  distended  sections  of  the  organ. 
In  children  the  abdomen  may  reach  an  enormous  size  and  the  veins  are  promi- 
nent and  distended.  On  bimanual  palpation  the  tumor  is  felt  to  occupy  the 
lumbar  region  and  can  usually  be  lifted  slightly  from  its  bed;  in  some  cases 
it  is  very  movable,  even  when  large ;  in  others  it  is  fixed,  fi.rm,  and  solid.  The 
respiratory  movements  have  but  slight  influence  upon  it.  Eapidly  growing 
renal  tumors  are  soft,  and  on  palpation  may  give  a  sense  of  fluctuation.  A 
point  of  considerable  importance  is  the  fact  that  the  colon  crosses  the  tumor, 
and  can  usually  be  detected  without  difiiculty. 

Diagnosis. — In  children  very  large  abdominal  tumors  are  either  renal  or 
retroperitoneal.  The  retroperitoneal  sarcoma  (Lobstein's  cancer)  is  more 
central,  but  may  attain  as  large  a  size.  If  the  case  is  seen  only  toward  the 
end,  a  differential  diagnosis  may  be  impossible;  but,  as  a  rule,  the  sarcoma 
is  less  moveable.  It  is  to  be  remembered  that  these  tiunors  may  invade  the 
kidney.  On  the  left  side  an  enlarged  spleen  is  readily  distinguished,  as  the 
edge  is  very  distinct  and  the  notch  or  notches  well  marked ;  it  descends  dur- 
ing respiration,  and  the  colon  lies  behind,  not  in  front  of  it.  On  the  right 
side  growths  of  the  liver  are  occasionally  confounded  with  renal  tumors:  but 
such  instances  are  rare,  and  there  can  usually  be  detected  a  zone  of  resonance 
between  the  upper  margin  of  the  renal  tumor  and  the  ribs.  Late  in  the 
disease  this  is  not  possible,  for  the  renal  tumor  is  in  close  union  with  the 
liver.     Metastases  should  be  searched  for,  especially  in  the  lungs. 

A  malignant  growth  in  a  movable  kidney  may  be  very  deceptive  and  may 
simulate  cancer  of  the  ovary'  or  myoma  of  the  uterus.  The  great  mobility 
upward  of  the  renal  growth  and  the  negative  result  of  examination  of  the 
pelvic  viscera  are  the  reliable  points. 

When  the  growth  is  srjjsXi  and  the  patient  in  good  condition  removal  of 


CYSTIC  DISEASE  OF  THE  KIDNEY  719 

the  organ  may  be  undertaken,  but  the  percentage  of  cases  of  recovery  is  very 
small^  only  5.4  per  cent.  (G.  "Walker). 


XIII.     CYSTIC  DISEASE  OF  THE  KIDNEY 

The  following  varieties  of  cysts  are  met  with : 

Small  Cysts. — These  are  described  in  connection  with  chronic  nephritis, 
and  result  from  dilatation  of  obstructed  tubules  or  of  Bowman's  capsules. 
There  are  cases  very  difficult  to  classify,  in  which  the  kidneys  are  greatly  en- 
larged and  very  cystic  in  middle-aged  or  elderly  persons,  and  yet  not  so  large 
as  in  the  congenital  form. 

Solitary  Cysts. — Solitary  cysts,  ranging  in  size  from  a  marble  to  an 
orange,  or  even  larger,  are  occasionally  found  in  kidneys  which  present  no 
other  changes.  In  exceptional  cases  they  may  form  tumors  of  considerable 
size,  Xewman  operated  on  one  which  contained  25  ounces  of  blood.  They, 
too,  in  all  probability,  result  from  obstruction. 

Polycystic  Kidneys. — In  the  polycystic  kidneys,  the  greatly  enlarged  or- 
gans, weighing  even  as  much  as  six  pounds,  are  represented  by  a  conglomera- 
tion of  cysts,  varying  in  size  from  a  pea  to  a  marble.  Little  or  no  renal  tissue 
may  be  noticeable,  although  in  microscopic  sections  it  is  seen  that  a  consid- 
erable amount  remains  in  the  interspaces.  The  cysts  contain  a  clear  or  turbid 
fluid,  sometimes  reddish  brown  or  even  blackish  in  color,  and  may  be  of  a 
colloidal  consistence.  Albumin,  blood  crystals,  cholesterin,  with  triple  phos- 
phates and  fat  drops,  are  found  in  the  contents.  Urea  and  uric  acid  are 
rarely  present.  The  cysts  are  lined  by  a  flattened  epithelium.  They  occur  in 
the  fetus,  and  sometimes  are  of  such  a  size  as  to  obstruct  labor.  In  the  adult 
they  are  usually  bilateral,  and  there  is  every  reason  to  believe  that  they  begin 
in  early  life  and  increase  gradually.  Indeed,  a  progressive  growth  has  been 
noticed  (Alfred  King).  They  may  be  found  in  connection  with  cystic  dis- 
ease of  the  liver  and  other  organs.  It  is  difficult  to  account  for  the  origin  of 
this  remarkable  condition,  which  some  regard  as  a  defect  of  development  rather 
than  a  pathological  change,  and  point  to  the  association  in  the  fetal  cases  of 
other  anomalies,  as  imperforate  anus.  Others  believe  the  condition  to  be  a 
new  growth — a  sort  of  mucoid  endothelioma. 

It  is  interesting  to  note  that  several  members  of  a  family  may  be  affected. 
In  one  instance  mother  and  son  were  the  subjects  of  the  disease. 

SYMPTOiis. — Of  a  series  of  cases  seen  in  adults  the  condition  was  recog- 
nized during  life  in  the  majority.  •  The  features  are  characteristic. 

(a)  Bilateral  tumors  in  the  renal  regions,  which  may  increase  in  size 
under  observation.  They  may  cause  great  enlargement  of  the  upper  zone  of 
the  abdomen.  The  colon  and  stomach  are  in  front  of  the  tumors,  on  the 
surface  of  which  in  thin  subjects  the  cysts  may  be  palpable  or  even  visible. 

While  both  kidneys  are,  as  a  rule,  involved,  one  may  be  much  smaller  than 
the  other. 

{h)  Hcematuria,  which  may  recur  at  intervals  for  years. 

(c)  The  signs  of  a  cTironic  interstitial  nephritis — (1)  pallor  or  muddy 
complexion;  in  rare  instances  a  bronzing  of  the  skin;  (2)  sclerosis  of  the  ar- 
teries;   (3)    hypertrophy  of  the  heart  with   accentuated   second   sound;    (4) 


no  DISEASES  OF  THE  KIDNEYS 

urine  abundant,  of  low  specific  gravity,  with  albumin,  and  liyaline  and  gran- 
ular tube  casts,  and  in  one  case  cholesterin  crystals.  Death  occurs  from 
ursmia  or  the  cardio-vascular  complications  of  chronic  nephritis.  A  rare 
event  is  rupture  of  a  cyst  with  the  formation  of  a  perinephric  abscess  and 
peritonitis.     The  skin  may  be  much  pigmented. 

Operation,  by  exposing  the  kidney  and  draining  the  cysts,  has  been  suc- 
cessful. When  the  condition  is  unilateral  the  kidney  has  been  removed  and 
the  patients  have  remained  well  for  years. 

Other  Varieties. — Occasionally  the  kidneys  and  liver  present  numerous 
small  cysts  scattered  through  the  substance.  The  spleen  and  the  thyroid  also 
may  be  involved,  and  there  may  be  congenital  malformation  of  the  heart. 
The  cysts  in  the  kidney  are  small,  and  neither  so  numerous  nor  so  thickly  set 
as  in  the  conglomerate  form,  though  in  these  cases  the  condition  is  probably 
the  result  of  some  Congenital  defect.  There  are  cases,  however,  in  which  the 
kidneys  are  very  large.  It  is  more  common  in  the  lower  animals  than  in 
man.  Instances  of  it  occur  in  the  hog;  in  one  case  the  liver  weighed  40 
pounds,  and  was  converted  into  a  mass  of  simple  cysts.  The  kidneys  were 
less  involved.  Charles  Kennedy  found  references  to  12  cases  of  combined 
cystic  disease  of  the  liver  and  kidneys. 

The  echinococcus  cysts  have  been  described  under  the  section  on  parasites. 
Paranephric  cysts  (external  to  the  capsule)  are  rare;  they  may  reach  a  large 
size. 

XIV.     PERINEPHRIC  ABSCESS 

Suppuration  in  the  connective  tissue  about  the  kidney  may  follow  (1) 
blows  and  injuries;  (2)  the  extension  of  inflammation  from  the  pelvis  of  the 
kidney,  the  kidney  itself,  or  the  ureters;  (3)  rupture  of  a  septic  infarct  in  the 
kidney;  (4)  perforation  of  the  bowel,  most  commonly  the  appendix,  in  some 
instances  the  colon;  (5)  extension  of  suppuration  from  the  spine,  as  in  caries, 
or  from  the  pleura,  as  in  empyema;  (6)  as  a  sequel  of  the  fevers,  particularly 
in  children. 

Post  mortem  the  kidney  is  surrounded  by  pus,  particularly  at  the  pos- 
terior part,  though  the  pus  may  lie  altogether  in  front,  between  the  kidney 
and  the  peritoneum.  Usually  the  abscess  cavity  is  extensive.  The  pus  is 
often  offensive  and  may  have  a  distinctly  faecal  odor  from  contact  with  the 
large  bowel.  It  may  burrow  in  various  directions  and  burst  into  the  pleura 
and  be  discharged  through  the  lungs.  A  more  frequent  direction  is  down  the 
psoas  muscle,  when  it  appears  in  the  groin,  or  it  may  pass  along  the  iliacus 
fascia  and  appear  at  Poupart's  ligament.  It  may  perforate  the  bowel  or  rup- 
ture into  the  peritoneum;  sometimes  it  penetrates  the  bladder  or  vagina. 

Post  mortem  we  occasionally  find  a  condition  of  chronic  perinephritis  in 
which  the  fatty  capsule  of  the  kidney  is  extremely  firm,  with  numerous  bands 
of  fibrous  tissue,  and  is  stripped  off  from  the  proper  capsule  with  the  greatest 
difficulty.     Such  a  condition  probably  produces  no  symptoms. 

Symptoms, — There  may  be  intense  pain,  aggra^'ated  by  pressure,  in  the 
lumbar  region.  In  other  instances  the  onset  is  insidious,  without  pain  in  the 
renal  region ;  on  examination  signs  of  deep  seated  suppuration  may  be  de- 
tected.    On  the  affected  side  tliere  is  usually  pain,  which  may  be  referred  to 


PEEINEPHRIC  ABSCESS  721 

the  neighborhood  of  the  hip  joint  or  to  the  joint  itself,  or  radiate  down  the 
thigh  and  be  associated  witli  the  retraction  of  the  testis.  The  patient  lies 
with  the  thigh  flexed,  so  as  to  relax  the  psoas  muscle,  and  in  walking  throws, 
as  far  as  possible,  the  weight  on  the  opposite  leg.  He  also  keeps  the  spine 
immobile,  assumes  a  stoojDing  posture  in  walking,  and  has  great  difficulty  in 
voluntarily  adducting  the  thigh   (Gibney). 

There  may  be  pus  in  the  urine  if  the  disease  has  extended  from  the  pelvis 
or  the  kidney,  but  in  other  forms  the  urine  is  clear.  When  pus  has  formed 
there  are  usually  chills  with  irregular  fever  and  sweats.  On  examination, 
deep  seated  induration  is  felt  between  the  last  rib  and  the  crest  of  the  ilium. 
Bimanual  palpation  may  reveal  a  distinct  tumor  mass.  (Edema  or  puffiness 
of  the  skin  is  frequently  present. 

Diagnosis. — The  diagnosis  is  usually  easy;  when  doubt  exists  the  aspirator 
needle  should  be  used.  We  can  not  always  differentiate  the  primary  forms 
from  those  due  to  perforation  of  the  kidney  or  of  the  bowel.  This,  however, 
makes  but  little  difference,  for  the  treatment  is  identical.  It  is  usually  pos- 
sible by  the  history  and  examination  to  exclude  diseases  of  the  vertebra.  In 
children  hip-joint  disease  may  be  suspected,  but  the  pain  is  higher,  and  there 
is  no  fullness  or  tenderness  over  the  hip- joint  itself.  In  left-sided  abscess 
with  the  fluoroscope,  on  quickly  moving  the  patient,  a  wave  can  be  seen  in  the 
fluid    (Fussell  and  Pancoast). 

Treatment. — The  treatment  is  clear- — early,  free,  and  permanent  drainage. 


SECTION  IX 
DISEASES  OF  THE  BLOOD-FORMINd  ORGANS 

I.    ANiEMIA 

Angemia,  a  reduction  of  the  amount  of  blood  as  a  whole  or  of  its  cor- 
puscles, or  of  certain  of  its  constituents,  may  be  due  to  failure  in  the  manu- 
facture, to  increase  in  the  consumption,  or  to  a  loss,  sudden  or  gradual,  as 
in  hemorrhage.    Anaemia  may  be  local,  confined  to  certain  parts,  or  general, 

involving  the  entire  body. 

LOCAL  ANEMIA 

Tissue  irrigation  with  blood  is  primarily  from  the  heart,  but  provision  is 
made  for  variations  in  the  supply,  according  to  the  needs  of  a  part.  The 
sluices  are  worked  by  the  stop-cock  action  of  the  arteries,  which  contract  or 
expand  under  vaso-niotor  influence,  central  and  peripheral.  If  the  sluices  of 
one  large  district  are  too  widely  open,  so  much  blood  may  enter  that  other 
important  regions  have  not  enough  to  keep  them  at  work.  Local  anaemia  of 
the  brain,  causing  swooning,  ensues  when  the  mesenteric  channels,  capable 
of  holding  all  the  blood  of  the  body,  are  wide  open.  Emotional  stimuli,  reflex 
from  pain,  etc.,  removal  of  pressure,  as  after  tapping  in  ascites,  may  cause 
this.  Possibly  many  of  the  nervous  and  other  symptoms  in  enteroptosis 
are  due  to  the  relative  anaemia  of  the  cerebral  and  spinal  systems,  owing  to  the 
persistent  overfilling  of  the  mesenteric  reservoir.  We  know  little  of  local 
anaemia  of  the  various  organs,  but  functional  disturbance  in  the  liver,  kidneys, 
pancreas,  heart,  etc.,  may  result  from  a  permanently  low  pressure  in  the  local 
blood  "mains."  Anaemia  from  spasm  of  the  arterial  walls  is  seen  in  Eaynaud's 
disease,  which  usually  affects  the  peripheral  vessels,  causing  local  syncope  of 
the  fingers,  but  it  may  occur  in  the  visceral  vessels,  particularly  of  the  brain, 
and  cause  temporary  hemiplegia,  aphasia,  etc. 

Pseudo-ancemia  is  common.  Pallor  may  exist  with  a  normal  or  even  a 
plus  blood  count  and  color  index.  The  transient  pallor  in  nausea  and  after  a 
drinking  bout  is  a  vaso-motor  affair.  In  aortic  insufficiency,  in  lead-workers, 
in  the  morphia  habitue,  the  skin  may  be  permanently  pale.  The  skin  of  the 
face  may  be  unusually  thick  or  the  capillaries  poorly  developed,  as  in  seden- 
tary workers  in  contrast  to  the  ruddy  complexion  of  country  people.  The 
Latin  races  are  paler  than  the  Anglo-Saxons.  There  are  healthy  and  strong 
individuals  with  a  permanent  pallor  and  normal  corpuscles  and  haemoglobin. 

GENERAL  ANJEMIA— CLASSIFICATION 

The  general  anemias  may  be  divided  into  the  secondary  or  symptomatic 
and  the  primary  or  essential. 

722 


ANEMIA  733 

Acute  Secondary  Ancptnia 

Etiology. — In  rupture  of  a  large  vessel,  or  of  an  aneurism,  in  the  peptic 
ulcer,  or  in  injury  to  blood  vessels  the  loss  of  three  or  four  pounds  of  blood 
may  prove  fatal.  Seven  and  a  half  pounds  may  be  shed  into  one  cavity  (rup- 
ture of  an  aneurism  into  the  pleura).  A  patient  with  hgematemesis  lost  ten 
pounds  of  blood  in  one  week,  and  yet  recovered  from  the  immediate  effects. 
Even  after  the  severest  traumatic  haemorrhage  the  blood  count  is  rarely  so 
low  as  in  certain  forms  of  hemolytic  anaemia.  Thus  in  the  case  of  hgemate- 
mesis just  mentioned  the  red  blood-corpuscles  were  1,390,000  per  c.  mm. 

Symptoms. — Dyspnoea,  rapid  action  of  the  heart,  and  faintness  are  the 
prominent  symptoms  of  an  acutely  produced  anaemia.  There  is  marked  pallor 
of  the  skin  and  mucous  membranes,  the  pulse  is  jerking,  the  vessels  throb, 
particularly  the  abdominal  aorta,  and  the  pistol  shot  sound  is  heard  over 
them,  the  temperature  is  low,  the  patient  feels  giddy  and  faint  and  has  noises 
in  the  ears.  If  the  bleeding  continues  there  may  be  nausea,  vomiting,  and, 
with  the  rapid  loss  of  large  quantities  of  blood,  convulsions.  Examination 
shows  a  great  diminution  of  the  red  blood-corpuscles,  often  below  two  millions 
per  c.  mm.  The  haemoglobin  is  proportionately  lower,  giving  a  color  index  of 
about  0.8.  Irregularity  in  the  red  blood-corpuscles  is  seen;  nucleated  red 
corpuscles,  usually  normoblasts,  appear  early;  the  leucocytes  are  increased, 
usually  the  multi-nuclear  neutrophiles.  The  process  of  regeneration  goes  on 
with  great  rapidity;  the  watery  and  saline  constituents  are  readily  restored 
by  absorption ;  the  albuminous  elements  are  quickly  renewed,  but  it  may  take 
weeks  or  months  for  the  red  blood-corpuscles  to  reach  the  normal  standard. 
In  a  case  of  purpura  the  red  blood-corpuscles  fell  between  the  20th  and  30th 
April  to  below  two  millions,  and  the  leucocytes  rose  to  12,000.  It  was  not  until 
July  that  the  red  blood-corpuscles  reached  four  million,  and  the  blood  was  not 
normal  until  September.  The  hemoglobin  is  restored  more  slowly  than  the 
corpuscles. 

In  repeated  haemorrhages  the  picture  depends  upon  the  interval  between 
the  losses  of  blood.  If  long  enough  to  allow  of  complete  regeneration  each 
time  the  total  amount  of  blood  lost  may  be  very  great.  Ehrlich  mentions 
the  case  of  a  patient  with  haemoptysis  who  lost  20  kilograms  of  blood  in  61A 
months.  If,  however,  the  intervals  are  short,  so  that  complete  recovery  from 
each  loss  of  blood  is  not  possible,  a  chronic  anaemia  is  soon  induced  with  a 
very  watery  plasma,  a  low  color  index,  and  lymphocytosis. 

Secondary  AmiBmia 

Etiology. — There  are  many  causes,  the  most  important  of  which  are: 
(a)  I na7iition.— This  may  be  brought  about  by  defective  food  supply,  or 
by  conditions  which  interfere  with  the  proper  reception  and  preparation  of 
the  food,  as  in  cancer  of  the  oesophagus  and  chronic  dyspepsia.  The  reduc- 
tion in  mass  may  be  extreme,  but  the  plasma  suffers  proportionately  more  than 
the  corpuscles,  which,  even  in  the  wasting  of  cancer  of  the  oesophagus,  may 
not  be  reduced  more  than  one-half  to  three-fourths.  The  reduction  in  the 
plasma  may  be  so  great  that  the  corpuscles  show  a  relative  increase. 

(&)   Infections. — In  many  acute  fevers  anaemia  is  produced,  which  may 


724  DISEASES  OF  THE  BLOOD-FORMINCt  OEGANS 

persist  after  the  infection  has  subsided.  We  see  this  particularly  in  typhoid 
fever,  rheumatic  fever,  sepsis,  and  malaria.  Certain  animal  parasites,  as  the 
hookworm,  and  bothriocephalus,  cause  a  profound  anaemia. 

(c)  Intoxications. — Inorganic  poisons,  such  as  lead,  mercury,  arsenic;  or- 
ganic poisons,  as  the. toxins  of  various  fevers;  and  certain  autogenous  poisons 
occurring  in  chronic  affections,  such  as  nephritis  and  jaundice. 

An  interesting  type  of  toxic  anaemia  is  caused  by  arseniuretted  hydrogen 
gas  in  submarines  due  to  the  slow  action  of  gas  evolved  from  the  metallic 
portion  of  the  battery  plates.  Of  thirty  cases  studied  by  Dudley,  the  chief 
symptoms  were  dyspnoea,  albuminuria,  puffiness  of  the  face  with  conjuncti- 
vitis, jaundice  and  mild  neuritic  symptoms.  The  anaemia  was  never  extreme, 
i.  e.  below  two  millions,  the  color  index  was,  as  a  rule,  high  with  numerous 
megaloblasts. 

(d)  Hcemorrhage. — This,  if  repeated,  may  cause  severe  anaemia.  This  is 
particularly  shown  in  cases  of  persistent  bleeding  from  haemorrhoids. 

(e)  Long  continued  drain  upon  the  system,  as  in  chronic  suppuration, 
prolonged  lactation,  and  in  rapidly  growing  tumors  of  all  sorts. 

Symptoms. — Loss  of  bodily  and  mental  vigor  with  loss  of  weight  and  ob- 
vious anaemia  are  the  important  features.  The  patient  tires  easily,  the  ap- 
petite is  poor,  digestion  often  faulty,  palpitation  is  complained  of,  and  there 
may  be  feelings  of  faintness,  and,  as  the  anaemia  progresses,  swelling  of  the 
feet.  There  is  not  infrequently  slight  fever.  Petechiae  on  the  skin  are  not 
uncommon,  and  retinal  haemorrhages  may  occur.  The  blood  picture  is  dis- 
tinctive. The  red  blood-corpuscles  are  reduced,  but  rarely  below  two  millions 
per  c.  mm.  The  hgemoglobin  is  relatively  lower  than  the  red  cells,  thus  with 
70  per  -cent,  of  red  cells  there  may  be  only  40  per  cent,  of  haemoglobin,  a  low 
color  index.  The  red  blood-corpuscles  are  irregular  in  shape,  nucleated  forms 
may  be  present,  and  the  leucocytes  are  usually  increased  in  number. 

Treatment. — The  traumatic  cases  do  best,  and  with  plenty  of  good  food 
and  fresh  air  the  blood  is  readily  restored.  In  severe  cases  transfusion  should 
be  done.  The  extraordinary  rapidity  with  which  the  normal  percentage  of 
red  blood-corpuscles  is  reached  without  any  medication  whatever  is  an  im- 
portant lesson.  The  cause  of  the  hgemorrhage  should  be  sought  and  the  neces- 
sary indications  met.  The  large  group  depending  on  the  drain  on  the  albumi- 
nous materials  of  the  blood,  as  in  nephritis,  suppuration,  and  fever,  is  dif- 
ficult to  treat  successfully,  and  so  long  as  the  cause  keeps  up  it  is  impossible 
to  restore  the  normal  blood  condition.  The  anaemia  of  inanition  requires  plenty 
of  nourishing  food.  When  dependent  on  organic  changes  in  the  gastro-intesti- 
nal  mucosa  not  much  can  be  expected  from  either  food  or  medicine.  In  the 
toxic  cases  due  to  mercury  and  lead  the  poison  must  be  eliminated  and  a  nu- 
tritious diet  given  with  full  doses  of  iron.  In  a  great  majority  of  these  cases 
there  is  deficient  blood  formation,  and  the  indications  are  briefly  three :  plenty 
of  food,  an  open-air  life,  and  iron.  As  a  rule,  it  makes  but  little  difference 
what  form  of  the  drug  is  administered.  In  the  majority  of  cases  Blaud's 
mass  (gr.  v-x,  0.3-0.6  gm.)  does  well.  In  some  cases  the  citrate  of  iron  hypo- 
dermically  (gr.  ii,  0.12  gm.)  is  advisable  if  there  is  gastric  disturbance. 
In  severe  forms  the  patient  should  be  at  rest  in  bed  and  in  the  open  air,  if 
possible. 


AN.^MIA  '  7:35 


PRIMARY   OR   ESSENTIAL  ANEMIA 

1.  Chlorosis 

Definition. — An  anaemia  of  unknown  cause,  occurring  in  young  girls,  char- 
acterized by  a  marked  diminution  of  the  haemoglobin  with  cardio-vascular  and 
sometimes  nervous  symptoms. 

Etiology. — It  is  a  disease  of  girls,  more  often  of  blondes  than  of  brunettes. 
It  is  doubtful  if  males  are  ever  affected.  The  age  of  onset  is  between  the 
fourteenth  and  seventeenth  years ;  under  the  age  of  twelve  cases  are  rare.  Ee- 
currences,  which  are  common,  may  extend  into  the  third  decade.  There  exists 
a  lowered  energy  in  the  blood-making  organs,  associated  in  some  way  with 
the  evolution  of  the  sexual  apparatus  in  women.  Possibly  the  internal  secre- 
tion of  the  ovaries  is  at  fault  and  some  think  the  adrenals. 

The  disease  is  most  common  among  the  ill-fed,  overworked  girls  of  large 
towns,  who  are  confined  all  day  in  close,  badly  lighted  rooms,  or  have  to  do 
much  stair-climbing.  Cases  occur,  however,  under  the  most  favorable  condi- 
tions of  life,  but  not  often  in  country-bred  girls,  as  Maudlin  sings  in  the 
Com,pleat  Angler.  Lack  of  proper  exercise  and  of  fresh  air  and  the  use  of 
improper  food  are  important  factors.  Emotional  and  nervous  disturbances 
may  be  prominent — so  prominent  that  certain  writers  have  regarded  the  dis- 
ease as  a  neurosis.  De  Sauvages  speaks  of  a  chlorose  par  amour.  Newly  ar- 
rived Irish  girls  were  very  prone  to  the  disease  in  Montreal.  The  "corset  and 
chlorosis"  expresses  0.  Eosenbach's  opinion.  Menstrual  disturbances  are  not 
uncommon,  but  are  probably  a  sequence,  not  a  cause,  of  chlorosis.  Constipa- 
tion has  been  assigned  as  a  cause.  The  incidence  of  the  disease  is  decreasing 
rapidly  in  the  United  States. 

Symptoms. —  (a)  Geneeal. — ^The  symptoms  are  those  of  anemia.  The 
subcutaneous  fat  is  well  retained  or  even  increased  in  amount.  The  complex- 
ion is  peculiar;  neither  the  blanched  aspect  of  haemorrhage  nor  the  muddy 
pallor  of  grave  anaemia,  but  a  curious  yellow  green  tinge,  which  has  given  to 
the  disease  its  name,  and  its  popular  designation,  the  green  sickness.  Oc- 
casionally the  skin  shows  areas  of  pigmentation,  particularly  about  the  joints. 
The  color  may  be  deceptive,  as  the  cheeks  may  have  a  reddish  tint,  particu- 
larly on  exertion  (chlorosis  rubra).  The  subjects  complain  of  breathlessness 
and  palpitation,  and  there  may  be  a  tendency  to  fainting — symptoms  which 
often  lead  to  the  suspicion  of  heart  or  lung  disease.  Puffiness  of  the  face  and 
swelling  of  the  ankles  may  suggest  nephritis.  The  disposition  often  changes, 
and  the  girl  becom'es  low-spirited  and  irritable.  The  eyes  have  a  peculiar  bril- 
liancy and  the  sclerotics  are  of  a  bluish  color. 

(&)  Special  ^Features. — Blood. — The  drop  as  expressed  looks  pale.  Jo- 
hann  Duncan,  in  1867,  first  called  attention  to  the  fact  that  the  essential 
feature  was  not  a  great  reduction  in  the  number  of  the  corpuscles,  but  a  quan- 
titative change  in  the  haemoglobin.  The  corpuscles  themselves  look  pale.  In 
C3  consecutive  cases  examined  by  Thayer  the  average  number  per  cubic  milli- 
metre of  the  red  blood-corpuscles  was  4,09fi,544,  or  over  80  per  cent.,  whereas 
the  percentage  of  haemoglobin  for  tlie  total  number  was  42.3  per  cent.  There 
may  be  all  the  physical  characteristics  and  symptoms  of  a  profound  anaemia 


726  DISEASES  OF  THE  BLOOD-FOEMIXG  OEGAXS 

with  the  number  of  the  blood-corpuscles  nearly  at  the  normal  standard.  Xo 
other  form  of  anemia  presents  this  feature,  at  least  with  the  same  constancy 
and  in  the  same  degree.  The  importance  of  the  reduction  in  the  hgemoglobin 
depends  upon  the  fact  that  it  is  the  iron-containing  elements  of  the  blood 
with  which  in  respiration  the  oxygen  enters  into  combination.  This  marked 
diminution  has  also  been  determined  by  chemical  analysis  of  the  blood.  In 
severe  cases  the  red  cells  may  be  extremely  irregular  in  size  and  shape — 
poikilocytosis.  The  color  is  noticeably  pale  and  the  deficiency  may  be  seen 
either  in  individual  corpuscles  or  in  the  blood  itself.  Xucleated  red  cor- 
puscles (normoblasts)  may  be  found  in  severe  cases.  The  leucocytes  may 
show  a  slight  increase;  the  average  in  the  63  cases  above  referred  to  was 
8,467  per  cmm.  The  lymphocytes  are  usually  normal;  the  blood  platelets  may 
be  increased. 

(c)  Gasteo-ixtestixal  Symptoms. — The  appetite  is  capricious,  and  pa- 
tients may  have  a  longing  for  unusual  articles,- particularly  acids.  In  some 
instances  they  eat  all  sorts  of  indigestible  things,  such  as  chalk  or  even  earth. 
Distress  after  eating  and  even  cardialgic  attacks  may  be  present.  Constipa- 
tion is  a  common  symptom.  The  stomach  may  be  found  vertically  placed; 
sometimes  the  organ  is  dilated.  The  motor  power  is  usually  well  retained. 
Enteroptosis  with  palpable  right  kidney  is  not  uncommon. 

(d)  CiECULATOET  SYMPTOMS. — Palpitation  of  the  heart  may  be  the 
most  distressing  symptom.  The  transverse  dulness  may  be  increased.  A 
systolic  murmur  is  heard  at  the  apex  or  at  the  base;  more  commonly  at  the. 
latter,  but  in  extreme  cases  at  both.  A  di-astolic  murmur  is  rarely  heard. 
The  systolic  murmur  is  usually  loudest  in  the  second  left  intercostal  space, 
where  there  is  sometimes  a  distinct  pulsation.  On  the  right  side  of  the  neck 
over  the  jugular  vein  a  continuous  murmur  may  be  heard.  The  pulse  is  usu- 
ally full  and  soft.  Visible  impulse  is  present  in  the  veins  of  the  neck,  as 
noted  by  Lancisi.     Pulsation  in  the  peripheral  veins  is  sometimes  seen. 

Thrombosis  in  the  veins  may  occur,  most  commonly  in  the  femoral,  but 
occasionally  in  the  cerebral  sinuses.  In  86  cases  the  veins  of  the  legs  were 
affected  in  48,  the  cerebral  sinuses  in  29  (Lichtenstern).  The  chief  danger 
in  thrombosis  of  the  extremities  is  pulmonary  embolism,  which  occurred  in  13 
of  52  cases  collected  by  Welch. 

Fever  is  not  uncommon.  Chlorotic  patients  suifer  frequently  from  head- 
ache and  neuralgia,  which  may  be  paroxysmal.  The  hands  and  feet  are  often 
cold.  Dermatographia  is  common.  Hysterical  manifestations  are  not  infre- 
quent. Menstrual  disturbances  are  very  common — amenorrhoea  or  dysmenor- 
rhoea.  With  the  improvement  in  the  blood  condition  this  function  is  usually 
restored. 

Dia^osis. — The  green  sickness,  as  it  is  sometimes  called,  is  in  many  in- 
stances recognized  at  a  glance.  The  well-nourished  condition  of  the  girl,  the 
peculiar  complexion,  which  is  most  marked  in  brunettes,  and  the  white  or 
bluish  sclerotics  are  very  characteristic.  '  A  special  danger  exists  in  mistaking 
the  apparent  anaemia  of  the  early  stage  of  pulmonary  tuberculosis  for  chlorosis. 
The  palpitation  of  the  heart  and  shortness  of  breath  frequently  suggest  heart- 
disease,  and  the  oedema  of  the  feet  and  general  pallor  cause  the  cases  to  be 
mistaken  for  nephritis.  In  the  great  majority  of  cases  the  characters  of  the 
blood  readily  separate  chlorosis  from  other  forms  of  ansemia. 


ANEMIA  727 

Treatment. — This  affords  one  of  the  most  brilliant  instances — of  which 
we  have  but  three  or  four — of  the  specific  action  of  a  remedy.  Apart  from  the 
action  of  quinine  in  malarial  fever,  and  of  arsenic,  mercury  and  iodide  of 
potassium  in  syphilis,  there  is  no  other  drug  the  beneficial  effects  of  which 
we  can  trace  with  the  accuracy  of  a  scientific  experiment.  It  is  a  minor  matter 
liow  the  iron  cures  chlorosis.  In  a  week  we  give  to  a  case  as  much  iron  as  is 
contained  in  the  entire  blood,  as  even  in  the  worst  case  of  chlorosis  there  is 
rarely  a  deficit  of  more  than  2  grams  of  this  metal. 

In  chlorosis,  there  is  an  increase  in  the  red  blood-corpuscles  under  the 
influence  of  iron,  and  the  red  cells  may  rise  above  normal.  The  increase  in 
the  haemoglobin  is  slower  and  the  maximum  percentage  may  not  be  reached 
for  a  long  time.  There  is  no  better  form  than  Blaud's  pills.  During  the  first 
week  one  pill  (gr.  v,  0.3  gm.)  is  given  three  times  a  day;  in  the  second  week, 
two  pills;  in  the  third  week,  three  pills,  three  times  a  day.  An  important 
feature  in  the  treatment  is  to  persist  in  the  use  of  iron  for  at  least  three 
months,  and,  if  necessary,  subsequently  to  resume  it  in  smaller  doses,  as  re- 
currences are  so  common.  The  diet  should  consist  of  good,  easily  digested 
food.  Special  care  should  be  directed  to  the  bowels,  and  if  constipation  is 
present  a  saline  purge  should  be  given  each  morning.  The  dyspeptic  symptoms 
may  be  relieved  by  alkalies.  Dilute  hydrochloric  acid  is  often  useful.  Eest 
in  bed  is  important  in  severe  cases. 

2.  Pernicious  or  Addisonian  Ancemia 

Definition. — A  recurring  and  usually  fatal  anemia  caused  by  hgemolytic 
agents  and  characterized  by  an  embryonic  type  of  hsematopoiesis. 

History. — Addison,  after  whom  the  disease  should  be  called,  gave  the 
first  accurate  account  (1855).  Channing  described  cases  of  severe  ansemia 
in  the  puerperal  state.  The  writings  of  Gusserow  and  Biermer  in  the  early 
seventies  did  much  to  awaken  interest  in  the  disease.  The  studies  of  Pepper 
(Secundus),  H.  C.  Wood,  and  Palmer  Howard  made  the  disease  familiar  to 
American  and  Canadian  physicians. 

Distribution. — It  is  a  widespread  disease,  the  incidence  of  which  in  any 
community  is  a  good  deal  a  matter  of  keenness  on  the  part  of  the  practitioners 
(Cabot).     It  appears  to  be  increasing. 

Etiolo^. — The  figures  here  quoted  are  from  Cabot's  analysis  of  some 
1,200  cases  given  in  his  article  in  our  "System  of  Medicine."  It  is  a  disease 
of  middle  life;  a  great  majority — 922 — occurred  over  the  age  of  36.  The 
youngest  patient  we  have  seen  was  a  boy  of  ten  years.  Two  or  three  cases 
may  occur  in  one  family,  as  a  father  and  two  girls. 

The  cause  remains  obscure,  the  nature  and  origin  of  the  htemolysins  are 
unknown.  Bunting  has  produced  a  very  similar  blood  condition  in  animals  by 
injecting  ricin.  The  bothriocephalus  angemia  is  stated  to  be  due  to  a  lipoid 
body  that  may  be  extracted  from  the  worm.  Ha^molytic  bodies  have  been  ex- 
tracted from  the  intestinal  mucosa,  but  it  has  not  hecv.  shown  tliat  they  are 
specific.  Oral  sepsis  and  intestinal  toxaemia  have  been  brought  forward  and 
supported  by  many  arguments  (Hunter)  but  there  must  be  something  in  ad- 
dition. Naturally  in  the  present  endocrine  craze  hypcrsplenism  has  been 
in\oked.     IMoflitt  calls  attention  to  the  similarity  of  the  disease  to  a  protozoal 


728  DISEASES  OF  THE  BLOOD-FOEMIXG  ORGAXS' 

infection — the  remission,  the  nervous  lesions,  and  the  beneficial  effects  of  ar- 
senic. 

In  the  horse  there  is  a  form  of  ansemia  due  to  the  presence  of  the  larvffi 
of  the  (Estrus  equi,  a  conunon  parasite  in  the  stomach  (the  infectious  anaemia 
of  the  French).  Anaemia  may  be  produced  experimentally  by  extracts  of  these 
larva?,  and  apparently  also  when  these  extracts  are  freed  from  the  hsemolytic 
lipoids  with  which  the  anaemia  of  the  bothriocephalus  is  associated. 

Nervous  shock  has  appeared  to  be  a  factor  in  a  few  cases. 

Sex. — It  is  twice  as  common  in  males,  but  under  the  age  of  30  women  are 
more  often  affected. 

Among  other  factors  in  cases  with  the  blood  picture  resembling  the  Ad- 
disonian anaemia  are : — 

Pregnancy  and  Parturition. — The  anaemia  may  (1)  come  on  during  preg- 
nancy or  (2)  follow  delivery,  without  any  special  loss  of  blood,  or  (3)  be  an 
acute  septic  anaemia.     There  were  18  in  Cabot's  series  of  1,200  cases. 

Intestinal  Parasites. — Anaemia  of  a  severe  and  even  pernicious  type  may 
be  associated  with  the  bothriocephalus  or  the  hook-worm. 

Hcemorrhage. — Anaemia  after  haemorrhage  is  usually  of  the  secondary  type, 
but  in  every  series  of  cases  of  Addison's  anaemia  will  be  found  a  few  with  a 
history  of  bleeding  piles,  epistaxis  or  loss  of  blood  from  other  sources. 

We  have  not  got  much  beyond  the  position  of  Addison,  who  characterized 
the  disease  which  he  was  describing  as  "a  general  anaemia  occurring  without 
any  discoverable  cause  whatever;  cases  in  which  there  had  been  no  previous 
loss  of  blood,  no  existing  diarrhoea,  no  chlorosis,  no  purpura,  no  renal,  splenic, 
myasmatic,  glandular,  strumous,  or  malignant  disease." 

Pathology. — The  body  is  rarely  emaciated.  A  lemon  tint  of  the  skin  is 
present  in  a  majority  of  the  cases.  The  muscles  often  are  intensely  red  in 
color,  like  horse  flesh,  while  the  fat  is  light  yellow.  Haemorrhages  are  com- 
mon on  the  skin  and  serous  surfaces.  The  heart  is  usually  large,  flabby,  and 
empty.  In  one  instance  only  2  drams  of  blood  were  found  in  the  right  heart, 
and  between  3  and  4  in  the  left.  The  muscle  substance  of  the  heart  is  in- 
tensely fatty,  and  of  a  pale,  light  yellow  color.  In  no  affection  do  we  see  more 
extreme  fatty  degeneration.  The  lungs  show  no  special  changes.  The  stom- 
ach in  many  instances  is  normal,  but  in  some  cases  of  fatal  anaemia  the  mu- 
cosa is  extensively  atrophied.  The  liver  may  be  enlarged  and  fatty.  The. 
iron  is  in  excess,  a  striking  contrast  to  the  condition  in  cases  of  secondary 
anaemia.     It  is  deposited  in  the  outer  and  middle  zones  of  the  lobules. 

The  spleen  shows  no  important  changes.  In  one  of  Palmer  Howard's  cases 
the  organ  weighed  only  1  ounce  and  5  drams.  The  iron  .pigment  is  usually 
in  excess.  The  lymph  glands  may  be  of  a  deep  red  color  (haemo-lymph 
gland).  The  amount  of  iron  pigment  is  increased  in  the  kidneys,  chiefly  in  the 
convoluted  tubules.  The  bone-marrow  is  usually  red,  lymphoid  in  character, 
showing  great  numbers  of  nucleated  red  corpuscles,  especially  the  larger  forms 
called  by  Ehrlich  gigantoblasts.  There  are  cases  in  which  the  bone-marrow 
shows  no  signs  of  activity — aplastic  ananiia. 

Spinal  cord  lesions  were  present  in  84  per  cent,  of  the  post  mortems  col- 
lected by  Cabot,  a  sclerosis  chiefly  of  the  posterior  columns  in  the  cervical  re- 
gion. Foci  of  a  similar  nature  occur  in  the  brain  both  in  the  gray  and  white 
matter  (Woltman). 


ANEMIA  729 

Symptoms.. — The  combiuatiun  of  pallor  with  good  nutrition  is  a  striking 
feature.  As  a  rule  there  is  very  slight  loss  in  weight  and  the  fat  is  well  pre- 
served, in  contrast  to  most  of  the  secondary  angemias,  with  which  wasting  is 
associated.  The  description  given  by  Addison  is  masterly:  "It  makes  its 
approach  in  so  slow  and  insidious  a  manner  that  the  patient  can  hardly  fix  a 
date  to  the  earliest  feeling  of  that  languor  which  is  shortly  to  become  so  ex- 
treme. The  countenance  gets  pale,  the  whites  of  the  eyes  become  pearly,  the 
general  frame  flabby  rather  than  wasted,  the  pulse  perhaps  large,  but  remark- 
ably soft  and  compressible,  and  occasionally  with  a  slight  jerk,  especially  under 
the  slightest  excitement.  There  is  an  increasing  indisposition  to  exertion, 
with  an  uncomfortable  feeling  of  faintness  or  breathlessness  in  attempting  it; 
the  heart  is  readily  made  to  palpitate;  the  whole  surface  of  the  body  presents 
a  blanched,  smooth,  and  waxy  appearance;  the  lips,  gums,  and  tongue  seem 
bloodless,  the  flabbiness  of  the  solids  increases,  the  appetite  fails,  extreme 
languor  and  faintness  supervene,  breathlessness  and  palpitations  are  produced 
by  the  most  trifling  exertion  or  emotion;  some  slight  oedema  is  probably  per- 
ceived about  the  ankles;  the  debility  becomes  extreme — the  patient  can  no 
longer  rise  from  bed ;  the  mind  occasionally  wanders ;  he  falls  into  a  prostrate 
and  half-torpid  state,  and  at  length  expires ;  nevertheless,  to  the  very  last,  and 
after  a  sickness  of  several  months'  duration,  the  bulkiness  of  the  general 
frame  and  the  amount  of  obesity  often  present  a  most  striking  contrast  to  the 
failure  and  exhaustion  observable  in  every  other  respect." 

A  surprising  fact  is  that  there  are  patients  with  extreme  anaemia  who  are 
remarkably  vigorous.  One  may  see  patients  with  a  count  of  about  two  mil- 
lion red  cells  who  insist  that  they  are  able  to  do  everything  as  usual  except 
for  a  little  shortness  of  breath. 

The  appearance  of  the  patient  is  usually  very  characteristic.  The  com- 
bination of  a  lemon-yellow  tint  of  the  skin  with  retention  of  the  fat  gives  a 
very  suggestive  picture.  Sometimes  the  tint  is  icteroid.  In  rare  cases  there 
is  a  white,  ansemic  pallor,  and  in  a  third  groKp  a  brownish  tinge  of  the  skin 
(which  is  sometimes  associated  with  leucoderma)  deep  enough  to  suggest  Ad- 
dison's disease.  Muscular  weakness,  palpitation,  headache,  dyspnoea,  vertigo, 
and  oedema  of  the  feet  are  common  in  this  as  in  other  types  of  anaemia. 

G astro-intestinal  symptoms  are  not  uncommon.  Paroxysms  of  pain  in 
the  stomach  with  or  without  diarrhoea  may  occur  in  crises.  In  fully  one-half 
of  the  cases  diarrhoea  occurs  at  some  time  during  the  course.  The  hydro- 
chloric acid  is  usually  greatly  diminished  or  absent,  and  there  may  be  com- 
plete achylia.  A  sore  mouth  and  tongue,  a  feature  to  which  attention  was 
called  especially  by  William  Hunter,  has  not  been  common  in  our  experience. 
There  may  be  marked  glossitis  and  ulceration.  Pyorrhoea  alveolaris  may  be 
said  to  be  present  in  all  cases,  and  the  teeth  are  often  very  bad. 

Complaint  of  palpitation  and  disturbance  of  the  heart  is  common.  Slight 
dilatation  is  common;  murmurs  are  rarely  missed,  generally  hsemic  and  basic. 
Apex  diastolic  murmurs  may  occur  without  valve  lesions.  Extraordinary 
throbbing  of  the  arteries  may  occur,  so  that  aneurism  may  be  suspected;  the 
pulse  may  be  collapsing.  CEdema  is  common,  usually  in  the  feet,  sometimes 
in  the  hands.  The  urine  is  usually  of  low  specific  gravity,  pale,  and  with 
diminished  pigments.  Sometimes,  as  pointed  out  by  Hunter  and  Mott,  it  is 
of  a  deep  sherry  color,  due  to  great  excess  of  urobilin.     Increase  of  urobilin 


730  DISEASES  OP  THE  BLOOD-FOEMIKG  ORGANS 

and  urobilinogen  in  the  urine  and  stools  is  a  constant  finding,  and  the  pres- 
ence of  these  substances  in  the  urine  in  the  absence  of  signs  of  biliary  or 
hepatic  disease  is  suggestive  of  pernicious  anemia.  The  amount  is  of  some 
value  in  the  immediate  prognosis. 

Nervous  System. — The  more  carefully  the  cases  are  investigated  the 
greater  the  frequency  of  nervous  lesions.  Numbness  and  tingling  are  com- 
mon and  sometimes  there  are  marked  neuritic  pains.  Multiple  neuritis  may  be 
a  feature  of  the  disease  or  due  to  arsenic.    There  are  three  groups  of  cases : 

(a)  The  patient  may  have  had  no  special  symptoms  pointing  to  involve- 
ment of  the  nervous  system,  but  post  mortem  well  marked  lesions  of  the  cord 
are  found. 

(&)  With  the  anaemia  there  are  signs  of  spinal  cord  lesions,  a  postero- 
lateral sclerosis,  with  spastic  features  and  increased  reflexes,  or  the  picture 
may  be  rather  of  the  tabetic  type — lightning  pains,  girdle  sensation,  areas 
of  ansesthesia,  loss  of  the  reflexes. 

(c)  There  is  a  remarkable  group  carefully  described  by  Risien  Russell, 
Batten,  and  Collier,  in  which  the  nervous  symptoms,  usually  those  of  a  postero- 
lateral sclerosis,  precede  the  anaemia. 

As  the  disease  progresses  there  may  be  great  depression,  sometimes  delu- 
sions, but  mental  symptoms,  as  a  rule,  are  not  marked. 

Haemorrhages  are  not  uncommon,  chiefly  in  the  form  of  small  petechias. 
Retinal  haemorrhages  are  frequent.     Optic  neuritis  is  rare. 

Blood. — The  total  quantity  is  much  diminished.  The  drop  may  look  of 
good  color,  but  it  is  abnormally  fluid.  The  red  blood-corpuscles  are  greatly 
diminished;  the  average  count  in  81  cases,  when  they  came  under  observa- 
tion, was  1,575,000  per  c.  mm.  There  is  no  other  disease  which  so  often  reduces 
the  number  of  red  blood-corpuscles  below  two  millions  per  c.  mm.  In  12  per 
cent,  of  our  cases  the  count  was  under  one  million.  The  lowest  count  on 
record  is  in  a  patient  of  Quincke's,  143,000  per  c.  mm. 

The  haemoglobin,  though  quantitatively  reduced,  is  relatively  high.  The 
color  index  is  over  1  and  may  be  1.5.  Marked  irregularity  in  size  and  shape 
of  the  red  cells  with  many  large  forms  is  a  special  feature.  The  macrocytes 
measure  8,  10  or  even  15  /a.  On  the  other  hand,  there  are  a  great  many 
very  small  red  corpuscles — microcytes,  from  3  to  6  fi  in  diameter,  and  of  a 
deep  red  color.  The  irregularity  in  shape  is  remarkable.  Some  are  elongated, 
rod-like,  others  pyriform;  one  end  of  the  corpuscle  may  be  of  normal  shape, 
while  the  other  is  extended  like  the  neck  of  a  bottle.  Stippling  of  the  red 
blood-corpuscles  is  common  with  dark  blue  or  blackish  discoloration — the  so- 
called  polychromatophilia.  Mitochondria,  small  bodies  of  a  lipoid  nature, 
may  be  seen  in  the  red  cells. 

Nucleated  red  blood-corpuscles  are  constantly  present,  varying  very  much 
in  numbers  from  day  to  day.  There  are  two  types — normoblasts  of  the  aver- 
age size,  and  the  megaloblasts,  which  are  much  larger.  There  are  frequently 
intermediate  forms  between  these  two  groups.  These  nucleated  red  cells  vary 
extraordinarily  in  different  cases,  and  there  may  be  what  have  been  called 
blood  crises,  in  which  a  large  number  of  the  nucleated  reds  appear.  In  one 
such  crisis  there  were  14,388  normoblasts,  460  intermediates,  and  138  megalo- 
blasts per  c.  mm.     These  crises  are  sometimes  followed  by  gains  in  the  blood 


ANEMIA 


731 


count,  but  they  may  be  terminal  events,  and  not  specially  indicative  of  active 
blood  regeneration. 

The  leucocytes  are  generally  normal  or  diminished  in  number.  Polynu- 
clear  cells  are  rarely  reduced.  Occasionally  there  is  a  marked  increase  in  the 
small  mononuclear  forms.     Myelocytes  are  frequently  present,   even  up  to 


FEB. 

MAR. 

APR. 

MAY 

JUNE 

JULY 

AUG. 

SEPT.                 OCT. 

-  : 

;  *  :  2  s 

r    «    S    S    S 

o    2    S     S 

tn   2  t:   S 

-  o    "    S 

,=  s  :  S 

6,»:2S^.^sg. 

110^ 

iOOjJ 

5,000,000 

- 

- 

--- 

-- 

... 

- 

_. 

" 

- 

...... 

90,1 

80,'J 

4,000,000 

70;^ 

r 

.^ 

K 

/ 

1 

"^ 

^« 

\ 

60^ 

3,000,000 

/ 

/ 

/ 

'^ 

s 

^S 

// 

f 

\ 

S, 

\ 

s 

501 

/ 

/ 

^S 

""V 

( 

^^ 

V, 

^> 

s 

v 

^0% 

2,000,000 

) 

•>V 

>«> 

V. 

s 

> 

s 

// 

\ 

> 

< 

301 

> 

f 

s 

S. 

«^ 

/ 

\ 

^ 

^ 

\ 

20^ 

1,000,000 

"- 

^ 

^ 

•^ 

s 

N 

^s 

10,1 

500,000 

8,000 

-• 

:— : 

-■■■■ 

-_: 

:— 

-• 

: 

.■:— 

-• 

.— 

-:•:- 

-: 

:-- 

-:j- 

-•■ 

:_ 

- 

:— 

-■■ 

■- 

-■■■■■ 

— • 

•- 

-• 

•- 

-• 

-• 

r-  -.-jl 

6,000 

/^ 

^' 

A 

4,000 

1 

f 

■x 

"^. 

^^ 

/■ 

\ 

w^ 

6- 

^ 

^  ^ 

2,000 

J 

\ 

r  — 

bs« 

*  — 

"" 

■>. 

■^. 

110^ 


100/. 


Q0% 


50^ 


40^ 


30^ 


20^ 


10^ 


MEAN  NORM. 
NUMBER  OF 

WHITE 
CORPUSCLES 


eUiCK,  RED  CORPUSCLES. 


RED,  HAEMOGLOBIN. 

Chart  XV. — Pernicious  Anaemia 


BLUE,  COLORLESS  CORPUSCLES. 


8  and  10  per  cent.  Blood-platelets  are  usually  low;  counts  of  100,000  and 
less  are  not  uncommon  (Pratt). 

Chart  XV  shows  the  blood  condition  in  a  case  during  nine  months. 

The  metabolism  has  been  the  subject  of  many  studies.  A  pathological 
destruction  of  proteins  is  usually  present  but  a  positive  nitrogen  balance  may 
be  maintained  by  forced  feeding  (Mosenthal). 

Aplastic  Anaemia. — A  certain  number  of  cases  of  primary  anaemia  run 
a  rapid  and  progressive  course,  without  remissions;  and  death  occurs  within 
a  few  weeks  or  months  from  the  beginning  of  the  attack.     Post  mortem,  in- 


732  DISEASES  OF  THE  BLOOD-FOEMIXG  ORGANS 

stead  of  an  active  hyperplasia  of  the  bone  marrow,  there  is  atrophy  or  aplasia. 
To  these  cases  the  term  "aplastic  anasmia"  has  been  given.  It  is  a  sub-type  of 
pernicious  ansemia  with  identical  clinical  features,  except  that  it  runs  a  more 
rapid  course,  is  met  with  in  yoilnger  persons,  the  color  index  may  be  low, 
hemorrhages  are  more  common,  there  may  be  leucopenia,  and  erythroblasts 
are  usually  absent.  The  haemorrhages  may  be  very  severe,  and  some  of  the 
cases  are  of  a  pronounced  purpuric  type. 

The  diagnosis  is  only  certain  after  an  examination  of  the  bones,  when  it 
is  found  that  the  marrow  of  the  long  bones  is  fatty,  and  even  the  red  mar- 
row may  have  disappeared  from  the  short  bones. 

Prognosis  and  Course. — The  disease  may  run  a  very  acute  course.  In  a 
patient  of  Finley's  in  Montreal  the  fatal  termination  occurred  within  ten 
days  of  the  onset  of  the  symptoms.  The  course  may  be  from  six  to  twelve 
weeks,  but,  as  a  rule,  it  is  a  chronic  malady  with  remarkable  remissions.  It 
is  rare  to  meet  with  a  case  in  which  recovery  does  not  take  place  from  the 
first  attack.  The  number  of  remissions  varies  from  two  or  three  to  five 
or  six.  In  524  cases  analyzed  by  Cabot  for  this  special  point,  296  had  one 
remission,  118  two,  65  three,  21  four,  and  24  five.  The  duration  of  the  re- 
mission may  be  from  three  months  to  four  years.  In  81  cases  treated  in  the 
Hopkins  Hospital  death  occurred  in  27  while  under  observation.  The  aver- 
age duration  in  these  cases  was  about  a  year. 

The  ultimate  prognosis  in  a  great  majority  of  cases  is  bad;  only  one  case 
in  our  series  appears  to  have  recovered  completely,  another  was  alive  and  in 
good  health  six  years  after  the  last  attack,  and  a  third  four  years  after.  In 
Cabot's  series  there  were  ten  cases  which  had  lasted  seven  years  or  more,  but 
there  were  only  6  out  of  the  1,200  cases  analyzed  which  he  regarded  as  hav- 
ing completely  recovered. 

Diagnosis. — Few  diseases  are  more  readily  recognized  at  sight.  There 
is  something  very  characteristic  about  the  general  appearance  of  a  patient 
with  Addisonian  angemia,  and  nowadays  practitioners  are  much  more  alert, 
and  the  disease  is  better  known.  The  lemon  colored  tint  of  the  skin  may 
suggest  jaundice;  the  anemia,  puffy  face,  swollen  ankles,  and  albumin  in  the 
urine,  nephritis;  the  pigmentation,  Addison's  disease;  the  shortness  of  breath 
and  palpitation,  heart  disease;  the  pallor  and  gastric  symptoms,  cancer  of  the 
stomach.  The  retention  of  fat,  the  insidious  onset,  the  absence  of  signs  of 
local  disease,  and  the  blood  features  are  the  important  diagnostic  points.  In 
a  doubtful  case  the  evidences  of  changes  in  the  cord  should  be  looked  for;  if 
present  they  are  an  important  aid.  From  cancer  of  the  stomach  pernicious 
anemia  is  distinguished  by  the  absence  of  wasting,  the  high  color  index  of  the 
blood,  the  lower  corpuscular  count,  and  by  the  marked  improvement  in  the 
first  attacks  under  proper  treatment. 

Treatment. — There  are  five  essentials :  first,  a  diagnosis ;  secondly,  rest  in 
bed  for  weeks  or  even  months,  if  possible  (thirdly)  in  the  open  air;  fourthly, 
all  the  good  food  the  patient  can  take; -fifthly,  arsenic;  Fowler's  solution  in 
increasing  doses,  beginning  with  n\  iii  or  v  (0.2  to  0.3  c.  c.)  three  times  a 
day,  and  increasing  nx  i  each  week  imtil  the  patient  takes  TTL  xv  (1  c.  c.) 
three  times  a  day.  Other  forms  of  arsenic  may  be  tried,  as  sodium  cacodylate 
or  atoxyl  hypodermic-ally.  Atoxyl  can  be  given  in  doses  of  gr.  ss  (0.032  gm.) 
every  five  days,  and  the  amount  gradually  increased.    Arsphenamine  in  small 


LEUK^^MIA  733 

doses  (0.2  gm.)  at  short  intervals  has  apparently  been  useful  in  some  cases. 
It  is  generally  helpful  to  give  dilute  hydrochloric  acid  in  full  doses,  twice 
after  each  meal.  Accessories  are  oil  inunctions;  bone-marrow,  which  has  the 
merit  of  a  recommendation  by  Galen;  in  some  cases  iron  seems  to  do  good. 
Care  should  be  taken  of  the  mouth  and  teeth,  and  mouth  infection  thoroughly 
treated.  Focal  infection  anywhere  should  receive  proper  treatment.  Gastric 
lavage  and  irrigations  of  the  colon  are  useful  in  some  cases. 

Splenectomy  has  been  done  in  a  number  of  cases,  but  it  is  well  to  be  cau- 
tious in  judging  of  its  value.  Some  patients  have  been  helped  for  a  time,  but 
it  is  not  proved  that  permanent  benefit  results. 

Transfusion  is  again  in  vogue,  and  with  a  much  improved  technique.  In 
patients  with  a  rapidly  falling  count  a  transfusion  may  start  improvement. 
The  transfusion  may  be  repeated  three  or  four  times  at  intervals  of  ten  days 
or  two  weeks.  It  is  important  to  use  a  homologous  blood.  Bloomfield's  study 
(1918)  seems  to  show  that,  even  with  the  new  methods,  results  are  not  more 
satisfactory  than  in  the  hands  of  the  men  who  first  practised  it  in  the  seventies. 


II.     LEUKEMIA 

Definition.-— A  disease  characterized  by  a  permanent  increase  in  the  leuco- 
cytes of  the  blood,  associated  with  hyperplasia  of  the  leucoblastic  tissues. 

History..— In  October,  1845,  Hughes  Bennett  recorded  a  case  of  "suppura- 
tion of  the  blood  with  enlargement  of  the  spleen  and  liver,"  and  he  afterward 
gave  the  disease  the  name  of  "leukocythgemia."  A  month  later  Virchow  de- 
scribed a  similar  condition  of  "white  blood"  to  which  he  gave  the  name  of 
"leukaemia.'"  In  1870  Neumann  determined  the  importance  of  the  changes  in 
the  bone  marrow.  The  work  of  Ehrlich  enabled  us  to  classify  the  cases  ac- 
cording to  the  blood  changes. 

Varieties. — The  whole  hematopoietic  system — marrow,  spleen,  and  lymph 
glands — is  involved.  Formerly  we  spoke  of  three  different  groups — the 
splenic,  lymphatic,  and  medullary,  but  we  now  recognize  that  the  leucoblastic 
hyperplasia  may  begin  in  any  part  of  the  blood-glandular  system,  marrow, 
lymph  glands,  and  probably  in  the  spleen.  The  differences  in  the  types  de- 
pend upon  the  dominance  of  the  lymphoid  or  the  myeloid  process,  so  that  we 
now  divide  the  cases  roughly  into  two  great  groups:  (1)  the  myelocytic  or 
myeloid,  corrCvSponding  to  the  spleno-medullary  type,  and  (2)  the  lymphoid, 
which  represents  the  lymphatic  variety.  Some  cases  not  fitting  accurately 
into  either  are  spoken  of  as  "atypical"  or  "transitional"  forms. 

The  relation  to  pregnancy  is  interesting.  Conception  is  rare  during  the 
course.  The  disease  iliay  begin  during  pregnancy  and  progress  rapidly.  In 
Cameron's  case  (Montreal)  the  grandmother,  mother  and  brother  had  symp- 
toms suggestive  of  leukaemia.  During  pregnancy  the  disease  was  first  noted 
Avhen  her  sixth  child  was  three  months  old  and  he  died  of  leuksemia  at  the 
sixth  month.  She  was  leukgemic  through  her  seventh  pregnancy  and  was  de- 
livered with  a  red  cell  count  of  one  million  and  the  white  blood  count  1 :10. 
The  child  became  purpuric  and  died  on  the  fourth  day  with  the  red  cell 
count  normal  and  tlu>  leucocytes  al)out  35,000.  Another-  child  aged  8  had 
leuk.Tmia  also. 


734  DISEASES  OF  THE  BLOOD-FOEMING  OEGANS 

I.  Myeloid  Leukemia. — Etiology. — The  acute  cases  resemble  an  infec- 
tion. The  cause  remains  unknown.  The  disease  may  be  a  myeloma.  Mul- 
tiple cases  have  been  reported  in  a  family.  The  disease  is  not  very  rare.  There 
were  24  cases  in  the  Johns  Hopkins  Hospital  in  fifteen  years.  It  is  not  more 
frequent  in  malarial  regions. 

It  is  rather  more  common  in  males  than  in  females,  and  between  the  30th 
and  50th  years.     The  youngest  of  our  patients  was  a  child  of  eight  months. 

It  has  followed  a  blow.  Patients  may  have  had  a  tendency  to  haemorrhage, 
but,  as  a  rule,  the  disease  appears  in  fairly  healthy  persons  without  any  recog- 
nizable cause. 

Morbid  Anatomy. — Dropsy  is  sometimes  present.  There  may  be  a  condi- 
tion of  polysemia;  the  heart  and  veins  are  distended  with  large  blood-clots. 
In  one  case  the  weight  of  blood  in  the  heart  chambers  alone  was  620  grams. 
There  may  be  remarkable  distention  of  the  portal,  cerebral,  pulmonary,  and 
subcutaneous  veins.  The  blood  is  usually  clotted,  and  the  enormous  increase 
in  the  leucocytes  gives  a  pus  like  appearance  to  the  coagula,  so  that  it  has 
happened  more  than  once,  as  in  Yirchow's  memorable  case,  that  on  opening 
the  right  auricle  the  observer  at  first  thought  he  had  cut  into  an  abscess.  The 
coagula  have  a  peculiar  greenish  color,  somewhat  like  the  fat  of  a  turtle  and 
so  intense  as  to  suggest  the  color  of  chloroma.  The  fibrin  is  increased.  Char- 
cot's octahedral  crystals  may  separate  from  the  blood  after  death. 

In  the  myelitic  form  the  spleen  is  greatly  enlarged,  the  capsule  may  be 
thickened,  and  the  vessels  at  the  hilus  enlarged.  The  weight  may  range  from 
2  to  18  pounds.  The  organ  is  in  a  condition  of  chronic  hyperplasia.  It  cuts 
with  resistance,  has  a  uniformly  reddish  brown  color,  and  the  Malpighian 
bodies  are  invisible.  Grayish  white,  circumscribed,  lymphoid  tumors  may 
occur  throughout  the  organ,  contrasting  strongly  with  the  reddish  brown  ma- 
trix. Instead  of  a  fatty  tissue,  the  medulla  of  the  long  bones  may  resemble 
the  consistent  matter  which  forms  the  core  of  an  abscess,  or  it  may  be  dark 
brown  in  color.  There  may  be  hgemorrhagic  infarctions.  There  may  be  much 
expansion  of  the  shell  of  bone  with  localized  swellings. 

Leukgemic  enlargements  in  the  solitary  and  agminated  glands  of  Peyer 
may  occur  and  leukaemic  growths  have  been  found  in  the  stomach,  omentum 
and  peritoneum.  The  thymus  may  be  enlarged  in  the  acute  cases.  The  liver 
may  be  greatly  enlarged,  due  to  a  diffuse  leuksemic  infiltration  or  to  definite 
growths.  There  are  rarely  changes  of  importance  in  the  lungs.  In  159  cases 
collected  by  Gowers  there  were  13  instances  of  leuksemic  nodules  in  the  liver 
and  10  in  the  kidneys.     Tumors  of  the  skin  are  rare. 

Symptoms. — Anemia  is  not  a  necessary  accompaniment  of  all  stages  of 
the  disease;  the  subjects  may  look  very  healthy  and  well.  The  onset  is  in- 
sidious, and,  as  a  rule,  the  patient  seeks  advice  for  progressive  enlargement 
of  the  abdomen  and  shortness  of  breath,  or  the  pallor;,  palpitation,  and  other 
symptoms  of  anaemia.  Bleeding  at  the  nose  is  common.  Gastro-intestinal 
symptoms  may  precede  the  onset.  Occasionally  the  first  symptoms  are  of  a 
very  serious  nature.  In  one  case  a  boy  played  lacrosse  two  days  before  the 
onset  of  the  final  haematemesis ;  and  in  another  case  a  girl,  who  had,  it  was 
supposed,  only  a  slight  chlorosis,  died  of  fatal  hemorrhage  from  the  stomach 
before  any  suspicion  had  been  aroused  as  to  the  true  condition. 

The  gradual  increase  in  the  volume  of  the  apleen.  is  the  most  prominent 


LEUKAEMIA  735 

feature  in  a  majority  of  the  cases.  Pain  and  tenderness  are  common,  though 
the  progressive  enlargement  may  be  painless.  A  creaking  fremitus  may  be 
felt  on  palpation.  The  enlarged  organ  extends  downward  to  the  right,  and 
may  be  felt  just  at  the  costal  edge,  or  when  large  it  may  extend  as  far  over 
as  the  navel.  In  many  cases  it  occupies  fully  one  half  of  the  abdomen,  reach- 
ing- to  the  pubes  below  and  extending  beyond  the  middle  line.  As  a  rule,  the 
edge,  in  some  the  notch  or  notches,  can  be  felt  distinctly.  Its  size  varies 
greatly  from  time  to  time.  It  may  be  perceptibly  larger  after  meals.  A 
hEemorrhage  or  free  diarrhoea  may  reduce  the  size.  The  pressure  of  the  en- 
larged'organ  may  cause  distress  after  eating;  in  one  case  it  caused  fatal  ob- 
struction of  the  bowels.  On  auscultation  a  murmur  may  sometimes  be  heard 
over  the  spleen,  and  Gerhardt  described  a  pulsation  in  it. 

The  long  bones  are  tender;  leuksemic  tumors  are  rare  but  there  may  be 
localized  swellings,  particularly  on  the  ribs,  which  are  tender  and  yield  to  firm 
pressure. 

The  pulse  is  usually  rapid,  soft,  compressible,  but  often  full  in  volume. 
The  veins  may  be  very  large  and  full,  and  pulsation  in  those  of  the  hand  and 
arm  is  common.  There  are  rarely  any  cardiac  symptoms.  The  apex  beat  may 
be  lifted  an  interspace  by  the  enlarged  spleen.  Toward  the  close  oedema  may 
occur  in  the  feet  or  general  anasarca.  Haemorrhage  is  common.  There  may 
be  most  extensive  purpura,  or  hsemorrhagic  exudate  into  pleura  or  peritoneum. 
Epistaxis  is  the  most  frequent  form.  Hemoptysis  and  hematuria  are  rare. 
Bleeding  from  the  gums  may  be  present.  Hsematemesis  proved  fatal  in  two 
of  our  cases,  and  in  a  third  a  large  cerebral  haemorrhage  rapidly  killed. 

Local  gangrene  may  develop,  with  signs  of  intense  infection  and  high 
fever.  There  are  very  few  pulmonary  symptoms.  The  shortness  of  breath  is 
due,  as  a  rule,  to  the  anemia.  Toward  the  end  there  may  be  oedema  of  the 
lungs  or  pneumonia.  The  gastro-intestinal  symptoms  are  rarely  absent.  Nau- 
sea and  vomiting  are  early  features  in  some  cases,  and  diarrhoea  may  be  very 
troublesome,  even  fatal.  Intestinal  hemorrhage  is  not  common.  There  may 
be  a  dysenteric  process  in  the  colon.  Jaundice  rarely  occurs.  Ascites  may 
be  a  prominent  symptom,  probably  due  to  the  presence  of  the  splenic  tumor. 
A  leukemic  peritonitis  also  may  be  present,  due  to  new  growths  in  the  mem- 
branes. 

The  nervous  system  is  not  often  involved.  Facial  paralysis  has  been  noted. 
Headache,  dizziness,  and  fainting  spells  are  due  to  anemia.  The  patients  are 
usually  tranquil.  Coma  may  follow  cerebral  hemorrhage.  Paraplegia  may 
be  due  to  pressure  of  a  leukemic  tumor  on  the  cord. 

There  is  a  peculiar  retinitis,  due  chiefly  to  the  extravasation  of  blood,  but 
there  may  be  aggregations  of  leucocytes,  forming  small  leukemic  growths. 
Optic  neuritis  is  rare.  Deafness  has  frequently  been  observed;  it  may  appear 
early  and  possibly  is  due  to  hemorrhage.  Features  suggestive  of  Meniere's 
disease  may  come  on  suddenly,  due  to  leukemic  infiltration  or  hemorrhage 
into  the  semi-circular  canal. 

The  urine  presents  no  constant  changes.  The  uric  acid  is  always  in 
excess.  Priapism,  a  curious  symptom,  is  present  in  many  cases,  and  may 
be  the  first  symptom.  It  may  persist  for  weeks.  The  cause  is  thrombosis  of 
the  veins  in  some  cases. 

Fever  was  present  in  two-thirds  of  our  series.     Periods  of  j^yrexia  may 


736  DISEASES  OF  THE  BLOOD-FORMING  ORGANS 

alternate  with  prolonged  intervals  of  freedom.  The  temperature  may  range 
from  103°  to  103°  F. 

Blood. — In  all  forms  of  the  disease  the  diagnosis  must  be  made  by  the 
examination  of  the  blood,  as  it  alone  offers  distinctive  features. 

The  striking  change  is  an  increase  in  the  leucocytes.  The  average  in  our 
series  vs^as  298,700  per  c.  mm.,  and  the  average  ratio  to  the  red  cells  was  1  to 
10.  Counts  above  500,000  per  c.  mm.  are  common,  and  they  may  rise  above 
1,000,000  per  c.  mm.  The  proportion  of  white  to  red  cells  may  be  1  to  5,  or 
may  even  reach  1  to  1.  There  are  instances  on  record  in  which  the  number  of 
leucocytes  has  exceeded  that  of  the  red  corpuscles. 

The  increase  is  in  all  the  forms.  The  polynuclear  neutrophiles  make  up 
from  30  to  50  per  cent. ;  both  the  small  and  the  large  lymphocytes  are  in- 
creased; the  eosinophiles  and  the  mast  cells  show  both  a  percentage  and  ab- 
solute increase.  The  abnormal  cells,  the  myelocytes,  range  from  30  to  50 
per  cent.  Normoblasts  and  megaloblasts  are  common.  There  is  no  anaemia 
at  first.  The  red  cell  count  may  be  normal,  but  sooner  or  later  angemia  comes 
on,  and  the  count  may  fall  to  2,000,000  per  c.  mm.  The  color  index  is  usu- 
ally low.  The  blood  platelets  are  increased.  Charcot-Leyden  crystals  may 
separate  from  the  clots  and  the  haemoglobin  shows  a  remarkable  tendency  to 
crystallize. 

Aleuk^^mic  Intervals. — It  has  long  been  known  that  the  white  cells 
may  fall  to  normal  or  even  below.  In  a  case  in  the  Johns  Hopkins  Hospital, 
the  leucocytes  diminished  from  500,000  per  c.  mm.  on  Jan.  26  to  6,000  on 
Feb.  16,  and  throughout  the  greater  part  of  March  were  as  low  as  2,000  per 
c.  mm.  This  followed  the  use  of  arsenic.  With  this  the  spleen  may  or  may 
not  reduce.  The  same  may  occur  spontaneouslj'',  but  has  been  frequently 
seen  following  the  benzol,  radium  and  X-ray  treatment.  The  question  arises 
whether  it  is  always  possible  in  the  aleuksemic  intervals  to  diagnose  the  dis- 
ease from  the  examination  of  the  blood.  In  some  cases  the  films  are  normal. 
These  aleukemic  phases  are  not  rare  but  unfortunately  are  only  transitory. 

II.  Lymphoid  Leukemia. — Less  common,  this  occurs  in  acute  and  chron- 
ic forms. 

A.  Acute  Lymphatic  Leukemia  (acute  lymphadenosis)  is  the  most 
terrible  of  all  blood  diseases.  It  occurs  in  younger  persons  and  more  fre- 
quently in  males.  In  onset  and  course  the  disease  resembles  an  acute  infec- 
tion. Swelling  of  the  tonsils,  ulcerative  angina,  stomatitis,  fever,  haemor- 
rhages and  a  rapid  anaemia  are  the  dominant  features.  Dyspnoea,  nausea, 
vomiting,  and  diarrhoea  are  not  uncommon.  Some  cases  resemble  fulminant 
purpura,  and  cutaneous  haemorrhages  may  be  present  before  the  patient  feels 
ill.  The  glands  of  the  neck  enlarge  and  usually  other  groups,  but  death  may 
occur  without  marked  adenitis.  The  spleen  is  usually  palpable,  rarely  very 
large.  Heemorrhages  from  the  mucous  membranes  and  into  the  serous  sacs 
are  common.  The  course  is  rapid,  and  death  may  occur  within  a  week  of 
onset;  more  often  in  from  three  to  six  weeks.  Remissions  may  occur  and  a 
case  beginning  acutely  may  linger  for  three  or  four  months. 

Leukcemia  cutis,  most  common  in  this  form,  is  characterized  by  nodular 
tumors  in  the  skin,  which  may  break  down  rapidly,  haemorrhages,  pigmenta- 
tion of  the  skin,  and  fever.  The  spleen  and  lymph  glands  may  be  little,  if  at 
all,  enlarged. 


LEUKEMIA  737 

The  hlood  picture  in  the  acute  form  may  give  the  only  data  for  diagnosis. 
The  anaemia  is  rapid  with  tlie  usual  changes  in  the  blood  cells.  The  leucocytes 
are  increased  but  less  as  a  rule  than  in  the  myeloid  forms.  Counts  of  100,000- 
200,000  per  c.  mm.  are  frequent  and  the  count  may  rise  to  above  1,000,000. 
The  distinctive  feature  is  the  predominance  of  large  lymphocytes,  usually  over 
90  per  cent.  Atypical  blood  pictures  may  be  met  with — a  mixed  small  and 
large  lymphocytosis,  macrolymphocytes  and  their  variants. 

The  enlargement  of  the  spleen  and  lymph  glands  is  less  marked  than  in 
the  myeloid  form.  Lymphoid  swellings  in  the  mouth,  throat  and  intestines 
are  common,  and  small  tumors  may  be  widely  scattered  on  the  serous  mem- 
branes, skin,  in  the  lungs,  and  even  in  the  nervous  system.  The  bone  marrow 
is  deep  red,  but  the  changes  depend  much  on  the  duration  of  the  disease. 

B.  Chronic  Lymphatic  Leukemia  (chronic  lymphadenosis)  is  less 
common.  Its  existence  has  been  denied,  but  cases  of  three,  five,  ten  and  thirteen 
years'  duration  have  been  reported.  A  patient  of  W.  H.  Draper's  of  New  York 
seen  ten  years  after  the  onset  had  a  sheaf  of  blood  counts  from  every  clinician 
of  note  in  Europe  and  the  United  States.  There  was  no  anaemia,  the  leucocytes 
were  242,000  per  c.  mm.,  the  superficial  lymph  glands  were  enlarged  and  the 
spleen  of  moderate  size. 

It  occurs  in  older  persons,  rarely,  if  ever,  in  children;  the  general  health 
may  be  very  good  and  the  only  inconvenience  felt  is  from  the  bunches  of  en- 
larged glands.  The  spleen  is  rarely  very  large;  the  mesenteric  and  retroperi- 
toneal groups  may  form  big  tumors.  After  lasting  two  or  more  years  acute 
symptoms  may  come  on — fever,  haemorrhages,  stomatitis,  tonsillitis.  Pigmenta- 
tion of  the  skin,  itching  with  urticaria  and  lymphomas  may  be  present,  giving 
a  skin  picture  very  like  that  of  Hodgkin's  disease.  The  blood  shows  at  first 
little  or  no  anaemia.  The  leucocytes  are  usually  above  100,000  per  c.  mm. 
and  very  high  counts  are  common.  The  small  lymphocytes  predominate  up 
to  90-95  per  cent.  The  large  forms  are  rare  until  the  late  stages  when 
ansemia  supervenes  and  the  other  elements  show  little  or  no  change. 

Atypical  Leukaemias. —  (1)  Mixed  leukaemias,  in  part  myeloid  and  in 
part  lymphoid;  but  in  nearly  all  cases  of  the  ordinary  spleno-medullary  leu- 
kaemia a  certain  percentage  of  lymphocytes  is  present,  which  toward  the 
end  may  be  materially  increased. 

(2)  Cases  luith  atypical  hlood  changes,  such  as  a  very  high  percentage  of 
eosinophiles,  or  a  condition  with  a  very  high  proportion  of  plasma  cells. 

(3)  Chloroma  is  an  atypical  lymphoid  leukaemia  in  which  the  lymphatic 
tumors  have  a  greenish  color.  It  is  more  common  in  children.  Exophthal- 
mos is  frequent  owing  to  tumor  formation  in  the  orbit.  The  tumor  growths 
occur  chiefly  in  the  skull,  the  orbit,  the  long  bones,  and  throughout  the  vis- 
cera. The  typical  picture  of  this  distribution  may  be  present  without  the 
green  tint  of  chloroma.    The  nature  of  the  pigment  is  unknown. 

(4)  In  a  few  rare  instances  a  condition  of  leukamia  has  been  found  with- 
out changes  in  the  blood-making  organs. 

(5)  Leukancemia. — This  term  was  invented  by  Leube  to  describe  a  condi- 
tion showing  features  both  of  leukamia  and  severe  anaemia.  The  cases  are 
now  regarded  as  a  myeloid  leukamia  with  severe  anaemia.  Glandular  en- 
largement is  usually  present ;  the  onset  may  be  like  the  acute  types  of  leukae- 
mia, and  the  blood  pictiii'c  cithor  of  the  lymphoid  or  of  the  myeloid  type. 


738  DISEASES  OF  THE  BLOOD-FOEMING  ORGANS 

Diagnosis. — The  recognition  of  the  acute  forms  may  be  difficulty,  particu- 
larly those  which  begin  with  marked  angina  and  cutaneous  haemorrhages.  It 
may  not  be  until  a  blood  examination  is  made  or  the  glands  enlarge  that 
suspicion  is  aroused.  The  chronic  forms  are  easily  recognized.  The  enlarged 
spleen  at  once  suggests  a  blood  count,  upon  which  alone  the  diagnosis  rests. 
The  diagnosis  may  be  made  by  the  ophthalmic  surgeon.  In  the  lymphatic 
form,  too,  the  diagnosis  rests  with  the  blood  examination.  One  has  to  recog- 
nize that  there  are  certain  cases  of  sepsis  with  marked  lymphocytosis,  in  which 
the  white  blood-corpuscles  may  reach  30,000  or  40,000  per  c.  mm.  When  the 
regional  lymph  glands  are  involved  this  may  raise  a  doubt.  Cabot  gives  an 
instance  of  a  child  in  whom  after  pneumonia  and  whooping-cough  there  was  a 
leucocytosis  of  94,000  per  c.  mm.  It  is  important  to  remember  that  in  the 
ordinary  myelitic  forms  under  treatment  with  arsenic  or  with  X-rays  the  in- 
crease of  leucocytes  may  disappear,  but  the  differential  count  may  still  be 
characteristic. 

Prognosis. — Recovery  in  leukemia  is  practically  unknown.  The  acute 
cases  die  within  three  months ;  the  fchronic  forms  last  from  six  months  to  four 
or  five  years.     The  chronic  lymphatic  form  is  the  most  protracted. 

Association  with  Other  Diseases. — Tuberculosis  is  not  uncommon.  Dock 
collected  27  cases,  in  none  of  which  did  the  tuberculosis  show  any  special  in- 
fluence. Intercurrent  infections  as  influenza,  erysipelas,  or  sepsis  may  have 
a  remarkable  effect  upon  the  disease.  In  a  case  reported  by  Dock,  after  an 
attack  of  influenza  the  leucocytes  fell  from  367,000  to  7,500  per  c.  mm.  A 
course  of  antistreptococcic  serum  may  do  the  same. 

Treatment. — Fresh  air,  good  diet,  and  abstention  from  mental  worry  and 
care  are  the  important  general  indications.  The  indicatio  morhi  can  not  be 
met.     There  are  certain  remedies  which  have  an  influence  upon  the  disease. 

Of  these  arsenic  is  the  best.  Fowler's  solution  can  be  begun  in  doses  of 
three  drops  and  increased  to  the  limit  of  tolerance  or  sodium  cacodylate  given 
by  injection.  Benzol  has  been  extensively  used  but  should  be  given  with  cau- 
tion and  discontinued  if  there  is  a  drop  in  the  red  cell  count.  If  the  number 
of  leucocytes  decreases  steadily,  the  drug  should  be  discontinued  when  the 
number  falls  to  25,000.  The  dose  is  3  i  (4  c.  c.)  per  day  given  in  capsules 
with  olive  oil.  The  X-rays,  while  not  curative,  add  to  the  duration  of  life. 
They  should  not  be  used  in  the  acute  forms.  The  exposure  should  be  over  the 
long  bones  at  first  and  care  should  be  taken  to  watch  for  any  signs  of  toxaemia. 
Radium  has  been  successful  in  a  considerable  number  of  cases.  Both  it  and 
the  X-rays  usually  cause  a  marked  drop  in  the  leucocytes.  Either  may  be 
used  with  arsenic  or  benzol  administration.  Removal  of  the  spleen  has  been 
done  after  radium  treatment  but  the  value  of  this  is  doubtful.  Recurrence-  is 
to  be  expected  after  any  treatment. 


m.    HODGKIN'S  DISEASE 

Definition. — A  disease  characterized  by  enlargement  of  the  lymph-glands 
with  progressive  anaemia  and  a  fatal  termination. 

Anatomically  there  is  an  increase  in  the  adenoid  tissue  of  the  glands,  pro- 
liferation of  the  endothelial  cells,  formation  of  mononuclear  and  multiuu- 


HODGKIN'S  DISEASE  739 

clear  giant  cells,  the  presence  of  eosinophiles,  and  thickening  of  the  fibrous 
reticulum. 

History. — In  1832  Hodgkin  recorded  a  series  of  cases  of  enlargement  of 
the  Ij^mphatic  glands  and  spleen.  From  the  motley  group  that  Hodgkin  de- 
scribed, "Wilks  picked  out  the  disease  and  called  it  anwmia  lymphatica.  Other 
names  that  have  been  given  to  it  are  adenie  by  Trousseau,  pseudo-leukcemia 
by  Cohnheim,  and  generalized  lympliadenoma. 

Etiology. — A  widely  spread  disease  in  Europe  and  America,  a  majority  of 
the  cases  occur  in  young  adults,  and  more  frequently  in  males  than  in  fe- 
males. Twins  and  sisters  have  been  known  to  be  attacked.  The  cause  is  un- 
known. Certain  features  suggest  an  acute  infection :  the  rapid  course  of  some 
cases,  the  association  Mdth  local  irritation  in  the  mouth  and  tonsils,  the  fre- 
quency with  which  the  disease  starts  in  the  cervical  glands,  the  gradual  ex- 
tension from  one  gland  group  to  another,  and  the  recurring  exacerbations  of 
fever.  Bunting  and  Yates  described  a  diphtheroid  organism  with  which  they 
produced  in  the  monkey  a  chronic  lymphadenitis  clinically  resembling  Hodg- 
kin's  disease.  Possibly  the  disease  is  a  spirillosis — in  favor  of  which  are  the 
presence  of  eosinophilia,  so  characteristic  of  infection  with  animal  parasites, 
the  presence  of  eosinophilic  cells  in  the  glands,  and  the  influence  of  arsenic 
on  the  disease.  Sternberg  suggested  that  the  disease  was  a  special  form  of 
tuberculosis;  but  the  histological  changes  are  quite  characteristic,  tubercle 
bacilli  are  not  present  in  uncomplicated  cases,  the  tuberculin  test  may  be 
negative,  and  when  present  the  tuberculosis  appears  to  be  a  terminal  infec- 
tion. 

Morbid  Anatomy. — The  superficial  lymph  glands  are  found  most  exten- 
sively involved,  and  from  the  cervical  groups  they  form  continuoiis  chains 
uniting  the  mediastinal  and  axillary  glands.  The  masses  may  pass  beneath 
the  pectoral  muscles  and  even  beneath  the  scapula.  Of  the  internal  glands, 
those  of  the  thorax  are  most  often  affected,  and  the  tracheal  and  bronchial 
groups  may  form  large  masses.  The  trachea  and  the  aorta  with  its  branches 
may  be  completely  surrounded;  the  veins  may  be  compressed,  rarely  the  aorta 
itself.  The  masses  perforate  the  sternum  and  invade  the  lung  deeply.  The 
retroperitoneal  glands  may  form  a  continuous  chain  from  the  diaphragm  to 
the  inguinal  canals.  They  may  compress  the  ureters,  the  lumbar  and  sacral 
nerves,  and  the  iliac  veins.  They  may  adhere  to  the  broad  ligament  and  the 
uterus  and  simulate  fibroids.  At  an  early  stage  the  glands  are  soft  and  elas- 
tic; later  they  may  become  firm  and  hard.  Fusion  of  contiguous  glands  does 
not  often  occur,  and  they  tend  to  remain  discrete,  even  after  attaining  a  large 
size.  The  capsule  may  be  infiltrated,  and  adjacent  tissues  invaded.  On  sec- 
tion the  gland  presents  a  grayish  white  semi-translucent  appearance,  broken 
by  intersecting  strands  of  fibrous  tissue ;  there  is  no  caseation  of  necrosis  un- 
less a  secondary  infection  has  occurred. 

The  spleen  is  enlarged  in  75  per  cent,  of  the  cases;  in  young  children  the 
enlargement  may  be  great,  but  the  organ  rarely  reaches  the  size  of  the  spleen 
in  ordinary  leukaemia.  In  more  than  half  of  the  cases  lymphoid  growths  are 
present.  The  marrow  of  the  long  bones  may  be  converted  into  a  rich  lymphoid 
tissue.  The  lymphatic  structures  of  the  tonsillar  ring  and  of  the  intestines 
may  show  marked  hyperplasia.  The  liver  is  often  enlirged,  and  may  present 
scattered  nodular  tumors,  which  may  also  occur  in  the  kidneys. 


740  DISEASES  OF  THE  BLOOD-FOEMING  OEGANS 

Histology. — The  studies  of  Andrewes  and  of  Dorothy  Reed  show  a  very 
characteristic  microscopic  picture — proliferation  of  the  endothelial  and  reticu- 
lar cells,  with  the  formation  of  lymphoid  cells  of  uniform  size  and  shape,  and 
characteristic  giant  cells,  the  so-called  lymphadenoma  cells,  containing  four 
or  more  nuclei.  Eosinophiles  are  always  present,  and  proliferation  of  the 
stroma  leads  to  fibrosis  of  the  gland.  The  difference  between  the  soft  and  hard 
forms  depends  largely  upon  the  stage.  When  tuberculosis  occurs  as  a  second- 
ary infection  the  two  processes  may  be  readily  distinguished. 

Symptoms. — A  tonsillitis  may  precede  the  onset.  Enlargement  of  the 
cervical  glands  is  usually  an  initial  symptom;  it  is  rare  to  find  other  super- 
ficial groups  or  the  deeper  glands  attacked  first.  Months  or  even  several  years 
may  elapse  before  the  glands  in  the  axillae  and  groin  become  involved.  During 
what  may  be  called  the  first  stage  the  patient's  general  condition  is  good; 
then  ansemia  comes  on,  not  marked  at  first,  but  usually  progressive.  In  the 
majority  of  cases  the  spleen  is  enlarged,  but  it  never  reaches  the  dimension 
of  the  leuksemic  organ.  There  may  be  very  little  pain  until  the  internal 
glands  become  involved.  With  swelling  of  the  mediastinal  glands  there  are 
cough,  dyspnoea,  and  often  intense  cyanosis,  with  all  the  signs  of  intratho- 
racic tumor.  There  may  be  moderate  fever.  Bronzing  of  the  skin  may  occur, 
apart  altogether  from  the  use  of  arsenic.  Pruritus  may  be  a  very  depressing 
symptom,  and  boils  and  ecthymatous  blebs  may  occur.  The  leucocytes  show 
no  characteristic  changes.  There  may  be  a  moderate  eosinophilia  and,  as  the 
aneemia  progresses,  nucleated  red  corpuscles  appear,  and  toward  the  end  there 
are  instances  of  a  great  increase  in  the  lymphocytes.  As  the  disease  progresses 
there  is  marked  emaciation  with  great  asthenia,  and  sometimes  anasarca. 
This  represents  the  common  clinical  course,  but  there  are  many  variations, 
among  which  the  following  are  the  most  common: 

(a)  An  ACUTE  foem  has  been  described.  In  one  case  beginning,  like  so 
many  .cases  of  lymphatic  leukaemia,  with  angina,  the  whole  course  was  less 
than  ten  weeks.     Ziegler  mentions  two  cases  of  death  within  a  month. 

(6)  Localized  Foem. — The  enlargement  may  be  localized  to  certain 
groups,  those  in  the  neck,  the  groin,  the  retroperitoneum,  or  the  thorax.  Some 
of  these  cases  present  great  difficulty  in  diagnosis,  particularly  when  there 
are  febrile  paroxysms  with  very  slight  involvement  of  the  external  groups. 
The  disease  may  be  confined  to  one  region  for  a  year  or  more  before  there  is 
any  extension.  The  localized  mediastinal  group  often  presents  a  very  remark- 
able picture — pressure  signs,  pain,  orthopncea — and,  unless  there  are  other 
groups  involved,  or  enlargement  of  the  spleen,  it  may  be  impossible  to  make 
the  diagnosis  during  life. 

(c)  WiTi-i  Eelapsing  Pyeexia.^To  this  remarkable  type  Pel  and  aft- 
erward Ebstein  called  attention.  MacNalty  made  a  careful  study  of  this 
syndrome,  which  is  one  of  the  most  remarkable  in  medicine.  The  relapsing 
pyrexia  may  occur  in  cases  with  involvement  of  the  internal  glands  alone,  or, 
more  frequently,  with  a  general  involvement  of  all  the  groups.  "Following 
on  a  period  of  low  pyrexia,  or  of  normal  or  subnormal  temperature,  there  is  a 
steady  rise  occupying  two  or  four  days  to  a  maximum,  which  may  reach  105°. 
For  about  three  days  the  temperature  remains  at  a  high  level,  and  then  there 
is  a  gradual  fall  by  lysis  occupying  about  three  days,  and  the  temperature 
then  lieeonies  su1)-noTmar'  (IMacNalty).     Au  afehrilo  period  ol'  ton  rlays  or  two 


HODGKIX'S  DISEASE  7-tl 

weeks  then  oecurt?,  to  be  followed  by  another  bout  of  fever.  This  ma}'  be  re- 
peated for  many  months.  In  one  case  the  pyrexia  lasted  for  exactly  fourteen 
days  for  many  successive  paroxysms.  During  the  fever  the  glands  swell  and 
may  become  hot  and  tender.  This  febrile  type  may  occur  in  connection  with 
involvement  of  the  internal  glands  alone.  In  one  patient  whose  cervical  glands 
had  been  thoroughly  removed  there  were  typical  Pel-Ebstein  paroxysms,  and 
we  could  find  no  enlarged  glands,  internal  or  external. 

(d)  Latext  Type. — In  his  monograph  Ziegler  called  attention  to  the 
importance  of  this  form,  in  which  ana?mia,  fever,  and  constitutional  symp- 
toms may  be  present  with  enlargement  of  the  internal  glands.  In  one  case 
of  this  type  the  retroperitoneal  glands  alone  were  involved.  Symmers  re- 
ported an  instance  in  which  the  glands  and  the  hilus  of  the  liver  were  at- 
tacked. 

(e)  Splenomegalic  Form. — Enlargement  of  the  spleen  is  present  in  a 
large  proportion  of  cases  of  Hodgkin's  disease.  Whether  or  not  there  is  a  type 
involving  the  spleen  alone  without  the  lymph  glands  is  still  a  question.  For- 
merly, under  the  name  pseudo-leukaemia  of  Cohnheim,  many  cases  of  simple 
enlargement  of  the  spleen  with  or  without  anasmia  were  spoken  of  as  pseudo- 
hnl'cemia  splenica.  It  is  not  improbable  that  the  disease  may  originate  in 
the  lymphoid  tissue  of  the  spleen,  and  cases  have  been  reported  by  Ziegler, 
Symmers,  Warrington,  and  others.  It  must  be  very  difficult  to  distinguish 
such  cases  clinically  from  the  early  stages  of  Banti's  disease. 

(/)  Lymphogranulomatosis. — The  skin  lesions  may  be  in  the  form  of  a 
true  lymphogranulomatosis,  which  is  rare,  or  show  a  wide  variety  of  changes. 
Among  these  are :  pruritus,  urticaria,  oedema,  petechise  and  marked  pigmenta- 
tion. 

(g)  Lymphadenia  ossium  has  been  described — cases  in  which  there  have 
been  multiple  bone  tumors  of  the  bone  marrow  and  of  the  periosteum  with 
enlargement  of  the  glands  and  spleen.  How  far  these  should  be  grouped  with 
Hodgkin's  disease  seems  very  doubtful. 

Diagnosis. —  (a)  Tuberculosis. — In  the  case  of  enlargement  of  the  glaiids 
on  one  side  of  the  neck  beginning  in  a  young  person,  it  is  often  not  easy  to 
determine  whether  the  disease  is  tuberculosis  or  beginning  Hodgkin's  dis- 
ease. Two  points  should  be  decided.  First,  one  of  the  small  glands  of  the 
affected  side  should  be  excised  and  the  structure  carefully  studied.  The  his- 
tological changes  in  Hodgkin's  disease  differ  markedly  from  those  in  tubercu- 
losis. Secondly,  tuberculin  should  be  used  if  the  patient  is  afebrile.  In  early 
tuberculosis  of  the  glands  of  the  neck  the  reaction  is  prompt  and  decisive. 
In  the  later  stages,  when  many  groups  of  glands  are  involved  and  cachexia 
well  advanced,  the  tuberculin  reaction  may  be  present  in  Hodgkin's  disease, 
but  even  then  the  histological  changes  are  distinctive.  Other  points  to  be 
noted  are  the  tendency  in  the  tuberculous  adenitis  to  coalescence  of  the 
glands,  adhesion  to  the  skin,  with  suppuration,  etc.,  and  the  liability  to 
tuberculosis  of  the  lung  or  pleura.  There  is  a  type  of  generalized  tuljerculous 
adenitis  which  occurs  particularly  in  negroes  and  simulates  Hodgkin's  dis- 
ease M^ith  enlargement  of  the  gland  groups  in  the  neck,  arms  and  axilla,  never 
perhaps  so  much  as  in  Hodgkin's  disease,  but  firm,  elastic  masses.  There  is 
irregular  remittent  fever,  not  with  periods  of  apyrexia,  the  course  may  be 


742  DISEASES  OF  THE  BLOOD-FORMING  ORGANS 

protracted,  and  at  autopsy  only  the  internal  and  external  lymph  glands  may 
be  found  involved, 

(h)  LEUKuSiMiA.^The  blood  examination  gives  the  diagnosis  at  once,  as 
Hodgkin's  disease  presents  only  a  slight  leucocytosis.  A  difficulty  arises  only 
in  those  instances  of  leuksemia  in  which  the  leucocytes  gradually  decrease 
or  the  number  for  a  time  becomes  normal.  Histologically  there  are  striking 
differences  between  the  structure  of  the  glands  in  the  two  conditions. 

(c)  Lympho-sakcoma. — Clinically  the  cases  may  resemble  Hodgkin's  dis- 
ease very  closely,  and  in  the  literature  the  two  diseases  have  been  confounded. 
The  glands,  as  a  rule,  form  larger  masses,  the  capsules  are  involved,  and  ad- 
jacent structures  are  attacked,  but  this  may  be  the  case  in  Hodgkin's  disease. 
Pressure  signs  in  the  chest  and  abdomen  are  much  more  common  in  lympho- 
sarcoma. But  the  most  satisfactory  mode  of  diagnosis  is  examination  of  sec- 
tions of  a  gland.  The  blood  condition,  the  type  of  fever,  etc.,  need  a  more 
careful  study  in  this  group  of  cases. 

Course. — There  are  acute  cases  in  which  the  enlargements  spread  rapidly 
and  death  follows  in  a  few  months.  As  a  rule,  the  disease  lasts  for  two  or 
three  years.  Remarkable  periods  of  quiescence  may  occur,  in  which  the 
glands  diminish  in  size,  the  fever  disappears,  and  the  general  condition  im- 
proves. Even  a  large  group  of  glands  may.  almost  completely  disappear,  or 
a  tumor  mass  on  one  side  of  the  neck  may  subside  while  the  inguinal  glands 
are  enlarging.  Usually  a  cachexia  with  anaemia  and  swelling  of  the  feet  pre- 
cedes death.  A  fatal  event  may  occur  early  from  great  enlargement  of  the 
mediastinal  glands. 

Treatment. — When  the  glands  are  small  and  limited  to  one  side  of  the 
neck,  operation  should  be  advised;  even  v/hen  both  sides  of  the  neck  are  in- 
volved, if  there  are  no  signs  of  mediastinal  growth,  operation  is  justifiable. 
The  course  of  the  disease  may  be  delayed,  even  if  cure  does  not  follow. 

Radium  or  the  X-rays  do  good  in  selected  cases.  Certainly  the  glands 
have  been  reduced  in  size,  but  there  is  no  proof  of  a  complete  cure.  Other 
local  treatment  of  the  glands  seems  to  do  but  little  good. 

Arsenic  is  the  only  drug  which  has  a  positive  value  and  in  some  cases 
the  effects  on  the  glands  are  striking.  It  may  be  given  in  the  form  of  Fowler's 
solution  in  increasing  doses.  Recoveries  have  been  reported  (?).  Ill  effects 
from  the  larger  doses  are  rare.  Peripheral  neuritis  followed  the  use  of 
3  i'^j  o  j,  nx  xviij  during  a  period  of  less  than  three  months.  Quinine  and  iron 
are  useful  as  tonics.    For  the  pressure  pains  morphia  should  be  given. 


IV.     PURPURA 

Strictly  speaking,  purpura  is  a  symptom,  not  a  disease;  but  under  this 
term  are  conveniently  arranged  a  number  of  affections  characterized  by  ex- 
travasations of  the  blood  into  the  skin.  In  the  present  state  of  our  knowledge 
a  satisfactory  classification  can  not  be  made.  W.  Koch  groups  all  forms,  in- 
cluding haemophilia,  under  the  designation  hcpmorrhagic  diathesis,  believing 
that  intermediate  forms  link  the  mild  purpura  simplex  and  the  most  intense 
purpura  h^emorrhagica.  For  a  full  discussion  of  the  subject  see  Pratt's  ar- 
ticle in  our  "System  of  Medicine,"  Vol.  IV. 


PURPUEA  743 

The  purpuric  spots  vary  from  1  to  3  or  4  mm,  iu  diameter.  When  small 
and  pin-point-like  they  are  called  petechiae;  when  large,  they  are  known  as 
ecchymoses.  At  first  bright  red  in  color,  they  become  darker,  and  gradually 
fade  to  brownish  stains.     They  do  not  disappear  on  pressure. 

The  following  is  a  provisional  grouping  of  the  cases : 

Symptomatic  Purpura. —  (a)  Infectious. — In  pysemia,  septicgemia,  and 
malignant  endocarditis  (particularly  in  the  last  affection)  ecchymoses  may 
be  very  abundant.  In  typhus  fever  the  rash  is  always  purpuric.  Measles, 
scarlet  fever,  and  more  particularly  small-pox  and  cerebro-spinal  fever,  have 
each  a  variety  characterized  by  an  extensive  .purpuric  rash. 

(h)  Toxic. — The  virus  of  snakes  produces  extravasation  of  blood  with 
great  rapidity — a  condition  carefully  studied  by  Weir  Mitchell.  Certain  medi- 
cines, particularly  copaiba,  quinine,  belladonna,  mercury,  ergot,  and  the  io- 
dides occasionally,  are  followed  by  a  petechial  rash.  Purpura  may  follow  the 
use  of  comparatively  small  doses  of  iodide  of  potassium.  A  fatal  event  may 
be  caused  by  a  small  amount,  as  in  a  case  reported  by  Stephen  Mackenzie  of  a 
child  who  died  after  a  dose  of  2%  grains.  An  erythema  may  precede  the 
hgemorrhage.  It  is  not  always  a  simple  purpura,  but  may  be  an  acute  febrile 
eruption  of  great  intensity.  Workers  with  benzol,  which  is  used  as  a  solvent 
for  rubber,  may  be  attacked  with  severe  purpura.  Cases  such  as  those  reported 
by  Selling  have  been  in  connection  with  the  coating  of  tin  cans,  while  the 
Swedish  cases  occurred  in  connection  with  the  manufacture  of  bicycle  tires. 
Under  this  division,  too,  comes  the  purpura  so  often  associated  with  jaundice. 

(c)  Cacpiectic, — Under  this  heading  are  best  described  the  instances  of 
purpura  which  occur  in  the  constitutional  disturbance  of  cancer,  tuberculo- 
sis, Hodgkin's  disease,  nephritis,  scurvy,  and  in  the  debility  of  old  age.  In 
these  cases  the  spots  are  usually  confined  to  the  extremities.  They  may  be 
very  abundant  on  the  lower  limbs  and  about  the  wrists  and  hands.  This 
constitutes,  probably,  the  commonest  variety  of  the  disease,  and  many  exam- 
ples of  it  can  be  seen  in  the  wards  of  any  large  hospital. 

(d)  Neurotic. — One  variety  is  met  with  in  cases  of  organic  disease.  It 
is  the  so-called  myelopathic  purpura,  which  is  seen  occasionally  in  tabes  dor- 
salis,  particularly  following  attacks  of  the  lightning  pains  and,  as  a  rule,  in- 
volving the-  area  of  the  skin  in  which  the  pains  have  been  most  intense. 
Cases  have  been  met  with  in  acute  and  transverse  myelitis,  and  occasionally 
in  severe  neuralgia.  Another  form  is  the  remarkable  hysterical  condition  in 
which  stigmata,  or  bleeding  points,  appear  upon  the  skin. 

(e)  Mechanical. — This  variety  is  most  frequently  seen  in  venous  stasis 
of  any  form,  as  in  the  paroxysms  of  whooping  cough,  in  epilepsy  and  about 
tight  bandages. 

Arthritic  Purpura. — This  form  is  characterized  by  involvement  of  the 
joints.  It  is  usually  known,  therefore,  as  "rheumatic,"  though  in  reality  the 
evidence  upon  which  this  view  is  based  is  not  conclusive.  Of  200  cases  of 
purpura  analyzed  by  Stephen  Mackenzie,  61  had  a  history  of  rheumatism.  It 
seems  more  satisfactory  to  use  the  designation  arthritic.  Three  groups  of 
cases  may  be  recognized : 

(a)  Purpura  Simplex. — A  mild  form,  often  known  as  purpura  simplex, 
seen  most  commonly  in  children,  in  whom,  with  or  without  articular  pain, 
a  crop  of  purpuric  spots  appears  upon  the  legs,  less  commonly  upon  the  trunk 


744  DISEASES  OF  THE  BLOOD-FORMIXG  ORGANS 

and  arms.  As  pointed  out  by  Graves^  this  form  may  be  associated  with 
diarrhcea.  The  disease  is  seldom  severe.  There  may  be  loss  of  appetite,  and 
slight  anasmia.  Fever  is  not,  as  a  rule,  present,  and  the  patients  get  well  in 
a  week  or  ten  days.  Usually  regarded  as  rheumatic,  and  certainly  associated, 
in  some  instances,  with  rheumatic  manifestations,  yet  in  a  majority  of  the 
patients  the  arthritis  is  slighter  than  in  rheumatic  fever  and  no  other  mani- 
festations are  present.  The  average  duration  is  six  weeks,  but  there  are 
elironic  cases  lasting  a  year  or  more. 

(h)  PrRPURA  (Peliosis)  Eheumatica  {Schdnleins  Disease). — ^This  re- 
markable affection  is  characterized  by  multiple  arthritis  and  an  eruption 
which  varies  greatly  in  character,  sometimes  purpuric,  more  commonly  asso- 
ciated with  urticaria  or  with  erythema  exudativum.  The  purpuric  spots  are 
of  small  size  and  appear  in  successive  crops.  The  disease  is  most  common  in 
males  between  the  ages  of  twenty  and  thirty.  It  not  infrequently  sets  in  with 
sore  throat,  a  fever  from  101°  to  103°,  and  articular  pains.  The  rash,  which 
makes  its  appearance  first  on  the  legs  or  about  the  affected  joints,  may  be  a 
simple  purpura  or  may  show  ordinary  urticarial  wheals.  In  other  instances 
there  are  nodular  infiltrations,  not  to  be  distinguished  from  erythema  nodo- 
sum. The  combination  of  wheals  and  purpura,  the  purpura  urticans,  is  very 
distinctive.  Much  more  rareh'  vesication  is  met  with,  the  so-called  pemphigoid 
purpura.  The  amount  of  oedema  is  variable;  occasionally  it  is  excessive. 
These  are  the  cases  which  have  been  described  as  febrile  purpuric  cedeina.  The 
temperature  range,  in  mild  cases,  is  not  high,  but  may  reach  102°  or  103°  F. 

The  urine  is  sometimes  reduced  in  amount  and  may  be  albuminous.  The 
joint  afl'ections  are  usually  slight,  though  associated  with  much  pain,  par- 
ticularly as  the  rash  comes  out.  Eelapses  may  occur  and  the  disease  may 
return  at  the  same  time  for  several  years  in  succession. 

The  diagnosis  of  Schonlein's  disease  oifers  no  difficulty.  The  association 
of  multiple  arthritis  with  purpura  and  urticaria  is  very  characteristic. 

Schonlein's  peliosis  is  thought  b}^  most  writers  to  be  of  rheumatic  origin, 
and  certainly  many  of  the  cases  have  the  characters  of  ordinary  rheumatic 
fever,  plus  purpura.  By  man}',  however,  it  is  regarded  as  a  special  affection, 
of  which  the  arthritis  is  a  manifestation  analogous  to  that  which  occurs  in 
haemophilia  and  scurvy.  The  frequency  with  which  sore  throat  precedes  the 
attack,  and  the  occasional  occurrence  of  endocarditis  or  pericarditis,  are  cer- 
tainly very  suggestive  of  true  rheumatism. 

The  cases  usuall}'  do  well,  and  a  fatal  event  is  extremely  rare.  The  throat 
s}Tnptoms  may  persist  and  give  trouble.  In  some  instances  necrosis  and 
sloughing  of  a  portion  of  the  uvula  has  followed. 

YiscEEAL  Lesioxs  IX  PURPURA. — In  any  form  of  purpura,  in  the  ery- 
themas, and  in  urticaria  visceral  lesions  may  occur,  (a)  Gastro-intestinal 
crises,  pain,  vomiting,  melsena,  and  diarrhoea.  The  attacks  have  often  been 
mistaken  for  appendicitis  or  for  intussusception,  and  at  operation  the  condi- 
tion has  been  found  to  be  an  acute  sero-hajmorrhagic  infiltration  of  a  limited 
area  of  the  stomach  or  bowel.  Identical  attacks  occur  in  angio-neurotic  cedema. 
These  crises  may  occur  for  years  in  children  before  an  outbreak  of  purpura  or 
urticaria  gives  a  clue  to  their  nature,  (h)  Enlargement  of  the  spleen  is 
usually  present  in  these  cases,  (c)  Albuminuria  and  acute  nephritis  may 
occur  and  form  the  most  serious  complication,  of. which  seven  cases  in  the 


PUEPUEA 


745 


series  died  (Am.  J.  Med.  Sc,  Jan.,  1904).    The  combination  of  purpura  with 
colic  is  usually  spoken  of  as  Henoch's  purpura. 

Chronic  Purpura. — For  years  patients  may  have  outbreaks  of  purpura  with- 
out serious  symptoms.  One  patient  was  practically  never  free  from  spots 
somewhere  on  the  skin  for  thirty-three  years,  during  which  time  she  had  had 
several  severe  attacks  of  nose-bleed,  during  which  the  purpura  increased 
greatly.  x\nother  patient  had  recurring  purpura  on  the  legs  for  many  years, 
with  great  pigmentation  and  thickening  of  the  skin.     There  is  a  form  of  in- 


APRIL.                                       MAY.                                                   JUNE.                                  JULY. 

5SSSgS.,,»  =  2J:;:S;S3SSSS-»«^»::2::-2SSSSS-".«"- 

■no% 

n^ 

100^ 

5,000,000 

'  1 

90% 

c 

X  1 

80^ 

4,000,  OOO 

1    i^Tl —               1 

! 

y"          y     1 

70% 

1 

I 

^' 

/-          T';/—^ 

J^ 

r 

^^"T             i 

60^ 

3,000,( 

)00 

^ 

/ 

1 

^ 

r-^^"^                        1 

\ 

/ 

" 

^ 

T  i                     i 

50^ 

V 

v 

/ 

'■ 

^ 

» 

\ 

,► 

,^ 

^ 

.- 

40% 

2,000,000 

/ 

/ 

w 

/ 

j 

1    I             t 

30^ 

1 

-■}: — iS: — -i:—  -i. 

-i 

!-- 

' 

-c- 

.•— 

- 

-■:■ 

_ 

- 

t! 

-\ 

- 

; .!.  _L.!. : s. 'i!-\-  V — ri 

1 

14,000 

t 

12.000 

'S 

i        T 

10,000 

^ 

s 

8,000      i 

\ 

6,000 

^H 

- 

■^ 

^ 

=jj 

», 

4,000 

■"^s. 

2,000 

^^ 

CORPUSCLES 


BLACK.  RED  CORPUSCLES. 


RED,  HAEMAGLOBIN, 


BLUE,  COLORLESS  CORPUSCLES. 


(JH.A.RT  XVI. — The  Rapidity  with  which  Anaemia  is  Produced  in  Purpura  H^mob- 

RHAGICA,  AND  THE  GRADUAL  RECOVERY. 


termittent  purpura  with  attacks  over  long  series  of  years,  as  long  as  twenty, 
sometimes  only  on  the  skin,  at  other  times  with  involvement  of  the  mucous 
membranes  (Eisner). 

Purpura  Haemorrhagica. — Under  this  heading  may  be  considered  cases  of 
very  severe  purpura  with  hsernorrhages  fr(?m  the  mucous  membranes.  The 
affection,  known  as  the  morbus  maculosus  of  Werlhof,  is  most  common  in 
young  and  delicate  individuals,  particularly  in  girls;  but  the  disease  may  at- 
tack adults  in  full  vigor.  After  a  few  days  of  weakness  and  debility,  pur- 
puric spots  appear  on  the  skin  and  rapidly  increase  in  number  and  size. 
Bleeding  from  the  mucous  surfaces  sets  in,  and  the  epistaxis,  hfematuria,  and 
hemoptysis  may  cause  profound  angemia.     Death  may  take  place  from  loss 


746  DISEASES  OF  THE  BLOOD-FORMING  ORGANS 

of  blood,  or  from  haemorrhage  into  the  brain.  Slight  fever  usually  accom- 
panies the  disease.  In  favorable  cases  the  affection  terminates  in  from  ten 
days  to  two  weeks,  but  the  average  duration  is  two  months  and  there  are 
chronic  forms  which  persist  for  years.  There  are  instances  of  purpura  hsemor- 
rhagica  of  great  malignancy,  which  may  prove  fatal  within  twenty-four  hours 
— purpura  fulminans.  This  form  is  most  common  in  children,  is  character- 
ized chieflj'  by  cutaneous  hasmorrhages,  and  death  may  occur  before  any  bleed- 
ing takes  place  from  the  mucous  membranes. 

In  the  diagnosis  of  purpura  hgemorrhagica  it  is  important  to  exclude 
Scurvy,  which  may  be  done  by  the  consideration  of  the  previous  health,  the 
circumstances  under  which  the  disease  occurs,  and  by  the  absence  of  swelling 
of  the  gums.  The  malignant  forms  of  the  fevers,  particularly  small-pox  and 
measles,  are  distinguished  by  the  prodromes  and  the  higher  temperature.  As 
regards  the  special  blood  features,  the  blood  plates  are  markedly  decreased, 
there  is  prolonged  bleeding  time  and  a  non-retractile  soft  blood  clot.  In  the 
other  purpuras  the  blood  plates  are  normal.  The  special  points  in  the  diag- 
nosis from  haemophilia  are  considered  under  that  disease.  The  possibility  of 
mistaking  the  acute  forms  of  leukaemia  for  purpura  should  be  kept  in  mind. 

Treatment. — In  symptomatic  purpura  attention  should  be  paid  to  the  con- 
ditions under  which  it  occurs,  and  measures  should  be  employed  to  increase 
the  strength  and  to  restore  a  normal  blood  condition.  Tonics,  good  food,  and 
fresh  air  meet  these  indications.  The  patient  should  always  be  at  rest  in  bed. 
In  the  simple  purpura  of  children,  or  that  associated  with  slight  articular 
trouble,  arsenic  in  full  doses  should  be  given.  No  good  is  obtained  from  the 
small  doses,  but, the  Fowler's  solution  should  be  pushed  freely  until  physiolog- 
ical effects  are  obtained.  In  peliosis  rheumatica  the  sodium  salicylate  may 
be  given,  but  with  discretion.  It  does  not  seem  to  have  any  special  control 
over  the  haemorrhages. 

Aromatic  sulphuric  acid  (iTl,  xv-xxx,  1-2  c.  c.)  may, be  given  three  times 
a  day,  but  oil  of  turpentine  is  perhaps  the  best  remedy,  in  10  or  15-minim 
(1  c.  c.)  doses  three  or  four  times  a  day.  The  calcium  salts,  preferably  the 
lactate,  may  be  given  in  doses  of  15  grains  (1  gm.)  three  or  four  times  a  day 
for  a  few  days.  In  bleeding  from  the  mouth,  gums,  and  nose  the  inhalation 
of  carbon  dioxide,  irrigations  with  2-per-cent.  gelatin  solution,  and  epineph- 
rine should  be  tried.  The  last  remedy  has  often  acted  promptly.  The  treat- 
ment of  the  severe  forms  is  the  same  as  that  given  in  haemophilia.  The 
intramuscular  injection  of  20-40  c.  c.  of  citrated  blood  is  the  most  useful 
measure  in  severe  cases. 

HyEMORRHAGIC  DISEASES  OF  THE  NEW-BORN 

SypMlis  Haemorrhagica  Neonatorum. — The  child  may  be  born  healthy, 
or  there  may  be  signs  of  hemorrhage  at  birth.  Then  in  a  few  days  there 
are  extensive  cutaneous  extravasations  and  bleeding  from  the  mucous  sur- 
faces and  from  the  navel.  The  child  may  become  deeply  jaundiced.  The 
post  mortem  shows  numerous  extravasations  in  the  internal  organs  and  exten- 
sive syphilitic  changes  in  the  liver  and  other  organs. 

Epidemic  Haemoglobinuria  {WinckeX's  Disease). — Hemoglobinuria  in  the 
new-born,  which  occasionally  occurs  in  epidemic  form  in  lying-in  institutions, 


HEMOPHILIA  747 

is  a  very  fatal  affection,  which  sets  in  usually  about  the  fourth  day  after  birth. 
The  cliild  becomes  jaundiced,  and  there  are  marked  gastro-intestinal  symp- 
toms, with  fever,  jaundice,  rapid  respiration,  and  sometimes  cyanosis.  The 
urine  contains  albumin  and  blood  coloring  matter — methaemoglobin.  The 
disease  has  to  be  distinguished  from  the  simple  icterus  neonatorum,  Avith  wbich 
there  may  sometimes  be  blood  or  blood  coloring  matter  in  the  urine.  The 
post  mortem  shows  an  absence  of  any  septic  condition  of  the  umbilical  ves- 
sels, but  the  spleen  is  swollen,  and  there  are  punctiform  haemorrhages  in  dif- 
ferent parts.  Some  cases  have  shown  marked  acute  fatty  degeneration  of  the 
internal  organs — the  so-called  Buhl's  disease. 

Morbus  Maculosus  Neonatorum. — Apart  from  the  common  visceral  haem- 
orrhages, the  result  of  injuries  at  birth,  bleeding  from  one  or  more  of  the 
surfaces  is  a  not  uncommon  event  in  the  new-born,  particularly  in  hospital 
practice.  Torty-five  cases  occurred  in  6,700  deliveries  (C.  W.  Townsend). 
The  bleeding  may  be  from  the  navel  alone,  but  more  commonly  it  is  general. 
Of  Townsend's  50  cases,  in  20  the  blood  came  from  the  bowels,  in  1-1  from  the 
stomach,  in  14  from  the  mouth,  in  12  from  the  nose,  in  18  from  the  navel,  in 
3  from  the  navel  alone.  The  bleeding  begins  within  the  first  week,  but  in  rare 
instances  is  delayed  to  the  second  or  third.  Thirty-one  of  the  cases  died  and 
19  recovered.  The  disease  is  usually  of  brief  duration,  death  occurring  in 
from  one  to  seven  days.  The  temperature  is  often  elevated.  The  nature  of 
the  disease  is  unknown.  As  a  rule,  nothing  abnormal  is  found  post  mortem. 
The  general  and  not  local  nature  of  the  affection,  its  self  limited  character, 
the  presence  of  fever,  and  the  greater  prevalence  of  the  disease  in  hospitals 
suggest  an  infectious  origin  (Townsend).  The  bleeding  may  be  associated 
with  intense  haematogenous  jaundice.  Kot  every  case  of  bleeding  from  the 
stomach  or  bowels  belongs  in  this  category.  Ulcers  of  the  oesophagus,  stomach, 
and  duodenum  have  been  found  in  the  new-born.  The  child  may  draw  the 
blood  from  the  breast  and  subsequently  vomit  it. 

Treatment. — The  most  useful  measure  is  the  intramuscular  injection  ol* 
fresh  or  citrated  human  blood  in  amounts  of  20-40  c.  c.  This  should  be 
repeated  every  four  to  eight  hours  if  the  haemorrhage  continues. 


V.    HiEMOPHILIA 

Definition. — A  disease  characterized  by  deficiency  in  the  thromboplastic 
substances,  thereby  rendering  the  individual  liable  to  severe  and  recurring 
haemorrhages.  The  defect  is  hereditary,  confined  to  the  male  sex  but  trans- 
mitted by  the  female  alone. 

History. — Our  knowledge  of  this  remarkable  condition  dates  from  1803, 
when  John  C.  Otto,  a  Philadelphia  physician,  published  "an  account  of  an 
haemorrhagic  disposition  occurring  in  certain  families,"  and  first  used  the 
word  "bleeder."  The  works  of  Grandidier  and  of  Wickham  Legg  give  full 
clinical  details,  and  the  monograph  of  Bulloch  and  Tildes  (Dulan  &  Co.,  Lon- 
don, 1911)  presents  in  extraordinary  detail  every  aspect  of  the  disease. 

Distribution. — A  majority  of  the  cases  have  been  reported  from  Germany, 
Switzerland,  and  the  United  States.  Jews  are  supposed  to  be  more  prone  to 
the  disease,  but  this  Bulloch  doubts,  and  he  discredits  tlie  negro  cases. 


748  DISEASES  OF  THE  BLOOD-FOEMIXG  OEGANS 

Sex. — Bulloch  and  Fildes  claim  to  have  established  the  fact  of  immunity 
in  females^  denying  the  authenticity  of  all  the  published  cases  (19).  "In 
none  of  the  families  of  bleeders  ...  do  we  find  any  unequivocal  evidence  of 
abnormality  in  the  women,  that  is  to  say,  any  abnormality  beyond  what  might 
be  expected  in  any  collection  of  females  taken  at  random." 

Inheritance.- — Otto  pointed  out  in  his  original  paper  that  while  the  fe- 
males do  not  themselves  bleed  they  alone  transmit  the  tendency.  Of  171  re- 
corded instances  of  transmission,  160  conform  to  the  "law  of  ISTasse"  that 
the  disease  is  transmitted  by  the  unaffected  female — "the  conductor"  (Bul- 
loch and  Fildes).  They  explain  the  11  exceptions,  and  conclude  that  the  dis- 
ease is  not  capable  of  being  propagated  through  a  male.  Hsemophilia  with- 
out demonstrable  inheritance  is  very  rare.  It  is  the  best  illustration  in  man 
of  sex-limited  inheritance,  the  mechanism  of  which  has  been  worked  out  so 
beautifully  by  Morgan  and  his  pupils  in  Drosophilia. 

Pathog^enesis. — The  blood  looks  normal.  Delay  in  the  coagulation  time, 
up  to  30  or  even  40  minutes,  and  imperfect  clot  formation  are  the  outstand- 
ing features.  In  contrast  to  purpura  hgemorrhagica  the  platelets  are  normal. 
The  essential  defect  is  a  congenital  inability  to  produce  a  proper  thrombin, 
through  the  agency  of  Avhich  the  fibrinogen  is  converted  into  fibrin.  Sahli 
first  suggested  that  the  disease  was  due  to  a  deficiency  in  the  thrombokinase. 
"It  may  be  classed  as  one  of  the  ferment-deficiency  diseases,  with  a  strong 
hereditary  association  similar  to  other  ferment-deficiency  diseases  such  as 
cystinuria,  alkaptonuria,  etc."  (Vines).  The  deficiency. is  relative,  not  abso- 
lute, and  is  on  the  organic  side  of  the  clotting  mechanism,  and  not  in  the  in- 
organic side,  e.  g.,  due  to  lack  of  calcium  salts.  One  of  the  difficulties  in  ex- 
plaining the  bleeding  in  hsemophilia  is  the  fact  that  the  haemorrhage  con- 
tinues in  spite  of  the  presence  of  clots  in  and  about  the  wound.  Addis  be- 
lieves that  a  higher  amount  of  thrombokinase  is  required  to  produce  rapid 
clotting  in  hEemophilic  than  in  normal  blood.  In  a  wound,  coagulation  may 
occur  only  in  those  parts,  as  at  the  side,  where  the  concentration  of  this  ma- 
terial is  highest;  but  the  clot  itself  prevents  the  addition  of  further  quantities 
of  the  thrombokinase  from  the  tissues,  and  when  the  quantity  of  thrombin 
set  free  from  the  primary  clot  is  insufficient  completely  to  coagulate  the  blood 
in  the  centre  of  the  wound,  the  bleeding  may  continue  indefinitely. 

Symptoms. — "The  cardinal  symptoms  are  three  in  number  ...  an  in- 
herited tendency  in  tnales  to  Meed''  (Bulloch  and  Fildes).  A  trifiing  in- 
jury, of  no  moment  in  a  normal  person,  determines  a  haemorrhage,  which 
has  no  tendency  to  stop,  but  the  blood  trickles  or  oozes  until  death  follows 
or  there  is  spontaneous  arrest.  The  bleeding  may  bo  external,  internal,  or 
into  joints.  A  majority  of  the  attacks  may  be  traced  to  trauma  but  spontane- 
ous bleeding  may  occur.  The  liability  is  first  noticed  in  children  and  per- 
sists to  adult  life,  gradually  diminishing  and  eventually  disappearing.  Tooth 
extraction  is  a  very  common  cause.  Epistaxis  is  a  frequent  occurrence,  head- 
ing the  list  in  Grandidier's  series  of  334  cases.  Other  localities  were :  mouth 
43,  stomach  15,  bowels  36,  urethra  16,  lungs  17,  and  a  few  instances  of  bleed- 
ing from  the  tongue,  finger-tips,  tear  papilla,  eyelids,  external  ear,  -^mlva, 
navel,  and  scrotum.  Trivial  operations,  as  circumcision,  have  been  followed 
by  fatal  haemorrhage.     Abdominal  colic,  due  to  bleeding  into  the  intestinal 


HEMOPHILIA  .  749 

wall,  may  occur  as  in  Henoch's  purpura.  The  patient  may  be  admitted  to 
hospital  for  appendicitis. 

Hsemarthrosis,  due  to  bleeding  from  the  synovial  membrane,  and  periar- 
ticular bleedings  are  common.  The  knee  is  most  commonly  attacked,  and  the 
affection  has  been  mistaken  for  tuberculosis.  Konig  distinguishes  three  stages 
— ha^marthrosis,  panarthritis,  and  deformity. 

Eugenics. — The  women  of  bleeder  families  should  not  marry  or  marrying, 
they  should  not  bear  children.     Males  may  marry  safely. 

Diagnosis. — The  monograph  by  Bulloch  and  Fildes  should  be  read  by  all 
who  value  accuracy  of  observation  and  of  investigation.  Forms  of  bleeding 
are  so  common  that  it  is  a  simjsle  matter  to  construct  a  pedigree  showing  au 
inherited  "hemorrhagic  diathesis."  It  is  essential  for  the  diagnosis  that  the 
individual  should  have  been  more  or  less  subject  to  bleeding  from  various 
parts  throughout  his  life.  "No  solitary  haemorrhage,  however  inexplicable, 
should,  in  our  opinion,  be  regarded  as  hemophilia;  it  is  necessary  to  show 
that  the  individual  has  been  repeatedly  attacked,  if  not  from  birth,  from 
infancy"  (Bulloch  and  Fildes).  There  is  no  laboratory  method  by  which  we 
can  determine  the  deficiency  of  the  organic  ferment  on  which  the  bleeding  de- 
pends. 

In  the  diagnosis  from  purpura  hemorrhagica  the  following  points  are 
important.  In  hemophilia  puncture  of  the  skin  rarely  causes  hemorrhage,  in 
purpura  it  usually  does;  the  blood  plates  are  normal  in  hemophilia,  much 
reduced  in  purpura;  the  coagulation  time  is  prolonged  in  hemophilia  (but  not 
constantly  so;  it  may  be  normal  in  the  intervals  between  attacks),  normal  or 
nearly  so  in  purpura;  the  "bleeding  time"  is  not  prolonged  in  hemophilia, 
much  prolonged  in  purpura ;  in  hemophilia  the  blood  clot  retracts  normally 
but  not  in  purpura;  the  application  of  a  tourniquet  to  the  upper  arm  is 
without  result  in  hemophilia  but  in  purpura  results  in  the  formation  of  pe- 
techie  on  the  forearm.  As  regards  heredity,  it  is  well  to  remember  that  there 
are  cases  of  hereditary  purpura,  some  being  found  in  hemophiliac  families. 

Treatment. — Rational  treatment  consists  in  an  attempt  to  supply  the 
missing  substance  by  the  injection  of  serum  or  transfusion.  A  most  useful 
measure  is  the  subcutaneous  or  intramuscular  injection  of  fresh  or  citrated 
human  blood  in  doses  of  20  to  40  c.  c.  Previous  testing  is  not  necessary. 
Fresh  blood  or  serum  from  animals,  such  as  the  horse  or  rabbit,  is  also  ef- 
fective given  subcutaneously  in  the  same  dosage.  The  injection  should  be 
repeated  every  twelve  hours  while  necessary.  The  use  of  fresh  anti-diphther- 
itic serum  may  be  effectual.  With  obstinate  bleeding  and  severe  anemia  trans- 
fusion should  be  done.  For  surface  hemorrhage,  compression  should  be  em- 
ployed combined  with  tbe  application  of  various  substances,  as  a  sterile  solu- 
tion of  gelatine  (2  per  cent.),  epinephrine  (1  to  1000),  cocaine  (5  per  cent.), 
or  fresh  blood  or  serum.  The  last  has  been  injected  into  or  around  the  wound 
with  advantage.  Heiujophilia  should  be  excluded  befol'e  any  surgical  opera- 
tion is  done.  The  males  in  hemophiliac  families  should  be  protected  from 
injury  and  active  games  forliidden. 


750  DISEASES  OF  THE  BLOOD-FOEMING  OEGANS 

VI.    ERYTHREMIA 

(Vaquez'  Disease,  Polycythcemia  Vera) 

Definition. — A  symptom-complex  characterized  by  cyanosis,  polycythaemia 
and  splenic  enlargement.  It  seems  probable  that  it  is  not  a  definite  specific 
disease  but  a  syndrome  with  a  varied  etiology  and  pathology.  Lucas  (1912) 
in  a  study  of  the  subject  pointed  out  the  difficulty  of  distinguishing  between 
primary  and  secondary  polycythaemia.  Warthin  has  drawn  attention  to 
"Ayerza's  Disease  or  Syndrome"  in  which  the  features  mentioned  above  were 
associated  with  syphilitic  disease  of  the  pulmonary  arteries.  It  may  be  that 
erythsemia  will  prove  to  be  a  condition  always  secondary  to  various  causes. 
In  the  cases  with  pulmonary  arterio-sclerosis  the  resulting  changes  are  re- 
garded as  compensatory. 

Pathology. — We  see  polycythaemia  as  a  secondary  condition  in  high  alti- 
tudes, and  in  stasis  of  the  blood  in  congenital  heart  disease  and  in  emphysema 
of  the  lungs.  The  high  altitude  hyperglobulism  is  com.pensatory  to  lack  of 
oxygen  in  the  air,  and  there  is  an  increased  activity  of  the  bone  marrow.  In 
erythraemia  proper  an  increased  activity  of  the  bone  marrow  is  present.  The 
splenic  enlargement  is  a  secondary  result  of  increased  blood  formation  and 
destruction.  In  the  cases  with  pulmonary  arterio-sclerosis  there  is  marked 
right  heart  hypertrophy. 

Symptoms. — The  three  cardinal  features  are  a  change  in  the  appearance 
of  the  patient,  enlargement  of  the  spleen,  and  polycythaemia.  The  superficial 
blood  vessels,  capillaries,  and  veins  look  full,  so  that  the  skin  is  always  con- 
gested, in  warm  weather  of  a  brick  red  color,  in  cold  weather  cyanosed.  The 
engorgement  of  the  face  may  be  extreme,  extending  to  the  conjunctivse,  and 
in  the  cold  the  cyanosis  of  the  face  and  hands  may  be  as  marked  as  any  that 
is  ever  seen.  There  is  often  marked  vasomotor  instability,  the  hand  becoming 
deeply  engorged  when  held  down,  and  rapidly  anemic  when  held  up. 

The  spleen  is  usually  enlarged,  but  not  to  the  great  extent  of  leuksemia. 
It  may  vary  in  size  from  time  to  time.    It  is  hard,  firm,  and  painless. 

The  total  bulk  of  blood  is  enormously  increased,  and  the  ratio  of  cor- 
puscles to  plasma  is  high.  The  polycythaemia  ranges  from  7  to  12  or  even 
13  millions  of  red  corpuscles  per  c.  mm.  As  a  rule,  they  are  normal  in  ap- 
pearance and  shape;  nucleated  red  blood-corpuscles  may  be  present,  the  he- 
moglobin ranging  from  130  to  160  per  cent.,  but  the  color  index  is  relatively 
low.  Moderate  leucocytosis.  is  the  rule  with  a  high  percentage  of  mononuclears 
in  some  cases ;  a  few  myelocytes  may  be  present.    The  specific  gravity  is  high. 

Of  other  symptoms  the  most  common  are  incapacity  for  work,  headache, 
flushing,  and  giddiness.  Constipation  is  common,  and  albuminuria  is  usually 
present.  The  blood  pressure  may  be  high;  occasionally  there  may  be  haemor- 
rhages into  the  skin  and  from  the  mucous  membranes,  Eecurring  ascites, 
probably  in  association  with  the  splenic  tumor,  is  present  in  some  cases. 

Christian  has  emphasized  the  frequency  of  nervous  symptoms,  among  whicli 
are  headache,  dizziness,  paresthesias,  paresis  and  paralysis.  Disturbances  of 
vision  are  common.     In  some  cases  the  symptoms  suggest  brain  tumor.     In 


ENTEEOGENOUS  CYANOSIS  751< 

early  stages  circulatory  disturbance  is  probably  responsible;  later  cerebral 
hEemorrhage  or  thrombosis  occurs. 

Morris  reported  three  cases  with  the  general  appearance  of  the  disease  and 
with  slight  enlargement  of  the  spleen,  but  without  polycythaemia.  Geisbock 
described  a  variety,  polycythcemia  hypertonica,  with  increased  tension,  arterio- 
sclerosis, and  nephritis. 

In  the  form  called  "Ayerza's  Disease"  or  "cardiacos  negros"  there  is  head- 
ache, vertigo,  somnolence,  cyanosis,  dyspnoea,  cough,  haemoptysis,  and  polycy- 
thaemia. There  is  a  pulmonary  stage  lasting  for  some  years  followed  by  the 
"cardiacos  negros"  stage  lasting  for  two  to  five  years,  with  marked  enlargement 
of  the  right  heart.  The  X-ray  plate  shows  the  shadow  of  the  dilated  pulmo- 
nary artery. 

Diagnosis. — The  triad  of  features  above  referred  to  are  sufficient  in  the 
absence  of  congenital  heart  disease,  emphysema,  and  forms  of  cyanosis  asso- 
ciated with  poisoning  by  coal  tar  products.  In  a  few  rare  cases  the  poly- 
cythaemia has  been  associated  with  tuberculosis  of  the  spleen. 

Prognosis. — The  prognosis  is  bad  for  cure,  but  the  condition  may  persist 
for  years  with  reasonably  good  health.  Cardiac  failure,  haemorrhage,  and  re- 
curring ascites  have  been  the  usual  modes  of  death. 

Treatment. — When  there  is  much  fullness  of  the  head  and  vertigo,  re- 
peated bleedings  have  given  relief.  Inhalations  of  oxygen  may  be  tried  when 
the  cyanosis  is  extreme.  Saline  purges  and  a  diet  low  in  purin  and  iron  con- 
tent are  also  helpful.  Benzol  is  of  value  in  some  cases.  It  can  be  given  in 
doses  of  1T|_  XV  (1  c.  c.)  three  times  a  day  and  the  dose  increased  even  to  3  i 
(4  c.  c).  The  blood  count  is  a  good  guide  for  the  proper  dose.  If  syphilis  is 
suspected  active  treatment  should  be  given.  The  X-rays  have  done  no  good  in 
our  cases.    Splenectomy  should  not  be  performed. 


VII.     ENTEROGENOUS  CYANOSIS 

(Methcemoglohincemia  and  Sulphcemoglohincemia) 

Definition. — A  form  of  permanent  cyanosis  due  to  changes  in  the  compo- 
sition of  the  hgemoglobin  of  the  blood. 

Etiology. — It  has  long  been  known  that  with  the  use  of  certain  drugs 
changes  were  induced  in  the  haemoglobin.  In  poisoning  by  potassium  chlorate 
methsemoglobiuffimia  occurs  often  with  an  active  haemolysis.  Carbon  monox- 
ide, sulphuretted  hydrogen,  the  coal-tar  products,  acetanilide,  phenacetin,  sul- 
phonal,  and  trional  may  cause  a  chronic  cyanosis.  Stokvis  brought  forward 
evidence  to  show  that  certain  cases  of  chronic  cyanosis  are  associated  with 
intestinal  disturbances,  and  he  gives  this  form  the  name  "enterogenous." 
Some  of  the  forms  are  associated  with  metha^moglobingemia,  others  witli  sul- 
phaemoglobinaemia.  In  a  doubtful  case,  with  absence  of  lesions  of  the  heart  or 
lungs,  a  spectroscopic  examination  of  the  blood  will  determine  if  the  cyanosis 
is  of  this  nature,  and  which  of  the  two  derivatives  of  haemoglobin  is  causing 
it. 

Methsemoglobingemia. — Several  of  the  patients  have  had  chronic  diarrha^a, 
in  two  associated  with  parasites,     In  Stokvis'  case  there  was  clubbing  of  the 


752  DISEASES  OF  THE  BLOOD-FOEMING  OEGANS 

fingers  without  any  recognizable  cause.  Gibson  and  Douglas  obtained  from 
the  blood  of  their  patient  a  pure  culture  of  a  colon  organism  and  suggested 
the  name  "Microbic  cyanosis."  In  connection  with  this  observation  it  may 
be  mentioned  that  methsemoglobinsemia  has  been  met  with  in  Winckel's  dis- 
ease, in  one  case  of  which  the  staphylococcus  has  been  isolated  from  the  blood. 
But  a  still  more  striking  confirmation  is  Boycott's  discovery  of  an  infective 
methgemoglobinaemia  in  rats,  caused  by  Gaertner's  bacillus,  which  gives  a  re- 
markable bluish  tint  to  the  skin  of  white  rats. 

Sulphaemoglobinaemia. — The  appearance  of  the  patients  is  very  much  the 
same.  They  look  very  badly,  even  death-like,  but  feel  comfortable,  and  there 
is  no  shortness  of  breath.  The  main  complaints  are  cyanosis,  constipation, 
weakness  and  headache.  A  nitrite-producing  bacillus  has  been  found  in  the 
saliva  in  some  cases.  Intestinal  disturbances  have  been  present  in  a  number 
of  cases,  and  Garrod  suggests  that  it  is  a  chronic  poisoning  by  hydrogen  sul- 
phide, possibly  absorbed  from  the  intestines.  In  treatment,  foci  of  infection 
should  be  treated,  especially  in  the  mouth,  and  the  patient  should  be  purged 
frequently. 


SECTION  X 

DISEASES  OF  THE  CIRCULATORY  SYSTEM 

A.    DISEASES  OF  THE  PERICARDIUM 

I.     PERICARDITIS 

Pericarditis  is  the  result  of  infective  processes,  primary  or  secondary,  or 
arises  by  extension  of  inflammation  from  cuntiguous  organs. 

Etiolo^. — Primary,  so-called  idiopathic,  inflammation  is  rare ;  but  it  has 
been  met  with  in  children  without  any  evidence  of  rheumatism  or  of  any  local 
or  general  disease.     Certain  of  the  cases  are  tuberculous. 

Pericarditis  from  injury  usually  comes  under  the  care  of  the  surgeon  in 
coimection  with  the  primary  wound.  The  trauma  may  be  from  within,  due 
to  the  passage  of  a  foreign  body — a  needle,  a  pin,  or  a  bone — through  the 
oesophagus — a  variety  exceedingly  common  in  cows  and  horses. 

Secondary  :  (a)  Occurs  most  frequently  in  connection  with  rheumatic 
fever.  In  our  330  cases  of  rheumatic  fever  (Johns  Hopkins  Hospital)  peri- 
carditis occurred  in  twenty — practically  6  per  cent.  The  articular  trouble  may 
be  slight  or,  indeed,  the  disease  may  be  associated  with  acute  tonsillitis  in 
rheumatic  subjects.  Certain  of  the  so-called  idiopathic  cases  have  their  origin 
in  an  acute  tonsillitis.  The  pericarditis  may  precede  the  arthritis,  (h)  In 
septic  processes;  in  the  acute  necrosis  of  bone  and  in  puerperal  fever  it  is  not 
uncommon,  (c)  In  tuberculosis,  in  which  the  disease  may  be  primary  or  part 
of  a  general  involvement  of  the.  serous  sacs  or  associated  with  extensive  pul- 
monary disease,  (d)  In  the  fevers.  Not  infrequent  after  scarlet  fever,  it  is 
rare  in  measles,  small-pox,  typhoid  fever,  and  diphtheria.  In  pneumonia  it  is 
not  uncommon,  occurring  in  31  among  665  cases  (Chatard).  In  184  post 
mortems  there  were  29  instances  of  pericarditis.  It  is  most  frequent  in  double 
pneumonia,  and  in  our  series  with  disease  of  the  right  side,  if  only  one  lung 
was  involved.  Pericarditis  sometimes  complicates  chorea;  it  was  present  in 
19  of  73  autopsies;  in  only  8  of  these  was  arthritis  present,  (e)  Terminal 
pericarditis.  In  gout,  in  chronic  nephritis — pericardite  hrightique  of  the 
French — in  arterio-sclerosis,  in  scurvy,  in  diabetes,  and  in  chronic  illness  of 
all  sorts  a  latent  pericarditis  is  common  and  usually  overlooked. 

(/)  By  Extension. — In  pneumonia  it  is  most  often  met  with  in  children 
and  alcoholics.  \Yith  simple  pleurisy  it  is  rare.  In  ulcerative  endocarditis, 
purulent  myocarditis,  and  in  aneurism  of  the  aorta  pericarditis  is  occasionally 
found.  It  may  also  follow  extension  of  the  disease  from  the  mediastinal 
glands,  the  ribs,  sternum,  vertebrae,  and  even  from  the  abdominal  viscera. 

The  ordinary  pus  cocci,  the  pneumococcus,  and  the  tubercle  l)acillus  are 
the  chief  organisms  met  with  in  acute  pericarditis. 

753 


754  DISEASES  OF  THE  CIECULATOEY  SYSTEM 

Pericarditis  occurs  at  all  ages.  Cases  have  been  reported  in  the  fetus.  In 
the  new-born  it  may  result  from  septic  infection  through  the  navel.  Through- 
out childhood  the  incidence  of  rheumatic  fever  and  scarlet  fever  makes  it  a 
frequent  affection,  whereas  late  in  life  it  is  most  often  associated  with  tubercu- 
losis, nephritis,  and  gout.  Males  are  somewhat  more  frequently  attacked  than 
females.  The  so-called  epidemics  of  pericarditis  have  been  outbreaks  of  pneu- 
monia with  this  as  a  frequent  complication. 

ACUTE    FIBRINOUS   PERICARDITIS 

This,  the  most  common  and  benign  form,  is  distinguished  by  the  small 
amount  of  exudate  which  coats  the  surface  in  a  thin  layer  and  may  be  partial 
or  general.  In  the  mildest  grades  the  membrane  looks  lustreless  and  rough- 
ened, due  to  a  thin  fibrinous  sheeting,  which  can  be  lifted  with  the  knife,  show- 
ing beneath  an  injected  or  ecchymotic  serosa.  As  the  fibrinous  sheeting  in- 
creases in  thickness  the  constant  movement  of  the  adjacent  surfaces  gives  to 
it  sometimes  a  ridge-like,  at  others  a  honeycombed  appearance.  With  more 
abundant  fibrinous  exudation  the  membranes  present  an  appearance  resembling 
buttered  surfaces  which  have  been  drawn  apart.  The  fibrin  is  in  long  shreds, 
and  the  heart  presents  a  curiously  shaggy  appearance — the  hairy  heart  of  old 
writers,  cor  villosum. 

In  mild  grades  the  subjacent  muscle  looks  normal,  but  in  the  more  pro- 
longed and  severe  cases  there  is  myocarditis,  and  for  2  or  3  mm.  beneath  the 
visceral  layer  fhe  muscle  presents  a  pale,  turbid  appearance.  Many  of  these 
acute  cases  are  tuberculous  and  the  granulations  are  easily  overlooked  in  a 
superficial  examination. 

There  is  usually  a  slight  amount  of  fluid  entangled  in  the  meshes  of  fibrin, 
but  there  may  be  very  thick  exudate  without  much  serous  effusion. 

Symptoms. — Unless  sought  for  there  may  be  no  objective  signs,  and  for 
this  reason  it  is  often  overlooked,  and  in  hospitals  the  disease  is  relatively 
more  common  in  the  post  mortem  room  than  in  the  wards. 

Pain  is  a  variable  symptom,  not  usually  intense,  and  in  this  form  rarely 
excited  by  pressure.  It  is  more  marked  in  the  early  stage,  and  may  be  referred 
either  to  the  prsecordia  or  to  the  region  of  the  xiphoid  cartilage.  In  some 
instances  the  pain  is  of  an  aggravated  and  most  distressing  character  resem- 
bling angina.  Fever  is  usually  present,  but  it  is  not  always  easy  to  say  how 
much  depends  upon  the  primary  disease,  and  how  much  upon  the  pericarditis. 
It  is  as  a  rule  not  high,  rarely  exceeding  102.5°  F.  In  rheumatic  cases  hyper- 
pyrexia has  been  observed. 

Physical  Signs. — Inspection  is  negative;  palpation  may  reveal  the  pres- 
ence of  a  distinct  fremitus  caused  by  the  rubbing  of  the  roughened  pericardial 
surfaces.  This  is  usually  best  marked  over  the  right  ventricle.  It  is  not  al- 
ways to  be  felt,  even  when  the  friction  sound  on  auscultation  is  loud  and  clear. 
Auscultation:  The  friction  sound,  due  to  the  movement  of  the  pericardial 
surfaces  upon  each  other,  is  one  of  the  most  distinctive  of  physical  signs.  It 
is  double,  corresponding  to  the  systole  and  diastole ;  but  the  synchronism  with 
the  heart  sounds  is  not  accurate,  and  the  to  and  fro  murmur  usually  outlasts 
th«  time  occupied  by  the  first  and  second  sounds.  In  rare  instances  the  fric- 
tion is  single;  more  frequently  it  appears  to  be  triple  in  character — a  sort  of 


PERICAEDITIS  755 

canter  rh3'thm.  The  sounds  have  a  peculiar  rubbing,  grating  quality,  charac- 
teristic when  once  recognized,  and  rarely  simulated  by  endocardial  murmurs. 
Sometimes  instead  of  grating  there  is  a  creaking  quality — the  hruit  de  cuir 
neiif — the  new  leather  murmur  of  the  French.  The  pericardial  friction  ap- 
pears superficial,  very  close  to  the  ear,  and  is  usually  intensified  by  pressure 
with  the  stethoscope.  It  is  best  heard  over  the  right  ventricle,  the  part  of  the 
heart  most  closely  in  contact  with  the  front  of  the  chest — that  is,  in  the  fourth 
and  fifth  interspaces  and  adjacent  portions  of  the  sternum.  There  are  in- 
stances in  which  the  friction  is  most  marked  at  the  base,  over  the  aorta,  and 
at  the  superior  reflection  of  the  pericardium.  Occasionally  it  is  best  heard  &t 
the  apex.  It  may  be  limited  to  a  very  narrow  area,  or  transmitted  up  and 
down  the  sternum.  There  are,  however,  no  definite  lines  of  transmission  as  in 
endocardial  murmurs.  An  important  point  is  the  variability  of  the  sounds, 
both  in  position  and  quality ;  they  may  be  heard  at  one  visit  and  not  at  an- 
other. The  maximum  of  intensity  will  be  found  to  vary  with  position.  Fric- 
tion may  be  present  with  a  thin,  almost  imperceptible,  layer  of  exudate;  on 
the  other  hand  it  ma}'  not  be  present  with  a  thick,  buttery  layer.  The  rub  may 
be  entirely  obscured  by  the  loud  bronchial  rales  in  pneumonia,  in  which  disease 
pericarditis  is  recognized  clinically  in  about  half  the  cases,  only  13  in  31  cases 
in  the  Hopkins  series. 

Diagnosis. — There  is  rarely  any  difficulty  in  determining  the  jDresence  of 
a  dry  pericarditis,  for  the  friction  sounds  are  distinctive.  The  double  murmur 
of  aortic  insufficiency  may  simulate  closely  the  to  and  fro  pericardial  rub.  The 
constant  character  of  the  aortic  murmur,  the  direction  of  transmission,  the 
phenomena  in  the  arteries,  the  blood  pressure  record,  and  the  associated  con- 
ditions should  prevent  this  error. 

Pleuro-pericardial  friction  is  very  common,  and  may  be  associated  with 
endo-pericarditis,  particularly  in  cases  of  pneumonia.  It  is  frequent,  too,  in 
tuberculosis.  It  is  best  heard  over  the  left  border  of  the  heart,  and  is  much 
affected  by  the  respiratory  movement.  Holding  the  breath  or  taking  a  deep 
inspiration  may  abolish  it.  The  rhythm  is  not  the  simple  to  and  fro  diastolic 
and  systolic,  but  the  respiratory  rhythm  is  superadded,  usually  intensifying 
the  murmur  during  expiration  and  lessening  it  on  inspiration.  In  tubercu- 
losis of  the  lungs  there  are  instances  in  which,  with  the  friction,  a  loud  systolic 
click  is  heard,  due  to  the  compression  of  a  thin  layer  of  lung  and  the  expul- 
sion of  a  bubble  of  air  from  a  softening  focus  or  from  a  bronchus. 

And,  lastly,  it  is  not  very  uncommon,  in  the  region  of  the  apex  beat,  to 
hear  a  series  of  fine  crepitant  sounds,  systolic  in  time,  often  very  distinct,  sug- 
gestive of  pericardial  adhesions,  but  heard  too  frequently  for  this  cause. 

Course  and  Termination. — Simple  fibrinous  pericarditis  never  kills,  but 
it  occurs  so  often  in  connection  with  serious  affections  that  we  have  frequent 
opportunities  to  see  all  stages  of  its  progress.  In  the  majority  of  cases  the 
inflammation  subsides  and  the  thin  fibrinous  lamina)  gradually  become  con- 
verted into  connective  tissue,  which  unites  the  pericardial  surfaces  firmly  to- 
gether. A  very  thin  layer  may  "clear"  without  leaving  adhesions.  In  other 
instances  the  inflammation  progresses,  with  increase  of  the  exudation,  and  the 
condition  is  changed  from  a  "dry"  to  a  "moist"  pericarditis,  or  the  pericarditis 
with   effusion.      In    some   instances   the   simple   plastic   pericarditis   becomes 


756  DISEASES  OF  THE  CIECULATOEY  SYSTEM 

chronic,  and  great  thickening  of  both  visceral  and  parietal  layers  is  gradually 
induced. 

PERICARDITIS    WITH    EFFUSION 

Etiology. — Commonly  a  direct  sequence  of  the  dry  or  plastic  pericarditis, 
of  which  it  is  sometimes  called  the  second  stage,  this  form  is  found  most  fre- 
quently in  association  with  rheumatic  fever,  tuberculosis,  and  septicsemia,  and 
sets  in  usually  with  prsecordial  pain,  with  slight  fever  or  a  distinct  chill.  In 
children  the  disease  may,  like  pleurisy,  come  on  without  local  symptoms,  and, 
after  a  week  or  two  of  failing  health,  slight  fever,  shortness  of  breath,  and 
increasing  pallor,  the  physician  may  find,  to  his  astonishment,  signs  of  ex- 
tensive pericardial  effusion.  These  latent  cases  are  often  tuberculous.  W. 
Ewart  called  special  attention  to  latent  and  ephemeral  pericardial  effusions, 
which  he  thinks  are  often  of  short  duration  and  of  moderate  size,  with  an 
absence  of  the  painful  features  of  pericarditis. 

Morbid  Anatomy. — The  effusion  may  be  sero-fibrinous,  hgemorrhagic,  or 
purulent.  The  amount  varies  from  200  to  300  c.  c.  to  2  litres.  In  the  cases  of 
sero-fibrinous  exudation  the  pericardial  membranes  are  covered  with  thick, 
creamy  fibrin,  which  may  be  in  ridges  or  honeycombed,  or  may  present  long, 
villous  extensions.  The  parietal  layer  may  be  several  millimetres  in  thickness 
and  form  a  firm,  leathery  membrane.  The  hsemorrhagic  exudation  is  usually 
associated  with  tuberculous  or  cancerous  pericarditis,  or  with  the  disease  in 
the  aged.  The  lymph  is  less  abundant,  but  both  surfaces  are  injected  and 
often  show  numerous  hsemorrhages.  Thick,  curdy  masses  of  lymph  are  usually 
found  in  the  dependent  part  of  the  sac.  In  many  cases  the  effusion  is  really 
sero-jDurulent,  a  thin,  turbid  exudation  containing  flocculi  of  fibrin. 

The  pericardial  layers  are  greatly  thickened  and  covered  with  fibrin.  When 
the  fluid  is  pus,  they  present  a  grayish,  rough,  granular  surface.  Sometimes 
there  are  distinct  erosions  on  the  visceral  membrane.  The  heart  muscle  in 
these  cases  becomes  involved  to  a  greater  or  less  extent  and,  on  section,  the 
tissue,  for  a  depth  of  from  2  to  3  mm.,  is  pale  and  turbid,  and  shows  evidence 
of  fatty  and  granular  change.  Endocarditis  coexists  frequently,  but  rarely 
results  from  the  extension  of  the  inflammation  through  the  wall  of  the  heart. 

Symptoms. — Even  with  copious  effusion  the  onset  and  course  may  be  so 
insidious  that  no  suspicion  of  the  true  nature  of  the  disease  is  aroused. 

As  in  the  simple  pericarditis,  pain  may  be  present,  either  sharp  and  stab- 
bing or  as  a  sense  of  distress  and  discomfort  in  the  cardiac  region.  It  is  more 
frequent  with  effusion  than  in  the  plastic  form.  Pressure  at  the  lower  end  of 
the  sternum  usually  aggravates  it.  Dyspnoea  is  a  common  and  important 
symptom,  one  which,  perhaps,  more  than  any  other,  excites  suspicion  of  grave 
disorder  and  leads  to  careful  examination  of  heart  and  lungs.  The  pati&nt  is 
restless,  lies  upon  the  left  side  or,  as  the  effusion  increases,  sits  up  in  bed. 
Associated  with  the  dyspnoea  is  in  many  cases  a  peculiarly  dusky,  anxious 
countenance.  Tlie  pulse  is  rapid,  small;  sometimes  irregidar,  and  may  present 
the  characters  known  as  pulsus  paradoxus,  in  which  during  each  inspiration  the 
pulse  beat  becomes  very  weak  or  is  lost.  These  symptoms  are  due,  in  great 
part,  to  the  direct  mechanical  effect  of  the  fluid  within  the  pericardium  which 
embarrasses  the  heart's  action.  Other  pressure  effects  are  distention  of  the 
veins  of  the  nock,  dvsphagia.  whicli  may  1)C  a  marked  symptom,  and  irritative 


rEKK'ARDITlS  757 

cough  from  coniiDression  of  the  trachea.  Aphonia  is  not  uncommon,  owing 
to  compression  or  irritation  of  the  recurrent  laryngeal  as  it  winds  round  the 
aorta.  In  massive  effusion  the  pericardial  sac  occupies  a  large  portion  of  the 
antero-lateral  region  of  the  left  side  and  the  condition  has  frequently  heen 
mistaken  for  pleurisy.  Even  in  moderate  grades  the  left  lung  is  somewhat 
compressed,  an  additional  element  in  the  production  of  the  dyspnoea. 

Great  restlessness,  insomnia,  and  in  the  later  stages  low  delirium  and  coma 
are  symptoms  in  the  more  severe  cases.  Delirium  and  marked  cerel^ral  symp- 
toms are  associated  with  the  hyperpyrexia  of  rheumatic  cases,  but  apart  from 
the  ordinary  delirium  there  may  be  peculiar  mental  symptoms.  The  patient 
may  become  melancholic  and  show  suicidal  tendencies.  In  other  cases  the  con- 
dition resembles  closely  delirium  tremens.  Sibson,  who  specially  described  the 
condition,  states  that  the  majority  of  such  cases  recover.  Chorea  may  also  oc- 
cur, as  was  pointed  out  by  Bright.  Convulsions  are  rare  but  have  occurred 
during  paracentesis. 

Physical  Signs. — In^spection. — In  children  the  prgecordia  bulges  and 
with  copious  exudation  the  antero-lateral  region  of  the  left  chest  becomes  en- 
larged. A  wavy  impulse  may  be  seen  in  the  third  and  fourth  interspaces,  or 
there  may  be  no  impulse  visible.  The  intercostal  spaces  bulge  somewhat  and 
there  may  be  marked  oedema  of  the  wall.  The  epigastrium  may  be  more  promi- 
nent. Perforation  externally  through  a  space  is  very  rare.  Owing  to  the  com- 
pression of  the  lung,  the  expansion  of  the  left  side  is  greatly  diminished.  The 
diaphragm  and  left  lobe  of  the  liver  may  be  pushed  down  and  may  produce  a 
distinct  prominence  in  the  epigastric  region. 

Palpation. — A  gradual  diminution  and  final  obliteration  of  the  cardiac 
impulse  is  a  striking  feature  in  progressive  effusion.  The  position  of  the  apex 
beat  is  not  constant.  In  large  effusions  it  is  usually  not  felt.  In  children 
as  the  fluid  collects  the  pulsation  may  be  best  seen  in  the  fourth  space,  but  this 
may  not  be  the  apex  itself.  'The  pericardial  friction  may  lessen  with  the  ef- 
fusion, though  it  often  persists  at  the  base  when  no  longer  palpable  over  the 
right  ventricle,  or  may  be  felt  in  the  erect  and  not  in  the  recumbent  posture. 
Fluctuation  can  rarely,  if  ever,  be  detected. 

Percussion  gives  most  important  indications.  The  gradual  distention  of 
the  pericardial  sac  pushes  aside  the  margins  of  the  lungs  so  that  a  large  area 
comes  in  contact  with  the  chest  wall  and  gives  a  greatly  increased  percussion 
dulness.  The  form  of  this  dulness  is  irregularly  pear-shaped ;  the  base  or 
broad  surface  directed  downward  and  the  stem  or  apex  directed  upward  toward 
the  manubrium.  There  is  a  disproportionate  extension  of  dulness  upward  and 
to  the  right,  with  dulness  in  the  right  fifth  interspace  extending  one  or  two 
inches  to  the  right  of  the  sternum  (Eotch's  sign),  Williamson  could  not  verify 
this  in  an  experimental  study.  In  large  effusions  there  may  be  impaired  reso- 
nance in  the  left  axilla,  and  Bamberger  called  attention  to  an  area  of  dulness 
near  the  angle  of  the  scapula  with  bronchial  breathing,  which  may  alter  when 
the  patient  leans  forward. 

Auscultation. — The  friction  sound  heard  in  the  early  stages  may  disappear 
when  the  effusion  is  copious,  but  often  persists  at  the  base  or  at  the  limited 
area  of  the  apex.  It  may  be  audible  in  the  erect  and  not  in  the  recumbent 
posture.  With  the  absorption  of  the  fluid  the  friction  returns.  One  of  the 
most  important  signs  is  the  gradual  weakening  of  the  heart  sounds,  which 


758  DISEASES  OF  THE  CIRCULATOBY  SYSTEM 

Avith  the  increase  in  the  effusion  may  become  so  muffled  and  indistinct  as  to  be 
scarcely  audible.  The  heart's  action  is  usually  increased  and  the  rhythm  dis- 
turbed. Occasionally  a  systolic  endocardial  murmur  is  heard.  Early  and  per- 
sistent accentuation  of  the  pulmonary  second  sound  may  be  present. 

Important  accessory  signs  in  large  effusion  are  due  to  pressure  on  the  left 
lung.  The  antero-lateral  margin  of  the  lower  lobe  is  pushed  aside  and  in  some 
instances  compressed,  so  that  percussion  in  the  axillary  region,  in  and  just 
below  the  transverse  nipple  line,  gives  a  modified  percussion  note,  usually  a 
dull  tympany.  Variations  in  the  position  of  the  patient  may  change  this 
modified  percussion  area,  over  which  on  auscultation  there  is  either  feeble  or 
tubular  breathing.     The  left  lobe  of  the  liver  may  be  pushed  down. 

Course. — Cases  vary  extremely  in  the  rapidity  -with  which  the  effusion 
takes  place.  In  every  instance,  when  a  pericardial  friction  murmur  has  been 
detected,  the  practitioner  should  first  outline  with  care — using  the  aniline 
pencil — the  upper  and  lateral  limits  of  cardiac  dulness,  secondly  mark  the  po- 
sition of  the  apex  beat,  and  thirdly  note  the  intensity  of  the  heart  sounds. 
In  many  instances  the  exudation  is  slight  in  amount,  reaches  a  maximum 
within  forty-eight  hours,  and  then  gradually  subsides.  In  other  instances  the 
accumulation  is  more  gradual  and  progressive,  increasing  for  several  weeks. 
To  such  cases  the  term  chronic  has  been  applied.  The  rapidity  with  which  a 
sero-fibrinous  effusion  may  be  absorbed  is  surprising.  The  possibility  of  the 
absorption  of  a  purulent  exudate  is  shown  by  the  cases  in  which  the  pericar- 
dium contains  semi-solid  grayish  masses  in  all  stages  of  calcification.  With 
sero-fibrinous  effusion,  if  moderate  in  amount,  recovery  is  the  rule,  with  in- 
evitable union,  however,  of  the  pericardial  layers.  In  some  of  the  septic  cases 
there  is  a  rapid  formation  of  pus  and  a  fatal  result  may  follow  in  three  or 
four  days.  More  commonly,  when  death  occurs  with  large  effusion,  it  is  not 
until  the  second  or  third  week  and  takes  place  by  gradual  asthenia. 

Prog^nosis. — In  the  sero-fibrinous  effusions  the  outlook  is  good,  and  a  large 
majority  of  all  the  rheumatic  cases  recover.  The  purulent  effusions  are,  of 
course,  more  dangerous ;  the  septic  cases  are  usually  fatal,  and  recovery  is  rare 
in  the  slow,  insidious  tuberculous  forms. 

Diagnosis. — Probably  no  serious  disease  is  so  frequently  overlooked.  Post 
mortem  experience  shows  how  often  pericarditis  is  not  recognized,  or  goes  on 
to  resolution  and  adhesion  without  attracting  notice.  In  a  case  of  rheumatic 
fever,  watched  from  the  outset,  with  the  attention  directed  daily  to  the  heart, 
it  is  one  of  the  simplest  of  diseases  to  diagnose;  but  when  one  is  called  to  a 
case  for  the  first  time  and  finds  perhaps  an  increased  area  of  prgecordial  dul- 
ness, it  is  often  very  hard  to  determine  with  certainty  whether  or  not  effusion 
is  present.  The  difficulty  usually  lies  in  distinguishing  between  dilatation  of 
the  heart  and  pericardial  effusion.  Although  the  differential  signs  are  simple 
enough  on  paper,  it  is  notoriously  difficult  in  certain  cases,  particularly  in 
stout  persons,  to  say  which  of  the  conditions  exists.  The  points  which  deserve 
attention  are: 

(a)  The  character  of  the  impulse,  which  in  dilatation,  particularly  in  thin- 
chested  people,  is  commonly  visible  and  wavy.  (6)  The  shock  of  the  cardiac 
sounds  is  more  distinctly  palpable  in  dilatation,  (c)  The  area  of  dulness  in 
dilatation  rarely  has  a  triangular  form;  nor  does  it,  except  in  cases- of  mitral 
stenosis,  reach  so  high  along  the  left  sternal  margin  or  so  low  in  the  fifth  and 


PERICARDITIS  759 

sixth  interspaces  ivithout  visible  or  palpable  impulse.  An  upper  limit  of  dul- 
ness  shifting  with  change  of  position  speaks  strongly  for  effusion,  (d)  In 
dilatation  the  heart  sounds  are  clearer,  often  sharp  or  fetal  in  character;  gal- 
lop rhythm  is  common,  whereas  in  effusion  the  sounds  are  distant  and  muf- 
fled, (e)  Rarely  in  dilatation  is  the  distention  sufficient  to  compress  the  lung 
and  produce  the  tympanitic  note  in  the  axillary  region,  or  flatness  behind, 
(/)  The  X-ray  picture  may  be  very  definite,  and  unlike  any  form  of  dilata- 
tion or  hypertrophy  of  the  heart. 

The  number  of  excellent  observers  who  have  acknowledged  that  they  have 
failed  sometimes  to  discriminate  between  these  two  conditions,  and  who  have 
indeed  performed  paracentesis  cordis  instead  of  paracentesis  pericardii,  is  per- 
haps the  best  comment  on  the  difficulties. 

Massive  (1%  to  2-litre)  exudations  have  been  confounded  with  a  pleural 
effusion  and  the  pericardium  has  been  tapped  under  the  impression  that  the 
exudate  was  pleuritic.  The  dull  tympany  in  the  infrascapular  region,  the  ab- 
sence of  well-defined  movable  dulness,  and  the  feeble,  muffled  sounds  are  in- 
dicative points.  Followed  from  day  to  day  there  is  rarely  much  difficulty,  but 
it  is  different  when  a  patient  seen  for  the  first  time  presents  a  large  area  of 
dulness  in  the  antero-lateral  region  of  the  left  chest,  and  there  is  no  to  and 
fro  pericardial  friction  murmur.  Many  of  the  cases  have  been  regarded  as 
encapsulated  pleural  effusions. 

A  special  difficulty  exists  in  recognizing  the  large  exudate  in  pneumonia. 
The  effusion  may  be  very  much  larger  than  the  signs  indicate,  and  the  involve- 
ment of  the  adjacent  lung  and  pleura  is  confusing.  In  at  least  three  cases  in 
our  series  we  should  have  tapped  the  sac;  post  mortem  the  effusion  was  more 
than  a  litre. 

The  nature  of  the  fluid  can  not  positively  be  determined  without  aspira- 
tion ;  but  a  fairly  accurate  opinion  can  be  formed  from  the  nature  of  the  pri- 
mary disease  and  the  general  condition  of  the  patient.  In  rheumatic  cases  the 
exudation  is  usually  sero-fibrinous ;  in  septic  and  tuberculous  cases  it  is  often 
purulent  from  the  outset;  in  senile,  nephritic,  and  tuberculous  cases  the  exu- 
date may  be  haemorrhagic. 

Treatment. — The  patient  should  have  absolute  quiet,  mentally  and  bodily, 
so  as  to  reduce  the  heart's  action  to  a  minimum.  Drugs  given  for  this  pur- 
pose, such  as  aconite  or  digitalis,  are  of  doubtful  utility.  Local  bloodletting 
by  cupping  or  leeches  is  advantageous  in  robust  subjects,  particularly  in  the 
cases  of  extension  in  pneumonia.  The  ice  bag  is  of  great  value.  It  may  be 
applied  to  the  prsecordia  at  first  for  an  hour  or  more  at  a  time,  and  then  con- 
tinuously. It  reduces  the  frequency  of  the  heart's  action  and  seems  to  retard 
the  progress  of  an  effusion.  Blisters  are  not  indicated  in  the  early  stage.  Mor- 
phia should  be  given  for  pain  or  severe  distress. 

When  effusion  is  present,  the  following  measures  to  promote  absorption 
may  be  adopted :  Blisters  to  the  prsecordia,  a  practice  not  so  much  in  vogue 
now  as  formerly.  It  is  surprising,  however,  in  some  instances,  how  quickly 
an  effusion  will  subside  on  their  application.  Purges  and  iodide  of  potassium 
are  of  doubtful  utility.  The  diet  should  be  light,  dry,  and  nutritious.  The 
action  of  the  kidneys  may  be  promoted  by  the  infusion  of  digitalis  and  potas- 
sium acetate. 

When  signs  of  serious  impairment  of  the  heart  occur,  as  indicated  by  dysp- 


760  DISEASES  OF  THE  CIBCrLATOEY  SYSTEM 

noea,  small,  rapid  pulse,  dusky,  anxious  countenance,  paracentesis  or  incision 
of  the  pericardium  should  be  performed.  With  the  sero-fibrinous  exudate, 
such  as  commonh'  occurs  after  rheumatism,  aspiration  is  sufficient;  but  when 
the  exudate  is  purulent,  the  pericardium  should  be  freely  incised  and  freely 
drained.  The  puncture  may  be  made  in  the  fourth  or  fifth  interspace,  outside 
the  left  nipple  line.  In  large  effusions  the  pericardium  can  be  readily  reached 
without  danger  by  thrusting  the  needle  upward  and  backward  close  to  the  costal 
margin  in  the  left  costo-xiphoid  angle.  The  results  of  paracentesis  of  the  peri- 
cardium have  not  been  satisfactory.  With  an  earlier  operation  in  many  in- 
stances and  a  more  radical  one  in  others — incision  and  free  drainage,  not  as- 
piration, when  the  fluid  is  purulent — the  percentage  of  recoveries  will  be 
greatly  increased.  Repeated  tapping  may  be  needed.  One  patient  with  tuber- 
culous effusion,  tapped  three  times,  recovered  completely  and  was  alive  three 
years  afterward. 

CHEONIC  ADHESIVE  PERICARDITIS 

(Adhei'ent  Pericardium,  Indurative  Mediastino-pericarditis) 

The  remote  prognosis  in  pericarditis  is  very  variable.  A  large  majority  of 
these  cases  get  well  and  have  no  further  trouble,  but  in  young  persons  serious 
results  sometimes  follow  adhesions  and  thickening  of  the  layers.  As  Sequira 
has  pointed  out,  the  danger  is  here  directly  in  proportion  to  the  amount  of 
dilatation  and  weakening  of  the  pericardium  in  consequence  of  the  inflamma- 
tion. The  loss  of  the  firm  support  afforded  to  the  heart  by  the  rigid  fibrous 
bag  in  which  it  is  inclosed  is  the  important  factor.  There  are  two  groups  of 
cases  of  adherent  pericardium. 

(a)  Simple  adhesion  of  the  peri-  and  epicardial  lajers,  a  common  sequence 
of  pericarditis,  met  with  post  mortem  as  an  accidental  finding.  It  is  not  neces- 
sarily associated  with  disturbance  in  the  fimction  of  the  heart,  which  in  a 
large  proportion  of  the  cases  is  neither  dilated  nor  hypertrophied. 

(&)  Adherent  pericardium  with  chronic  mediastinitis  and  union  of  the 
outer  layer  of  the  pericardium  to  the  pleura  and  to  the  chest  walls.  This  con- 
stitutes one  of  the  most  serious  forms  of  cardiac  disease,  particularly  in  early 
life,  and  may  lead  to  an  extreme  grade  of  hypertrophy  and  dilatation  of  the 
heart.  The  peritoneum  may  be  involved  with  perihepatitis,  cirrhosis,  and  as- 
cites (Pick's  disease). 

Symptoms. — The  symptoms  of  adherent  pericardium  are  those  of  hyper- 
trophy and  dilatation  of  the  heart,  and  later  of  cardiac  insufficiency.  G.  D. 
Head  in  a  careful  study  of  59  cases  divides  them  into  (1)  a  small  silent  group 
with  no  symptoms,  (2)  a  larger  group  with  all  the  features  of  cardiac  disease, 
and  (3)  a  group  comprising  11  cases  in  his  series  in  which  the  features  were 
hepatic.  To  this  last  group  much  attention  has  been  paid  since  Pick's  descrip- 
tion. The  hepatic  features  dominate  the  picture  and  the  diagnosis  of  cirrhosis 
of  the  liver  is  usually  made.  Eecurring  ascites  is  the  special  feature  and  one 
patient  was  tapped  one  hundred  and  twenty-one  times.  There  is  chronic  peri- 
tonitis, with  great  thickening  of  the  capsule  of  the  liver  and  consequent  con- 
traction of  the  organ. 

Diagnosis. — The  following  are  important  points  in  the  diagnosis:  Inspec- 
tion.— x\  majority  of  the  signs  of  value  come  under  this  heading,      (a)   The 


PEEICAEDITIS  761 

praecordia  is  prominent  and  there  may  be  marked  asymmetry,  owing  to  the 
enormous  enlargement  of  the  heart,  (b)  The  extent  of  the  cardiac  impulse  is 
greatly  increased,  and  may  sometimes  be  seen  from  the  third  to  the  sixth 
interspaces,  and  in  extreme  cases  from  the  right  parasternal  line  to  outside 
the  left  nipple,  (c)  The  character  of  the  cardiac  impulse.  It  is  undulatory, 
wavy,  and  in  the  apex  region  there  is  marked  systolic  retraction,  (d)  Dia- 
phragm phenomena.  John  Broadbent  called  attention  to  a  very  valuable 
sign  in  adherent  pericardium.  When  the  heart  is  adherent  over  a  large  area 
of  the  diaphragm  there  is  with  each  pulsation  a  systolic  tug,  which  may  be 
communicated  through  the  diaphragm  to  the  points  of  its  attachment  on  the 
wall,  causing  a  visible  retraction.  This  has  long  been  recognized  in  the  re- 
gion of  the  seventh  or  eighth  rib  in  the  left  parasternal  line,  but  Broadbent 
called  attention  to  the  fact  that  it  was  frequently  best  seen  on  the  left  side 
behind,  between  the  eleventh  and  twelfth  ribs.  This  is  a  valuable  and  quite 
common  sign,  and  may  sometimes  be  very  localized.  One  difficulty  is  that, 
as  A.  W.  Tallant  pointed  out,  it  may  occur  in  thin  chested  persons  with  great 
hypertrophy  of  the  heart.  Sir  William  Broadbent  called  attention  to  the  fact 
that  owing  to  the  attachment  of  the  heart  to  the  central  tendon  of  the  dia- 
phragm this  part  does  not  descend  with  inspiration,  during  which  act  there  is 
not  the  visible  movement  in  the  epigastrium,  (e)  Diastolic  collapse  of  the 
cervical  veins,  the  so-called  Friedreich's  sign,  is  not  of  much  moment. 

Palpation. — The  apex  beat  is  fixed,  and  turning  the  patient  on  the  left 
side  does  not  alter  its  position.  On  placing  the  hand  over  the  heart  there  is 
felt  a  diastolic  shock  or  rebound,  which  some  have  regarded  as  the  most  re- 
liable of  all  signs  of  adherent  pericardium. 

Percussion. — The  area  of  cardiac  dulness  is  usually  much  increased.  In  a 
majority  of  instances  there  are  adhesions  between  the  pleura  and  the  pericar- 
dium, and  the  limit  of  cardiac  dulness  above  and  to  the  left  may  be  fixed  and 
is  uninfluenced  by  deep  inspiration.  This,  too,  is  an  uncertain  sign,  inasmuch 
as  there  may  be  close  adhesions  between  the  pleura  and  the  pericardium  and 
between  the  pleura  and  the  chest  wall,  which  at  the  same  time  allow  a  very 
considerable  degree  of  mobility  to  the  edge  of  the  lung. 

AuscuJiation. — The  phenomena  are  variable  and  uncertain.  In  the  cases 
in  children  with  a  history  of  rheumatism  endocarditis  has  usually  been  pres- 
ent. Even  in  the  absence  of  chronic  endocarditis,  when  the  dilatation  reaches 
a  certain  grade,  there  are  murmurs  of  relative  insufficiency,  which  may  be 
present  not  only  at  the  mitral  but  also  at  the  tricuspid  and  pulmonary  orifices. 
Theodore  Fisher  called  attention  to  the  fact  that  there  may  be  a  well-marked 
presystolic  murmur  in  connection  with  adherent  pericardium.  Occasionally 
the  layers  of  the  pericardium  are  united  in  places  by  strong  fibrous  bands,  5-7 
mm.  long  by  3-5  mm.  wide.  In  one  such  case  Drasche  heard  a  remarkable 
whirring,  systolic  murmur  with  a  twanging  quality. 

The  pulsus  paradoxus,  in  which  during  inspiration  the  pulse-wave  is  small 
and  feeble,  is  sometimes  present,  but  it  is  not  a  diagnostic  sign  of  either 
simple  pericardial  adhesion  or  of  the  cicatricial  mediastino-peri carditis.  Treat- 
ment has  to  be  directed  to  the  heart  muscle  and  is  largely  that  of  mvocarditis. 
Cardiolysis,  Brauer's  operation,  has  been  helpful  in  a  few  cases.  Four  or  five 
centimetres  of  the  fourth,  fifth,  and  sixth  left  ribs  with  a  couple  of  centimetres 
of  the  corresponding  cartilages  are  resected,  by  which  means  the  heart's  action 


763  DISEASES  OF  THE  CIECULATOEY  SYSTEM 

is  less  embarrassed.  It  is  a  justifiable  procedure  in  selected  cases — in,  for  ex- 
ample, a  child  with  a  very  large,  tumultuously  acting  heart,  with  much  bulging 
of  the  chest. 


II.  OTHER  AFFECTIONS  OF  THE  PERICARDIUM 

Hydropericardium,. — The  pericardial  sac  contains  post  mortem  a  few  cubic 
centimetres  of  clear,  citron  colored  fluid.  In  connection  with  general  dropsy, 
due  to  kidney  or  heart  disease,  more  commonly  the  former,  the  effusion  may 
be  excessive,  adding  to  the  embarrassment  of  the  heart  and  the  lungs,  particu- 
larly when  the  pleural  cavities  are  the  seat  of  similar  transudation.  There 
are  rare  instances  in  which  efi^usion  into  the  pericardium  occurs  after  scarlet 
fever  with  few,  if  any,  other  dropsical  symptoms.  Hydropericardium  is  fre- 
quently overlooked. 

In  rare  cases  the  serum  has  a  milky  character — chylopericardium. 

Hsemopericardium. — This  condition  is  met  with  in  aneurism  of  the  first 
part  of  the  aorta,  of  the  cardiac  wall,  or  of  the  coronary  arteries,  and  in  rup- 
ture and  wounds  of  the  heart.  Death  usually  follows  before  there  is  time  for 
the  production  of  symptoms  other  than  those  of  rapid  heart  failure  due  to  com- 
pression. In  rupture  of  the  heart  the  patient  may  live  for  many  hours  or 
even  days  with  symptoms  of  progressive  heart  failure,  dyspnoea,  and  the  signs 
of  effusion.  In  the  pericarditis  of  tuberculosis,  of  cancer,  of  nephritis,  and  of 
old  people  the  exudate  is  often  blood  stained. 

Pneumopericardium. — This  is  an  excessively  rare  condition,  of  which 
"Walter  James  was  able  to  collect  only  38  cases  in  1903.  We  have  met  with  but 
one  instance,  from  rupture  of  a  cancer  of  the  stomach.  Perforation  of  the 
sac  occurred  in  all  but  5,  in  which  the  gas  bacillus  was  the  possible  cause,  as 
in  Xicholl's  case  in  which  this  organism  was  isolated.  Seven  cases  were  due 
to  perforation  of  the  cesophagus  and  eight  to  penetrating  wounds  from  without. 
The  physical  signs  are  most  characteristic.  A  tympany  replaces  the  normal 
pericardial  flatness.  On  auscultation  there  is  a  splashing,  gurgling,  churning 
sound,  called  by  the  French  hruit  de  moulm.  This  was  described  in  19  of  the 
cases  collected  by  James.     Of  the  38  cases,  26  died. 

Calcified  Pericardium. — This  remarkable  condition  may  follow  pericardi- 
tis, particularly  the  suppurative  and  tuberculous  forms ;  occasionally  it  extends 
from  the  calcified  valves.  It  may  be  partial  or  complete.  Of  59  cases  collected 
by  A.  E.  Jones,  in  38  there  were  no  cardiac  symptoms.  Adherent  pericardium 
was  diagnosed  in  one  case.  Jones'  careful  study  shows  that  the  condition  is 
usually  latent  and  unrecognized. 


SYMPTOMATIC  AND  MECHANICAL  DISOEDEES  763 

B.    DISEASES  OF  THE  HEART 
I.     SYMPTOMATIC  AND  MECHANICAL  DISORDERS 

L     SYMPTOMATIC  DISORDERS 

Introduction. — There  are  a  number  of  disturbances  referred  to  the  heart 
which  cannot  be  termed  diseases — the  term  symptom-complex  is  a  better  des- 
ignation. They  may  occur  without  any  sign  of  organic  cardiac  disease  but 
frequently  cause  extreme  distress  to  the  individual.  It  is  not  possible  to  group 
them  in  any  systematic  way.  In  some  there  are  only  subjective  sensations,  in 
others  these  occur  with  objective  findings.  We  should  remember  that  back  of 
subjective  disorders  there  is  some  cause  and  the  effort  should  always  be  made 
to  find  it.  Disturbances  in  the  nervous  system  and  in  the  internal  secretions, 
unrecognized  myocardial  disease  and  the  effects  of  toxic  agents  are  particu- 
larly important. 

(1)  Heart  consciousness. — In  health  we  are  unconscious  of  the  action 
of  the  heart.  A  not  infrequent  indication  of  debility  or  overwork  is  the  con- 
sciousness of  the  cardiac  pulsations  which  may  be  perfectly  regular.  It  may 
be  most  evident  when  the  patient  is  lying  down.  It  is  usually  due  to  nervous 
fatigue,  some  form  of  debility  or  anaemia.  Occasionally  it  is  present  with  or- 
ganic disease. 

(2)  Cardiac  pain. — This  may  be  referred  to  the  whole  prgecordia  or  to 
local  areas,  most  often  about  the  apex  or  outside  it.  The  area  corresponds  to 
the  distribution  of  the  eighth  cervical  to  the  fourth  dorsal  segments.  A  dis- 
tinction should  be  made  between  aortic  pain  (aortitis,  acute  and  chronic,  some 
cases  of  angina  pectoris,  and  aneurism)  and  cardiac  pain.  The  former  is 
usually  felt  over  the  upper  pait  of  the  sternum  and  may  be  referred  to  the 
arms.  It  is  important  to  secure  an  exact  statement  of  the  seat  of  pain.  The 
influence  of  exertion,  emotion,  fear  and  excitement  in  causation  is  important. 
There  are  many  causes  for  more  or  less  persistent  cardiac  pain:  (1)  Myocar- 
ditis, in  which  the  pain  is  sometimes  described  as  a  pressure.  (2)  Dilatation 
(3)  Pericarditis.  (4)  Valvular  disease,  especially  aortic.  (5)  Certain  toxic 
influences,  especially  tobacco.  (6)  With  the  "Effort  Syndrome."  (7)  Angina 
pectoris  (some  cases).  (8)  With  digestive  disturbances,  especially  distention. 
(9)  In  a  large  group  in  which  no  evidence  of  cardiac  disease  can  be  found  and 
often  termed  "cardiac  neurosis,"  which  means  little.  This  is  common  in 
women,  especially  at  the  menopause,  and  is  especially  marked  in  those  who  are 
"neurotic."  Two  forms  are  common :  in  one  there  is  a  dull  more  or  less  con- 
tinuous pain  and  in  the  other  sharp  stabbing  pains  of  short  duration.  Emo- 
tion is  a  frequent  exciting  cause.  In  many  a  definite  disturbance  of  sensa- 
tion can  be  found,  usually  near  the  apex. 

The  term  "pseudo-angina  pectoris,"  so  frequently  used,  should  be  dropped 
from  our  terminology.  It  has  no  set  meaning  and  is  very  variously  employed. 
Some  use  it  as  synonymous  with  vaso-motor  angina  pectoris.  The  group  in- 
cludes cases  in  neurotic  persons  or  in  those  who  have  used  too  much  tobacco. 
The  attacks  have  no  necessary  relation  to  exertion  and  may  come  on  at  night 
or  when  the  patient  is  at  rest;  they  are  commoner  in  women  and  may  occur 


764  DISEASES  OF  THE  CIRCULATOEY  SYSTEM 

at  any  age;  and  are  not  associated  with  demonstrable  organic  disease  of  the 
heart  or  aorta.  The  attacks  may  last  for  an  hour  or  longer.  It  must  not  be 
forgotten  that  there  are  cases  of  mild  angina  pectoris.  It  is  safer  to  regard 
doubtful  cases  as  examples  of  this  than  to  label  them  '"pseudo-angina." 

The  diagnosis  of  pain  is  based  on  the  patient's  statement;  the  estimation 
of  its  severity  can  be  made  by  observation.  The  recognition  of  its  cause  de- 
mands thorough  study.  Careful  search  should  be  made  for  organic  vascular 
disease;  always  suspect  this  until  its  absence  is  proved.  Particular  attention 
should  be  given  to  the  state  of  the  nervous  system.  The  source  of  pain  mis- 
takenly regarded  as  cardiac  but  due  to  disease  elsewhere  is  usually  recognized 
by  a  thorough  examination. 

The  treatment  must  be  based  on  accurate  diagnosis.  In  the  "nervous 
group/'  the  meaning  of  the  symptom  should  be  explained  and  every  efEort  made 
to  correct  the  causal  factors.  The  use  of  bromides  is  indicated  until  there  is 
improvement  in  the  general  condition.  A  dose  of  aromatic  spirit  of  ammonia 
or  Hoffman's  anodyne  is  often  helpful. 

(3)  "Effort  syndrome,"  "neuro -circulatory  asthenia,"  "disordered  action 
of  the  heart,"  "irritable  heart." — The  condition  to  which  these  terms  are  ap- 
plied does  not  represent  a  specific  disease  but  a  combination  of  symptoms  in 
which  shortness  of  breath,  fatigue,  and  vaso-motor  disturbances  are  the  prin- 
cipal features.  The  condition  is  not  confined  to  soldiers ;  it  occurs  in  civil  life, 
and  in  females  and  children  as  well  as  in  men.  The  subjects  are  usually  of  a 
sub-normal  type  physically  and  unable  to  do  heavy  physical  work.  The  etiolog- 
ical factors  are  many.  Infection  plays  a  part,  especially  rheumatic  fever,  ton- 
sillitis, influenza,  focal  infection,  etc. ;  syphilis  plays  a  very  small  part.  Hy- 
perthyroidism is  a  factor  in  a  small  percentage  only.  Disturbance  of  the  cen- 
tral nervous  system  is  important.  Certain  of  the  patients  are  of  the  viscerop- 
totic  build,  with  long  thin  bodies,  and  in  them  cardioptosis  ("dropped  heart") 
is  relatively  common.  Stress  and  strain  which  they  are  unfitted  to  endure  is  a 
common  determining  factor  in  war. 

Symptoms. — Shortness  of  breath,  rarely  at  rest,  but  almost  invariably  on 
exertion,  is  the  most  frequent  complaint,  and  is  increased  by  effort,  especially  if 
hurried.  "With  this  goes  severe  fatigue  and  exhaustion,  sometimes  with  tre- 
mor. Pain  is  common,  usually  prsecordial  or  in  the  lower  left  costal  region, 
and  increased  by  exercise.  Prsecordial  tenderness  and  disturbance  of  sensa- 
tion maj^  accompany  it.  Palpitation  of  the  heart  on  exertion  and  excitement 
often  occiirs.  Syncope  is  not  uncommon.  Giddiness  is  frequent  and  may 
occur  with  change  in  position  or  on  exertion.  Vaso-motor  phenomena  are 
common;  the  hands  and  feet  are  blue,  there  is  profuse  sweating,  and  dermo- 
graphia  is  marked.  The  patients  show  a  nervous  "make-up,"  and  are  easily 
upset.  The  pulse  rate  is  increased  and  responds  quickly  to  exertion.  The 
return  to  normal  after  exercise  is  slow.  The  blood  pressure  does  not  show  any 
striking  changes.  The  heart  shows  an  absence  of  signs  of  myocardial  disease. 
Care  must  be  taken  to  recognize  the  condition  in  which  an  overacting  "ner- 
vous" heart  simulates  mitral  stenosis. 

In  treatment  any  suggestion  of  "heart  disease"  should  be  avoided,  and 
every  effort  made  to  explain  the  condition.  Search  should  be  made  for  the  eti- 
ology and  a  causal  factor  treated  if  possible,  especially  a  focus  of  infection. 
The  whole  method  of  life  should  be  reviewed  and  every  effort  made  to  im- 


SYMPTOMATIC  AKD  MECHANICAL  DISORDEES  765 

prove  the  general  health  by  proper  exercise,  bathing  and  good  hygiene.  Car- 
diac drugs  are  not  needed  but  general  tonics  should  be  given  if  indicated. 

(4)  Palpitation. — In  health  we  are  unconscious  of  the  action  of  the 
heart.  One  of  the  first  indications  of  debility  or  overvrork  is  the  consciousness 
of  the  cardiac  pulsations,  which  may,  however,  be  perfectly  regular  and  or- 
derly. This  is  not  palpitation.  The  term  is  properly  limited  to  irregular  or 
forcible  action  of  the  heart  perceptible  to  the  individual.  The  condition  of 
extra-systole  is  present  in  many  cases. 

Etiology. — The  expression  "perceptible  to  the  individual"  covers  the  es- 
sential element  in  palpitation  of  the  heart.  The  most  extreme  disturbance  of 
rhythm  may  be  unattended  with  subjective  sensations  of  distress,  and  there 
may  be  no  consciousness  of  disturbed  action.  On  the  other  hand,  there  are 
cases  in  which  complaint  is  made  of  the  most  distressing  palpitation  and  sen- 
sations of  throbbing,  in  which  examination  reveals  a  regularly  acting  heart,  the 
sensations  being  entirely  subjective.  This  symptom  occurs  in  a  large  group  of 
cases  in  which  there  is  increased  excitability  of  the  nervous  system.  Palpita- 
tion may  be  a  marked  feature  at  the  time  of  puberty,  at  the  climacteric,  and 
occasionally  during  menstruation.  It  is  common  in  hysteria  and  neurasthenia, 
particularly  in  the  form  of  the  latter  associated  with  dyspepsia.  Emotions, 
such  as  fright,  are  common  causes  of  palpitation.  It  may  occur  as  a  sequence 
of  the  acute  fevers.    Females  are  more  liable  to  the  affection  than  males. 

In  a  second  group  the  palpitation  results  from  the  action  upon  the  heart 
of  certain  substances,  such  as  tobacco,  coffee,  tea,  and  alcohol.  And,  lastly, 
palpitation  may  be  associated  with  organic  disease  of  the  heart,  either  of  the 
myocardium  or  valves.  As  a  rule  it  is  a  purely  nervous  phenomenon,  seldom 
associated  with  organic  disease  in  which  the  most  violent  action  and  extreme 
irregularity  may  exist  without  a  subjective  element  of  consciousness  of  the 
disturbance.     It  occurs  frequently  with  hyperthyroidism. 

Symptoms. — In  the  mildest  form,  such  as  occurs  during  a  dyspeptic  at- 
tack, there  are  slight  fluttering  of  the  heart  and  a  sense  of  what  patients  some- 
times call  "goneness.''  In  more  severe  attacks  the  heart  beats  violently,  its 
pulsations  against  the  chest  wall  are  visible,  the  rapidity  of  the  action  is  much 
increased,  the  arteries  throb  forcibly,  and  there  is  a  sense  of  great  distress.  In 
some  instances  the  heart's  action  is  not  at  all  quickened.  The  most  striking 
cases  are  in  neurasthenic  women,  in  whom  the  mere  entrance  of  a  person  into 
the  room  may  cause  the  most  violent  action  of  the  heart  and  throbbing  of  the 
peripheral  arteries.  The  pulse  may  be  rapidly  increased  until  it  reaches  150  or 
160..  A  diffuse  flushing  of  the  skin  may  appear  at  the  same  time.  After  such 
attacks  there  may  be  the  passage  of  a  large  quantity  of  pale  urine.  In  many 
cases  of  palpitation,  particularly  in  young  men,  the  condition  is  at  once  re- 
lieved by  exertion. 

The  physical  examination  of  the  heart  is  usually  negative.  The  sounds, 
the  shock  of  which  may  be  very  palpable,  are  clear,  ringing,  and  metallic,  but 
not  associated  with  murmurs.  The  second  sound  at  the  base  may  be  accentu- 
ated. A  murmur  may  sometimes  be  heard  over  the  pulmonary  artery  or  even 
at  the  apex  in  cases  of  rapid  action  in  neurasthenia  or  in  severe  ansemia.  The 
attacks  may  be  transient,  lasting  only  for  a  few  minutes,  or  may  persist  for  an 
hour  or  more.  In  some  instances  any  attempt  at  exertion  renews  the  attack. 
Sometimes  in  vigorous  young  adults  who  are  upset  nervously,  especially  after 


766  DISEASES  OF  THE  CIECULATOEY  SYSTEM 

exertion  or  during  excitement,  the  signs  of  mitral  stenosis  are  simulated. 
There  is  a  systolic  shock  preceded  by  a  suggestion  of  a  thrill.  On  ausculta- 
tion it  may  be  difficult  to  decide  whether  or  not  there  is  a  short  presystolic 
murmur.  A  short  period  of  observation  usually  removes  the  uncertainty  and 
the  administration  of  amyl  nitrite,  which  increases  the  murmur  of  mitral 
stenosis,  is  an  aid.  Organic  murmurs  are  sometimes  increased  by  pressure  on 
the  eyeballs. 

The  diagnosis  should  always  include  the  conditions  which  are  responsible. 
Nervous  states  (especially  the  anxiety  neuroses  and  those  due  to  disturbance 
in  the  sexual  sphere),  ansemia,  gastro-intestinal  disorders,  and  particularly  the 
possible  influence  of  the  thyroid  gland  should  be  considered.  In  the  condi- 
tion termed  plirenocardia  there  are  palpitation,  pain  in  the  cardiac  region  or 
to  the  left  of  the  apex,  and  respiratory  disorder  shown  by  frequent  attempts 
to  take  a  deep  breath.  There  may  be  spasm  of  the  diaphragm  with  cardiop- 
tosis. 

The  'prognosis  is  usually  good,  though  it  may  be  extremely  difficult  to 
remove  the  conditions  underlying  the  palpitation. 

Treatment. — An  important  element  is  to  get  the  patient's  mind  quieted 
and  assure  him  that  there  is  no  actual  danger.  The  mental  element  is  often 
very  strong.  If  an  underlying  cause  can  be  found  this  should  receive  atten- 
tion. In  palpitation,  before  using  drugs,  it  is  well  to  try  the  effect  of  hygienic 
measures.  As  a  rule,  moderate  exercise  may  be  taken  with  advantage.  Eegu- 
lar  hours  should  be  kept,  and  at  least  ten  hours  out  of  the  twenty-four  should 
be  spent  in  the  recumbent  posture.  A  tepid  bath  may  be  taken  in  the  morn- 
ing, or,  if  the  patient  is  weak  and  nervous,  in  the  evening,  followed  by  a 
thorough  rubbing.  Hot  baths  and  the  Turkish  bath  should  be  avoided.  The 
dietetic  management  is  important  and  it  is  best  to  prohibit  alcohol,  tea,  and 
coffee  absolutely.  The  diet  should  be  light  and  the  patient  should  avoid  tak- 
ing large  meals.  Articles  of  food  known  to  cause  flatulency  should  not  be 
used.  If  a  smoker,  the  patient  should  give  up  tobacco.  Sexual  excitement  is 
particularly  pernicious,  and  the  patient  should  be  warned  specially  on  this 
point.  The  cases  of  palpitation  due  to  excesses  or  to  errors  in  diet  and  dys- 
pepsia are  readily  remedied  by  hygienic  measures. 

A  course  of  iron  is  often  useful.  Strychnia  is  particularly  valuable,  and 
is  perhaps  best  administered  as  the  tincture  of  nux  vomica  in  large  doses. 
Very  little  good  is  obtained  from  the  smaller  quantities.  It  should  be  given 
freely,  20  minims  (1.3  c.  c.)  three  times  a  day.  If  there  is  great  rapidity  of 
action,  aconite  may  be  tried.  There  are  cases  associated  with  sleeplessness 
and  restlessness  which  are  greatly  benefited  by  the  bromides.  Digitalis  is 
very  rarely  indicated,  but  in  obstinate  cases  it  may  be  tried  with  the  nux 
vomica. 

II.     MECHANICAL  DISORDEES   OF   THE   HEART-BEAT 

Normal  Mechanism. — In  the  normal  heart-beat  there  is  contraction  of 
the  chambers  in  proper  sequence  due  to  a  stimulus  which  originates  in  the 
sino-auricular  node  ("pacemaker")  situated  in  the  wall  of  the  right  auricle 
close  to  the  mouth  of  the  superior  vena  cava.  This  node  originates  orderly 
waves  of  contraction   (73  per  minute)   which  pass  through  the  walls  of  the 


SYMPTOMATIC  AND  MECHANICAL  DISORDERS  767 

auricles  to  the  ventricles  by  a  special  conduction  path  at  the  origin  of  which 
is  a  node  (of  Tawara)  situated  low  down  in  the  wall  of  the  right  auricle. 
From  this  the  auriculo-ventricular  bundle  (of  His)  extends,  dividing  below 
to  send  branches  to  the  two  ventricles.  These  by  further  subdivisions  supply 
the  ventricular  fibres.  The  stimulus  to  contraction  requires  a  definite  period 
for  preparation  and  the  interval  is  constant.  "The  muscular  fibres  of  the 
heart  possess  the  power  of  rhythmically  creating  a  stimulus,  of  being  able  to 
receive  a  stimulus,  of  responding  to  a  stimulus  by  contracting,  of  conveying 
the  stimulus  from  muscle  fibre  to  muscle  fibre,  and  of  maintaining  a  certain 
ill-defined  condition  called  tone."     (Gaskill.) 

A.     DISTUEBANCES  OF  EATE 

(1)  Tachycardia  (with  normal  mechanism). — The  rapid  action  may  be 
perfectly  natural.  There  are  individuals  whose  normal  heart  action  is  at 
100  or  even  more  per  minute.  Emotional  causes,  violent  exercise,  and  fevers 
all  produce  great  increase  in  the  rapidity  of  the  heart's  action.  The  extremely 
rapid  action  which  follows  fright  may  persist  for  days  or  even  weeks.  Cases 
are  not  uncommon  at  the  menopause. 

There  are  cases  in  which  it  depends  upon  definite  changes  in  the  pneumo- 
gastrics  or  in  the  medulla.  Cases  have  been  reported  in  which  tumor  or  clot 
in  or  about  the  medulla  or  pressure  upon  the  vagi  has  been  associated  with 
rapid  heart.  Tachycardia  occurs  under  many  conditions,  such  as  hyperthy- 
roidism, mitral  stenosis  (apart  from  fibrillation),  interference  with  the  vagus 
(mediastinal  tumor,  etc.),  post-febrile  conditions,  anaemia,  the  effect  of  cer- 
tain drugs  (belladonna,  thyroid  extract),  nervous  disturbance,  toxic  states 
(tobacco),  etc.  The  tachycardia  may  persist  for  months  or  indefinitely,  and 
there  is  serious  interference  with  the  amount  of  muscular  exertion  such  per- 
sons can  take;  in  addition  there  is  a  sense  of  weakness  and  sometimes  faint- 
ing attacks.  The  diagnosis  of  the  cause  is  essential  and  on  this  the  treatment 
must  be  based. 

(2)  Bradycardia  (True). — Slow  action  of  the  heart  is  sometimes  normal 
and  may  be  a  family  peculiarity.  Napoleon  is  stated  to  have  had  a  pulse  of 
only  40  per  minute. 

In  any  case  of  slow  pulse  it  is  important  first  to  make  sure  that  the  num- 
ber of  heart  and  arterial  beats  correspond.  In  many  instances  this  is  not 
the  case,  and  with  a  radial  pulse  at  40  the  cardiac  pulsations  may  be  80,  half 
the  beats  not  reaching  the  wrist.  The  heart  contractions,  not  the  pulse  wave, 
should  be  taken  into  account. 

Physiological  Bradycardia. — As  age  advances  the  pulse  rate  becomes  slow. 
In  the  puerperal  state  the  pulse  may  beat  from  44  to  60  per  minute,  or  may 
even  be  as  low  as  34.  It  is  seen  in  premature  labor  as  well  as  at  term  but  the 
explanation  is  not  clear.  Slowness  of  the  pulse  is  associated  with  hunger. 
Bradycardia  depending  on  individual  peculiarity  is  extremely  rare. 

Pathological  Bradycardia  is  met  with  under  the  following  conditions:  (a) 
In  convalescence  from  acute  fevers.  This  is  extremely  common,  particularly 
after  pneumonia,  typhoid  fever,  and  diphtheria.  It  is  most  frequent  in  young 
persons  and  in  cases  which  have  run  a  normal  course,  (b)  In  diseavses  of  the 
digestive  system,  such  as  chronic  dyspepsia,  ulcer  or  cancer  of  the  stomach. 


768  DISEASES  OF  THE  CIECULATORY  SYSTEM 

and  jaundice,  (c)  In  diseases  of  the  respiratory  system.  Here  it  is  by  no 
means  so  common,  but  it  is  seen  not  infrequently  in  emphysema,  (d)  In 
diseases  of  the  circulatory  system.  Bradycardia  is  not  common  in  diseases  of 
the  valves.  It  is  most  frequent  in  fatty  and  fibroid  changes  in  the  heart,  but 
is  not  constant  in  them,  (e)  In  diseases  of  the  urinary  organs.  It  occurs 
occasionally  in  nephritis  and  may  be  a  feature  of  ursemia.  (/)  From  the  ac- 
tion of  toxic  agents.  It  occurs  in  uraemia,  poisoning  by  lead,  alcohol,  and  fol- 
lows the  use  of  tobacco,  cofi'ee,  and  digitalis,  (g)  In  constitutional  disorders, 
such  as  anffimia,  chlorosis,  and  diabetes,  (h)  In  diseases  of  the  nervous  sys- 
tem. Apoplexy,  epilepsy,  one  stage  of  tuberculous  meningitis,  cerebral  tumors, 
affections  of  the  medulla,  and  diseases  and  injuries  of  the  cervical  cord  may 
be  associated  with  a  slow  pulse.  In  general  paresis,  mania,  and  melancholia 
it  is  not  infrequent,  (i)  It  occurs  occasionally  in  affections  of  the  skin  and 
sexual  organs,  and  in  sunstroke,  or  in  prolonged  exhaustion  from  any  cause. 
Treatment. — For  the  bradycardia  itself  little  can  be  done.  The  cause 
should  receive  attention. 

B.     DISTURBANCES  OF  RHYTHM  AND  FORCE 

1.  Sinus  Arrhytihmia. — This  depends  on  changes  in  the  control  of  the 
sino-auricular  node  in  which  the  effect  of  vagus  influence  is  important.  It  is 
frequently  seen  in  connection  with  respiration,  especially  in  deep  breathing. 
The  rate  increases  with  inspiration  and  slows  with  expiration.  This  is  com- 
mon in  young  children  and  about  the  time  of  puberty,  and  is  seen  occasionally 
in  adults.  In  other  cases  it  may  be  responsible  for  attacks  of  f aintness  or  syn- 
cope, sometimes  with  a  slow  rate  and  a  low  blood  pressure.  The  occurrence 
of  irregularity,  also  with  slow  pulse  rate,  and  which  has  no  order  in  its  oc- 
currence, is  sometimes  seen.  It  may  occur  after  the  administration  of  digi- 
talis, in  rheumatic  myocarditis  or  with  the  bradycardia  so  common  after  pneu- 
monia.    The  condition  is  not  serious  in  any  way. 

Diagnosis. — This  is  usually  clear.  The  irregularity  is  of  the  whole  beat 
and  the  pulse  and  apex  beat  correspond.  The  occurrence  with  respiration  is 
significant.    Exercise,  fever  and  atropine  usually  abolish  this  irregularity. 

Treatment. — None  is  required  and  this  condition  should  not  be  regarded 
as  an  indication  for  rest  or  lessened  activity. 

(2)  Extra-systole  (Premature  contraction). — A  common  form  of  irregu- 
larity is  that  due  to  extra-systole,  to  understand  which  it  must  be  remem- 
bered that  to  a  stimulus  strong  enough  to  set  up  a  contraction  the  heart  an- 
swers with  all  the  contractility  of  which  it  is  capable  at  the  moment  (Bow- 
ditch's  law  of  maximal  contraction).  A  second  property  of  the  heart  muscle 
is  that  it  possesses  a  "refractory  phase"  in  which  normally  it  is  not  excitable, 
or  answers  only  to  very  strong  stimuli.  Extra-systoles  are  caused  by  patho- 
logical impulses  which  may  arise  in  the  auricle  or  ventricle,  rarely  in  the 
tissue  between  them.  An  extra  impulse,  arising  in  the  ventricle  and  causing 
it  to  contract  anticipates  the  next  regular  impulse  which  arrives  when  the 
ventricle  is  in  the  "refractory  phase"  and  hence  it  does  not  contract,  so  that 
this  auricular  impulse  is  wasted.  Until  the  next  regular  impulse  reaches  the 
ventricle  there  will  be  the  usual  interval  and  hence  the  diastole  is  longer  than 
normal.     The  period  of  disturbed  rhythm  is  equal  to  two  cycles  of  the  usual 


SYMPTOMATIC  AND  MECHANICAL  DISOEDEES  769 

rhythm.  If  the*  pathological  impulse  arises  in  the  auricle  there  is  premature 
contraction  of  both  the  auricle  and  ventricle  followed  by  a  normal  pause.  The 
time  of  disturbance  is  not  equal  to  two  cycles  of  the  usual  rhythm.  There  is 
usually  a  disturbance  of  the  fundamental  rhythm. 

The  premature  beat  is  not  an  efficient  one  and  may  not  open  the  aortic 
valves.  If  it  does  the  impulse  may  or  may  not  reach  the  radial  artery;  if 
it  does  the  pulse  wave  will  be  small  and  follow  close  on  the  preceding  regular 
impulse.  On  auscultation  two  sounds  are  heard  if  the  aortic  valves  are 
opened,  otherwise  only  a  first  sound.  Evidently  there  can  be  many  variations 
in  the  sounds  and  character  of  the  pulse.  Graphic  records  are  usually  neces- 
sary to  distinguish  between  the  auricular  and  ventricular  origin  of  premature 
contractions.  If  a  murmur  is  present  it  may  be  absent  or  less  loudly  heard 
with  the  premature  beat.  Fever,  exercise,  a  change  in  posture,  and  a  rapid 
heart  rate  may  cause  the  temporary  disappearance  of  extra-systoles. 


Fig.  1. — Premature  Contractions  of  Ventricular  Origin. 

The  grouping  of  pulse  beats  shows  the  manner  of  production  of  bigeminal,  tri- 
geminal,  and   quadrigeminal   pulses. 

The  irregularity,  inequality,  and  intermission  of  the  pulse  as  met  with  in 
every  day  experience  are  largely  due  to  the  occurrence  of  extra-systoles,  which 
may  present  all  sorts  of  combinations  and  groupings,  depending  upon  whether 
the  extra  pulse  beats  are  perceptible  or  not.  And  yet  there  may  be  no  actual 
pathological  change,  and  so  far  as  the  maintenance  of  the  circulation  is  con- 
cerned the  heart  may  be  acting  in  a  satisfactory  manner.  The  subjective  sen- 
sations vary  greatly.  In  some  the  extra-systoles  are  not  noticed  but  many 
complain  of  a  variety  of  symptoms  and  especially  of  the  pause  with  the  suc- 
ceeding strong  contraction.     Some  patients  are  greatly  disturbed  by  them. 

Extra-systoles  occur  at  all  ages  and  under  the  most  varied  conditions  but 
are  most  common  in  persons  over  fifty.  There  are  several  classes  of  cases. 
The  arrhythmia  may  be  a  life-long  condition.  Without  any  recognizable 
disease,  without  any  impairment  of  the  action  of  the  heart,  there  is  permanent 
irregularity.  This  may  be  a  peculiarity  of  the  heart-muscle  of  the  individual, 
who  has  extra-systole  for  the  same  reason — physiological  but  not  well  under- 
stood— as  the  dog  and  horse,  in  which  animals  this  phenomenon  is  common. 
The  late  Chancellor  Terrier,  of  McGill  University,  who  died  at  the  age  of 
eighty-seven,  had  an  extremely  irregular  heart  action  for  the  last  fifty  years 
of  his  life.  In  debilitated  and  neurasthenic  persons  there  may  be  an  irritable 
weakness  of  the  heart  associated  with  extra-systole,  and  palpitation  of  a  dis- 
tressing character.  In  a  second  group  toxic  agents,  as  tobacco,  tea,  coffee,  or 
the  toxins  of  the  infectious  diseases  are  responsible.  Digitalis  may  be  a  cause. 
Even  reflexly,  as  in  flatulent  dyspepsia,  extra-systoles  may  arise.     Thirdly,  a 


770  DISEASES  OF  THE  CIECULATOEY  SYSTEM 

high  blood  pressure  can  set  up  extra-systoles;  also  change  in  posture.  And, 
lastly,  organic  disease  of  the  heart  itself,  especially  myocardial. 

The  significance  of  premature  contractions  is  not  always  easy  to  determine. 
They  are  often  temporar}^,  especially  in  young  persons,  but  should  not  be  re- 
garded lightly.  It  is  wiser  to  regard  them  as  meaning  some  pathological 
change  until  the  contrary  is  proved  than  to  make  light  of  them  and  recognize 
the  error  later.  In  those  who  have  reached  fifty  years  of  age  they  may  be  the 
warning  of  serious  myocardial  damage.  The  patient  seen  to-day  with  extra- 
systoles  may  return  with  auricular  fibrillation  in  two  or  three  years. 

Treatment. — This  must  depend  on  the  other  conditions  found  and  not  on 
the  extra-systoles  themselves.  In  nervous  patients,  bromide  is  indicated.  The 
condition  itself  does  not  require  digitalis. 

(3)  Paroxysmal  Tachycardia. — This  is  characterized  by  paroxysmal  at- 
tacks, beginning  and  ending  abruptly,  in  which  the  heart  rate  increases  to  be- 
tween 100  and  200  a  minute  (the  common  rate  is  between  110  and  190).  The 
abnormal  impulses  arise  from  a  new  focus  which  may  be  in  the  auricle  or 
ventricle,  usually  in  the  auricle.  They  represent  "essentially  a  regular  series 
of  extra-sj'stoles"  (Lewis). 

It  may  occur  at  any  age  but  is  most  frequent  in  young  adults,  and  more 
often  in  males.  There  may  be  definite  myocardial  disease  but  some  patients 
show  no  sign  of  any  lesion  in  the  intervals.  Xaturally  one  is  suspicious  of 
some  underlying  factor  (myocardial).  Exertion,  emotion  or  digestive  dis- 
turbance may  initiate  an  attack  but  in  some  cases  no  cause  can  be  given.  The 
duration  of  an  attack  varies  from  a  few  seconds  to  ten  or  more  days. 

The  symptoms  vary  greatly  with  the  duration  and  severity  of  the  attack. 
A  striking  feature  is  the  abrupt  onset.  In  the  very  short  attacks  the  patient 
may  not  be  conscious  of  any  disturbance  or  make  any  complaint.  In  more 
marked  attacks  there  may  be  discomfort  and  palpitation,  with  weakness, 
sweating  and  gastric  disturbance.  Thoracic  pain  of  varying  distributipn  is 
common,  sometimes  with  disturbance  of  sensation.  If  dilatation  of  the  heart 
follows  there  are  the  symptoms  associated  with  it.  In  the  examination  there 
may  be  little  except  the  rapid  heart  and  the  general  condition  is  often  good. 
There  may  be  marked  pulsation  in  the  veins  of  the  neck.  The  heart  rate  should 
be  determined  by  auscultation.  The  sounds  are  very  short  and  sharp,  like  the 
fetal  heart  sounds.  If  there  has  been  a  previous  murmur  it  may  have  disap- 
peared. Enlargement  of  the  heart,  passive  congestion  of  the  lungs, .some- 
times with  bloody  sputum,  cyanosis,  oedema,  and  enlargement  of  the  liver 
with  abdominal  tenderness  may  be  found. 

In  diagnosis  the  history  of  previous  attacks  and  of  the  onset  of  the  present 
one  is  important.  The  cases  of  tachycardia  of  other  etiology  rarely  cause 
doubt  The  rapid  rate  with  loss  of  compensation  should  not  cause  difficulty. 
Change  in  posture  does  not  alter  the  rate  in  paroxysmal  tachycardia.  In  cases 
of  doubt  a  tracing  is  diagnostic. 

The  outloolc  is  good  but  always  has  an  element  of  uncertainty.  In  pro- 
longed attacks  with  marked  disturbance  of  the  circulation  there  is  always  some 
danger.  The  condition  of  the  heart  between  attacks  and  the  behavior  of  the 
muscle  during  the  attack  are  important  points.  As  to  the  patient  becoming 
free  of  the  attacks,  it  is  difficult  to  speak  with  any  certainty.  The  condition 
is  compatible  with  long  life.    The  late  H.  C.  Wood  had  a  patient,  aged  eighty- 


SYMPTOMATIC  AND  MECHANICAL  DISOEDhliS 


771 


seven,  who  had  attacks  at  intervals  for  fifty  years  in  which  the  pulse  rate  was 
usually  200.     The  taking  of  ice  water  or  strong  coffee  arrested  the  attacks. 

Treatment. — In  an  attack  the  patient  should  be  quiet  and  in  the  position 
which  gives  him  the  greatest  comfort.  The  diet  should  be  liquid.  If  there  is 
gastric  disturbance,  the  giving  of  sedatives  and  alkalies  may  be  useful.  An 
ice  bag  applied  over  the  prsecordia  often  gives  relief,  if  it  does  not  stop  the  at- 
tack. The  most  diverse  procedures  may  stop  an  attack,  such  as  placing  the 
head  between  the  knees,  being  suspended  with  the  head  down,  pressure  on  the- 
vagus  in  the  neck,  or  on  the  eye-balls,  any  sustained  respiratory  effort,  the 
production  of  vomiting,  the  application  of  a  tight  abdominal  binder,  etc.  The 
giving  of  strophanthin  (gr.  1/250,  0.00026  gm.)  or  epinephrin  (TIX  x,  0.6  c.  c. 
of  a  1-10,000  solution)  intravenously  may  be  effectual.  Chloral  hydrate  or 
morphia  may  be  given  to  secure  sleep.  Any  indicated  symptomatic  treatment 
should  be  given.  Between  attacks,  any  exciting  cause  should  be  avoided,  the 
general  health  improved  if  possible,  and  attention  paid  to  any  gastro-intestinal 
disturbance.    The  wearing  of  an  abdominal  binder  is  sometimes  useful. 


W^^ 


mMfamim 


'^^^mA^^^-Ks^^VJ ,  -^'1 


T'W] 


Fig.  2. — Auricular  Flutter. 

The  curve  shows  a  series  of  regular  waves  due  to  auricular  contractions,  interrupted 
by  sharp  spikes  due  to  ventricular  contractions.  The  ratio  between  auricular  contrac- 
tions and  ventricular  responses  varies  (2:1,  3:1  and  4:1)  and  averages  3:1.  The  slower 
ventricular  rate  is  caused  by  a  partial  heart-block.  The  auricular  rate  is  210  per  min- 
ute; the  ventricular  responses  average  70. 


(4)  Auricular  Flutter. — In  this  rather  rare  condition  new  impulses  arise 
in  the  auricle,  probably  from  a  single  focus,  which  cause  it  to  beat  rhythmically 
at  a  rate  of  200  to  350  per  minute.  As  Lewis  says,  this  may  not  be  readily 
distinguished  from  paroxysmal  tachycardia  but  when  the  rate  is  over  200 
special  characteristics  appear.  Heart  block  is  almost  always  present  with  it, 
the  ventricular  rate  being  half  that  of  the  auricle;  2:1  block  is  common  but 
other  ratios  occur.  The  rate  of  the  auricle  is  regular;  the  ventricle  is  usually 
regular  but  sometimes  irregular.  It  is  most  frequent  in  advanced  years,  more 
common  in  males  and  usually  associated  with  arterio-sclerosis  and  myocarditis. 

The  symptoms  are  fewer  than  might  be  expected  and  depend  on  the  state 
of  the  muscle  of  the  ventricle.  There  may  be  a  complaint  of  palpitation  and 
attacks  of  syncope.  Occasionally  the  ventricle  takes  the  auricular  rate,  with 
which  the  condition  is  very  grave,  but  such  attacks  are  usually  of  short  dura- 
tion. The  recognition  may  be  possible  only  by  electrocardiographic  tracings 
if  the  rate  of  the  ventricle  is  not  very  rapid ;  otherwise  a  rate  of  130  or  over 
is  very  suggestive.  The  outlook  is  relatively  good  and  is  influenced  by  the 
state  of  the  muscle  and  response  to  treatment.     This  consists  in  the  use  of 


772 


DISEASES  OF  THE  CIRCULATOEY  SYSTEM 


digitalis  or  strophanthus  in  full  doses.    If  disappearance  of  the  flutter  results, 
this  is  usually  permanent. 

(5)  Auricular  Fibrillation. — This  common  manifestation  of  cardiac  ir- 
regularity is  exceedingly  important  to  recognize  clinically.  In  the  most  pro- 
nounced form  it  is  seen  in  the  last  stages  of  mitral  stenosis,  in  which  the  pulse 
shows  extreme  irregularity,  which,  when  once  established,  seldom  returns  to 
normal.  A  study  of  its  features  in  this  condition  gave  Mackenzie  the  clue 
to  its  explanation.  He  found  that  in  certain  cases  the  transition  from  regular 
to  irregular  pulse  of  this  type  occurred  with  suddenness,  and  that,  whereas 
before  the  irregularity  supervened  the  jugular  pulse  showed  the  normal  fea- 
tures in  the  presence  of  auricular  carotid  and  ventricular  waves,  with  a  marked 
presystolic  murmur  and  thrill  at  the  apex,  after  the  irregularity  was  estab- 
lished, the  auricular  wave  disappeared  from  the  jugular  pulse  and  the  presys- 
tolic murmur  from  the  apex.     The  inference  drawn  was  that  the  right  auricle 


Amu>(IIUIJ.IllJLU.I.LUJIJUlaAAU.A.li^.LIJ.I.J>l 

my^-->-/Vv^r^lAyv---^v'>A/MA~-.A^/^ 

--^..^-^.v^ 

jVi^^JvAfKAJv.l^^xM-- 

kJt.lJLU.*-.tAJi.VJt»_kj.AJUJUjL»JULJLlJjLlJ 

Fig.  3. — Auricular  Fibrillation. 

The  altered  rhythm,  the  variations  in  volume,  and  the  rapid  pulse  rate  are  evident 
from  the  lower  record  (radial  artery) .  The  venous  pulse  record  above  shows  fibrillary 
waves  during  ventricular  diastole,  with  an  absence  of  a  waves  produced  by  normally  con- 
tracting auricles. 


was  so  dilated  as  to  prevent  the  formation  of  a  normal  auricular  contraction. 
Complete  proof  of  the  cause  of  this  condition  has  been  supplied  by  Lewis,- 
who  found  that  patients  with  this  irregularity  showed  in  galvanometric  trac- 
ings from  the  auricle  numerous  small  and  continuous  waves,  exactly  similar 
to  those  obtained  in  the  dog  after  fibrillation  of  the  auricle  has  been  induced 
by  faradic  stimulation  of  the  appendix  of  the  right  auricle,  or  by  ligation  of 
the  right  coronary  artery.  The  auricles  do  not  contract  normally  but  are  in 
diastole  with  many  fibrillary  twitchings  arising  from  pathological  impulses 
originating  in  many  areas.  These  impulses  are  probably  identical  with  those 
which  excite  premature  contractions.  These  numerous  abnormal  impulses 
come  to  the  auricular-ventricular  bundle  but  only  some  of  them  are  able  to 
pass  and  these  reach  the  ventricle  in  an  irregular  fashion.  Hence  the  con- 
tractions of  the  ventricle  are  disturbed  and  irregular.  The  state  of  the 
bundle  determines  how  many  impulses  pass  and  hence  the  ventricular  rate 
shows  great  variation.  Heart-block  and  auricular  fibrillation  may  occur  to- 
gether. 

Auricular  fibrillation  forms  a  large  proportion  of  the  cases  showing  car- 
diac irregularity — about  40  per  cent.  (Lewis).  Of  etiological  factors  the 
most  important  is  mitral  stenosis,  whether  in  the  rheumatic  form  or  that 
seen  in  women  with  no  history  of  rheumatism.     It  is  essentially  a  sign  of 


SYMPTOMATIC  AND  MECHANICAL  DISOEDEES 


773 


marked  myocardial  disease.  The  average  age  of  onset  in  those  with  a  pre- 
vious history  of  rheumatism  is  30  to  40;  in  the  non-rheumatic  group  it  is 
between  50  and  60. 

The  symptoms  depend  largely  on  the  associated  conditions  and  are  those 
of  marked  myocardial  failure.     The  ventricular  rate  has  some  influence,  as 


Fig.  4.— Auricular  Fibrillation. 

Several  cardiac  contractions  at  the  apex  (upper  tracing)  produced  no  pulsation  at 
the  wrist;  others  are  so  small  as  not  to  be  felt.  Synchronous  counts  at  the  apex  and 
wrist  for  10  seconds  show  18  and  13  impulses  respectively.  The  jugular  shows  only  o 
and  V  waves,  due  to  ventricular  activity.  Waves  due  to  contraction  of  the  auricles  are 
absent,  since  they  have  ceased  to  act  as  efficient  contracting  chambers. 


when  it  is  very  rapid  (120-160),  the  distress  and  general  symptoms  of  dilata- 
tion are  more  marked.  The  pulse  is  extremely  irregular  in  every  way  and  an 
irregular  pulse  with  a  rate  over  120  is  usually  due  to  fibrillation.  The  more 
rapid  the  rate,  the  greater  the  irregularity.  There  is  often  a  marked  differ- 
ence between  the  heart  and  pulse  rate.  The  diagnosis  is  clear  with  a  very  rapid 
heart  but  when  the  rate  is  below  100  there  may  be  slight  difficulty  until  a 
careful  study  is  made.     Tracings  remove  any  difficulty. 

In  prognosis  the  occurrence  of  fibrillation  is  always  of  grave  omen.  The 
condition  is  compatible  with  life  for  years  but  always  means  serious  myocar- 
dial damage.  The  ventricular  rate  is  of  value,  a  persistent  rate  of  120  or  over 
means  a  grave  outlook  and  each  increase  in  rate  above  this  is  more  serious. 
The  influence  of  treatment  is  of  value  in  estimating  the  outlook. 

Treatment. — For  the  general  condition  of  the  heart  the  problem  is  that 
of  myocardial  insufficiency,  but  for  the  fibrillation  the  remedy  is  digitalis, 
which  acts  by  blocking  the  passage  of  many  of  the  impulses  from  auricle  to 
ventricle.  The  dosage  is  that  which  keeps  the  heart  at  the  best  possible  rate, 
and  must  be  decided  for  each  patient.  The  dosage  of  digitalis  depends  some- 
what on  the  severity  of  the  condition;  the  present  tendency  is  to  give  larger 
doses  than  formerly.  In  any  case  the  object  is  to  produce  the  required  effect, 
whatever  dose  is  required.  Many  of  the  patients  should  continue  the  use  of 
digitalis  permanently. 

(6)  Heart-block  (Stokes-Adams  Syndrome). — In  the  adult  heart  the 
auriculo-ventricular  bundle  of  His  is  18  mm.  long,  2.5  mm.  broad,  and  1.5 
mm.  thick;  it  arises  in  the  septum  of  the  auricles  below  the  foramen  ovale 
and  passes  downward  and  forward  through  the  trigonum  fibrosum  of  auric- 
ulo-ventricular junction,  where  it  comes  into  close  relation  with  the  mesial 


774 


DISEASES  OF  THE  CIECULATOEY  SYSTEM 


leaflet  of  the  tricuspid  valve.  Passing  along  the  upper  edge  of  the  muscular 
septum,  just  where  it  joins  with  the  posterior  edge  of  the  membranous  sep- 
tum, it^  radiates  throughout  the  ventricles.  If  the  function  of  the  auriculo- 
ventricular  bundle  is  impaired  there  may  be  a  delay  in  the  conduction  of  the 
impulse  or  it  may  be  blocked  completely.  This  may  occur  only  with  certain 
impulses  (partial  limrt-hloclc)  or  with  all  (complete  heart-block).  In  the 
latter  event  the  ventricles,  released  from  the  control  of  the  normal  pace-mak- 
er, assume  their  own  rhythm  (usually  about  30  a  minute). 


SIBO-AURIC- 
ULAR   HODE 
(  KEITH- 
FLACK    ) 


SIBO-AORIC- 
XJLAR  NODE 
IKEira-PLACK) 


AORIOULO- 
TAWARA'S  VEHTRICU- 
HODE  LAR    (HIS) 

BUNDLE 


TAWARA'S 
SODE 


RIGHT 
BRAHCH 


Fig.  5. — Diagram  Showing  the  Sino-auricular  Node  and  the  Axjkicular  Bundle, 
A,  viewed  from  the  right;  B,  cross  section  of  the  heart,  viewed  from  the  front. 
(Kindness  of  A.  D.  Hirschf elder.) 

Etiology. — Heart-block  may  occur  at  any  age  depending  on  the  cause. 
It  is  more  common  in  males.  It  is  not  infrequent  in  infectious  diseases,  es- 
pecially rheumatic  fever,  diphtheria  and  pneumonia,  but  occurs  in  many  others. 
Syphilis  is  an  important  cause  owing  to  the  auriculo-ventricular  bundle  being 
affected  in  the  myocardial  involvement  or  by  a  gumma.  Any  form  of  myocar- 
ditis, acute  or  chronic,  may  be  responsible.  The  action  of  digitalis  in  auricular 
fibrillation  depends  largely  on  its  action  on  the  impulses  passing  from  auricle 
to  ventricle  and  hence  it  is  one  of  the  causes  of  heart-block.  The  lesion  in 
the  bundle  may  be  acute,  usually  in  infections,  or  chronic,  with  fibrosis, 
gumma,  etc. 

The  symptoms  are  variable,  and  depend  to  a  considerable  extent  on  the 
associated  conditions.  Some  patients  make  little  complaint  but  dizziness,  weak- 
ness and  fainting  attacks  are  not  uncommon.  In  the  more  severe  forms  the 
syncopal  attacks  are  more  frequent  and  severe.  One  variety  is  described  under 
the  Stokes- Adams  syndrome.  (It  may  be  emphasized  that  this  and  heart- 
block  are  not  synonymous  terms.)  The  signs  vary  with  the  grade  of  block. 
An  early  manifestation  may  be  reduplication  of  the  first  or  second  sound  due 
to  lengthening  of  the  A-V  interval  which  represents  a  delay  in  conduction.  A 
dropped  beat  is  easily  recognized  and  if  the  ventricle  is  beating  regularly  at 
half  the  rate  of  the  auricle  (2:1  bloc'k)  the  pulse  may  be  40  to  50  a  minute. 
Halving  of  the  ventricular  rate  under  digitalis  therapy  is  always  suggestive. 
It  may  be  that  the  auricular  rate  can  be  counted  by  the  pulsations  in  the 


SYMPTOMATIC  AND  MECHANICAL  DISOEDEES 


775 


veins  of  the  neck.  In  complete  block  the  ventricle  beats  at  a  rate  below  35, 
and  independently  of  the  auricle.  Faint  sounds  may  be  heard  during  the 
ventricular  diastole,  from  auricular  systoles.  While  the  diagnosis  can  often 
be  made  from  the  physical  signs,  tracings  render  it  certain.  A  block  may 
occur  in  one  of  the  branches  of  the  bundle  of  His.  Eeduplication  of  the  first 
sound  may  result.  Electrocardiographic  tracings  are  necessary  for  its  recog- 
nition. 


Fig.  6. — Partial  Heart-Block  with  2:1  Ratio;  auricular  rate  66,  ventricular  rate  33. 


T-vr-l!^ 


Fig.   7. — Complete  Heart-Block. 

The  small  blunt  vertical  waves  (110  per  minute)  are  due  to  auricular  contraction; 
the  diphasic  sharply  pointed  wave  and  the  large  blunt  wave  which  follows  represent 
ventricular  contractions  (34  per  minute).  The  contractions  of  the  auricles  and  ven- 
tricles are  independent  of  each  other. 


StoJces-Adams  Syndrome. — Clinically  this  presents  three  features:  (a)  slow 
pulse,  usually  permanent,  but  sometimes  paroxysmal,  falling  to  40,  20,  or 
even  6  per  minute;  (&)  cerebral  attacks — vertigo  of  a  transient  character,  syn- 
cope, pseudo-apoplectiform  attacks  or  epileptiform  seizures;  (c)  visible  auricu- 
lar impulses  in  the  veins  of  the  neck,  as  noted  by  Stokes — the  beats  varying 
greatly;  a  2  :1  or  3  :1  rhythm  is  the  most  common.  There  are  several  groups 
of  cases.  It  is  usually  a  senile  manifestation  associated  with  arterio-sclerosis. 
The  cases  in  young  adults  and  middle  aged  men  are  often  myocardial  and  of 
syphilitic  origin.  There  is  a  neurotic  group  in  which  all  the  features  may 
be  present,  and  in  which  post  mortem  no  lesions  have  been  found  (Edes  and 
Councilman).    In  the  attacks  of  slow  pulse  in  this  group  the  auricular  as  well 


776 


DISEASES  OF  THE  CIECrLATOEY  SYSTEM 


as  the  ventricular  rate  may  be  slow  and  equal,  the  normal  sequence  of  events 
being  preserved:  the  origin  of  the  condition  is  probably  vagal.  The  outlook 
in  this  class  of  cases  is  good;  in  the  others  it  is  a  serious  disease  and  usually 
fatal,  though  it  may  last  for  many  years.  The  cerebral  attacks  are  due  to 
anaemia  of  the  brain  or  of  the  medulla  in  consequence  of  the  imperfect  ven- 
tricular action.  In  one  of  our  cases  Baetjer  could  see  with  the  fluoroscope 
the  more  frequent  contraction  of  the  auricles. 

The  prognosis  in  the  cases  with  acute  infectious  disease  is  usually  good, 
with  perhaps  the  exception  of  diphtheria  and  some  cases  of  rheumatic  fever. 
In  the  chronic  forms  the  outlook  is  grave  and  sudden  death  is  always  possible. 
The  sjTicopal  and  convulsive  attacks  are  always  serious.  In  some  of  the  cases 
due  to  syphilis  proper  treatment  may  result  in  great  improvement.  In  every 
case  the  state  of  the  myocardium  is  important. 

Treatnient. — If  a  cause,  such  as  syphilis,  is  found,  the  indications  are 
evident.  Acute  heart-block  demands  absolute  rest  and  treatment  directed  to 
the  general  cardiac  condition.  Digitalis  should  be  given  with  care.  In  partial 
block  it  may  increase  the  difficulty  and  yet  the  heart  muscle  may  be  aided  by 
it.  In  complete  block  it  may  be  more  useful  and  it  cannot  increase  the  block. 
In  partial  heart-block  the  giving  of  atropine  may  be  useful  but  rather  in  the 
cases  due  to  acute  infections  than  those  with  sclerotic  processes.  There  is  no 
special  treatment  for  the  syncopal  attacks. 


Fig.  8. — Combixed  Alternation  of  the  Pulse  and  Premature  Conteactions. 

The  latter  part  of  the  record  shows  a  pulse  regular  as  to  sequence,  but  alternating 
as  to  volume.  In  the  first  part  this  sequential  regularity  is  irregularly  interrupted  by 
premature  contractions  of  ventricular  origin. 


(7)  Alternation  of  the  Heart. — In  this  there  is  disturbance  of  the  ven- 
tricular systole,  so  that  larger  and  smaller  amounts  of  blood  are  expelled  by 
alternate  contractions  and  consequently  the  pulse  shows  alternate  large  and 
small  beats.  It  is  suggested  that  a  variable  number  of  ventricular  fibres  con- 
tract and  so  vary  the  systoles.  It  is  seen  in  conditions  of  very  rapid  heart 
rate,  especially  paroxysmal  tachycardia,  in  which  it  has  no  special  significance. 
Its  occurrence  when  the  heart  rate  is  normal  or  nearly  so  has  a  very  different 
and  more  serious  meaning.  It  is  observed  in  a  variety  of  conditions  in  which 
marked  circulatory  disease  is  present,  in  severe  infections,  especially  pneu- 
monia, in  urgemia,  in  lead  poisoning,  and  in  patients  under  the  influence  of 
digitalis.  It  occurs  most  often  in  advanced  life  and  more  in  males.  It  is  com- 
paratively common  but  frequently  overlooked. 

The  condition  itself  probably  causes  no  symptoms  but  as  it  accompanies 


AFFECTIOXS  OF  THE  MYOCAEDIUM  777 

serious  circulatory  diseases,  the  features  of  these  are  present,  such  as  dysp- 
noea, anginal  pain,  etc.  It  should  be  searched  for  in  cases  of  hypertension, 
angina  pectoris,  myocarditis  and  when  extra-systoles  are  present.  It  may  be 
more  evident  after  exertion,  with  the  patient  standing  or  after  holding  the 
breath.  The  variations  may  be  felt  by  the  finger  but  tracings  give  the  most 
certain  evidence  of  its  presence.  The  difference  in  systolic  pressure  between 
the  large  and  small  beats  may  be  an  aid.  Comparison  with  the  heart  rate  dis- 
tinguishes it  from  a  dicrotic  pulse.  Excluding  the  cases  of  tachycardia  and 
usually  those  due  to  digitalis,  the  significance  of  alternation  is  always  serious. 
This  applies  particularly  to  the  cases  in  which  it  is  continuous,  but  in  all  it 
should  be  regarded  as  an  evidence  of  great  danger.  Sudden  death  is  com- 
paratively common.  The  treatment  is  that  of  the  underlying  condition  and 
special  emphasis  should  be  placed  on  rest,  thorough  and  prolonged. 


II.     AFFECTIONS  OF  THE  MYOCARDIUM 

I.     HYPEETEOPHY 

Varieties. — The  heart  enlarges  to  meet  a  demand  for  extra  work,  either 
general,  as  in  the  strain  of  athletics  (the  hypertrophy  of  work),  or  special 
to  combat  a  deficiency  of  cardiac  structure,  such  as  a  damaged  valve.  There 
are  two  forms,  one  in  which  the  cavity  or  cavities  are  of  normal  size,  and  the 
other  in  which  the  cavities  are  enlarged  and  the  walls  increased  in  thickness 
(eccentric  hypertrophy).  The  so-called  concentric  hypertrophy  in  which 
there  is  diminution  of  the  size  of  the  cavity  with  thickening  of  the  walls  is, 
as  a  rule,  a  post  mortem  change.  The  enlargement  may  affect  the  entire  or- 
gan, or  one  side,  or  only  one  chamber.  Xaturally,  as  the  left  ventricle  does 
the  chief  work  the  change  is  most  frequently  found  here.  Though  its  produc- 
tion is  assisted  by  adequate  nutrition,  hypertrojDhy  may  appear  even  under 
conditions  of  starvation,  given  otherwise  healthy  organs.  In  the  debilitated 
the  limits  to  which  hypertrophy  may  progress  are  small. 

Hypertrophy  of  the  left  ventricle  aloxe,  or  with  general  enlarge- 
ment of  the  heart,  is  brought  about  by — 

Conditions  affecting  the  heart  itself :  (a)  Disease  of  the  aortic  valve;  (6) 
mitral  insufficiency;  (c)  pericardial  adhesions;  {d)  sclerotic  myocarditis;  {e) 
disturbed  innervation  with  overaction^  as  in  exophthalmic  goitre,  and  as  a 
result  of  the  action  of  alcohol,  in  the  "beer  heart."  In  all  of  these  the  work 
of  the  heart  is  increased.  In  the  case  of  the  valve  lesions  the  increase  is  due 
to  increased  intraventricular  pressure;  in  the  case  of  the  adherent  pericardium 
and  myocarditis,  to  direct  interference  with  the  symmetrical  and  orderly  con- 
traction of  the  chambers. 

Conditions  acting  upon  the  Mood-vessels:  {a)  General  arterio-sclerosis, 
with  or  without  renal  disease,  especially  sclerosis  of  the  aorta,  the  renal  ar- 
teries, and  the  vessels  of  the  splanchnic  area;  (&)  all  states  of  increased  ar- 
terial tension  induced  by  the  contraction  of  the  smaller  arteries  under  the  in- 
fluence of  certain  toxic  substances,  which,  as  Bright  suggested,  "by  affecting 
the  minute  capillary  circulation,  render  great  action  necessary  to  send  the 
blood  through  the  distant  subdivisions  of  the  vascular  system":  (c)  prolonged 


778  DISEASES  OF  THE  CIECULATOEY  SYSTEM 

muscular  exertion,  which  enormously  increases  the  blood  pressure  in  the  ar- 
teries; {d)  narrowing  of  the  aorta,  as  in  congenital  stenosis. 

Htpeeteophy  of  the  right  yextricle  is  met  with  under  the  following 
conditions — 

(a)  Lesions  of  the  mitral  valve,  either  incompetence  or  stenosis,  which 
act  by  increasing  the  resistance  in  the  pulmonar}^  vessels.  (&)  Pulmonary 
lesions  with  obliteration  of  any  number  of  blood  vessels  within  the  lungs,  as 
in  emphysema  or  cirrhosis,  (c)  Valvular  lesions  on  the  right  side  occasionally 
cause  hypertrophy  in  the  adult,  not  infrequently  in  the  fetus,  {d)  Clironic 
valvular  disease  of  the  left  heart  and  perimrdial  adhesions  are  sooner  or  later 
associated  with  hypertrophy  of  the  right  ventricle. 

In  the  auricles  simple  hypertrophy  is  never  seen;  there  is  always  dilata- 
tion with  hypertrophy.  In  the  left  auricle  the  condition  develops  in  lesions 
at  the  mitral  orifice,  particularly  stenosis.  The  right  auricle  hypertrophies 
when  there  is  greatly  increased  blood  pressure  in  the  lesser  circulation,  wheth- 
er due  to  mitral  stenosis  or  pulmonary  lesions.  Xarrowing  of  the  tricuspid 
orifice  is  a  rare  cause. 

Symptoms. — There  may  be  no  complaint  attributable  to  the  hypertrophy, 
and  if  associated  with  renal  disease  or  arterio-sclerosis  there  may  be  a  marked 
sense  of  well-being.  If,  however,  the  cardiac  defect  be  not  fully  compensated, 
the  patient  may  complain  of  slight  giddiness,  headache,  a  sense  of  palpitation 
in  the  thorax,  and  some  dyspnoea  on  exertion. 

In  hypertrophy  of  the  right  auricle  the  venous  pulsation  in  the  neck  may 
be  more  evident,  and  a  tracing  may  show  a  marked  increase  in  the  size  of  the 
auricular  wave.  An  increase  in  dulness  to  the  right  of  the  sternum  in  the 
third  and  fourth  interspaces  may  be  detected,  and  on  very  rare  occasions  a 
sound  preceding  that  of  the  ventricle  over  that  area.  Hypertrophy  of  the 
right  ventricle  causes  a  slight  bulging  of  the  costal  angle  with  a  positive 
instead  of  a  negative  pulsation  at  this  spot.  The  apex  beat  may  be  diffuse,  as 
the  enlarged  right  ventricle  prevents  the  left  ventricle  from  coming  into  con- 
tact with  the  chest  wall.  The  venous  pulsation  in  the  neck  is  usually  marked, 
and  the  first  souiid  over  the  tricuspid  area  louder  than  normal.  Hypertrophy 
of  the  left  auricle,  which  is  seldom  marked  and  never  unassociated  with  dila- 
tation, may  be  detected  occasionally  by  dulness  toward  the  base  of  the  left 
lung  behind;  it  is  easily  diagnosed  by  the  extension  backward  of  the  cardiac 
shadow  in  oblique  illumination  of  the  chest  by  the  X-rays.  Hypertrophy  of 
the  left  ventricle  is  usually  easy  to  diagnose.  There  is  a  forcible  impulse  at 
the  apex  beat,  both  visible  and  palpable.  This  impulse  may  cause  a  movement 
of  a  large  area  of  the  chest  wall.  The  apex  beat,  if  there  be  only  slight  dilata- 
tion, is  usually  displaced  downward,  and  is  found  in  the  6th  and  7th  spaces; 
but  if  the  dilatation  be  marked,  the  apex  beat  becomes  more  diffuse  and  is 
found  well  outside  the  nipple  line  in  the  4th,  5th,  and  6th  spaces.  The  first 
sound  is  usually  marked  and  sometimes  has  a  distinct  booming  sound.  The 
second  sound  at  the  base  is  accentuated.  The  pulse  is  full  and  of  high  tension 
at  the  height  of  the  ventricular  impulse.  The  blood  pressure  is  usually 
raised. 


AFFECTIONS  OF  THE  MYOCAEDIUM  779 


II.     DILATATION 

As  with  other  hollow  muscular  organs,  the  size  of  the  chambers  of  the 
heart  varies  greatly  within  normal  limits.  Dilatation  may  be  an  acute  process 
and  quite  transitory,  as  after  severe  muscular  effort,  or  it  may  be  chronic,  in 
which  case  it  is  associated  with  hypertrophy.  Not  always,  however;  there  is 
an  extraordinary  heart  in  the  McGill  College  Museum  showing  a  parchment 
like  thinning  of  the  walls  with  uniform  dilatation  of  all  the  chambers;  in 
places  in  the  right  auricle  and  ventricle  only  the  epicardium  remains.  Dila- 
tation is  pathological  only  when  permanent.  Increase  in  capacity  means  in- 
creased work  and  in  consequence  hypertrophy  to  meet  the  demand. 

Etiology. — Two  important  causes  combine  to  produce  dilatation — in- 
creased pressure  within  the  cavities  and  impaired  resistance,  due  to  weakening 
of  the  muscular  wall — which  may  act  singly,  but  are  often  combined.  A 
weakened  wall  may  yield  to  a  normal  distending  force,  the  weakened  wall 
being  due  either  to  structural  change  in  the  cardiac  muscle  or  to  a  diminution 
of  its  natural  tonus. 

(a)  Heightened  endocaediac  pressure  results  either  from  an  increased 
quantity  of  blood  to  be  moved  or  an  obstacle  to  be  overcome.  It  does  not 
necessarily  bring  about  dilatation;  simple  hypertrophy  may  follow,  as  in  the 
early  period  of  aortic  stenosis,  and  in  the  hypertrophy  of  the  left  ventricle  in 
nephritis. 

The  size  of  the  cardiac  chambers  varies  in  health.  With  slow  action  of 
the  heart  the  dilatation  is  complete  and  fuller  than  it  is  with  rapid  action. 
Moderate  exertion  in  a  normal  heart,  or  even  prolonged  exertion  in  a  well- 
trained  heart,  lessens  the  heart  size,  but  in  conditions  of  ill  health  dilatation 
occurs.  Physiologically,  the  limits  of  dilatation  are  reached  when  the  cham- 
ber does  not  empty  itself  during  the  systole.  This  may  occur  as  an  acute, 
transient  condition  in  severe  exertion  in  an  untrained  or  feeble  condition — 
during,  for  example,  the  ascent  of  a  mountain. 

There  may  be  great  dilatation  of  the  right  heart,  as  shown  by  the  increased 
epigastric  pulsation  and  increase  in  the  cardiac  dulness.  The  safety  valve 
action  of  the  tricuspid  valves  may  come  into  play,  relieving  the  lungs  by  per- 
mitting regurgitation  into  the  auricle.  With  rest  the  condition  is  removed, 
but,  if  it  has  been  extreme,  the  heart  may  suffer  a  strain  from  which  it  may 
recover  slowly,  or,,  indeed,  the  individual  may  never  be  able  again  to  under- 
take severe  exertion.  In  the  process  of  training  the  getting  wind,  as  it  is 
called,  is  largely  a  gradual  increase  in  the  capability  of  the  heart,  particularly 
of  the  right  chambers.  A  degree  of  exertion  can  be  safely  maintained  in  full 
training  which  would  be  quite  impossible  under  other  circumstances,  because, 
by  a  gradual  process  of  what  we  may  call  physical  education,  the  heart  has 
strengthened  its  reserve  force — widened  enormously  its  limit  of  physiological 
work.  Endurance  in  prolonged  contests  is  measured  by  the  capabilities  of 
the  heart,  which  by  increasing  its  tonus  has  increased  its  resistance  to  dilata- 
tion. We  have  no  positive  knowledge  of  the  nature  of  the  changes  in  the  heart 
which  occur  in  this  process,  but  it  must  be  in  the  direction  of  increased  mus- 
cular and  nervous  energy.  The  large  heart  of  athletes  may  be  due  to  the 
prolonged  use  of  their  muscles,  but  no  man  becomes  a  great  runner  or  oars- 


780  DISEASES  OF  THE  CIECULATOEY  SYSTEM 

man  who  has  not  naturally  a  capable  if  not  a  large  heart.  Master  McGrath, 
the  celebrated  greyhound,  and  Eclipse,  the  race  horse,  both  famous  for  en- 
durance rather  than  speed,  had  very  large  hearts. 

Excessive  dilatation  during  severe  muscular  effort  results  in  heart-strain. 
A  man,  perhaps  in  poor  condition,  calls  upon  his  heart  for  extra  work  during 
the  ascent  of  a  high  mountain,  and  is  at  once  seized  with  pain  about  the  heart 
and  a  sense  of  distress  in  the  epigastrium.  He  breathes  rapidly  for  some 
time,  is  "puffed,^'  as  we  say,  but  the  symptoms  pass  off  after  a  night's  quiet. 
An  attempt  to  repeat  the  exercise  is  followed  by  another  attack,  or  an  attack 
of  cardiac  dyspnoea  may  come  on  while  at  rest.  For  months  such  a  man  may 
be  unfitted  for  severe  exertion  or  he  may  be  permanently  incapacitated.  In 
some  way  he  has  overstrained  his  heart  and  become  "broken-winded."  In  such 
cases  there  was  probably  previous  myocardial  change.  The  "heart-shock"  of 
Latham  includes  cases  of  this  nature — sudden  cardiac  break-down  during  ex- 
ertion, not  due  to  rupture  of  a  valve.  It  seems  probable  that  sudden  death 
during  long  continued  efforts,  as  in  a  race,  is  sometimes  due  to  overdistention 
and  paralysis  of  the  heart. 

Acute  dilatative  heart  weakness  is  seen  in  many  conditions,  as  in  Graves' 
disease,  in  paroxysmal  tachycardia,  in  old  myocardial  cases  following  exer- 
tion, and  in  angina  pectoris.  There  is  usually  a  striking  contrast  between 
the  wide  and  forcible  cardiac  impulse  and  the  small,  feeble,  irregular  pulse. 

Dilatation  occurs  in  all  forms  of  valve  lesions.  In  aortic  insufficiency 
blood  enters  the  left  ventricle  during  diastole  from  the  unguarded  aorta  and 
from  the  left  auricle,  and  the  quantity  of  blood  at  the  termination  of  diastole 
subjects  the  walls  to  an  extreme  degree  of  pressure,  under  which  they  inevi- 
tably yield.  In  time  they  augment  in  thickness,  and  present  the  typical  eccen- 
tric hypertrophy  of  this  condition. 

In  mitral  insufficiency  blood  which  should  have  been  driven  into  the  aorta 
is  forced  into  and  dilates  the  auricle  from  which  it  came,  and  then  in  the 
diastole  of  the  ventricle  a  large  amount  is  returned  from  the  auricle,  and  with 
increased  force.  In  mitral  stenosis  the  left  auricle  is  the  seat  of  greatly  in- 
creased tension  during  diastole,  and  dilates  as  well  as  hypertrophies;  the  dis- 
tention may  be  enormous.  Dilatation  of  the  right  ventricle  is  produced  by  a 
number  of  conditions,  which  were  considered  under  hypertrophy.  All  circum- 
stances, such  as  mitral  stenosis,  emphysema,  etc.,  which  permanently  increase 
the  tension  in  the  pulmonary  vessels  cause  its  dilatation. 

The  dilatation  and  hypertrophy  of  beer  drinkers  also  comes  in  this  group, 
as  it  is  brought  about  gradually  by  increased  endocardial  pressure. 

(b)  Impaired  nutrition  of  the  heart  walls  may  lead  to  a  diminution 
of  the  resisting  power  so  that  dilatation  readily  occurs. 

The  loss  of  tone  due  to  parenchymatous  degeneration  or  myocarditis  in 
fevers  may  lead  to  a  fatal  condition  of  acute  dilatation.  It  is  a  recognized 
cause  of  death  in  scarlatinal  dropsy  (Goodhart),  and  may  occur  in  rheumatic 
fever,  typhus,  typhoid,  etc.  'The  changes  in  the  heart  muscle  which  accom- 
pany acute  endocarditis  or  pericarditis  may  lead  to  dilatation,  especially  in  the 
latter  disease.  In  antemia,  leukaemia,  and  chlorosis  the  dilatation  may  be  con- 
siderable. In  sclerosis  of  the  walls  the  yielding  is  always  where  this  process 
is  most  advanced,  as  at  the  left  apex.  Under  any  of  these  circumstances  the 
walls  may  yield  with  normal  blood  pressure. 


AFFECTIONS  OF  THE  MYOCARDIUM  781 

Pericardial  adhesions  are  a  cause  of  dilatation,  and  we  generally  find  in 
cases  with  extensive  and  firm  union  considerable  hypertrophy  and  dilatation. 
There  is  usually  here  some  impairment  of  the  superficial  layers  of  muscle. 

III.     CAEDIAC  INSUFFICIENCY 

Etiology. — With  lessening  of  the  muscular  power  of  the  heart  the  rapidity 
with  which  the  blood  circulates  is  diminished,  and  the  tissues  fail  to  receive 
their  proper  supply  of  oxygen  and  food,  and  to  be  adequately  relieved  of  their 
waste  products — this  is  cardiac  failure.  The  same  effect  may  be  produced  in 
another  way.  The  amount  of  blood  in  the  body  is  much  less  than  the  total 
capacity  of  the  vascular  bed,  and  an  adequate  blood  supply  is  only  kept  up 
by  a  general  constriction  of  arterioles  which  dam  the  blood  in  the  arterial 
system,  but  if  by  any  chance  there  is  a  general  vaso-dilatation  of  the  arterioles, 
especially  those  in  the  splanchnic  area,  the  heart  does  not  receive  an  amount 
of  blood  sufficient  to  supply  the  bodily  needs,  with  the  same  effect  on  the  or- 
gans as  in  certain  forms  of  cardiac  failure.  This  condition  does  not  concern 
us  here,  but  it  must  be  mentioned  to  avoid  the  impression  that  all  failure  of  the 
circulation  means  failure  of  the  heart. 

The  failure  in  muscular  power  may  affect  any  cavity  singly  or  the  whole 
heart.  Weakness  of  the  left  ventricle  fails  to  give  proper  filling  of  the  ar- 
terial system  and  general  angemia  of  the  tissues  results.  Failure  of  the  left 
auricle  means  stasis  in  the  lung  vessels  with  deficient  aeration  of  the  blood, 
and  a  tendency  to  oedema  of  the  lung  or  to  effusion  into  the  pleural  cavity. 
Failure  of  the  right  auricle  and  ventricle  gives  cyanosis  of  the  organs,  dysp- 
noea at  rest  and  on  slight  exertion,  with  stasis  in  the  abdominal  organs  and 
oedema. 

The  reserve  power  with  which  the  cardiac  muscle  is  endowed  disappears  in 
heart  failure.  This  reserve,  greatest  in  youth,  is  increased  by  adequate  nutri- 
tion, certain  congenital  endowments,  and,  apart  from  other  defects,  by  hyper- 
trophy. It  is  lessened  by  defects  in  the  cardiac  structure,  gross  or  minute,  by 
defective  nutrition,  by  certain  bacterial  and  other  poisons,  and  with  advanc- 
ing years.  We  have  at  present  no  means  of  gauging  this  reserve  power  of  the 
organ  as  a  whole  or  in  its  different  parts. 

The  failure  may  be  sudden  or  slow,  according  to  the  kind  and  rapidity 
of  the  lesion  which  causes  it.  When  the  left  ventricle  fails  the  effect  may 
vary  from  immediate  death,  through  all  forms  of  fainting,  giddiness,  sense 
of  dissolution,  to '  a  mild  sense  of  bodily  or  mental  fatigue ;  when  the  right 
ventricle  fails  the  effect  varies  from  a  sudden  dyspnoea  to  a  dyspnoea  which 
comes  on  with  slight  exertion. 

As  to  the  actual  condition  in  cardiac  failure  generally,  it  is  by  no  means 
easy  in  all  cases  to  say  what  has  been  the  cause.  The  lesions  to  which  the' 
cardiac  musculature  is  liable  are  described  further  on,  yet  there  is  a  proportion 
of  cases  in  which  neither  by  post  mortem  examination  nor  careful  microscopic 
search  can  the  source  of  the  failure  be  even  suggested.  It  is  well  to  bear  in 
mind  a  suggestion  made  by  Aschoff,  namely,  that  in  certain  cases  the  failure 
is  due  not  so  much  to  the  implication  of  the  general  musculature  as  to  an 
affection  of  the  conducting  system  and  of  the  bundle  of  His  with  its  ramifica- 
tions. 


782  DISEASES  OF  THE  CIECULATOEY  SYSTEM 

The  hlood  pressure  in  cardiac  insufficiency  shows  no  uniform  figures.  The 
systolic  pressure  may  be  higli  even  in  a  failing  lieart.  In  serious  degrees  of 
myocardial  affection  it  is  usually  low.  In  cases  in  which  there  has  been  a 
raised  blood  pressure,  the  maximum  may  be  lower  or  higher  than  the  normal 
for  the  patient.  We  must  recognize  that  probably  in  early  stages  of  failure 
the  heart  is  stimulated  to  put  forth  increased  energy  at  each  beat,  and  that 
the  maximum  pressure  at  the  height  of  the  beat  slightly  over-compensates  the 
circulatory  defect. 

Acute  Cardiac  iNSUFFiciENCY.^Causes :  {a)  Wounds  of  the  heart,  (&) 
spontaneous  rupture  or  rupture  of  valves,  (c)  rapid  effusion  into  the  pericar- 
dium, {d)  access  of  air  to  the  chambers  of  the  heart,  as  from  operations  at 
the  root  of  the  neck  or  after  exposure  to  a  high  atmospheric  pressure,  (e) 
large  thrombi  quickly  formed  in  a  heart  cavity,  (/)  sudden  interference  with 
the  coronary  circulation,  esiDecially  the  left  coronary  artery,  {g)  mechanical 
interference  with  the  heart  from  pressure  on  the  trachea  or  larynx,  as  in 
strangulation,  {li)  acute  infections,  such  as  diphtheria  or  pericarditis,  (i) 
certain  poisons,  such  as  pilocarpine,  cocaine,  phosphorus,  etc.,  (;')  stimulation 
of  the  vagus  nerve,  its  centre  in  the  medulla,  or  its  termination  in  the  heart. 

Chronic  Cardiac  Insufficiency. — Causes:  (a-)  Lesions  of  the  heart 
muscle,  which  will  be  described  in  more  detail.  All  cardiac  failure  is  muscu- 
lar. The  myocardium  may  be  insufficiently  nourished,  as  in  the  starvation 
atrophy  of  new  growths  or  in  diabetes,  or  there  may  be  recognizable  lesions. 
One  or  more  of  the  functions  of  the  cardiac  muscle  may  be  interfered  with 
without  producing  any  changes  that  can  be  detected  by  the  microscope,  such 
as  the  failure  associated  with  aortic  disease.  (6)  Lesions  of  the  valves,  (c) 
Lesions  affecting  the  vascular  fields  of  the  efferent  arteries.  Emphysema, 
chronic  bronchitis,  asthma,  sclerosis  of  the  lungs,  chest  deformities,  and  mitral 
disease  produce  an  embarrassment  of  the  right  heart;  atheroma  of  the  aorta 
and  arterio-sclerosis,  especially  of  the  splanchnic  and  renal  area,  produce  fail- 
ure of  the  left  heart,  {d)  Over-exertion,  (e)  Certain  poisons,  such  as  al- 
cohol (especially  beer)  and  phosphorus.  (/)  Other  causes,  such  as  adherent 
pericardium  and  exophthalmic  goitre. 

Anatomical  Basis  of  Cardiac  InsuflB.ciency. — I.  Lesions  of  the  Coronary 
Arteries. — A  knowledge  of  the  changes  produced  in  the  myocardium  by  dis- 
ease of  the  coronary  vessels  gives  a  key  to  the  understanding  of  many  prob- 
lems in  cardiac  pathology.  The  terminal  branches  of  the  coronary  vessels  are 
end  arteries;  that  is,  the  communication  between  neighboring  branches  is 
through  capillaries  only.  J.  H.  Pratt  has  shown  that  the  vessels  of  Thebesius, 
Avhich  open  from  the  ventricles  and  auricles  into  a  system  of  fine  branches  and 
thus  communicate  with  the  cardiac  capillaries  and  coronary  veins,  may  be 
capable  of  feeding  the  myocardium  sufficiently  to  keep  it  alive  even  when  the 
coronary  arteries  are  occluded.  The  blocking  of  one  of  these  vessels  by  a 
thrombus  or  an  embolus  leads  usually  to  a  condition  known  as — 

(a)  Ancemic  necrosis,  or  white  infarct.  When  this  does  not  occur  the  rea- 
son may  be  sought  in  (1)  the  existence  of  abnormal  anastomoses,  which  by 
their  presence  take  the  coronary  system  out  of  the  group  of  end  arteries;  or 
(2)  the  vicarious  flow  through  the  vessels  of  Thebesius  and  the  coronary 
veins.  The  condition  is  most  commonly  seen  in  the  left  ventricle  and  in  the 
septum,  in  the  territory  of  distribution  of  the  anterior  coronary  artery.     Thp 


AFFECTIOXS  OF  THE  MYOCAEDIUM  783 

affected  area  has  a  yellowish  white  color,  sometimes  a  turbid,  parboiled  aspect, 
at  other  times  a  grayish  red  tint.  It  may  be  somewhat  wedge-shaped,  more 
often  it  is  irregular  in  contour  and  projects  above  the  surface.  Microscopically 
the  changes  are  characteristic.  The  nuclei  disappear  from  the  muscle  fibres 
or  undergo  fragmentation.  Leucocytes  wander  in  from  the  surrounding 
tissue  and  may  suffer  disintegration.  At  a  later  stage  a  new  growth  of  fibrous 
tissue  is  found  in  the  periphery  of  the  infarct  which  ultimately  may  entirely 
replace  the  dead  fibres.  In  some  instances  there  is  complete  transformation, 
and  a  firm  white  patch  of  hyaline  degeneration  may  appear  in  the  centre  of 
the  area.    Eupture  of  the  heart  may  be  associated  with  ansemic  necrosis. 

(b)  The  second  important  effect  of  coronary  artery  disease  is  seen  in  the 
production  of  fibrous  myocurditis.  This  may  result  from  the  gradual  trans- 
formation of  areas  of  anaemic  necrosis.  More  commonly  it  is  caused  by  the 
narrowing  of  a  coronary  branch  in  a  process  of  obliterative  endarteritis. 
Where  the  process  is  gradual  evidences  of  granulation  tissue  are  often  want- 
ing, and  any  distinction  between  the  necrotic  muscle  fibres  and  the  new  scar 
tissue  is  difficult  to  establish.  J.  B.  MacCallum  showed  that  the  muscle 
fibres  undergo  a  change  the  reverse  of  that  of  their  normal  development  and 
lose  their  fibril  bundles  preliminary  to  their  complete  replacement  by  con- 
nective tissue.  The  sclerosis  is  most  frequent  at  the  apex  of  the  left  ventricle 
and  in  the  septum,  but  may  occur  in  any  portion.  In  the  septum  and  walls 
there  are  often  streaks  and  patches  which  are  only  seen  in  carefully  made 
serial  sections.  Hypertrophy  of  the  heart  is  commonly  associated  with  this 
degeneration.    It  is  the  invariable  precursor  of  aneurism  of  the  heart. 

(c)  Sudden  Death  in  Coronary  Artery  Disease. — Complete  obliteration 
of  one  coronary  artery,  if  produced  suddenly,  is  usually  fatal.  When  induced 
slowly,  either  by  arterio-sclerosis  at  the  orifice  of  the  artery  at  the  root  of  the 
aorta  or  by  an  obliterating  endarteritis  in  the  course  of  the  vessel,  the  circu- 
lation may  be  carried  on  through  the  other  vessel.  Sudden  death  is  not  un- 
common, owing  to  thrombosis  of  a  vessel  which  has  become  narrowed  by 
sclerosis.  In  medico-legal  cases  it  is  a  point  of  primary  importance  to  re- 
member that  this  is  one  of  the  common  causes  of  sudden  death.  This  condi- 
tion should  be  carefully  sought  for,  inasmuch  as  it  may  be  the  sole  lesion,  ex- 
cept a  general,  sometimes  slight,  arterio-sclerosis.  In  the  most  extreme  grade 
one  coronary  artery  may  be  entirely  blocked,  wdth  the  production  of  extensive 
fibroid  disease,  and  a  main  branch  of  the  other  also  may  be  occluded. 

{d)  Septic  Infarcts. — In  pysmia  the  smaller  branches  of  the  coronary 
arteries  may  be  blocked  with  emboli  which  give  rise  to  infectious  or  septic 
infarcts  in  the  myocardium  in  the  form  of  abscesses,  varying  in  size  from  a 
pea  to  a  pin's  head.  These  may  not  cause  any  disturbance,  but  when  large 
they  may  perforate  into  the  ventricle  or  into  the  pericardium,  forming  what 
has  been  called  acute  ulcer  of  the  heart. 

II.  Acute  Interstitial  Myocarditis. — In  some  infectious  diseases  and 
in  acute  pericarditis  the  intermuscular  connective  tissue  may  be  swollen  and 
infiltrated  with  small  round  cells  and  leucocytes,  the  blood  vessels  dilated,  and 
the  muscle  fibres  the  seat  of  granular,  fatty,  and  hyaline  degeneration.  Oc- 
casionally, in  pyaemia  the  infiltration  with  pus  cells  has  been  diffuse  and  con- 
fined chiefly  to  the  interstitial  tissue.  Councilman  has  described  this  condi- 
tion of  the  heart  wall  in  gonorrhoea,  and  demonstrated  the  gouococcus  in  the 


784  DISEASES  OF  THE  CIECULATOEY  SYSTEM 

diseased  areas.  The  commonest  examples  are  found  in  diphtheria,  typhoid 
fever,  and  acute  endocarditis,  as  shown  by  the  studies  of  Eomberg.  The  foci 
may  be  the  starting  points  of  patches  of  fibrous  myocarditis. 

III.  Feagmentation  and  Segmentation. — This  condition  was  described 
by  Eenaut  and  Landouzy  in  1877,  and  has  been  carefully  studied.  Two  forms 
are  met  with:  1.  Segmentation.  The  muscle  fibres  have  separated  at  the 
cement  line.  2.  Fragmentation.  The  fracture  has  been  across  the  fibre  itself, 
and  perhaps  at  the  level  of  the  nucleus.  Longitudinal  division  is  unusual. 
Although  the  condition  doubtless  arises  in  some  instances  during  the  death 
agony,  as  in  sudden  death  by  violence,  in  others  it  would  seem  to  have  clinical 
and  pathological  significance.  It  is  foimd  associated  with  other  lesions,  fibrous 
myocarditis,  infarction,  and  fatty  degeneration.  J.  B.  MacCallum  distin- 
guished a  simple  from  a  degenerative  fragmentation.  The  first  takes  place  in 
the  normal  fibre,  which,  however,  shows  irregular  extensions  and  contractions. 
The  second  succeeds  degeneration  in  the  fibre.  Hearts  the  seat  of  marked  frag- 
mentation are  lax,  easily  torn,  the  muscle  fibres  widely  separated,  and  often 
pale  and  cloudy. 

IV.  Pakenghymatous  Degeneeation. — This  is  usually  met-  with  in  fe- 
vers, or  in  connection  with  endocarditis  or  pericarditis,  and  in  infections  and 
intoxicationo  generally.  It  is  characterized  by  a  pale,  turbid  state  of  the  car- 
diac muscle,  which  is  general,  not  localized.  Turbidity  and  softness  are  the 
special  features.  It  is  the  softened  heart  of  Laennec  and  Louis.  Stokes  speaks 
of  an  instance  in  which  "so  great  was  the  softening  of  the  organ  that  when 
the  heart  was  grasped  by  the  great  vessels  and  held  with  the  apex  pointing 
upward,  it  fell  down  over  the  hand,  covering  it  like  a  cap  of  a  large  mush- 
room."' Histologically,  there  is  a  degeneration  of  the  muscle  fibres,  which  are 
infiltrated  to  a  various  extent  with  granules  which  resist  the  action  of  ether, 
but  are  dissolved  in  acetic  acid.  Sometimes  this  granular  change  in  the  fibres 
is  extreme,  and  no  trace  of  the  strige  can  be  detected.  It  is  probably  the  ef- 
fect of  a  toxic  agent,  and  is  seen  in  its  most  marked  form  in  the  lumbar  muscles 
in  cases  of  toxic  hgemoglobinuria  in  the  horse. 

V.  Fatty  Heart. — Under  this  term  are  embraced  fatty  degeneration  and 
fatty  overgrowth. 

(a)  Fatfy  degeneration  is  a  common  condition,  and  mild  grades  are  met 
with  in  many  diseases.  It  is  found  in  the  failing  nutrition  of  old  age,  wast- 
ing diseases,  and  cachectic  states;  in  prolonged  infectious  fevers,  in  whi^h  it 
may  accompany  the  parenchymatous  change.  In  pernicious  anaemia  and  in 
phosphorus  poisoning  the  most  extreme  degrees  are  seen.  Pericarditis  is  usu- 
ally associated  with  fatty  or  parenchymatous  changes  in  the  superficial  layers 
of  the  myocardium.  Disease  of  the  coronary  arteries  is  a  much  more  common 
cause  of  fibroid  degeneration  than  of  fatty  heart.  Lastly,  in  the  hypertrophied 
ventricular  wall  in  chronic  heart-disease  fatty  change  is  by  no  means  infre- 
quent. This  may  be  limited  to  the  heart  or  be  more  or  less  general  in  the 
solid  viscera.  The  diaphragm  may  also  be  involved,  even  when  the  other 
muscles  show  no  special  changes.  There  appears  to  be  a  special  proneness  to 
fatty  degeneration  in  the  heart  muscle,  which  may  be  connected  with  its  in- 
cessant activity.  So  great  is  its  need  of  an  abundant  oxygen  supply  that  it 
feels  at  once  any  deficiency,  and  is  in  consequence  the  first  muscle  to  show  nu- 
tritional changes. 


AFFECTIOXS  OF  THE  MYOCARDIUM  785 

Anatomically  the  condition  may  be  local  or  general.  The  left  ventricle  is 
most  frequently  affected.  If  the  process  is  advanced  and  general,  the  heart 
looks  large  and  is  flabby  and  relaxed.  It  has  a  light  yellowish  brown  tint, 
or,  as  it  is  called,  a  faded  leaf  color.  Its  consistence  is  reduced  and  the  sub- 
stance tears  easily.  In  the  left  ventricle  the  papillary  columns  and  the  muscle 
beneath  the  endocardium  show  a  streaked  or  patchy  appearance.  Microscop- 
ically, the  fibres  are  seen  to  be  occupied  by  minute  globules  distributed  in 
rows  along  the  line  of  the  primitive  fibres  (Welch).  In  advanced  grades  the 
fibres  seem  completely  occupied  by  the  minute  globules. 

(h)  Fatty  Overgrowili. — This  is  usually  a  simple  excess  of  the  normal 
subpericardial  fat,  to  which  the  term  cor  adiposum  was  given  by  the  older 
writers.  In  pronounced  instances  the  fat  infiltrates  between  the  muscular 
substance  and,  separating  the  strands,  may  reach  even  to  the  endocardium. 
In  corpulent  persons  there  is  always  much  pericardial  fat.  It  forms  part  of 
the  general  obesity,  and  occasionally  leads  to  dangerous  or  even  fatal  impair- 
ment of  the  contractile  power  of  the  heart.  Of  122  cases  analyzed  by  Forch- 
heimer  there  were  88  males  and  34  females.  Over  80  per  cent,  occurred  be- 
tween the  fortieth  and  seventieth  years. 

The  entire  heart  may  be  enveloped  in  a  thick  sheeting  of  fat  through  which 
not  a  trace  of  muscle  substance  can  be  seen.  On  section  the  fat  infiltrates 
the  muscle,  separating  the  fibres,  and  in  extreme  cases — particularly  in  the 
right  ventricle — reaches  the  endocardium.  In  some  places  there  may  be  even 
complete  substitution  of  fat  for  the  muscle  substance.  In  rare  instances  the 
fat  may  be  in  the  papillary  muscles.  The  heart  is  usually  much  relaxed  and 
the  chambers  are  dilated.  Microscopically  the  muscle  fibres  may  show,  in  ad- 
dition to  the  atrophy,  marked  fatty  degeneration. 

VI.  Other  Degenerations. —  (a)  Brown  Atrophy. — This  is  a  common 
change  in  the  heart  muscle,  particularly  in  chronic  valvular  lesions  and  in  the 
senile  heart.  When  advanced  the  color  of  the  muscles  is  a  dark  red  brown, 
and  the  consistence  is  usually  increased,  t  The  fibres  present  an  accumulation 
of  yellow  brown  pigment  chiefly  about  the  nuclei,  (b)  Amyloid  degeneration 
is  occasionally  seen.  It  occur*  in  the  intermuscular  connective  tissue  and  in 
the  blood  vessels,  not  in  the  fibres,  (c)  The  hyaline  transformation  of  Zenker 
may  occur  in  prolonged  fevers.  The  affected  fibres  are  swollen,  homogeneous, 
translucent,  and  the  strise  are  very  faint,  {d)  Calcareous  degeneration  occa- 
sionally occurs  in  the  myocardium,  and  the  muscle  fibres  may  be  infiltrated 
with  lime  salts. 

Symptoms  of  Cardiac  Insufficiency. — The  symptoms  of  left  sided  cardiac 
failure  differ  from  those  of  the  right  side,  and  in  each  we  may  distinguish  a 
number  of  types,  which,  however,  merge  gradually  the  one  into  the  other. 
Failure  of  the  left  ventricle  is  seen  in  its  severest  forms  in  the  al)rupt  death 
stroke  of  angina  pectoris,  in  the  sudden  faints  with  sweats  and  heart  pain  of 
fatty  or  fibroid  hearts,  or  in  the  fainting  and  convulsive  attacks  of  Stokes- 
Adams  disease.  Less  severe  failure  may  be  seen  in  athletes  after  a  hard  race, 
when  vomiting  and  a  feeling  of  dissolution  are  present — a  type  which  is  some- 
times seen  in  angina,  when  it  is  liable  to  be  mistaken  for  a  gastro-intestinal 
upset.  The  milder  degrees  show  themselves  in  an  inability  to  take  much  ex- 
ercise or  to  do  mucli  mental  work  without  the  sense  of  great  fatigue.  Sudden 
and  slow  types  arc  also  seen  in  failure  of  the  right  side.     Subjected  to  a  slight 


786  DISEASES  OF  THE  CIECULATOEY  SYSTEM 

strain,  great  hyperpnoea  and  distress  niay  come  on,  and  one  form  of  cardiac 
dyspnoea  which  attacks  the  patient  at  night  is  of  this  nature.  The  severer 
forms  show  an  increasing  inability  to  undergo  slight  extra  exertion,  such  as 
mounting  stairs,  or  hyperpncea  even  when  at  rest  in  bed,  in  both  of  which 
there  is  usually  some  oedema  of  the  feet,  especially  at  night,  if  the  patient  is 
on  his  feet  most  of  the  day. 

Grouped  under  their  special  systems  the  symptoms  complained  of  by  pa- 
tients with  cardiac  failure  are  as  follows :  (a)  Cardio-vascular  system :  Pain 
in  the  cardiac  area  or  extending  to  the  shoulders  and  down  the  arms,  a  sense 
of  weight  in  the  prgecordium;  paliDitation  is  seldom  complained  of.  (&)  Ees- 
piratory  system :  Dyspnoea  at  rest  or  on  exertion,  or  orthopncea,  Cheyne- 
Stokes  respiration,  cough,  loss  of  voice  from  pressure  of  a  dilated  left  auricle 
on  the  left  recurrent  laryngeal  nerve,  hemoptysis  (from  lung  infarcts),  (c) 
Central  nervous  system;  sleeplessness,  mental  symptoms,  delusions,  melan- 
cholia, and  especially  toward  the  end  stupor  and  drowsiness,  (d)  Cyanosis, 
pallor,  oedema,  and  occasionally  purpura  in  the  lower  limbs,  (e)  Alimentary 
system:  The  stasis  in  the  abdominal  organs  in  right  heart  failure  produces 
loss  of  appetite,  indigestion,  flatulence,  vomiting,  constipation,  diarrhoea,  ab- 
dominal pain,  haemorrhoids,  etc.  (/)  Eenal  system:  The  urine  is  scanty, 
high  colored,  and  contains  a  slight  amount  of  albumin. 

Physical  examination  of  the  heart  may  reveal  an  apex-beat  which  is  feeble, 
outside  the  nipple  line,  diffuse,  and  whose  maximum  intensity  is  not  easily 
localized.  The  pulsation  may  be  marked  on  inspection  and  cover  a  v'ery  wide 
area;  arterial  pulsation  in  the  neck  in  the  left  heart  failure  may  be  great;  in 
right  heart  faiktre  the  Jugular  veins  may  be  very  dilated.  On  percussion  the 
cardiac  area  may  be  much  increased  to  the  right  or  to  the  left,  or  both.  On 
auscultation  the  sounds  may  be  difficult  to  hear,  or  feebler  than  normal;  mur- 
murs, usually  soft,  may  -be  present  at  both  apex  and  base.  Gallop  rhythm 
may  be  present.  The  pulse  may  show  great  variations;  marked  failure  may 
exist  with  a  full  bounding  pulse;  more  usually  it  is  feeble  with  diminished 
tension;  it  may  be  irregular,  intermittent,  slow,  or  rapid.  No  one  sign  or 
combination  of  signs  is  significant  of  cardiac  failure.  A  heart  may  be  insuffi- 
cient and  yet  perhaps  nothing  can  be  detected  by  physical  examination  except 
feeble  sounds  and  a  low  tension  pulse. 

The  myocardial  lesion  is  not  always  proportionate  to  the  intensity  of  the 
symptoms.  A  patient  may  present  enfeebled,  irregular  action  and  signs  of 
dilatation  with  shortness  of  breath  and  oedema,  and  the  post  mortem  show 
little  or  no  change  in  the  myocardium. 

When  dilatation  occurs  there  are  gallop  rhythm,  shortening  of  the  long 
pause,  and  a  systolic  murmur  at  the  apex.  Shortness  of  breath  on  exertion 
is  an  early  feature  in  many  cases,  and  anginal  attacks  may  occur.  There  is 
sometimes  a  tendency  to  syncope,  and  the  patient  may  wake  from  sleep  in  the 
early  morning  with  an  attack  of  severe  dyspnoea.  These  "spells"  may  be  as- 
sociated with  nausea  and  may  alternate-  with  others  in  which  there  are  anginal 
symptoms.  These  are  the  cases,  too,  in  which  for  weeks  there  may  be  mental 
symptoms.  The  patient  has  delusions  and  may  even  become  maniacal. 
Toward  the  close  the  type  of  breathing  known  as  Cheyne-Stokes  may  occur. 
It  was  described  in  the  following  terms  by  John  Cheyne,  speaking  of  a  case 
of  fatty  heart  (Dublin  Hospital  Eeports,  vol.  ii,  p.  321,  1818)  :    "For  several 


AFFECTIONS  OF  THE  MYOCARDIUM  787 

days  his  breathing  was  irregular;  it  would  entirely  cease  for  a  quarter  of  a 
minute,  then  it  would  become  perceptible,  though  very  low,  then  by  degrees 
it  became  heaving  and  quick,  and  then  it  would  gradually  cease  again:  this 
revolution  in  the  state  of  his  breathing  lasted  about  a  minute,  during  which 
there  were  about  thirty  acts  of  respiration."  It  is  seen  much  more  frequently 
in  arterio-sclerosis  and  uremic  states  than  in  fatty  heart. 

Fatty  overgrowth  of  the  heart  is  a  condition  certain  to  exist  in  very  obese 
persons.  It  produces  no  symptoms  until  the  muscular  fibre  is  so  weakened 
that  dilatation  occurs.  These  patients  may  for  years  present  a  feeble  but 
regular  pulse;  the  heart  sounds  are  weak  and  muffled,  and  a  murmur  may  be 
heard  at  the  apex.  Attacks  of  dyspnoea  are  not  uncommon,  and  the  patient 
may  sulfer  from  bronchitis.  The  physical  examination  is  often  difficult  because 
of  the  great  increase  in  the  fat,  and  it  may  be  impossible  to  define  the  area  of  ■ 
dulness. 

Thromhosis  of  the  coronary  arteries  occurs  usually  in  middle-aged  or 
elderly  people.  Their  vessels  are  sclerotic,  the  blood  pressure  may  be  high  and 
they  may  have  had  angina  pectoris.  The  seizure  is  severe  and  lasts  for  some 
time  if  death  does  not  occur  suddenly.  The  pain  is  substernal  or  referred  to 
the  lower  sternum  or  epigastrium.  It  rtiay  radiate  to  the  arms  or  neck.  If 
referred  to  the  abdomen  with  signs  of  collapse,  an  acute  abdominal  condition 
may  be  suspected.  Some  of  the  deaths  attributed  to  "acute  indigestion"  belong 
here.  The  heart  is  rapid,  often  irregular,  sometimes  dilated,  the  sounds  feeble, 
and  a  friction  rub  may  be  heard.  The  pulse  is  weak  and  the  blood  pressure 
lowered.  Pulmonary  stasis  or  oedema,  passive  congestion  of  the  kidney  and 
general  cedema  may  result.  Death  may  result  rapidly  or  after  some  hours. 
In  thrombosis  of  the  smaller  branches  recovery  may  follow. 

Cardioptosis. — This  is  found  in  thin  persons  Avith  visceroptosis.  The  heart 
is  narrow,  lies  vertically  and  is  low  in  position.  It  is  found  in  the  sub-normal 
type  with  arterial  hypoplasia,  a  tendency  to  under-nutrition,  and  vaso-motor 
instability.  Dilatation  occurs  readily,  with  any  slight  infection  or  disturb- 
ance, and  is  easily  overlooked  owing  to  the  small  size  of  the  heart  with  which 
a  normal  extent  of  dulness  represents  enlargement.  They  respond  quickly  to 
rest  and  digitalis. 

Functional  Tests. — There  are  many  of  these,  the  principle  being  to  have 
the  patient  perform  certain  exercises,  such  as  hopping  on  one  leg,  bending 
over,  etc.,  and  then  studying  the  circulatory  response.  The  exercise  chosen 
should  be  suitable  for  the  age  and  habits  of  the  patient.  The  extent  of  re- 
sponse (pulse  rate,  blood  pressure)  and  the  length  of  time  it  persists  are  im- 
portant points.  But  every  patient  is  constantly  doing  "functional  tests"  in  his 
daily  life,  which  careful  inquiry  should  elicit. 

We  may  group  the  cases  of  failure  from  myocardial  diseases  as  follows : 

(1)  Those  in  which  sudden  death  occurs  with  or  without  previous  indi- 
cations of  heart-trouble.  Sclerosis  of  the  coronary  arteries  exists — in  some 
instances  with  recent  thrombus  and  white  infarcts;  in  others,  extensive  fibroid 
disease;  in  others  again,  fatty  degeneration.  Many  patients  never  complain 
of  cardiac  distress,  but,  as  in  the  case  of  Chalmers,  the  celebrated  Scottish 
divine,  enjoy  unusual  vigor  of  mind  and  body. 

(2)  Cases  in  which  there  are  cardiac  arrhythmia,  shortness  of  breath  on 


788  DISEASES  OF  THE  CIRCULATOEY  SYSTEM 

exertion,  attacks  of  dyspnoea,  sometimes  anginal  attacks,  collapse  symptoms 
with  sweats  and  slow  pulse,  and  occasionally  marked  mental  symptoms. 

(3)  Cases  with  general  arterio-sclerosis  and  hypertrophy  and  dilatation 
of  the  heart.  They  are  robust  men  of  middle  age  who  have  worked  hard 
and  lived  carelessly.  Dyspnoea,  cough,  and  swelling  of  the  feet  are  the  early 
symptoms,  and  the  patient  comes  under  observation  either  with  a  gallop 
rhythm,  emljryocardia,  or  an  irregular  heart  with  an  apex  systolic  mumur 
of  mitral  insufficiency.  Eecovery  from  the  first  or  second  attack  is  the  rule. 
It  is  one  of  the  most  common  forms  of  heart-disease. 

Prognosis. — Each  case  must  be  judged  on  its  own  merits,  special  notice 
being  taken  of  the  age,  probable  origin,  and  anatomical  basis  of  the  insuffi- 
ciency. AYith  disturbance  of  rhythm  the  nature  of  this  should  be  determined 
as  this  has  an  important  bearing  on  the  outcome.  The  outlook  in  affections 
of  the  myocardium  occurring  late  in  life  is  extremely  grave.  Patients  re- 
cover, however,  in  a  surprising  way  from  the  most  serious  attacks,  particularly 
those  of  the  third  group. 

Treatment. — Some  patients  never  come  under  treatment;  the  first  are  the 
final  symptoms.  Other  cases  with  well  marked  failure,  if  treated  on  general 
lines,  recover  quickly.  Much  more  difficult  is  the  management  of  those  cases 
in  which  there  is  marked  disturbance  of  function  as  heart-block,  auricular 
fibrillation  or  alternation  of  the  heart. 

The  following  are  the  general  methods  in  the  treatment  of  cardiac  failure : 

(a)  Eest. — Disturbed  compensation  maj  be  completely  restored  by  rest 
of  the  body.  In  some  cases  with  oedema  of  the  ankles,  moderate  dilatation 
of  the  heart,  and  irregularity  of  the  pulse,  rest  in  bed  and  a  purge  suffice, 
within -a  week  or  ten  days,  to  restore  the  compensation. 

(6)  Diet. — In  acute  conditions  it  is  usually  well  to  limit  this  in  amount, 
especially  the  fluids.  With  marked  passive  congestion  liquid  diet  may  be  ad- 
visable; otherwise  small  amounts  of  simple  food  ma}^  be  given  at  short  inter- 
vals, lu  any  case  with  dilatation  it  is  well  to  limit  the  total  daily  intake  of 
fluids  to  1,500  c.  c.    A  "dry  diet"  for  a  few  days  is  sometimes  useful. 

(c)   The  eelief  of  the  embaeeassed  cieculatiox. 

(1)  By  Venesection. — In  cases  of  dilatation,  from  whatever  cause,  in 
mitral  or  aortic  lesions  or  distention  of  the  right  ventricle  in  emphysema, 
when  signs  of  venous  engorgement  are  marked  and  when  there  is  orthopnoea 
with  cj'anosis,  the  abstraction  of  from  20  to  30  ounces  of  blood  is  indicated. 
This  is  the  occasion  in  which  timely  venesection  may  save  the  patient's  life. 
It  is  particularly  helpful  in  the  dilated  heart  of  arterio-sclerosis. 

(2)  By  Depletion  through  the  Bowels. — This  is  particularly  valuable  when 
dropsy  is  present.  The  salines  are  to  be  preferred ;  before  breakfast  from  half 
r.n  ounce  to  an  ounce  and  a  half  of  Epsom  salts  may  be  given  in  concentrated 
form.  This  usuall}^  produces  liquid  evacuations.  The  compound  jalap  pow- 
der in  half  dram  (2  gm.)  doses,  or  elaterin  (gr,  1/10  0.006  gm.)  may  be 
employed  for  the  same  purpose.  Even  'when  the  pulse  is  very  feeble  cathartics 
are  well  borne,  and  they  deplete  the  portal  system  rapidly  and  efficiently. 

(3)  The  Use  of  Remedies  Which  Stimulate  the  Heart. — Of  these  by  far 
the  most  important  is  digitalis,  which  was  introduced  into  practice  by  Wither- 
ing. The  indication  for  its  use  is  weakness  of  the  heart  muscle,  most  especially 
when  auricular  fibrillation  is  present;  a  centra-indication  is  a  perfectly  bal- 


AFFECTIOXS  OF  THE  MYOCARDIUM  789 

anced  compensatory  hypertrophy.  Broken  compensation  in  valvular  disease, 
no  matter  Avhat  the  lesion  may  be,  is  the  signal  for  its  use.  It  slows  and  at 
the  same  time  increases  the  force  of  the  contractions.  It  acts  on  the  peripheral 
arteries,  so  that  a  steady  and  equable  flow  of  blood  is  maintained  in  the  cap- 
illaries, which,  after  all,  is  the  prime  aim  and  object  of  the  circulation.  High 
blood  j)ressure  is  not  a  contra-indication  to  its  use.  The  beneficial  effects  are 
best  seen  in  cases  of  mitral  disease  with  auricular  fibrillation.  On  theoretical 
grounds  it  has  been  urged  that  its  use  is  not  so  advantageous  in  aortic  insuffi- 
ciency, since  it  prolongs  the  diastole  and  leads  to  greater  distention.  This  need 
not  be  considered,  and  digitalis  is  just  as  serviceable  in  this  as  in  any  other 
condition  associated  with  progressive  dilatation.  It  may  be  given  as  the  tinc- 
ture or  the  infusion.  In  cases  of  cardiac  dropsy,  from  whatever  cause,  15 
minims  (1  c.  c.)  of  the  tincture  or  half  an  ounce  (15  c.  c.)  of  the  infusion 
may  be  given  every  three  hours  for  two  days,  after  which  the  dose  may  be 
reduced.  The  present  tendency  is  to  give  larger  doses.  Some  prefer  the  tinc- 
ture, others  the  infusion;  it  is  a  matter  of  indifference  if  the  drug  is  good. 
The  urine  of  a  patient  taking  digitalis  should  be  carefully  estimated  each 
day.  xls  a  rule,  when  its  action  is  beneficial,  there  is  within  twenty-four  hours 
an  increase  in  the  amount;  often  the  flow  is  very  great.  Under  its  use  the 
dyspnoea  is  relieved,  the  dropsy  gradually  disappears,  the  pulse  becomes  firmer, 
fuller  in  volume,  and  sometimes,  if  it  has  been  intermittent,  less  irregular. 

Ill  efl'ects  sometimes  follow  digitalis.  There  is  no  such  thing  as  a  cumu- 
lative action  of  the  drug  manifested  by  sudden  symptoms.  Toxic  effects  are 
seen  in  the  production  of  nausea  and  vomiting.  The  pulse  becomes  irregular 
and  small,  and  there  may  be  two  beats  of  the  heart  to  one  of  the  pulse,  or  al- 
ternation of  the  heart-beat.  The  urine  is  reduced  in  amount.  These  symp- 
toms subside  on  the  withdrawal  of  the  digitalis,  and  are  rarely  serious.  There 
are  patients  who  take  digitalis  uninterruptedly  for  years,  and  feel  palpitation 
and  distress  if  the  drug  is  omitted.  There  are  many  cases  of  auricular  fibrilla- 
tion in  which  the  irregularity  is  not  affected  by  the  digitalis.  When  the 
compensation  has  been  re-established  the  drug  may  be  omitted.  When  there 
is  dyspnoea  on  exertion  and  cardiac  distress,  from  5  to  10  minims  (0.3  to  0.6 
c.  c.)  three  times  a  day  may  be  advantageously  given  for  prolonged  periods, 
but  the  effects  should  be  carefully  watched.  In  cardiac  dropsy  digitalis  should 
be  used  at  the  outset  with  a  free  hand.  Small  doses  should  not  be  given,  but 
from  the  first  half -ounce  doses  of  the  infusion  every  three  hours,  or  from  15 
to  20  minims  of  -the  tincture.  In  severe  conditions  and  if  there  is  vomitins: 
it  may  be  necessary  to  give  digitalis  or  strophanthus  intramuscularly.  Some 
of  the  special  fluid  preparations  of  digitalis  suitable  for  hypodermic  use 
should  be  employed  in  doses  of  TIXlo — 30  (1-2  c.  c).  There  is  some  risk  in 
giving  these  drugs  intravenously  and  this  method!  should  be  used  only  in  a 
severe  emergency. 

Of  other  remedies  strophanthus  alone  is  of  service,  but  as  its  effect  is  un- 
certain when  given  by  mouth  it  should  be  administered  by  intramuscular  in- 
jection. Doses  of  10  to  15  minims  (O.G  to  1  c.  c.)  of  the  tincture  or  strophan- 
thin  gr.  1/200  (0.00032  gm.)  are  given  and  repeated  once  or  twice  at  inter- 
vals of  twenty-four  hours.  The  intramuscular  is  safer  than  the  intravenous  ad- 
ministration.    Convallaria,  caffeine,  adonis  vernalis  and  sparteine  are  recom- 


790  DISEASES  OF  THE  CIECULATORY  SYSTEM 

mended  as  substitutes  for  digitalis,  but  their  inferiority  is  so  manifest  that 
their  use  is  rarely  indicated. 

There  are  two  valuable  adjuncts  in  the  treatment  of  myocardial  disease — 
iron  and  strychnia.  When  anaemia  is  a  marked  feature  iron  should  be  given 
in  full  doses.  Arsenic  is  an  excellent  substitute,  and  one  or  other,  or  both, 
should  be  administered  in  all  instances  of  heart  trouble  when  anaemia  is 
present.  Strychnia  may  be  given  alone  or  in  combination  with  digitalis  in 
1  or  2  drop  doses  of  the  1  per  cent,  solution,  or  hypodermically  in  doses  of 
1/40-1/10  gr.  (0.0016  to  0.006  gm.). 

Treatment  of  Special  Symptoms. —  {a)  Dropsy. — The  improved  circula- 
tion under  the  influence  of  digitalis  hastens  the  interstitial  lymph  flow  and 
favors  resorption  of  the  fluid.  Cathartics,  by  depleting  the  blood,  promote 
the  absorption  of  the  fluid  from  the  lymph  spaces  and  the  lymph  sacs.  These 
two  measures  usually  suffice  to  rid  the  patient  of  dropsy.  In  some  cases,  how- 
ever, it  cannot  be  relieved,  and  the  legs  may  be  punctured  by  ordinary  as- 
pirating needles,  with  rubber  tubing  attached,  which  may  be  inserted  and  left 
for  hours;  they  often  drain  away  large  amounts.  If  done  with  care,  after  a 
thorough  cleaning,  and  if  antiseptic  precautions  are  taken,  scarification  is  a 
serviceable  measure.  Canton  flannel  bandages  may  be  applied  on  the  cedema- 
tous  legs.  In  case  of  marked  hydrothorax  or  ascites  tapping  is  advisable  be- 
fore digitalis  is  given. 

(6)  Dyspncea. — The  patients  are  usually  unable  to  lie  down  and  should 
have  a  comfortable  bed-rest — if  possible,  one  with  lateral  projections,  so  that 
in  sleeping  the  head  can  be  supported  as  it  falls  over.  The  shortness  of  breath 
is  associated  with  dilatation,  chronic  bronchitis,  or  hydrothorax.  The  chest 
should  be  carefully  examined,  as  hydrothorax  is  a  common  cause  of  shortness 
of  breath.  There  are  cases  of  mitral  regurgitation  with  recurring  hydro- 
thorax, usually  on  the  right  side,  which  is  relieved,  week  by  week  or  month 
by  month,  by  tapping.  For  the  nocturnal  dyspnoea,  particularly  when  com- 
bined with  restlessness,  morphia  is  invaluable  and  may  be  given  without  hesi- 
tation. The  value  of  the  calming  influence  of  opium  in  all  conditions  of 
cardiac  insufficiency  is  not  sufficiently  recognized.  There  are  instances  of 
cardiac  dyspnoea  unassociated  with  dropsy,  particularly  in  mitral  valve  dis- 
ease, in  which  nitroglycerin  or  sodium  nitrite  is  of  great  service,  given  in 
increasing  doses.  They  are  especially  serviceable  in  the  cases  in  which  the 
pressure  is  high. 

(c)  Palpitation  and  Cardiac  Distress. — In  instances  of  great  hyper- 
trophy and  in  the  throbbing  which  is  so  distressing  in  some  cases  of  aortic  in- 
sufficiency, aconite  is  of  service  in  doses  of  from  1  to  3  drops  every  two  or 
three  hours.  An  ice  bag  over  the  heart  is  also  of  service.  For  the  pains, 
which  are  often  so  marked  in  aortic  lesions,  iodide  of  potassium  in  10-grain 
(0.6  gm.)  doses,  three  times  a  day,  or  nitroglycerin  may  be  tried.  Small 
blisters  are  sometimes  advantageous.  It  must  be  remembered  that  an  im- 
portant cause  of  palpitation  and  cardiac  distress  is  flatulent  distention  of  the 
stomach  or  colon,  against  which  suitable  measures  must  be  directed. 

{d)  Gastric  Symptoms. — The  cases  of  cardiac  insufficiency  which  do 
badly  and  fail  to  respond  to  digitalis  are  most  often  those  in  which  nausea 
and  vomiting  are  prominent  features.  The  liver  is  often  greatly  enlarged  in 
these  cases;  there  is  more  or  less  stasis  in  the  hepatic  vessels,  and  but  little 


AFFECTIONS  OF  THE  MYOCARDIUM  791 

can  be  expected  of  drugs  until  the  venous  engorgement  is  relieved.  If  the 
vomiting  persists,  it  is  best  to  stop  food  and  give  small  bits  of  ice,  small 
quantities  of  milk  and  lime  water,  and  effervescing  drinks.  The  bowels  should 
be  freely  moved  and  drugs  given  hypodermically,  if  possible. 

(e)  Cough  and  Hemoptysis. — The  former  is  almost  a  necessary  con- 
comitant of  cardiac  insufficiency,  owing  to  engorgement  of  the  pulmonary  ves- 
sels and  more  or  less  bronchitis.  It  is  allayed  by  measures  directed  rather  to 
the  heart  than  to  the  lungs.  Haemoptysis  in  chronic  valvular  disease  is  some- 
times a  salutary  symptom.  An  army  surgeon,  who  was  invalided  during  the 
American  civil  war  on  account  of  haemoptysis,  supposed  to  be  due  to  tubercu- 
losis, had  for  many  years,  in  association  with  mitral  insufficiency  and  enlarged 
heart,  many  attacks  of  haemoptysis.  He  was  sure  that  his  condition  was  in- 
variably better  after  an  attack.  It  is  rarely  fatal,  except  in  some  cases  of 
acute  dilatation,  and  seldom  caUs  for  special  treatment. 

(/)  Sleeplessness. — One  of  the  most  distressing  features,  even  in  the 
stage  of  compensation,  is  disturbed  sleep.  Patients  may  wake  suddenly  with 
throbbing  of  the  heart,  often  in  an  attack  of  nightmare.  Subsequently,  when 
the  compensation  has  failed,  it  is  also  a  worrying  symptom.  The  sleep  is 
broken,  restless,  and  frequently  disturbed  by  frightful  dreams.  Sometimes  a 
dose  of  the  spirit  of  chloroform  with  spirit  of  camphor  will  give  a  quiet  night. 
The  compound  spirit  of  ether,  Hoffmann's  anodyne,  though  very  unpleasant 
to  take,  is  frequently  a  great  boon  in  the  intermediate  period  when  compensa- 
tion has  partially  failed  and  the  patients  suffer  from  restless  and  sleepless 
nights.  Paraldehyde  and  chloral  hydrate  are  sometimes  serviceable,  but  it  is 
best,  if  these  fail,  to  resort  to  morphia  without  hesitation. 

{g)  Penal  Symptoms. — With  broken  compensation  and  lowering  of  the 
tension,  the  urinary  secretion  is  diminished,  and  the  amount  may  sink  to  5  or 
6  ounces  in  the  day.  Digitalis  and  strophanthus  usually  increase  the  flow.  A 
brisk  purge  may  be  followed  by  auginented  secretion.  The  combination  in  pill 
form  of  digitalis,  squill,  and  calomel  will  sometimes  prove  effective  when 
digitalis  alone  has  failed.  Diuretin  in  doses  of  15  grains  (1  gm.)  four  times 
a  day  is  sometimes  useful. 

The  DIET  in  chronic  cardiac  diseases  is  often  very  difficult  to  regulate. 
Widal  and  others  have  shown  that  retention  of  the  chlorides  is  an  important 
factor  in  cardiac  dropsy  and  heart  failure.  A  milk  diet,  2  litres  a  day,  favors 
their  elimination,  and  in  the  intervals  between  attacks  a  salt  free  diet  as  far 
as  possible  should  be  used.  Starchy  foods  and  all  articles  likely  to  cause 
flatulency  should  be  forbidden. 

In  certain  cases  of  weak  heart,  particularly  when  it  is  due  to  fatty  over- 
growth, the  plans  recommended  by  Oertel  and  by  Schott  are  advantageous. 
They  are  invaluable  methods  in  those  forms  of  heart  weakness  due  to  intem- 
perance in  eating  and  drinking  and  defective  bodily  exercise.  The  Oertel 
plan  consists  of  three  parts :  First,  the  reduction  in  the  amount  of  liquid. 
This  is  an  important  factor  in  reducing  the  fat  in  these  patients.  It  also 
slightly  increases  the  density  of  the  blood.  Oertel  allows  daily  about  36  ounces 
of  liquid,  which  includes  the  amount  taken  with  the  solid  food.  Free  per- 
spiration is  promoted  by  bathing  (if  advisable,  the  Turkish  bath),  or  even 
by  the  use  of  pilocarpine. 

The  second  important  point  in  his  treatment  is  the  diet,  which  should 


792  DISEASES  OF  THE  CIECULATOEY  SYSTEM 

consist  largely  of  proteins.  Morning. — Cup  of  coffee  or  tea,  with  a  little  milk, 
about  6  ounces  altogether.  Bread,  3  ounces.  A'oow.— Three  to  4  ounces  of 
soup,  7  to  8  ounces  of  roast  beef,  veal,  game,  or  poultry,  salad  or  a  light  vege- 
table, a  little  fish;  1  ounce  of  bread  or  farinaceous  pudding;  3  to  6  ounces  of 
fruit  for  dessert.  No  liquids  at  this  meal,  as  a  rule,  but  in  hot  weather  6 
ounces  of  fluid  may  be  taken.  Afternoon. — Six  ounces  of  coffee  or  tea,  with  as 
much  water.  As  an  indulgence  an  ounce  of  bread.  Evening. — One  or  2  soft- 
boiled  eggs,  an  ounce  of  bread,  perhaps  a  small  slice  of  cheese,  salad,  and 
fruit;  10  to  12  ounces  of  fluid. 

The  most  important  element  is  graduated  exercise,  not  on  the  level,  but 
up  hills  of  various  grades.  The  distance  walked  each  day  is  gradually  length- 
ened.   In  this  way  the  heart  is  systematically  exercised  and  strengthened. 

The  Schott  Treatment. — This  consists  in  a  combination  of  baths  with 
exercises.  The  water  has  a  temperature  of  from  82°-95°  F.,  and  is  very 
richly  charged  with  CO2.  The  good  effects  are  claimed  to  come  from  a  cu- 
taneous excitation,  induced  by  the  mineral  and  gaseous  constituents  of  the 
bath,  and  a  stimulation  of  the  sensory  nerves.  There  is  no  question  that  the 
bath,  in  suitable  cases,  will  alter  the  position  of  the  apex  beat,  and  that  it  les- 
sens the  area  of  cardiac  dulness.  Artificial  baths  can  be  used  with  various 
strengths  of  sodium  chloride  and  calcium  chloride.  The  exercises,  resistance 
gymnastics,  consist  in  slow  movements  executed  by  the  patient  and  resisted  by 
the  operator.  The  best  cases  for  this  treatment  are  those  with  myocardial 
weakness.  For  valvular  heart  diseases  in  the  stage  of  broken  compensation 
with  dropsy,  etc.,  and  in  marked  arterio-sclerosis,  it  is  not  so  suitable.  The 
"neurotic  heart"  is  often  much  benefited. 


III.     ENDOCARDITIS 

Inflammation  of  the  lining  membrane  of  the  heart  is  usually  confined  to 
the  valves,  so  that  the  term  is  practically  synonymous  with  valvular  endo- 
carditis. It  occurs  in  two  forms — acute,  characterized  by  the  presence  of 
vegetations  with  loss  of  continuity  or  of  substance  in  the  valve  tissues ;  chronic, 
a  slow  sclerotic  change,  resulting  in  thickening,  puckering,  and  deformity. 

I.     ACUTE   ENDOCARDITIS 

This  occurs  in  rare  instances  as  a  primary,  independent  affection;  but 
in  the  great  majority  of  cases  it  is  an  accident  in  various  infective  processes, 
so  that  in  reality  the  disease  does  not  constitute  an  etiological  entity. 

For  convenience  of  description  we  speak  of  a  simple  or  benign,  and  a 
malignant,  ulcerative,  or  infective  endocarditis,  between  which,  however,  there 
is  no  essential  anatomical  difference,  as  all  gradations  can  be  traced,  and  they 
represent  but  different  degrees  of  intensity  of  the  same  process. 

Etiology.^  Simple  endocaeditis  does  not  constitute  a  disease  of  itself, 
but  is  invariably  found  with  some  other  affection.  In  330  cases  of  rheumatic 
fever  at  the  Johns  Hopkins  Hospital  there  were  110  cases  of  endocarditis. 
Bouillaud  first  emphasized  the  frequency  of  the  association  of  simple  endo- 
carditis with  rheumatic  fever.     Before  him,  however,  the  association  had  been 


ENDOCAEDITIS  793 

noticed.  Tonsillitis,  which  in  some  forms  is  regarded  as  a  rheumatic  affec- 
tion, may  be  complicated  with  endocarditis.  Of  the  specific  diseases  of  child- 
hood it  is  not  uncommon  in  scarlet  fever,  while  it  is  rare  in  measles  and 
chicken-pox.  In  diphtheria  simple  endocarditis  is  rare.  In  small-pox  it  is 
not  common.    In  typhoid  fever  it  occurred  six  times  among  1,500  cases. 

In  pneumonia  both  simple  and  malignant  endocarditis  are  common.  In 
100  autopsies  in  this  disease  at  the  Montreal  General  Hospital  there  were 
5  instances  of  the  former.  Among  61  cases  of  endocarditis  studied  bacterio- 
logically  in  Welches  laboratory,  pneumococci  were  found  in  21  (Marshall). 
Of  517  fatal  cases  of  acute  endocarditis,  115  were  in  connection  with  pneu- 
monia— 22.3  per  cent.  (E.  F.  Wells).  Acute  endocarditis  is  by  no  means 
rare  in  pulmonary  tuberculosis  and  was  found  in  12  cases  in  216  post  mortems. 

In  chorea  simple  warty  vegetations  are  found  on  the  valves  in  a  large 
majority  of  all  fatal  cases,  in  62  of  73  collected  cases.  There  is  no  disease  in 
which,  post  mortem,  acute  endocarditis  has  been  so  frequently  found.  And, 
lastly,  simple  endocarditis  is  met  with  in  diseases  associated  with  loss  of  flesh 
and  progressive  debility,  as  cancer,  gout,  and  nephritis. 

A  very  common  form  is  that  which  occurs  on  the  sclerotic  valves  in  old 
heart-disease — the  so-called  recurring  endocarditis. 

Malignant  or  infective  endocarditis  is  met  with:  (a)  As  a  primary 
disease  of  the  lining  membrane  of  the  heart  or  of  its  valves. 

(&)  As  a  secondary  affection  in  pneumonia,  in  various  specific  fevers,  in 
septic  processes  of  all  sorts,  and  most  frequently  of  all  as  an  infection  on  old 
sclerotic  valves.  In  a  majority  of  all  cases  it  is  a  local  process  in  an  acute  in- 
fection. Congenital  lesions  are  very  prone  to  the  severer  types  of  endocarditis, 
particularly  affections  of  the  orifice  of  the  pulmonary  artery  and  the  margins 
of  the  imperfect  ventricular  septum  (C.  Eobinson). 

The  existence  of  a  primary  endocarditis  has  been  doubted;  but  there  are 
instances  in  which  persons  previously  in  good  health,  without  any  history  oi 
affections  with  which  endocarditis  is  usually  associated,  have  been  attacked  by 
a  severe  infection.  In  one  case  death  occurred  on  the  sixth  day  and  no  lesions 
were  found  other  than  those  of  malignant  endocarditis. 

The  simple  endocarditis  of  rheumatic  fever  or  of  chorea  rarely  progresses 
into  the  malignant  form.  Of  all  acute  diseases  complicated  with  severe  endo- 
carditis pneumonia  probably  heads  the  list.  Gonorrhoea  is  a  much  more 
common  cause  than  has  been  supposed.  The  affection  may  complicate  erysip-a- 
las,  septicemia  (from  whatever  cause),  and  puerperal  fever.  Malignant  en- 
docarditis is  very  rare  in  tuberculosis,  typhoid  fever,  diphtheria,  dysentery, 
small-pox,  and  scarlet  fever. 

Morbid  Anatomy. —Simple  endocarditis  is  characterized  by  the  pres- 
ence on  the  valves  or  on  the  lining  membrane  of  the  chambers  of  minute  vege- 
tations, ranging  from  1  to  4  mm.  in  diameter,  with  an  irregular  and  fissured 
surface,  giving  to  them  a  warty  or  verrucose  appearance.  Often  these  little 
cauliflower-like  excrescences  are  attached  by  very  narrow  pedicles.  They  are 
more  common  on  the  left  side  of  the  heart  than  the  right,  and  occur  on  the 
mitral  more  often  than  on  the  aortic  valves.  The  vegetations  are  upon  the 
line  of  closure  of  the  valves — i.  e.,  on  the  auricular  face  of  the  auriculo-ven- 
tricular  valves,  a  little  distance  from  the  margin,  and  on  the  ventricular  side 
■  of  the  sigmoid  valves,  festooned  on  either  half  of  the  valve  from  the  corpora 


794  DISEASES  OF  THE  CIECULATOEY  SYSTEM 

Arantii.  It  is  rare  to  see  any  swelling  or  macroscopic  evidence  of  infiltration 
of  the  endocardium  in  the  neighborhood  of  even  the  smallest  of  the  granula- 
tions, or  of  redness,  indicative  of  distention  of  the  vessels,  even  when  they 
occur  upon  valves  already  the  seat  of  sclerotic  changes,  in  which  capillary 
vessels  extend  to  the  edges.  With  time  the  vegetations  may  increase  greatly 
in  size,  but  in  simple  endocarditis  the  size  rarely  exceeds  that  mentioned  abov  3. 
Hirschfelder  has  shown  experimentally  that  they  may  form  with  great  rapidity, 
even  in  a  few  hours. 

The  earliest  vegetations  consist  of  elements  derived  from  the  blood,  and 
are  composed  of  blood  platelets,  leucocytes,  and  fibrin  in  varying  proportions. 
At  a  later  stage  they  appear  as  small  outgrowths  of  connective  tissue.  The 
transition  of  one  form  into  the  other  can  often  be  followed.  The  process  con- 
sists of  a  proliferation  of  the  endothelial  cells  and  the  cells  of  the  subendo- 
thelial  layer  which  gradually  invade  the  fresh  vegetation,  and  ultimately  en- 
tirely replace  it.  The  blood  cells  and  fibrin  undergo  disintegration  and  are 
gradually  removed.  Even  when  the  vegetation  has  been  entirely  converted  into 
connective  tissue  it  is  often  found  at  autopsy  to  be  capped  with  a  thin  layer  of 
fibrin  and  leucocytes. 

Micro-organisms  are  generally,  even  if  not  invariably,  found  associated 
with  the  vegetations.  They  tend  to  be  entangled  in  the  granular  and  fibril- 
lated  fibrin  or  in  the  older  ones  to  cap  the  apices. 

Subsequent  Changes. —  (a)  The  vegetations  may  become  organized  and 
the  valve  restored  to  a  normal  state  ( ?).  (&)  The  process  may  extend,  and  a 
simple  may  become  an  ulcerative  endocarditis,  (c)  The  vegetations  may  be 
broken  off  and  carried  in  the  circulation  to  distant  parts,  (d)  The  vegeta- 
tions become  organized  and  disappear,  but  they  initiate  a  nutritive  change 
in  the  valve  tissue  which  ultimately  leads  to  sclerosis,  thickening,  and  de- 
formity. The  danger  in  any  case  of  simple  endocarditis  is  not  immediate,  but 
remote,  and  consists  in  this  perversion  of  the  normal  processes  of  nutrition 
which  results  in  sclerosis  of  the  valves. 

A  gradual  transition  from  the  simple  to  a  more  severe  affection,  to  which 
the  name  malignant  or  ulcerative  endocarditis  has  been  given,  may  bs 
traced.  Practically  in  every  case  of  ulcerative  endocarditis  vegetations  are 
present.  In  this  form  the  loss  of  substance  in  the  valve  is  more  pronounced, 
the  deposition — thrombus  formation — from  the  blood  is  more  extensive,  and 
the  micro-organisms  are  present  in  greater  number  and  often  show  increased 
virulence.  Ulcerative  endocarditis  is  often  found  in  connection  with  heart 
valves  already  the  seat  of  chronic  proliferative  and  sclerotic  changes. 

In  this  form  there  is  much  loss  of  substance,  which  may  be  superficial  and 
limited  to  the  endocardium,  or,  what  is  more  common,  it  involves  deeper 
structures,  and  not  very  infrequently  leads  to  perforation  of  a  valve,  the  sep- 
tum, or  even  of  the  heart  itself.  The  affected  valve  shows  necrosis,  wirli  more 
or  less  loss  of  substance ;  the  tissue  is  devoid  of  preserved  nuclei  and  presents 
a  coagulated  appearance.  Upon  it  a  mixture  of  blood  platelets,  fibrin  and 
leucocytes  enclosing  masses  of  micro-organisms  are  found.  The  subjacent 
tissue  often  shows  sclerotic  thickening  and  always  infiltration  with  exuded  cells. 

Parts  Affected. — The  following  figures,  taken  from  the  Goulstonian  lec- 
tures (Osier)  give  an  approximate  estimate  of  the  frequency  with  which  in 
209  cases  different  parts  of  the  heart  were  affected  in  malignant  endocarditis: 


ENDOCABDITIS  795 

Aortic  and  mitral  valves  together,  in  il ;  aortic  valves  alone,  in  53 ;  mitral 
valves  alone,  in  77;  tricuspid  in  lU;  the  pulmonary  valves  in  15;  and  the 
heart  walls  in  33.  In  9  instances  the  right  heart  alone  was  involved,  in  most 
tases  the  auriculo-ventricular  valves. 

Mural  endocarditis  is  seen  most  often  at  the  upper  part  of  the  septum 
of  the  left  ventricle.  Xext  in  order  is  the  endocarditis  of  the  left  auricle  on 
the  postero-external  wall.  The  vegetations  may  extend  along  the  intima  of 
the  pulmonary  artery  into  the  hilum  of  the  lung.  A  common  result  of  the 
ulceration  is  the  production  of  valvular  aneurism.  In  three  fourths  of  the 
cases  the  affected  valves  present  old  sclerotic  changes.  The  process  may  extend 
to  the  aorta,  producing  extensive  endarteritis  with  multiple  acute  aneurisms. 

Associated  Lesions, — The  associated  changes  are  those  of  the  primary 
disease,  those  due  to  embolism,  and  the  changes  in  the  myocardium.  In  the 
endocarditis  of  septic  processes  there  is  the  local  lesion — an  acute  necrosis,  a 
suppurative  wound,  or  puerperal  disease.  In  many  cases  the  lesions  are  those 
of  pneumonia,  rheumatism,  or  other  febrile  processes. 

The  changes  due  to  embolism  constitute  the  most  striking  features,  but  it 
is  remarkable  that  in  some  instances,  even  with  endocarditis  of  a  markedly 
ulcerative  character,  there  may  be  no  trace  of  embolic  processes.  The  infarcts 
may  be  few  in  number — only  one  or  two,  perhaps,  in  the  spleen  or  kidney — 
or  they  may  exist  in  hundreds  throughout  various  parts  of  the  body.  They 
may  present  the  ordinary  appearance  of  red  or  white  infarcts  of  a  suppurative 
character.  They  are  most  common  in  the  spleen  and  kidneys,  though  they  may 
be  numerous  in  the  brain,  and  in  many  cases  are  very  abundant  in  the  intes- 
tines. In  right  sided  endocarditis  there  may  be  infarcts  in  the  lungs.  In  many 
of  the  cases  there  are  innumerable  miliary  abscesses.  Acute  suppurative  men- 
ingitis was  met  with  in  5  of  23  of  the  Montreal  cases,  and  in  over  10  per 
cent,  of  the  209  cases  analyzed  in  the  literature.  Acute  suppurative  parotitis 
may  occur.  Lastly,  as  Eomberg  pointed  out,  the  accompanying  myocarditis 
plays  an  important  role.  The  valvular  insufficiency  in  an  acute  endocarditis 
is  probably  not  due  to  the  row  of  little  vegetations,  but  to  the  associated  myo- 
carditis, which  interferes  with  the  proper  closure  of  the  orifice. 

Bacteriology. — No  distinction  in  the  micro-organisms  found  in  the  two 
forms  of  endocarditis  can  be  made.  In  both,  cocci — streptococci,  staphylococci, 
pneumococci,  and  gonococci — are  the  most  frequent  bacteria.  More  rarely, 
especially  in  the  simple  vegetative  endocarditis,  the  bacilli  of  tuberculosis, 
typhoid  fever,  and  anthrax  have  been  encountered.  The  colon  bacillus  has 
also  been  found,  and  Howard  described  a  case  of  malignant  endocarditis  due 
to  an  attenuated  form  of  the  diphtheria  bacillus.  Marshall  in  61  cases  found 
the  pneumococci  in  21,  streptococci  alone  or  with  other  bacteria  in  26,  staphy- 
lococcus pyogenes  aureus  in  12.  The  meningococcus  may  cause  endocarditis. 
Combined  infections  are  not  uncommon.  In  the  chronic  infective  form  the 
Streptococcus  viridans  is  a  common  organism  (Libman). 

As  a  rule  no  organisms  are  found  in  the  simple  endocarditis  in  many 
chronic  diseases,  as  carcinoma,  tuberculosis,  nephritis,  etc.  They  may  have 
been  present  and  died  out,  or  the  lesions  may  be  caused  by  the  toxins. 

Symptoms.  — Xeither  the  clinical  course  nor  the  physical  signs  of  simple 
ENDOCARDITIS  are  in  any  respect  characteristic.  The  great  majority  of  the 
cases  are  latent  and  there  is  no  indication  whatever  of  cardiac  mischief.    En- 


796  DISEASES  OF  THE  CIECULATOEY  SYSTEM 

docarditis  is  frequently  found  post  mortem  in  persons  in  whom  it  was  not 
suspected  during  life.  There  are  certa'in  features,  however,  by  which  its  pres- 
ence is  indicated  with  a  degree  of  probability.  The  patient,  as  a  rule,  does 
not  complain  of  any  pain  or  cardiac  distress.  In  a  case  of  rheumatic  fever,  for 
example,  the  symptoms  to  excite  suspicion  would  be  increased  rapidity  of  the 
heart,  perhaps  slight  irregularity,  and  an  increase  in  the  fever,  without  ag- 
gravation of  the  arthritis.  Eows  of  tiny  vegetations  on  the  mitral  or  on  the 
aortic  segments  seem  a  trifling  matter  to  excite  fever,  and  it  is  difficult  in  the 
endocarditis  of  febrile  processes  to  say  definitely  in  every  instance  that  an 
increase  in  the  fever  depends  upon  this  complication;  but  a  study  of  the 
recurring  endocarditis— which  is  of  the  warty  variety,  consisting  of  minute 
beads  on  old  sclerotic  valves — shows  that  the  process  may  be  associated,  for 
weeks  or  months,  with  slight  fever  ranging  from  100°  to  1021/^°.  Palpitation 
may  be  a  marked  feature  and  is  a  symptom  upon  which  certain  authors  lay 
great  stress. 

The  diagnosis  rests  upon  physical  signs,  which  are  notoriously  uncertain. 
The  presence  of  a  murmur  at  one  or  other  of  the  cardiac  areas  in  a  case  of 
fever  is  often  taken  as  proof  of  the  existence  of  endocarditis — a  common  mis- 
take which  has  arisen  from  the  fact  that  a  murmur  is  common  to  it  and  to  a 
number  of  other  conditions.  At  first  there  may  be  only  a  slight  roughening 
of  the  first  sound,  which  may  gradually  increase  to  a  distinct  murmur.  The 
apex  systolic  bruit  is  probably  more  often  the  result  of  a  myocarditis.  It  may 
not  be  present  in  the  endocarditis  of  such  chronic  maladies  as  tuberculosis  and 
carcinoma,  since  in  them  the  muscle  involvement  is  less  common  (Krehl). 
Eeduplication  and  accentuation  of  the  pulmonic  second  sound  are  frequently 
present. 

It  is  difficult  to  give  a  satisfactory  clinical  picture  of  malignant  endo- 
CAEDiTis  because  the  modes  of  onset  are  so  varied  and  the  symptoms  so  di- 
verse. Arising  in  the  course  of  some  other  disease,  there  may  be  simply  an 
intensification  of  the  fever  or  a  change  in  its  character.  In  a  majority  of  the 
cases  there  are  present  certain  general  features,  such  as  irregular  pyrexia, 
sweating,  delirium,  and  gradual  failure  of  strength. 

Emholic  processes  may  give  special  characters,  such,  as  delirium,  coma,  or 
paralysis  from  involvement  of  the  brain  or  its  membranes,  pain  in  the  side 
and  local  peritonitis  from  infarction  of  the  spleen,  bloody  urine  from  implica- 
tion of  the  kidneys,  impaired  vision  from  retinal  haemorrhage  and  suppura- 
tion, and  even  gangrene  in  various  parts  from  the  distribution  of  the  emboli. 

Two  special  types  are  recognized — the  septic  or  pyemic  and  the  typhoid. 
In  some  the  cardiac  symptoms  are  most  prominent,  while  in  others  the  main 
symptoms  are  those  of  an  acute  affection  of  the  nervous  system. 

The  septic  type  is  met  with  usually  in  connection  with  an  external  wound, 
the  puerperal  process,  or  an  acute  necrosis  or  gonorrhoea.  There  are  rigors, 
sweats,  irregular  fever,  and  all  of  the  signs  of  septic  infection.  The  heart 
symptoms  may  be  completely  masked  by  the  general  condition,  and  attention 
called  to  them  only  on  the  occurrence  of  embolism.  In  many  cases  the  fea- 
tures are  those  of  a  severe  septicsemia,  and  the  organisms  may  be  isolated  from 
the  blood.  Optic  neuritis  is  not  uncommon,  and  was  present  in  15  cases  of 
chronic  septic  endocarditis  examined  by  Faulkner,  and  in  four  of  these  re- 
current retinal  haamorrhages  were  present. 


ENDOCAEDTTIS  797 

The  typhoid  type  is  by  far  the  most  common  and  is  characterized  by  a 
less  irregular  temperature,  early  prostration,  delirium,  somnolence,  and  coma, 
relaxed  bowels,  sweating,  which  may  be  of  a  most  drenching  character,  pe- 
techial and  other  rashes,  and  occasionally  parotitis.  The  heart  symptoms  may 
be  completely  overlooked,  and  in  some  instances  the  most  careful  examination 
has  failed  to  discover  a  murmur. 

Under  the  cardiac  group,  as  suggested  by  Bramwell,  may  be  considered 
those  cases  in  which  patients  with  chronic  valve  f/isease  are  attacked  with 
marked  fever  and  evidence  of  recent  endocarditis.  Many  such  cases  present 
symptoms  of  the  pysemic  and  typhoid  character  and  run  a  most  acute  course. 
In  others  there  may  be  only  slight  fever  or  even  after  a  period  of  high  fever 
recovery  takes  place. 

In  what  may  be  termed  the  cerebral  group  of  cases  the  clinical  picture 
may  simulate  a  meningitis.  There  may  be  acute  delirium  or,  as  in  three  of 
the  Montreal  cases,  the  patient  may  be  brought  into  the  hospital  unconscious. 

Certain  special  symptoms  may  be  mentioned.  The  fever  is  not  always  of 
a  remittent  type,  but  may  be  high  and  continuous.  Petechial  rashes  are  very 
common  and  render  the  similarity  very  strong  to  certain  cases  of  typhoid  and 
cerebro-spinal  fever.  In  one  case  the  disease  was  thought  to  be  hemorrhagic 
small-pox.  Erythematous  rashes  are  not  uncommon.  The  sweating  may  be 
most  profuse,  even  exceeding  that  which  occurs  in  pulmonary  tuberculosis 
and  malaria.  Diarrhoea  is  not  necessarily  associated  with  embolic  lesions  in 
the  intestines.  Jaundice  has  been  observed,  and  cases  are  on  record  which 
were  mistaken  for  acute  yellow  atrophy. 

The  heart  symptoms  may  be  entirely  latent  and  are  not  found  unless  a 
careful  search  be  made.  Instances  are  recorded  by  careful  observers  in  which 
the  examination  of  the  heart  has  been  negative.  Cases  with  chronic  valve 
disease  usually  present  no  difficulty  in  diagnosis. 

The  course  is  varied,  depending  largely  upon  the  nature  of  the  primary 
trouble.  Except  in  the  disease  grafted  upon  chronic  valvulitis  the  course  is 
rarely  extended  beyond  five  or  six  weeks.  The  most  rapidly  fatal  case  on 
record  is  described  by  Eberth,  the  duration  of  which  was  scarcely  two  da3^'^. 

Subacute  Bacterial  Endocarditis. — Due  particularly  to  the  work  of  Lib- 
man  we  recognize  that  these  cases  are  much  more  common  than  was  supposed. 
Organisms  of  the  Streptococcus  viridans  group  are  often  found.  A  special 
feature  is  that  the  patients  may  become  bacteria-free.  The  prominent  fea- 
tures given  by  Libman  are :  ( 1 )  Marked  progressive  anaemia,  ( 2 )  brown  pig- 
mentation of  the  face,  (3)  marked  renal  disease,  (4)  marked  splenic  en- 
largement and  (5)  endocarditic  symptoms,  such  as  fever,  embolism,  arthritis 
and  petechise.  The  cardiac  features  may  be  ( 1 )  those  of  any  form  of  valvular 
disease  and  (2)  those  due  largely  to  embolism.  The  renal  changes  are  es- 
pecially in  the  glomeruli  and  are  often  embolic.  Eenal  insufficiency  is  a 
common  cause  of  death.  The  anaemia,  is  of  the  secondary  type  and  usually 
the  leucocytes  are  normal  or  diminished.  Tenderness  over  the  sternum  is  a 
special  feature  arid  may  be  most  marked  in  the  bacteria-free  stage.  The 
course  may  be  prolonged,  the  blood  may  become  bacteria-free  and  some  pa- 
tients recover.  In  such  cases  the  splenic  enlargement  may  lead  to  an  error 
in  diagnosis. 

Chronic  Infective  Endocarditis. — This  is  almost  always  engrafted  on 


•J-OS  DISEASES  OF  THE  CIECtJLATOEY  SYSTEM 

an  old,  sometimes  an  unrecognized,  valve  lesion.  At  first  fever  is  the  only 
symptom;  in  a  few  cases  there  have  been  chills  at  onset  or  recurring  chills 
may  arouse  the  suspicion  of  malaria.  The  patient  may  keep  at  work  for 
months  with  a  daily  rise  of  temperature,  or  perhaps  an  occasional  sweat.  The 
heart  features  may  be  overlooked.  The  murmur  of  the  old  valve  lesion  may 
show  no  change,  and  even  with  the  most  extensive  disease  of  the  mitral  cusps 
the  heart's  action  may  be  little  disturbed.  For  months — six,  eight,  ten,  even 
thirteen  ! — fever  and  progressive  weakness  may  be  the  only  symptoms.  These 
are  the  cases  in  which,  with  recurring  chills,  the  diagnosis  of  malaria  is  made. 
With  involvement  of  the  aortic  segments  the  signs  of  a  progressive  lesion  are 
more  common.  Embolic  features  are  not  common,  occurring  only  tov/ard  the 
close.  Ephemeral  cutaneous  nodes,  red  raised  painful  spots  on  the  skin  of 
hands  or  feet  and  lasting  a  few  days,  rarely  occur  except  in  this  form.  Post 
mortem  a  remarkable  vegetative  endocarditis  has  been  found,  involving  usu- 
ally the  mitral  valves,  sometimes  with  much  encrusting  of  the  chordae  tendi- 
ne£e,  and  large  irregular  firm  vegetations  quite  different  to  those  of  the  ordi- 
nary ulcerative  form.  In  some  cases  the  aortic  and  tricuspid  segments  are  in- 
volved, and  the  vegetations  may  extend  to  the  walls  of  the  heart. 

Dia^osis. — In  many  cases  this  is  very  difficult;  in  others,  with  marked 
embolic  symptoms,  it  is  easy.  From  simple  endocarditis  it  is  readily  dis- 
tinguished, though  confusion  occasionally  occurs  in  the  transitional  stage, 
when  a  simple  is  developing  into  a  malignant  form.  The  constitutional  symp- 
toms are  of  a  graver  type,  the  fever  is  higher,  rigors  are  common,  and  septic 
symptoms  occur.  Perhaps  a  majority  of  the  cases  not  associated  with  puerperal 
processes  or  bone  disease  are  confounded  with  typhoid  fever.  A  dilferential 
diagnosis  may  be  impossible,  particularly  when  we  consider  that  in  typhoid 
fever  infarctions  and  parotitis  may  occur.  The  diarrhoea  and  abdominal  ten- 
derness may  also  be  present,  which  with  the  stupor  and  progressive  asthenia 
make  a  picture  not  to  be  distinguished  from  this  disease.  Points  which  may 
guide  us  are :  The  more  abrupt  onset  in  endocarditis,  the  absence  of  any 
regularity  of  the  pyrexia  in  the  early  stage  and  the  cardiac  pain.  Oppression 
and  shortness  of  breath  may  be  early  symptoms  in  malignant  endocarditis. 
Rigors,  too,  are  not  uncommon.  There  is  a  marked  leucocytosis  in  infective 
endocarditis.  Between  pygemia  and  malignant  endocarditis  there  are  prac- 
tically no  differential  features,  for  the  disease  really  constitutes  an  arterial 
pycemia  (Wilks).  In  the  acute  cases  resembling  malignant  fevers  the  diag- 
nosis of  typhus,  typhoid,  cerebro-spinal  fever,  or  even  of  hemorrhagic  small- 
pox may  be  made.  The  intermittent  pyrexia,  occurring  for  weeks  or  months, 
has  led  to  the  diagnosis  of  malaria,  but  this  disease  can  be  excluded  by  the 
blood  examination.    Blood  cultures  aid  greatly  in  the  diagnosis. 

The  cases  usually  terminate  fatally.  The  instances  of  recovery  are  the 
subacute  forms  and  the  recurring  endocarditis  developing  on. old  sclerotic 
valves  in  chronic  heart  disease. 

Treatment. — We  know  no  measures  by  which  in  rheumatic  fever,  chorea, 
or  the  eruptive  fevers  endocarditis  can  be  prevented.  As  it  is  probable  that 
many  cases  arise,  particularly  in  children,  in  mild  forms  of  these  diseases,  it 
is  well  to  insist  upon  rest  and  quiet,  and  to  bear  in  mind  that  of  all  complica- 
tions an  acute  endocarditis,  though  in  its  immediate  effects  harmless,  is  per- 
haps- the  most  serious.    This  statement  is  enforced  by  the  observations  of  Sib- 


ENDOCARDITIS  799 

son  that  on  a  system  of  absolute  rest  the  proportion  of  cases  of  rheumatic 
fever  attacked  by  endocarditis  was  less  than  of  those  who  were  not  so  treated. 
It  is  doubtful  whether  in  rheumatic  fever  the  salicylates  have  an  influence  in 
reducing  the  liability  to  endocarditis.  Considering  the  extremely  grave  after 
results  of  simple  endocarditis  in  children,  the  question  arises  whether  it  is 
possible  to  do  anything  to  avert  the  onset  of  progressive  sclerosis  of  the  af- 
fected valve.  Caton  recommends  a  systematic  plan  of  treatment:  (1)  Pro- 
longed rest  in  bed  for  three  months;  (2)  a  series  of  small  blisters  over  the 
heart;  and  (3)  iodide  of  potassium  in  moderate  doses  for  many  months.  If 
there  is  much  vascular  excitement  aconite  may  be  given  and  an  ice  bag  placed 
over  the  heart.  The  treatment  of  malignant  endocarditis  is  practically  that 
of  septicemia — useless  and  hopeless  in  a  majority  of  the  cases.  Blood  cul- 
tures should  be  taken  as  soon  as  possible  and  a  vaccine  prepared,  Horder  and 
others  have  reported  good  results.  Personally  we  have  not  seen  a  successful 
case. 

II.     CHRONIC   ENDOCARDITIS 

Definition. — A  sclerosis  of  the  valves  leading  to  shrinking,  thickening,  and 
adhesion  of  the  cusps,  often  with  the  deposition  of  lime  salts,  with  shortening 
and  thickening  of  the  chordse  tendinese,  leading  to  insufficiency  and  to  nar- 
rowing of  the  orifice.  It  may  be  primary,  but  is  oftener  secondary  to  acute 
endocarditis,  particularly  the  rheumatic  form. 

Etiology. — It  is  a  mistake  to  regard  every  case  of  sclerotic  valve  as  a  se- 
quel to  an  acute  endocarditis.  It  is  long  ago  since  Eoy  and  Adami  called  at- 
tention to  the  possibility  that  sclerosis  of  the  valve  segments  might  be  a  sequel 
of  high  pressure.  The  preliminary  endocarditis  may  be  a  factor  in  weakening 
the  valve,  the  progressive  thickening  of  which  may  be  a  direct  consequence 
of  the  strain.  As  age  advances  the  valves  begin  to  lose  their  pliancy,  show 
slight  sclerotic  changes  and  foci  of  atheroma  and  calcification.  The  poisons 
of  the  specific  fevers  may  initiate  the  change.  A  very  important  factor  in  the 
case  of  the  aortic  valves  is  syphilis.  The  strain  of  prolonged  and  heavy  mus- 
cular exertion  may  play  a  part.  In  the  aortic  segments  it  may  be  only  the 
valvular  part  of  a  general  arterio-sclerosis. 

The  frequency  with  which  chronic  endocarditis  is  met  with  may  be  gath- 
ered from  the  following  figures:  In  the  statistics,  from  12,000  to  14,000 
autopsies,  reported  from  Dresden,  Wiirzburg,  and  Prague,  the  percentage 
ranged  from  four  to  nine.  The  relative  frequency  of  involvement  of  the  vari- 
ous valves  is  thus  given  in  the  collected  statistics  of  Parrot:  The  mitral 
orifice  in  621,  the  aortic  in  380,  the  tricuspid  in  46,  and  the  pulmonary  in  11. 
This  gives  57  instances  in  the  right  to  1,001  in  the  left  heart. 

Morbid  Anatomy. — Vegetations  in  the  form  in  which  they  occur  in  acute 
endocarditis  are  not  present.  In  the  early  stage,  the  edge  of  the  valve  is  a 
little  thickened  and  perhaps  presents  a  few  small  nodular  prominences,  which 
in  some  cases  may  represent  the  healed  vegetations  of  the  acute  process.  In 
the  aortic  valves  the  tissue  about  the  corpora  Arantii  is  first  affected,  pro- 
ducing a  slight  thickening  with  an  increase  in  the  size  of  the  nodules.  The 
substance  of  the  valve  may  lose  its  translucency,  and  the  only  change  notice- 
able be  a  grayish  opacity  and  a  slight  loss  of  its  delicate  tenuity.  In  the  au- 
riculo-ventricular  valves  these  early  changes  are  seen  just  within  the  margin 


800  DISEASES  OF  THE  CIECULATOEY  SYSTEM 

and  here  it  is  not  uncommon  to  find  swellings  of  a  grayish  red,  somewhat  in- 
filtrated appearance,  almost  identical  with  the  similar  structures  on  the  intima 
of  the  aorta  in  arterio-sclerosis.  Even  early  there  may  be  seen  yellow  or  opaque 
white  subintimal  fatty  degenerated  areas.  As  the  sclerotic  changes  increase, 
the  fibrous  tissue  contracts  and  produces  thickening  and  deformity  of  the  seg- 
ment, the  edges  of  which  become  round,  curled,  and  incapable  of  that  delicate 
apposition  necessary  for  perfect  closure.  An  aortic  valve,  for  instance,  may  be 
narrowed  one  fourth  or  even  one  third  across  its  face,  the  most  extreme  grade 
of  insufficiency  being  induced  without  any  special  deformity  and  without  any 
narrowing  of  the  orifice.  In  the  auriculo-ventricular  segments  a  simple  proc- 
ess of  thickening  and  curling  of  the  edges  of  the  valves,  inducing  a  failure 
to  close  without  forming  any  obstruction  to  the  normal  course  of  the  blood- 
flow,  is  less  common.  Still,  we  meet  with  instances  at  the  mitral  orifice,  par- 
ticularly in  children,  in  which  the  edges  of  the  valves  are  curled  and  thick- 
ened, so  that  there  is  extreme  insufficiency  without  any  material  narrowing  of 
the  orifice.  More  frequently,  as  the  disease  advances,  the  chordae  tendineee 
become  thickened,  first  at  the  valvular  ends  and  then  along  their  course.  The 
edges  of  the  valves  at  their  angles  are  gradually  drawn  together  and  there  is 
a  narrowing  of  the  orifice,  leading  in  the  aorta  to  more  or  less  stenosis  and 
in  the  left  auriculo-ventricular  orifice — the  two  sites  most  frequently  involved 
— to  constriction.  Finally,  in  the  sclerotic  and  necrotic  tissues  lime  salts  are 
deposited  and  may  even  reach  the  deeper  structures  of  the  fibrous  rings,  so 
that  the  entire  valve  becomes  a  dense  calcareous  mass  with  scarcely  a  remnant 
of  normal  tissue.  The  chordae  tendineae  may  gradually  become  shortened, 
greatly  thickened^  and  in  extreme  cases  the  papillary  muscles  are  implanted 
directly  upon  the  sclerotic  and  deformed  valve.  The  apices  of  the  papillary 
muscles  usually  show  marked  fibroid  change. 

In  all  stages  the  vegetations  of  sitnple  endocarditis  may  be  present,  and  the 
severer,  ulcerative  forms  often  attack  these  sclerotic  valves. 

Chronic  m-wra^  endocarditis  produces  cicatricial  like  patches  of  a  gra3ash 
white  appearance  which  are  sometimes  seen  on  the  muscular  trabeculae  of  the 
ventricle  or  in  the  auricles.    It  often  occurs  with  myocarditis. 

The  endocarditis  of  the  fetus  is  usually  of  the  sclerotic  form  and  involves 
the  valves  of  the  right  more  frequently  than  those  of  the  left  side. 


IV.     CHRONIC  VALVULAR  DISEASE 

GENERAL  INTRODUCTION 

Effects  of  Valve  Lesions. — The  general  influence  on  the  work  of  the  heart 
may  be  briefly  stated  as  follows :  The  sclerosis  induces  insufficiency  or  steno- 
sis, which  may  exist  separately  or  in  combination.  The  narrowing  retards  in 
a  measure  the  normal  outflow  and  the  insufficiency  permits  the  blood  current 
to  take  an  abnormal  course.  The  result  in  the  former  case  is  difficulty  in  the 
expulsion  of  the  contents  of  the  chamber  through  the  narrow  orifice;  in  the 
other,  the  overfilling  of  a  chamber  by  blood  flowing  into  it  from  an  improper 
source  as  in  mitral  insufficiency,  when  the  left  auricle  receives  blood  both 
from  the  pulmonary  veins  and  from  the  left  ventricle.    In  both  instances  the 


CHEONIC  VALVULAE  DISEASE 


801 


effect  is  dilatation  of  a  chamber,  and  to  expel  the  normal  amount  of  blood  from 
a  dilated  chamber  a  relatively  greater  amount  of  energy  is  required,  which  by 
various  adjustments  the  muscle  is  stimulated  to  do. 

The  cardiac  mechanism  is  fully  prepared  to  meet  ordinary  grades  of  dila- 
tation which  constantly  occur  during  sudden  exertion.  A  man,  for  instance, 
at  the  end  of  a  hundred  yard  race  has  his  right  chambers  greatly  dilated  and 
his  reserve  cardiac  power  worked  to  its  full  capacity.  The  slow  progress  of 
the  sclerotic  changes  brings  about  a  gradual,  not  an  abrupt,  insufficiency,  and 
the  moderate  dilatation  which  follows  is  at  first  overcome  by  the  exercise  of 
the  ordinary  reserve  strength  of  the  heart  muscle.     Gradually  a  new  factor  is 


Reserve-force=     i 
Accommodation-  \ 
capacity 


Reserve-force"= 
Accommodation-  "^ 
capacity 


■Nb 


Power  of  work 
(body  at  rest) 


>. 


V_  Power  of  work 
(body  at  rest) 


Total  power  of  heart 
y  less  than  amount  needed 
'     when  the  body  is  at  rest. 
Insufficieocy  of  the  heart 


I.  Normal  heart 


II.  Heart  in  valvular  disease  in 
stage  of  compensation 


III.  Heart  in  uncompensated 
valvular  disease 


Fig.  9. — Diagrammatic  Presentation  Showing  the  Force  op  the  Heart  for  Work 
UNDER  Normal  Conditions  and  in  Valvular  Lesions. 


introduced.  The  constant  increase  in  the  energy  put  forth  by  the  heart  is  a 
stimulus  to  the  niuscle  fibres  to  increase  in  bulk  and  probably  also  in  number ; 
the  heart  hypertrophies,  and  the  effect  of  the  valve  lesion  becomes,  as  we  say, 
compensated.     The  equilibrium  of  the  circulation  is  in  this  way  maintained. 

The  nature  of  the  process  is  illustrated  in  the  accompanying  diagram,  from 
Martins.  The  perpendicular  lines  in  the  figures  represent  the  power  of  work 
of  the  heart.  While  the  muscle  in  the  healthy  heart  (Diagram  I)  has  at  its 
disposal  the  maximal  force,  a  c,  it  carries  on  its  work  under  ordinary  circum- 
stances (when  the  body  is  at  rest)  with  the  force  a  h  and  &  c  is  the  reserve 
force  by  which  the  heart  accommodates  itself  to  greater  exertion. 

If  there  be  a  gross  valvular  lesion,  the  force  required  to  do  the  ordinary 
work  of  the  heart  (at  rest)  becomes  very  much  increased  (Diagram  II).  But 
in  spite  of  this  enormous  call  for  force,  insufficiency  of  the  muscle  does  not 
necessarilv  result,  for  the  working  force  required  is  still  within  the  limits  of 


803  DISEASES  OF  THE  CIECULATOEY  SYSTEM 

the  maximal  power  of  the  heart,  a^  h^  being  less  than  o.^  Cj.  The  muscle  ac- 
commodates itself  to  the  new  conditions  by  making  its  reserve  force  mobile. 
If  nothing  further  occurred,  this  could  not  be  permanently  maintained,  for 
there  would  be  left  over  for  emergencies  only  the  small  reserve  force,  &i  y. 
Even  when  at  rest  the  heart  would  be  using  continuously  almost  its  entire 
maximal  force.  Any  slight  exertion  requiring  more  extra  force  than  that 
represented  by  the  small  value  l^  y  (say  the  effort  required  on  walking  or  on 
going  upstairs)  would  bring  the  heart  to  the  limit  of  its  working  power,  and 
palpitation  and  dyspnoea  would  appear.  Such  a  condition  does  not  last  long. 
The  working  power  of  the  heart  gradually  increases.  More  and  more  exertion 
can  be  borne  without  causing  dyspnoea,  for  the  heart  hypertrophies.  Finally, 
a  new,  more  or  less  permanent  condition  is  attained,  in  that  the  hypertrophied 
heart  possesses  the  maximal  force,  a^  c-^.  Owing  to  the  increase  in  volume  of 
the  heart  muscle,  the  total  force  of  the  heart  is  greater  absolutely  than  that  of 
the  normal  heart  by  the  amount  y  c^.  It  is,  however,  relatively  less  efficient, 
for  its  reserve  force  is  much  less  than  that  of  the  healthy  heart.  Its  capacity 
for  accommodating  itself  to  unusual  calls  upon  it  is  accordingly  permanently 
diminished. 

Turning  now  to  the  disturbances  of  compensation,  it  is  to  be  distinctly 
borne  in  mind  that  any  heart,  normal  or  diseased,  can  become  insufficient 
whenever  a  call  upon  it  exceeds  its  maximal  working  capacity.  The  liability 
to  such  disturbance  will  depend,  above  all,  upon  the  accommodation  limits  of 
the  heart — the  less  the  width  of  the  latter,  the  easier  will  it  be  to  go  beyond 
the  heart's  efficiency.  A  comparison  of  Diagrams  I  and  II  will  immediately 
make  it  clear  that  the  heart  in  valvular  disease  will  much  earlier  become  insuffi- 
cient than  the  heart  of  a  healthy  individual.  It  is  obvious  that  the  heart  in 
valvular  disease,  on  account  of  its  small  amount  of  reserve  force,  has 
to  do  maximal  or  nearly  maximal  work  far  more  frequently  than  does  the 
normal  heart.  The  power  of  the  heart  may  become  decreased  to  the  amount 
necessary  simply  to  carry  on  the  work  of  the  heart  when  the  body  is  at  rest, 
or  it  may  cease  to  be  sufficient  even  for  this.  The  reserve  force  gained  through 
the  compensatory  process  may  be  entirely  lost  (Diagram  III).  If  the  loss 
be  only  temporary,  the  exhausted  heart  muscle  quickly  recovering,  the  condi- 
tion is  spoken  of  as  a  "disturbance  of  compensation."  The  term  "loss  of  com- 
pensation" is  reserved  for  the  condition  in  which  the  disturbance  is  continu- 
ous. 

AORTIC  INSUFFICIENCY 

Insufficiency  of  the  aortic  valves  arises  either  from  inability  of  the  valve 
segments  to  close  an  abnormally  large  orifice  or  more  commonly  from  disease 
of  the  segments  themselves.  This  best-defined  and  most  easily  recognized  of 
valvular  lesions  was  first  carefully  studied  by  Corrigan,  whose  name  it  some- 
times bears. 

Etiology  and  Morbid  Anatomy. — It  is  more  frequent  in  males  than  in 
females,  affecting  chiefly  men  at  the  middle  period  of  life.  The  ratio  which 
it  bears  to  other  valve  diseases  has  been  given  as  from  30  to  50  per  cent. 

There  are  six  groups  of  cases:  I.  Those  due  to  congenital  malformation, 
particularly  fusion  of  two  of  the  cusps — most  commonly  those  behind  which 
the  coronary  arteries  are  given  off.     It  is  probable  that  an  aortic  orifice  may 


CHRONIC  VALVULAE  DISEASE  803 

be  competent  with  this  bicuspid  state  of  the  valves,  but  a  great  danger  is  the 
liability  of  these  malformed  segments  to  sclerotic  endocarditis.  Of  17  cases 
all  presented  sclerotic  changes,  and  the  majority  of  them  had,  during  life,  the 
clinical  features  of  chronic  heart-disease. 

II.  The  endocarditic  group.  Endocarditis  may  produce  an  acute  insuffi- 
ciency by  ulceration  and  destruction  of  the  valves;  the  aortic  valves  may  be 
completely  eroded  away.  The  valvulitis  of  rheumatic  fever,  while  more  rarely 
aortic,  is  common  enough,  and  the  insufficiency  is  caused  by  nodular  ex- 
crescences at  the  margins  or  in  the  valves,  which  may  ultimately  become  cal- 
cified;  more  often  it  induces  a  slow  sclerosis  of  the  valves  with  adhesions, 
causing  also  some  degree  of  narrowing. 

III.  Syphilis. — This  is  probably  the  most  important  cause,  especially  in 
young  and  middle  aged  patients.  The  spirochsetes  may  be  found  in  the  valves. 
The  process  frequently  involves  the  aorta  also.  In  some  cases  it  causes  a 
localized  process  at  the  root  of  the  aorta  which  may  involve  the  valves  second- 
arily or  cause  dilatation  of  the  aortic  ring  with  relative  insufficiency.  Some 
of  the  supposed  cases  of  cure  of  syphilitic  aortic  endocarditis  may  be  instances 
of  the  latter. 

IV.  The  arteriosclerotic  group.  A  common  cause  of  insufficiency  is  a 
slow,  progressive  sclerosis  of  the  segments,  resulting  in  a  curling  of  the  edges. 
It  may  be  associated  with  general  arterio-sclerosis.  The  condition  of  the 
valves  is  such  as  has  been  described  in  chronic  endocarditis.  It  may  be  noted, 
however,  how  slight  a  grade  of  curling  may  produce  serious  insufficiency.  As- 
sociated with  the  valve  disease  is,  in  a  majority  of  cases,  a  more  or  less  ad- 
vanced arterio-sclerosis  of  the  arch  of  the  aorta,  one  serious  effect  of  which 
may  be  a  narrowing  of  the  orifices  of  the  coronary  arteries.  The  sclerotic 
changes  are  often  combined  with  atheroma  which  may  exist  at  the  attached 
margin  of  the  valves  without  inducing  insufficiency.  In  other  instances  in- 
sufficiency may  result  from  a  calcified  spike  projecting  from  the  aortic  attach- 
ment into  the  body  of  the  valve,  and  so  preventing  its  proper  closure.  Ana- 
tomically one  can  usually  recognize  the  arterio-sclerotic  variety  by  the  smooth 
surface,  the  rounded  edges,  and  the  absence  of  excrescences. 

V.  Insufficiency  may  be  induced  by  rupture  of  a  segment — a  very  rare 
event  in  healthy  valves,  but  not  uncommon  in  disease,  either  from  excessive 
effort  during  heavy  lifting  or  from  the  ordinary  strain  on  a  valve  eroded  and 
weakened  by  ulcerative  endocarditis. 

VI.  Relative  insufficiency,  due  to  dilatation  of  the  aortic  ring  and  adjacent 
arch,  is  not  very  frequent.  It  occurs  in  extensive  arterial  sclerosis  of  the  as- 
cending portion  of  the  arch  with  great  dilatation  just  above  the  valves.  The 
valve  segments  are  usually  involved  with  the  arterial  coats,  but  the  changes 
in  them  may  be  very  slight.  In  aneurism  just  above  the  aortic  ring  relative 
insufficiency  of  the  valve  may  be  present. 

It  would  appear  from  the  careful  measurements  of  Beneke  that  the  aortic 
orifice,  which  at  birth  is  20  mm.,  increases  gradually  with  the  growth  of  the 
heart  until  at  one  and  twenty  it  is  about  60  mm.  At  this  it  remains  until  the 
age  of  forty,  beyond  which  date  there  is  a  gradual  increase  in  the  size  up  to 
the  age  of  eighty,  when  it  may  reach  from  68  to  70  mm.  There  is  thus  at  the 
period  in  which  sclerosis  of  the  valve  is  most  common  a  physiological  tendency 
toward  the  production  of  a  relative  insufficiency. 


804  DISEASES  OF  THE  CIECULATOEY  SYSTEM 

The  insufficiency  may  be  combined  with  various  grades  of  narrowing,  par- 
ticularly in  the  endocarditic  group.  In  a  majority  of  the  cases  of  the  arterio- 
sclerotic form  there  is  no  stenosis.  On  the  other  hand,  with  aortic  stenosis 
there  is  almost  without  exception  some  grade,  however  slight,  of  insufficiency. 

K"on-valvular  insufficiency  may  occur  when  there  is  a  stretching  of  the 
aortic  ring  in  connection  with  dilatation  of  the  ascending  portion  of  the  arch. 
Whether  insufficiency  occurs  apart  from  this  in  dilatation  of  the  left  ventricle 
has  been  much  discussed — a  relative  incompetency  similar  to  that  which 
occurs  at  the  pulmonary  orifice.  Cases  are  reported  in  which  transient  dias- 
tolic murmurs  have  occurred  with  dilatation  of  the  heart,  of  which  Anders 
reported  and  collected  corroborative  cases.  Some  years  ago  J.  B.  MacCallum, 
whose  untimely  death  was  a  great  loss  to  science,  described  a  sphincter-like 
band  of  muscle  encircling  the  opening  of  the  left  ventricle  into  the  aorta,  and 
in  these  cases  the  relaxation  of  this  ring  muscle  may  be  associated  with  in- 
sufficiency of  the  valve. 

Effects. — The  direct  effect  of  aortic  insufficiency  is  the  regurgitation  of 
blood  from  the  artery  into  the  ventricle,  causing  an  overdistention  of  the 
cavity  and  a  reduction  of, the  blood  column;  that  is,  a  relative  angemia  in  the 
arterial  tree.  The  amount  returning  varies  with  the  size  of  the  opening.  The 
double  blood  flow  into  the  left  ventricle  causes  dilatation  of  the  chamber,  and 
finally  hypertrophy,  the  grade  depending  upon  the  lesion.  In  this  way  the 
valve  defect  is  compensated,  and,  as  with  each  ventricular  systole  a  larger 
amount  of  blood  is  propelled  into  the  arterial  system,  the  regurgitation  of  a 
certain  amount  during  diastole  does  not,  for  a  time  at  least,  seriously  impair 
the  nutrition  of  the  peripheral  parts.  For  a  time  at  least  there  is  little  or  no 
resistance  offered  to  the  blood  flow  from  the  auricle — the  ventricle  accommo- 
dates itself  readily  to  the  extra  amount,  and  there  is  no  disturbance  in  the 
lesser  circulation.  In  acute  cases,  on  the  other  hand,  with  rapid  destruction 
of  the  segments,  there  may  be  the  most  intense  dyspnoea. and  even  profuse 
hgemoptysis.  In  this  lesion  dilatation  and  hypertrophy  reach  their  most  ex- 
treme limit.  The  heaviest  hearts  on  record  are  described  in  connection  with 
this  affection.  The  so-called  bovine  heart,  cor  hovinum,  may  weigh  35  or  40 
ounces,  or  even,  as  in  a  case  of  Dulles's,  48  ounces.  The  dilatation  is  usually 
extreme  and  is  in  marked  contrast  to  the  condition  of  the  chamber  in  cases  of 
pure  aortic  stenosis.  The  papillary  muscles  may  be  greatly  flattened.  The 
mitral  valves  are  usually  not  seriously  affected,  though  the  edges  may  present 
slight  sclerosis,  and  there  is  often  relative  insufficiency,  owing  to  distention 
of  the  mitral  ring.  Dilatation  and  hypertrophy  of  the  left  auricle  are  com- 
mon, and  secondary  enlargement  of  the  right  heart  occurs  in  all  cases  of  long 
standing.  In  the  arterio-sclerotic  group  there  is  an  ever  present  possibility 
of  narrowing  of  the  orifices  of  the  coronary  arteries  or  an  extension  of  the 
sclerosis  to  their  branches,  leading  to  fibroid  myocarditis.  In  the  endocarditis 
cases  the  intima  of  the  aorta  may  be  perfectly  smooth.  The  so-called  dynamic 
dilatation  of  the  arch  is  best  seen  in  these  cases,  A  young  girl,  whose  case 
had  been  reported  as  one  of  aneurism,  had  forcible  pulsation  and  a  tumor 
which  could  be  grasped  above  the  sternum — post  mortem  the  innominate  ar- 
tery did  not  admit  the  little  finger  and  the  arch  was  not  dilated ! 

Although  the  coronary  arteries,  as  shown  by  Martin  and  Sedgwick,  are 
filled  during  the  ventricular  systole,  the  circulation  in  them  must  be  embar- 


CHEOmC  VALVULAE  DISEASE  805 

rassed  in  aortic  insufficiency.  They  must  miss  the  effect  of  the  blood  pres- 
sure in  the  sinuses  of  Valsalva  during  the  elastic  recoil  of  the  arteries,  which 
surely  aids  in  keeping  the  coronary  vessels  full.  The  arteries  of  the  body 
usually  present  more  or  less  sclerosis  consequent  upon  the  strain  which  they 
undergo  during  the  forcible  ventricular  systole. 

Symptoms. — The  condition  is  often  discovered  accidentally  in  persons  who 
have  not  presented  any  features  of  cardiac  disease. 

Headache,  dizziness,  flashes  of  light,  and  a  feeling  of  faintness  on  rising 
quickly  are  among  the  earliest  symptoms.  Palpitation  and  cardiac  distress  on 
slight  exertion  are  common.  Long  before  any  signs  of  failing  compensation 
pain  may  be  a  marked  feature.  It  is  extremely  variable  in  its  manifestations. 
It  may  be  of  a  dull,  aching  character  confined  to  the  prgecordia  but  more  fre- 
quently it  is  sharp  and  radiating,  and  transmitted  up  the  neck  and  down  the 
arms,  particularly  the  left.  Disease  of  the  aorta  is  often  responsible  for  the 
pain.  Attacks  of  angina  pectoris  are  more  frequent  in  this  than  in  any  other 
valvular  disease.  Anemia  is  common,  much  more  so  than  in  aortic  stenosis  or 
mitral  affections. 

As  compensation  fails  more  serious  symptoms  are  shortness  of  breath  and 
oedema  of  the  feet.  The  attacks  of  dyspnoea  are  liable  to  come  on  at  night,  and 
the  patient  has  to  sleep  with  his  head  high  or  even  in  a  chair.  Cyanosis  is 
rare.  It  is  most  commonly  due  to  complicating  valve  disease,  or  it  is  stated 
that  it  may  result  from  bulging  of  the  septum  ventriculorum  and  encroach- 
ment upon  the  right  ventricle.  Of  respiratory  symptoms  cough  is  common, 
due  to  the  congestion  of  the  lungs  or  oedema.  Hgemoptysis  is  less  frequent 
than  in  mitral  disease  but  there  are  cases  in  which  it  is  profuse  and  believed 
to  be  due  to  tuberculosis  of  the  lungs.  General  dropsy  is  not  common,  but 
oedema  of  the  feet  may  occur  early  and  is  sometimes  due  to  the  angemia,  some- 
times to  the  venous  stasis,  at  times  to  both.  Unless  there  is  coexisting  mitral 
disease,  it  is  rare  for  the  patient  to  die  with  general  anasarca.  Sudden  death 
is  frequent;  more  so  than  in  other  valvular  diseases.  As  compensation  fails 
the  patient  takes  to  bed  and  slight  irregular  fever,  associated  usually  with  a 
recurring  endocarditis,  is  not  uncommon  toward  the  close.  Embolic  symptoms 
are  not  infrequent — pain  in  the  splenic  region  with  enlargement  of  the  organ, 
hgematuria,  and  in  some  cases  paralysis.  Distressing  drearns  and  disturbed 
sleep  are  more  common  in  this  than  in  other  forms  of  valvular  disease. 

Menial  symptoms  are  often  seen  with  this  lesion  or  the  patients  may  be 
irritable  and  difficult  to  manage;  toward  the  close  there  may  be  delirium, 
hallucinations,  and  morbid  impulses.  It  is  important  to  bear  this  in  mind, 
for  patients  occasionally  display  suicidal  tendencies. 

Physical  Signs. — Inspection  shows  a  wide  area  of  forcible  impulse  with 
the  apex  beat  in  the  sixth  or  seventh  interspace,  and  perhaps  as  far  out  as  the 
anterior  axillary  line.  In  young  subjects  the  prgecordia  may  bulge.  There 
may  be  slight  visible  pulsation  in  the  second  right  interspace,  or,  in  some  acute 
cases  of  insufficiency  or  ulcerative  endocarditis,  a  couple  of  inches  from  the 
sternal  margin.  In  very  slight  insufficiency  there  may  be  little  or  no  enlarge- 
ment. On  palpation  a  thrill,  diastolic  in  time,  is  occasionally  felt,  but  is  hot 
common.  The  impulse  is  usually  strong  and  heaving,  unless  in  extreme  dila- 
tation, when  it  is  wavy  and  indefinite.  Occasionally  two  or  three  interspaces 
between  the  nipple  line  and  sternum  are  depressed  with  systole  as  the  result 


806  DISEASES  OF  THE  CIECULATOEY  SYSTEM 

of  atmospheric  pressure.  Percussion  shows  a  great  increase  in  the  area  of 
heart  dulness,  chiefly  downward  and  to  the  left. 

Auscultation. — A  diastolic  murmur  is  heard  at  the  base  of  the  heart  and 
propagated  down  the  sternum.  It  may  be  feeble  or  inaudible  at  the  aortic 
cartilage,  and  is  usually  heard  best  at  midsternum  opposite  the  third  costal 
cartilage  or  along  the  left  border  of  the  sternum  as  low  as  the  ensiform  carti- 
lage. It  is  usually  soft,  blowing  in  quality,  and  is  prolonged,  or  "long  drawn," 
as  the  phrase  is.  It  is  produced  by  the  reflux  of  blood  into  the  ventricle.  In 
some  cases  it  is  loudly  transmitted  to  the  axilla  at^the  level  of  the  fourth  in- 
terspace, not  by  way  of  the  apex.  The  second  sound  may  be  well  heard  or  be 
replaced  by  the  murmur,  or  with  a  dilated  arch  the  second  sound  may  have  a 
ringing  metallic  or  booming  quality,  and  the  diastolic  murmur  is  well  heard, 
or  even  loudest,  over  the  manubrium. 

The  first  sound  may  be  clear  at  the  base ;  more  commonly  there  is  a  soft, 
short,  systolic  murmur.  In  the  arterio-sclerotic  group  the  systolic  bruit  is,  as 
a  rule,  short  and  soft,  while  in  the  endocarditic  group,  in  which  the  valve  seg- 
ments are  united  and  often  covered  with  calcified  vegetations  and  excrescences, 
the  systolic  murmur  is  rough  and  may  be  accompanied  by  a  thrill. 

At  the  apex,  or  toward  it,  the  diastolic  murmur  may  be  faintly  heard  propa- 
gated from  the  base.  With  full  compensation  the  first  sound  is  usually  clear 
at  the  apex ;  with  dilatation  there  is  a  loud  systolic  murmur  of  relative  mitral 
insufficiency,  which  may  disappear  as  the  dilatation  lessens. 

Flint  Murmur. — A  second  murmur  at  the  apex,  probably  produced  at  the 
mitral  orifice,  is  not  uncommon,  to  which  attention  was  called  by  the  late  Austin 
Flint.  It  is  of  a  rumbling,  echoing  character,  occurring  in  the  middle  or  latter 
part  of  diastole,  and  limited  to  the  apex  region.  It  is  similar  to,  though  less 
intense  than,  the  murmur  of  mitral  stenosis,  and  may  be  associated  with  a 
palpable  thrill.  It  is  probably  caused  by  the  impinging  of  the  regurgitant 
current  from  the  aortic  orifice  on  the  large,  anterior  fiap  of  the  mitral  valve, 
so  as  to  cause  interference  with  the  entrance  of  blood  at  the  time  of  auricular 
contraction.  The  condition  is  thus  essentially  the  same  as  in  a  moderate  mitral 
stenosis.  This  murmur  is  present  in  about  half  of  the  cases  of  uncomplicated 
aortic  insufficiency  (Thayer).  It  is  very  variable,  disappearing  and  reap- 
pearing again  without  apparent  cause.  The  sharp,  first  sound  and  abrupt 
systolic  shock,  so  common  in  true  mitral  stenosis,  are  rarely  present,  while 
the  pulse  is  characteristic  of  aortic  insufficiency. 

Arteries.— The  examination  of  the  arteries  in  aortic  insufficiency  is  of 
great  value.  Visible  pulsation  is  more  commonly  seen  in  the  peripheral  ves- 
sels in  this  than  in  any  other  condition.  The  carotids  may  be  seen  to  throb 
forcibly,  the  temporals  to  dilate,  and  the  brachials  and  radials  to  expand  with 
each  heart-beat.  With  the  ophthalmoscope  the  retinal  arteries  are  seen  to 
pulsate.  Not  only  is  the  pulsation  evident,  but  the  characteristic  jerking 
quality  is  apparent.  The  throbbing  carotids  may  lead  to  the  diagnosis  of 
aneurism.  In  many  cases  the  pulsation  can  be  seen  in  the  suprasternal  notch 
and  the  abdominal  aorta  may  lift  the  epigastrium  with  each  systole.  In  severe 
eases  with  great  hypertrophy,  particularly  if  anaemia  is  present,  the  vascular 
throbbing  may  be  of  an  extraordinary  character,  jarring  the  whole  front  of 
the  chest,  causing  the  head  to  nod,  and  even  the  tongue  may  throb  rhythmic- 
ally.    To  be  mentioned  with  this  is  the  cnpilkirii  pulse,  met  very  often  in 


CHEONIC  VALVULAK  DISEASE  807 

aortic  insufficiency,  and  best  seen  in  the  finger  nails  or  by  drawing  a  line  upon 
the  forehead,  when  the  margin  of  hypersemia  on  either  side  alternately  blushes 
and  pales.  In  extreme  grades -the  face  or  the  hand  may  blush  visibly  at  each 
systole.  It  is  met  with  also  in  profound  anaemia,  occasionally  in  neurasthenia, 
and  in  health  in  conditions  of  great  relaxation  of  the  peripheral  arteries.  Pul- 
sation may  also  be  present  in  the  peripheral  veins.  On  palpation  the  charac- 
teristic collapsing  or  Corrigan  pulse  is  felt.  The  pulse  wave  strikes  the  finger 
forcibly  with  a  quick  jerking  impulse,  and  immediately  recedes  or  collapses. 
The  characters  of  this  are  sometimes  best  appreciated  by  grasping  the  arm  at 
the  wrist  and  holding  it  up.  The  pulse  may  be  retarded  or  delayed — i.  e., 
there  is  an  appreciable  interval  between  the  beat  of  the  heart  and  the  pulsa- 
tion in  the  radial  artery,  which  varies  according  to  the  extent  of  the  regurgi- 
tation. Occasionally  in  the  carotid  artery  the  second  sound  is  distinctly  audible 
when  absent  at  the  aortic  cartilage.  Indeed,  according  to  Broadbent,  it  is  at 
the  carotid  that  we  must  listen  for  the  second  aortic  sound,  for  when  heard 
it  indicates  that  the  regurgitation  is  small  in  amount,  and  is  consequently  a 


Fig  10. — Pulse  Tracing  in  Aortic  Insufficiency;  an  Extra  Systole  is  Shown. 

favorable  prognostic  element.  In  the  larger  arteries  a  systolic  thud  or  shock 
may  be  heard  and  sometimes  a  double  murmur.  The  systolic  pressure  is  often 
high  and  the  diastolic  much  decreased..  The  sphygmographic  tracing  is  very 
characteristic.  The  high  ascent,  the  sharp  top,  the  quick  drop  in  wKich  the 
dicrotic  notch  and  wave  are  very  slightly  marked. 

The  studies  of  Stewart  and  of  W.  G.  MacCallum  have  shown  that  in  aortic 
insufficiency  the  low  position  of  the  dicrotic  notch  in  the  descending  arm  of 
the  pulse  wave  and  the  characteristic  collapsing  character  of  the  pulse  are  not 
due,  as  was  formerly  supposed,  to  the  regurgitation  in  the  left  ventricle,  but 
to  the  dilatation  of  the  peripheral  arteries,  which  is  a  sort  of  protective  adap- 
tation under  the  vaso-motor  influences. 

Aortic  insufficiency  may  be  fully  compensated  for  years.  Persons  do  not 
necessarily  suffer  any  inconvenience,  and  the  condition  is  often  found  acci- 
dentally. So  long  as  the  hypertrophy  equalizes  the  valvular  defect  there  may 
be  no  symptoms  and  the  individual  may  even  take  moderately  heavy  exercise 
without  experiencing  sensations  of  distress.  The  cases  which  last  the  longest 
are  those  in  which  the  insufficiency  follows  endocarditis  and  is  not  a  part  of  a 
general  arterio-sclerosis.  The  age  at  the  time  of  onset  is  a  most  important 
consideration,  as  in  youth  the  lesion  is  not  often  from  sclerosis,  and  the  coro- 
nary arteries  are  unaffected.  Coexistent  lesions  of  the  mitral  valves  tend  to 
disturb  compensation  early.  Pure  aortic  insufficiency  is  consistent  with  years 
of  average  health  and  with  a  tolerably  active  life. 

With  the  onset  of  myocardial  changes,  with  increasing  degeneration  of  the 
arteries,  particularly  with  a  progressive  sclerosis  of  the  arch  and  involvement 
of  the  orifices  of  the  coronary  arteries,  the  compensation  becomes  disturbed. 


808  DISEASES  OF  THE  CIRCULATORY  SYSTEM 

The  insufficiency  of  the  circulation  is  seen  first  on  the  arterial  side  in  occa- 
sional f aintings,  giddiness,  or  mental  irritability  and  enf eeblement ;  later  there 
may  be  mitral  regurgitation  and  embarrassment  of  the  right  side  of  the  heart 
with  its  usual  features.  In  advanced  cases  the  changes  about  the  aortic  ring 
may  be  associated  with  alterations  in  the  cardiac  nerves  and  ganglia  and  so 
introduce  an  important  factor. 

AORTIC  STENOSIS 

Narrowing  or  stricture  of  the  aortic  orifice  is  not  nearly  so  common  as 
insufficiency.  The  two  conditions,  as  already  stated,  may  occur  together,  how- 
ever, and  probably  in  almost  every  case  of  stenosis  there  is  some  leakage. 

Etiology  and  Morbid  Anatomy. — In  the  milder  grades  there  is  adhesion 
between  the  segments,  which  are  so  stiffened  that  during  systole  they  cannot 
be  pressed  back  against  the  aortic  wall.  The  process  of  cohesion  between  the 
segments  may  go  on  without  great  thickening,  and  produce  a  condition  in  which 
the  orifice  is  guarded  by  a  comparatively  thin  membrane,  on  the  aortic  face 
of  which  may  be  seen  the  primitive  raphes  separating  the  sinuses  of  Valsalva. 
In  some  instances  this  membrane  is  so  thin  and  presents  so  few  traces  of 
atheromatous  or  sclerotic  changes  that  the  condition  looks  as  if  it  had  origi- 
nated during  fetal  life.  More  commonly  the  valve  segments  are  thickened  and 
rigid,  and  have  a  cartilaginous  hardness.  In  advanced  cases  they  may  be 
represented  by  stiff,  calcified  masses  obstructing  the  orifice,  through  which  a 
circular  or  slit  like  passage  can  be  seen.  The  older  the  patient  the  more  likely 
it  is  that  the  valves  will  be  rigid  and  calcified. 

We  may  speak  of  a  relative  stenosis  of  the  aortic  orifice  when  with  normal 
valves  and  ring  the  aorta  immediately  beyond  is  greatly  dilated.  A  stenosis 
due  to  involvement  of  the  aortic  ring  in  sclerotic  and  calcareous  changes  with- 
out lesion  of  the  valves  is  referred  to  by  some  authors.  We  have  never  met  with 
an  instance  of  this  kind.  A  subvalvular  stenosis,  the  result  of  endocarditis 
in  the  mitro-sigmoidean  sinus,  usually  occurs  as  the  result  of  fetal  endocardi- 
tis. In  comparison  with  aortic  insufficiency,  stenosis  is  rare.  It  is  usually 
met  with  at  a  more  advanced  period  of  life  than  insufficiency,  and  the  most 
typical  cases  of  it  are  found  associated  with  extensive  calcareous  changes  in 
the  arterial  system  in  old  men. 

Owing  to  the  obstruction  the  ventricle  works  against  increased  resistance 
and  its  walls  become  hypertrophied,  usually  at  first  with  little  or  no  dilatation. 
We  see  in  this  condition  the  most  typical  instances  of  concentric  hypertrophy, 
in  which,  without  much,  if  any,  enlargement  of  the  cavity,  the  walls  are  greatly 
thickened.  The  systole  is  prolonged,  even  as  much  as  twenty-five  per  cent. 
There  may  be  no  changes  in  the  other  cardiac  cavities  if  compensation  is  well 
maintained;  but  with  its  failure  come  dilatation,  impeded  auricular  discharge, 
pulmonary  congestion,  and  increased  work  for  the  right  heart.  The  arterial 
changes  are,  as  a  rule,  not  so  marked  as  in  insufficiency,  for  the  walls  have 
not  to  withstand  the  impulse  of  greatly  increased  blood-wave  with  each  systole. 
On  the  contrary,  the  amount  of  blood  propelled  through  the  narrow  orifice  may 
be  smaller  than  normal,  though  when  compensation  is  fully  established  the 
pulse  wave  may  be  of  medium  volume. 

Symptoms. — Physical  Signs. — Inspection  may  fail  to  reveal  any  area  of 


CHEONIC  YALVULAE  DISEASE  809 

cardiac  impulse.  Particularly  is  this  the  case  in  old  men  with  rigid  chest 
walls  and  large  emphysematous  lungs.  Under  these  circumstances  there  may 
be  a  high  grade  of  hypertrophy  without  any  visible  impulse.  Even  when  the 
apex  beat  is  visible,  it  may  be,  as  Traube  pointed  out,  feeble  and  indefinite. 
In  many  cases  the  apex  is  seen  displaced  downward  and  outward,  and  the  im- 
pulse looks  strong  and  forcible. 

Palpation  reveals  in  many  cases  a  thrill  at  the  base  of  the  heart  of  maxi- 
mum force  in  the  aortic  region.  With  no  other  condition  do  we  meet  with 
thrills  of  greater  intensity.  The  apex  beat  may  not  be  palpable  under  the 
conditions  above  mentioned,  or  there  may  be  a  slow,  heaving,  forcible  impulse. 

Percussion  never  gives  the  same  wide  area  of  dulness  as  in  aortic  insuf- 
ficiency. The  extent  of  it  depends  largely  on  the  state  of  the  lungs,  whether 
emphysematous  or  not. 

Auscultation. — A  rough  systolic  murmur,  of  maximum  intensity  at  the 
aortic  cartilage,  and  propagated  into  the  great  vessels,  is  the  most  constant 
physical  sign.  One  of  the  last  lessons  learned  by  the  student  is  to  recognize 
that  a  systolic  murmur  at  the  aortic  area  does  not  necessarily  mean  obstruc- 


FiG.  11. — Pulse  Tracing  in  Aortic  Stenosis. 

tion  of  the  orifice.  Eoughening  of  the  valves,  or  of  the  intima  of  the  aorta, 
and  haemic  states  are  much  more  frequent  causes.  In  aortic  stenosis  the 
murmur  often  has  a  much  harsher  quality,  is  louder,  and  is  more  frequently 
musical  than  in  the  conditions  just  mentioned.  When  compensation  fails  and 
the  ventricle  is  dilated  and  feeble,  the  murmur  may  be  soft  and  distant.  The 
second  sound  is  rarely  heard  at  the  aortic  cartilage,  owing  to  the  thickening 
and  stiffness  of  the  valve.'  A  diastolic  murmur  is  not  uncommon,  but  in  many 
cases  it  can  not  be  heard.  Occasionally,  as  noted  by  W.  H.  Dickinson,  there 
is  a  musical  murmur  of  greatest  intensity  in  the  region  of  the  apex,  due  prob- 
ably to  a  slight  regurgitation  at  high  pressure  through  the  mitral  valves. 
The  pulse  in  pure  aortic  stenosis  is  small,  usually  of  good  tension,  well  sus- 
tained, regular,  and  perhaps  slower  than  normal. 

The  condition  may  be  latent  for  an  indefinite  period,  as  long  as  the  hy- 
pertrophy is  maintained.  Early  symptoms  are  those  due  to  defective  blood 
supply  to  the  brain,  dizziness,  and  fainting.  Palpitation,  pain  about  the  heart, 
and  anginal  symptoms  are  not  so  marked  as  in  insufficiency.  With  myocardial 
failure,  relative  insufficiency  of  the  mitral  valve  is  established,  and  the  patient 
may  present  all  the  features  of  engorgement  in  the  lesser  and  systemic  circu- 
lations. Many  of  the  cases  in  old  people,  without  presenting  any  dropsy, 
have  symptoms  pointing  rather  to  general  arterial  disease.  Cheyne-Stokes 
breathing  is  not  uncommon  with  or  without  uraemia. 

Diag-nosis. — With  an  extremely  rough  or  musical  systolic  murmur  of  max- 


810  DISEASES  OF  THE  CIKCULATOKY  SYSTEM 

imum  intensity  at  the  aortic  region,  hypertrophy  of  the  left  ventricle,  a  thrill, 
and  a  hard,  slow  pulse  of  moderate  volume  and  fairly  good  tension,  which  in  a 
tracing  gives  a  curve  of  slow  rise,  a  broad,  well  sustained  sUmmit  and  slow 
decline,  a  diagnosis  of  aortic  stenosis  can  be  made  with  some  degree  of  cer- 
tainty, particularly  if  the  subject  is  an  old  man.  Seldom  is  there  difficulty  in 
distinguishing  the  murmur  due  to  anemia,  since  it  is  rarely  so  intense  and  is 
not  associated  with  a  thrill  or  with  marked  hypertrophy  of  the  left  ventricle. 
In  aortic  insufficiency  a  systolic  murmur  is  usually  present,  but  has  neither 
the  intensity  nor  the  musical  quality,  nor  is  it  accompanied  by  a  thrill.  With 
roughening  and  dilatation  of  the  aorta  the  murmur  may  be  harsh  or  musical ; 
but  the  existence  of  a  second  sound,  accentuated  and  ringing  in  quality,  is 
usually  sufficient  to  differentiate  this  condition. 

MITRAL    INSUFFICIENCY 

Etiology. — Insufficiency  of  the  mitral  valve  ensues:  (a)  From  changes  in 
the  segments  whereby  they  are  contracted  and  shortened,  usually  combined 
with  changes  in  the  chord©  tendinese,  or  with  more  or  less  narrowing  of  the 
orifice.  (6)  As  a  result  of  changes  in  the  muscular  walls  of  the  ventricle, 
either  dilatation,  so  that  the  valve  segments  fail  to  close  an  enlarged  orifice, 
or  changes  in  the  muscufer  substance,  so  that  the  segments  are  imperfectly 
coapted  during  the  systole — muscular  insufficiency.  The  common  lesions  pro- 
ducing insufficiency  result  from  endocarditis,  which  causes  a  gradual  thick- 
ening at  the  edges  of  the  valves,  contraction  of  the  chordae  tendinese,  and 
union  of  the  edges  of  the  segnaents,  so  that  in  a  majority  of  the  instances  there 
is  not  only  insufficiency,  but  some  grade  of  narrowing  as  well.  Except  in 
children,  we  rarely  see  the  mitral  leaflets  curled  and  puckered  without  nar- 
rowing of  the  orifice.  Calcareous  plates  at  the  base  of  the  valve  may  prevent 
perfect  closure  of  one  of  the  segments.  In  long-standing  cases  the  entire  mitral 
structures  are  converted  into  a  firm  calcareous  ring.  From  valvular  insuffi- 
ciency the  other  condition  of  muscular  insufficiency  must  be  carefully  distin- 
guished. It  is  met  with  in  all  conditions  of  extreme  dilatation  of  the  left 
ventricle,  and  also  in  weakening  of  the  muscle  in  prolonged  fevers  and  in 
ansemia. 

Morbid  Anatomy. — The  effects  of  insufficiency  of  the  mitral  segment 
upon  the  heart  and  circulation  are  as  follows:  (a)  The  imperfect  closure 
allows  a  certain  amount  of  blood  to  regurgitate  from  the  ventricle  into  the 
auricle,  so  that  at  the  end  of  auricular  diastole  this  chamber  contains  not  only 
the  blood  which  it  has  received  from  the  lungs,  but  also  that  regurgitated 
from  the  left  ventricle.  This  necessitates  dilatation,  and,  as  increased  work  is 
thrown  upon  it  in  expelling  the  augmented  contents,  hypertrophy  as  well. 

(&)  With  each  systole  of  the  left  auricle  a  larger  volume  of  blood  is  forced 
into  the  left  ventricle,  which  dilates  and  subsequently  hypertrophies. 

(c)  During  the  diastole  of  the  left  auricle,  as  blood  is  regurgitated  into 
it  from  the  left  ventricle,  the  pulmonary  veins  are  less  readily  emptied.  In 
consequence  the  right  ventricle  expels  its  contents  less  freely,  and  in  turn 
becomes  hypertrophied  and  dilated. 

(d)  Finally,  the  right  auricle  also  is  involved,  its  chamber  is  enlarged, 
and  its  walls  are  increased  in  thickness. 


CHEONIC  VALVULAE  DISEASE  811 

(e)  The  effect  upon  the  pulmonary  vessels  is  to  produce  dilatation  both 
of  the  arteries  and  veins — often  in  long-standing  cases^  atheromatous  changes ; 
the  capillaries  are  distended,  and  ultimately  the  condition  of  brown  induration 
is  produced.  Perfect  compensation  may  be  effected,  chiefly  through  the  hyper- 
trophy of  both  ventricles,  and  the  effect  upon  the  peripheral  circulation  may 
not  be  manifested  for  years,  as'  a  normal  volume  of  blood  is  discharged  from 
the  left  heart  at  each  systole.  The  time  comes,  however,  when,  owing  either 
to  increase  in  the  grade  of  the  incompetency  or  to  failure  of  compensation,  the 
left  ventricle  is  unable  to  send  out  its  normal  volume  into  the  aorta.  Then 
there  are  overfilling  of  the  left  auricle,  engorgement  in  the  lesser  circulation, 
embarrassed  action  of  the  right  heart,  and  congestion  in  the  systemic  veins. 
For  years  this  somewhat  congested  condition  may  be  limited  to  the  lesser  cir- 
culation, but  finally  the  tricuspid  valves  become  incompetent,  and  the  sys- 
temic veins  are  engorged.  This  leads  to  the  condition  of  cyanotic  induration 
in  the  viscera  and,  when  extreme,  to  dropsical  effusion. 

Muscular  insufficiency,  due  to  impaired  nutrition  of  the  mitral  and  papil- 
lary muscles,  is  rarely  followed  by  such  perfect  compensation.  There  may  be 
in  acute  destruction  of  the  aortic  segments  an  acute  dilatation  of  the  left 
ventricle  with  relative  incompetency  of  the  mitral  segments,  great  dilatation 
of  the  left  auricle,  and  intense  engorgement  of  the  lungs,  under  which  circum- 
stances profuse  hemorrhage  may  result.  In  these  cases  there  is  little  chance 
for  the  establishment  of  compensation.  In  cases  of  hypertrophy  and  dilata- 
tion of  the  heart,  without  valvular  lesions,  the  insufficiency  of  the  mitral  valve 
may  be  extreme  and  lead  to  great  pulmonary  congestion,  engorgement  of  the 
systemic  veins,  and  a  condition  of  cardiac  dropsy,  which  can  not  be  distin- 
guished by  any  feature  from  that  of  mitral  insufficiency  due  to  lesion  of  the 
valve  itself.  In  chronic  nephritis  the  left  ventricle  may  gradually  fail,  lead- 
ing, in  the  later  stages,  to  relative  insufficiency  of  the  mitral  valve,  and  the 
production  of  pulmonary  and  systemic  congestion,  similar  to  that  induced  by 
the  most  extreme  grade  of  lesion  of  the  valve  itself.  Adherent  pericardium, 
especially  in  children,  may  lead  to  like  results. 

Symptoms. — During  the  development  of  the  lesion,  unless  the  insuffi- 
ciency comes  on  acutely  in  consequence  of  rupture  of  the  valve  segment  or  of 
ulceration,  the  compensatory  changes  go  hand  in  hand  with  the  defect,  and 
there  are  no  subjective  symptoms.  So,  also,  in  the  stage  of  perfect  compensa- 
tion, there  may.be  the  most  extreme  grade  of  mitral  insufficiency  with  enor- 
mous hypertrophy,  yet  the  patient  may  not  be  aware  of  the  existence  of  heart 
trouble,  and  may  suffer  no  inconvenience  except  perhaps  a  little  shortness  of 
breath  on  exertion.  It  is  only  when  the  compensation  has  not  been  perfectly 
effected,  or,  having  been  so,  is  broken  that  the  patients  begin  to  be 'troubled. 
The  symptoms  may  be  divided  into  two  groups : 

(a)  The  minor  manifestations  while  compensation  is  still  good.  Patients 
with  extreme  insufficiency  often  have  a  congested  appearance  of  the  face,  the 
lips  and  ears  have  a  bluish  tint,  and  the  venules  on  the  cheeks  may  be  en- 
larged— signs  in  many  cases  very  suggestive.  In  long  standing  cases,  par- 
ticularly in  children,  the  fingers  may  be  clubbed,  and  there  is  shortness  of 
breath  on  exertion.  This  is  one  of  the  most  constant  features  in  mitral  in- 
sufficiency and  may  exist  for  years,  even  when  the  compensation  is  perfect. 
Owing  to  the  somewhat  congested  condition  of  the  lungs  these  patients  have 


812  DISEASES  OF  THE  CIKCULATOEY  SYSTEM 

a  tendency  to  attacks  of  bronchitis  or  haemoptysis.  There  may  also  be  palpi- 
tation of  the  heart.  As  a  rule,  however,  in  well  balanced  lesions  in  adults, 
this  period  of  full  compensation  or  latent  stage  is  not  associated  with  symp- 
toms which  call  the  attention  to  an  affection  of  the  heart,  and  with  care  the 
patient  may  reach  old  age  in  comparative  comfort  without  being  compelled 
to  curtail  seriously  his  pleasures  or  his  work. 

(6)  Sooner  or  later  comes  a  period  of  broken  compensation,  in  which  the 
most  intense  symptoms  are  those  of  venous  engorgement.  There  are  palpita- 
tion, weak,  irregular  action  of  the  heart,  and  signs  of  dilatation.  The  irregu- 
larity may  be  due  to  extra-systoles  or  auricular  fibrillation.  Dyspnoea  is  an 
especial  feature,  and  there  may  be  cough.  A  distressing  symptom  is  the  cardiac 
"sleep-start,"  in  which,  just  as  the  patient  falls  asleep,  he  wakes  gasping  and 
feeling  as  if  the  heart  were  stopping.  There  is  usually'  slight  cyanosis,  and 
even  a  jaundiced  tint  to  the  skin.  The  most  marked  symptoms  are  those  of 
venous  stasis.  The  overfilling  of  the  pulmonary  vessels  accounts  in  part  for 
the  dyspnoea.  There  is  cough,  often  with  bloody  or  watery  expectoration,  and 
the  alveolar  epithelium  containing  brown  pigment-grains  is  abundant.  Drop- 
sical effusion  usually  sets  in,  beginning  in  the  feet  and  extending  to  the  body 
and  the  serous  sacs.  Right  sided  hydrothorax  may  recur  and  require  repeated 
tapping.  The  urine  is  usually  scanty  and  albuminous,  and  contains  tube  casts 
and  sometimes  blood  corpuscles.  With  judicious  treatment  compensation  may 
be  restored  and  all  the  serious  symptoms  pass  away.  Patients  usually  have  re- 
curring attacks  of  this  kind,  and  die  with  a  general  dropsy;  or  there  is  pro- 
gressive dilatation  of  the  heart.  Sudden  death  in  these  cases  is  rare.  Some 
cases  of  mitral  disease — stenosis  and  insufficiency — reach  what  may  be  called 
the  hepatic  stage,  when  all  the  symptoms  are  due  to  the  secondary  changes  in 
the  liver. 

Physical  Signs. — Inspection. — In  children  the  prsecordia  may  bulge  and 
there  may  be  a  large  area  of  visible  pulsation.  The  apex  beat  is  to  the  left 
of  the  nipple,  in  some  cases  in  the  sixth  interspace,  in  the  anterior  axillary 
line.  A  localized  right  ventricle  impulse  may  sometimes  be  seen  below  the 
right  costal  border  in  the  parasternal  line.  There  may  be  a  wavy  impulse  in 
the  cervical  veins,  which  are  often  full,  particularly  when  the  patient  is  re- 
cumbent. 

Palpation. — A  thrill  is  rare;  when  present  it  is  felt  at  the  apex,  often  in 
a  limited  area.  The  force  of  the  impulse  may  depend  largely  upon  the  stage 
in  which  the  case  is  examined.  In  full  compensation  it  is  forcible  and  heav- 
ing; when  the  compensation  is  disturbed,  usually  wavy  and  feeble. 

Percussion. — The  dulness  is  increased,  particularly  in  a  lateral  direction. 
There  is  no  disease  of  the  valves  which  produces,  in  long  standing  cases,  a 
more  extensive  transverse  area  of  heart  dulness.  It  does  not  extend  so  much 
upward  along  the  left  margin  of  the  sternum  as  beyond  the  right  margin  and 
to  the  left  of  the  nipple  line. 

Auscultation. — At  the  apex  there  is  a  systolic  murmur  which  wholly  or 
partly  obliterates  the  first  sound.  It  is  loudest  here,  and  has  a  blowing,  some- 
times musical  character,  particularly  toward  the  latter  part.  The  murmur  is 
transmitted  to  the  axilla  and  may  be  heard  at  the  back,  in  some  instances  over 
the  entire  chest.  There  are  cases  in  which,  as  pointed  out  by  ISTaunyn,  the  mur- 
mur is  heard  best  along  the  left  border  of  the  sternum.    Usually  at  the  apex 


.  CHEONIC  VALVULAR  DISEASE  813 

the  loudly  transmitted  second  sound  may  be  heard.  Occasionally  there  is  also 
a  soft,  sometimes  a  rough  or  rumbling  presystolic  murmur.  As  a  rule,  in  cases 
of  extreme  mitral  insufficiency  from  valvular  lesion  with  great  hypertrophy 
of  both  ventricles,  there  is  heard  only  a  loud  blowing  murmur  during  systole. 
A  murmur  of  mitral  insufficiency  may  vary  a  great  deal  according  to  the  posi- 
tion of  the  patient.  In  cases  of  dilatation,  particularly  when  dropsy  is  pres- 
ent, a  soft  systolic  murmur  due  to  tricuspid  regurgitation  may  be  heard  at 
the  ensiform  cartilage  and  in  the  lower  sternal  region.  An  important  sign 
is  the  accentuated  pulmonary  second  sound,  heard  to  the  left  of  the  sternum 
in  the  second  interspace,  or  over  the  third  left  costal  cartilage. 

The  pnlse,  during  the  period  of  full  compensation,  may  be  full  and  regular, 
often  of  low  tension.  Usually  with  the  first  onset  of  symptoms  it  becomes  ir- 
regular, a  feature  which  then  dominates  the  case  throughout.  There  may  be 
no  two  beats  of  equal  force  or  volume.  Often  after  the  disappearance  of  the 
symptoms  of  failure  of  compensation  the  irregularity  of  the  pulse  persists. 
This  is  usually  due  to  auricular  fibrillation. 

The  three  important  physical  signs  of  mitral  regurgitation  are:  (a)  Sys- 
tolic murmur  of  maximum  intensity  at  the  apex,  propagated  to  the  axilla  and 
heard  at  the  angle  of  the  scapula;  (b)  accentuation  of  the  pulmonary  second 
sound;  (c)  evidence  of  enlargement  of  the  heart,  particularly  increase  in  the 
transverse  diameter,  due  to  hypertrophy  of  both  ventricles. 

Diagnosis. — There  is  rarely  any  difficulty  in  the  diagnosis  of  mitral  insuf- 
ficiency. The  physical  signs  are  characteristic  and  distinctive.  Two  points 
are  to  be  borne  in  mind.  First,  a  murmur,  systolic  in  time,  and  of  maximum 
intensity  at  the  apex,  and  propagated  even  to  the  axilla,  does  not  necessarily 
indicate  mitral  insufficiency.  There  is  heard  in  this  region  a  large  group  of 
what  are  termed  accidental  murmurs,  the  precise  nature  of  which  is  doubtful. 
Some  are  cardio-respiratory. 

Second,  it  is  not  always  possible  to  say  whether  the  insufficiency  is  due  to 
lesion  of  the  valve  segment  or  to  dilatation  of  the  mitral  ring  and  relative 
incompetency.  Here  neither  the  character  of  the  murmur,  the  propagation, 
the  accentuation  of  the  pulmonary  second  sound,  nor  the  hypertrophy  assists 
in  the  differentiation.  The  history  is  sometimes  of  greater  value  than  the  ex- 
amination. The  cases  most  likely  to  lead  to  error  are  those  of  the  so-called 
idiopathic  dilatation  and  hypertrophy  (in  which  the  systolic  murmur  may  be 
of  the  greatest  intensity),  and  the  instances  of  arterio-sclerosis  with  dilated 
heart.  Balfour  and  others  maintain  that  organic  disease  of  the  mitral  leaflets 
sufficient  to  produce  insufficiency  is  always  accompanied  with  a  certain  degree 
of  narrowing  of  the  orifice,  so  that  the  only  unequivocal  proof  of  actual  disease 
of  the  mitral  valve  is  the  presence  of  a  presystolic  murmur. 

MITEAL    STENOSIS 

Etiology. — There  are  two  groups  of  cases,  one  following  an  acute  endo- 
carditis, the  other  the  result  of  a  slow  sclerosis  of  the  valves  without  any 
history  of  rheumatic  fever  or  other  infection.  It  is  much  more  common  in 
women  than  in  men — in  63  of  80  cases  noted  by  Duckworth,  while  in  4,791 
autopsies  at  Guy's  Hospital  during  ten  years  there  were  196  cases,  of  which 
107  were  females  and  89  males  (Samways).    This  is  not  easy  to  explain,  but 


814  DISEASES  OF  THE  CIECULATOKY  SYSTEM 

there  are  at  least  two  factors  to  be  considered.  Eheumatic  fever  prevails  more 
in  girls  than  in  boys  and  chorea  has  an  important  influence,  occurring  more 
frequently  in  girls  and  being  often  associated  with  endocarditis.  In  a  surpris- 
ing number  of  cases  of  what  the  French  call  pure  mitral  stenosis  no  recogniz- 
able etiological  factor  can  be  discovered.  This  has  been  regarded  by  some 
writers  as  favoring  the  view  that  they  may  be  of  congenital  origin,  but  con- 
genital aiJections  of  the  mitral  valve  are  notoriously  rare.  Whooping-cough, 
with  its  terrible  strain  on  the  heart-valves,  may  be  accountable  for  certain 
cases.  While  met  with  at  all  ages,  stenosis  is  certainly  most  frequent  in  young 
adult  women. 

Morbid  Anatomy. — The  valve  segments  and  chordae  may  be  fused  to- 
gether, the  result  of  repeated  attacks  of  endocarditis.  The  condition  varies  a 
good  deal,  according  to  the  amount  of  atheromatous  change.  In  many  cases 
the  curtains  are  so  welded  together  and  the  whole  valvular  region  so  thickened 
that  the  orifice  is  reduced  to  a  mere  chink — Corrigan's  button-hole  contraction. 
In  non-endocarditic  cases  the  curtains  are  not  much  thickened,  but  narrowing 
has  resulted  from  gradual  adhesion  at  the  edges,  and  thickening  of  the  chordse 
tendinese,  so  that  from  the  auricle  it  looks  cone  like — the  so-calleid  funnel 
shaped  variety.  The  instances  in  which  the  valve  segments  are  slightly  de- 
formed, but  in  which  the  orifice  is  considerably  narrowed,  are  regarded  by  some 
as  possibly  of  congenital  origin.  Occasionally  the  curtains  are  in  great  part 
free  from  disease,  but  the  narrowing  results  from  large  calcareous  masses, 
which  project  into  them  from  the  ring.  The  involvement  of  the  chordae  tendi- 
nese  is  usually  extreme,  and  the  papillary  muscles  may  be  inserted  directly  upon 
the  valve.  In  moderate  grades  of  constriction  the  orifice  will  admit  the  tip 
of  the  index  finger;  in  more  extreme  forms  the  tip  of  the  little  finger;  and 
occasionally  one  meets  with  a  specimen  in  which  the  orifice  seems  almost  ob- 
literated. The  heart  is  not  greatly  enlarged,  rarely  weighing  more  than  14  or 
15  ounces.  Occasionally,  in  an  elderly  person,  it  may  seem  only  slightly,  if  at 
all,  enlarged,  and  again  there  are  instances  in  which  the  weight  may  reach  as 
much  as  20  ounces.  The  left  ventricle  is  sometimes  small,  and  may  look  very 
small  in  comparison  with  the  right  ventricle,  which  forms  the  greater  portion 
of  the  apex.  In  cases  in  which  with  the  narrowing  there  is  insufficiency  the 
left  ventricle  may  be  moderately  dilated  and  hypertrophied. 

It  is  not  uncommon  at  the  examination  to  find  white  thrombi  in  the  ap- 
pendix of  the  left  auricle.  Occasionally  a  large  part  of  the  auricle  is  occu- 
pied by  an  ante-mortem  thrombus.  Still  more  rarely  the  remarkable  tall 
ihromhus  is  found,  in  which  a  globular  concretion,  varying  in  size  from  a 
walnut  to  a  small  egg,  lies  free  in  the  auricle. 

The  left  auricle  discharges  its  blood  with  greater  difficulty  and  in  conse- 
quence dilates,  and  its  walls  reach  three  or  four  times  their  normal  thickness. 
Although  the  auricle  is  by  structure  unfitted  to  compensate  an  extreme  lesion, 
the  probability  is  that  for  some  time  during  the  gradual  production  of  stenosis 
the  increasing  muscular  power  of  the  walls  counterbalances  the  defect.  In  36 
cases  of  well-marked  stenosis  Samways  found  the  auricle  hypertrophied  in  26. 
dilatation  coexisting  in  14.  Eventually  the-  tension  is  increased  in  the  pul- 
monary circulation  and  extra  work  thrown  on  the  right  ventricle,  which  gradu- 
ally hypertrophies.  Relative  incompetency  of  the  triscuspid  and  congestion  of 
the  systemic  veins  supervene. 


CHRONIC  VALVULAR  DISEASE  815 

Physical  Signs. — Inspection. — In  children  the  lower  sternum  and  the 
fifth  and  sixth  left  costal  cartilages  are  often  prominent,  owing  to  hypertrophy 
of  the  right  ventricle.  The  apex  beat  may  be  ill  defined.  Usually  it  is  not  dis- 
located far  beyond  the  nipple  line,  and  the  chief  impulse  is  over  the  lower 
sternum  and  adjacent  costal  cartilages.  Often  in  thin  chested  persons  there 
is  pulsation  in  the  third  and  fourth  left  interspaces  close  to  the  sternum. 
When  compensation  fails,  the  impulse  is  much  feebler,  and  in  the  veins  of 
the  neck  there  may  be  marked  pulsation  or  the  right  jugular  near  the  clavicle 
may  stand  out  as  a  prominent  tumor.  In  the  later  stage  there  is  great  en- 
largement with  pulsation  of  the  liver. 

Palpation  reveals  in  a  majority  of  the  cases  a  characteristic,  well  defined 
fremitus  or  thrill,  which  is  best  felt,  as  a  rule,  in  the  fourth  or  fifth  interspace 
within  the  nipple  line.  It  is  of  a  rough,  grating  quality,  often  peculiarly 
limited  in  area,  most  marked  during  expiration,  and  terminates  in  a  sharp, 
sudden  shock,  synchronous  with  the  impulse.  This  most  characteristic  of 
physical  signs  is  pathognomonic  of  narrowing  of  the  mitral  orifice,  and  is  per- 
haps the  only  instance  in  which  the  diagnosis  of  a  valvular  lesion  can  be 
made  by  palpation  alone.  The  cardiac  impulse  is  felt  most  forcibly  over  the 
lower  sternum  and  in  the  fourth  and  fifth  left  interspaces.  The  impulse  is 
felt  very  high  in  the  third  and  fourth  interspaces,  or  in  rare  cases  even  in  the 
second,  and  it  has  been  thought  that  in  the  latter  interspace  the  impulse  is 
due  to  pulsation  of  the  auricle.  It  is  always  the  impulse  of  the  conus  arteriosus 
of  the  right  ventricle ;  even  in  the  most  extreme  grades  of  mitral  stenosis  there 
is  never  such  tilting  forward  of  the  auricle  or  its  appendix  as  would  enable 
it  to  produce  an  impression  on  the  chest  wall. 

Percussion  gives  an  increase  in  the  cardiac  dulness  to  the  right  of  the 
sternum  and  along  the  left  margin;  not  usually  a  great  increase  beyond  the 
nipple  line,  except  in  extreme  cases. 

Auscultation. — The  findings^  are  varied  and  a  most  puzzling  combina- 
tion of  sounds  and  murmurs  may  be  heard.  In  some  cases  to  the  inner  side 
of  the  apex  beat,  often  in  a  very  limited  region,  there  is  heard  a  rough,  vibra- 
tory or  purring  murmur,  cumulative  or  crescendo  in  character,  often  of  short 
duration,  which  terminates  abruptly  in  the  loud  snapping  first  sound.  By 
combining  palpation  and  auscultation  the  purring  murmur  is  found  to  be 
synchronous  with  the  thrill  and  the  loud  shock  with  the  first  sound.  The  mur- 
mur may  occupy  the  entire  period  of  the  diastole,  or  the  middle  or  only  the 
latter  half,  corresponding  to  the  auricular  contraction.  A  difference  can  often 
be  noted  between  the  first  and  second  portions  of  the  murmur,  when  it  occupies 
the  entire  time.  In  some  cases  a  soft  diastolic  murmur  is  heard  after  the 
second  sound  at  the  apex.  This  may  increase  and  merge  into  the  presystolic 
murmur.  Often  there  is  a  peculiar  rumbling  or  echoing  quality,  which  in  some 
instances  is  very  limited  and  may  be  heard  only  over  a  single  bell-space  of  the 
stethoscope.  The  administration  of  amyl  nitrite  may  bring  out  the  murmur 
more  clearly.  A  rumbling,  echoing  presystolic  murmur  at  the  apex  is  heard 
in  some  cases  of  aortic  insufficiency  (Flint  murmur),  occasionally  in  adherent 
pericardium  with  great  dilatation  of  the  heart,  and  in  upward  dislocation  of 
the  organ.  The  Graham  Steell  murmur  of  relative  pulmonary  insufficiency 
may  be  heard  in  the  pulmonic  area. 

A  systolic  murmur  may  be  heard  at  the  apex  or  along  the  left  sternal 


816  DISEASES  OF  THE  CIKCULATORY  SYSTEM 

border,  often  of  extreme  softness  and  audible  only  when  the  breath  is  held. 
Sometimes  the  systolic  murmur  is  loud  and  distinct  and  is  transmitted  to  the 
axilla.  The  second  sound  in  the  second  left  interspace  is  loudly  accentuated, 
and  often  reduplicated.  It  may  be  transmitted  far  to  the  left  and  be  heard 
with  great  clearness  beyond  the  apex.  In  uncomplicated  cases  of  mitral 
stenosis  there  are  usually  no  murmurs  audible  at  the  aortic  region,  at  which 
spot  the  second  sound  is  less  intense  than  at  the  pulmonary  area.  In  advanced 
cases  at  the  lower  sternum  and  to  the  right  a  systolic  tricuspid  murmur  is 
sometimes  heard.  With  good  compensation  the  second  sound  is  heard  at  the 
apex;  its  disappearance  suggests  the  approach  of  decompensation.  Other 
points  to  be  noted  are  the  following:  The  usually  sharp,  snapping  first  sound 
which  follows  the  presystolic  murmur,  the  cause  of  which  is  by  no  means  easy 
to  explain.  It  can  scarcely  be  a  valvular  sound  produced  chiefly  at  the  mitral 
orifice,  since  it  may  be  heard  with  great  intensity  in  cases  in  which  the  valves 
are  rigid  and  calcified.  It  has  been  suggested  that  it  is  a  loud  "snap''  of  the 
tricuspid  valves  caused  by  the  powerful  contraction  of  the  greatly  hypertro- 
phied  right  ventricle.  Broadbent  thinks  it  may  be  due  to  the  abrupt  contrac- 
tion of  a  partially  filled  left,  ventricle.  The  sound  may  be  audible  at  a  dis- 
tance, as  one  sits  at  the  bedside  of  the  patient  (Graves).  In  one  patient  the 
first  sound  was  audible  six  feet,  by  measurement,  from  the  chest  wall. 

These  physical  signs,  it  is  to  be  borne  in  mind,  are  characteristic  only  of 
the  stage  in  which  compensation  is  maintained.  The  murmur  may  be  soft, 
almost  inaudible,  and  only  brought  out  after  exertion.  Finally  there  comes 
a  period  in  which,  with  the  establishment  of  auricular  fibrillation,  the  signs 
change.  This  is  due  to  the  absence  of  contraction  of  the  auricle.  Thus  a 
short  presystolic  murmur  may  disappear  as  there  is  not  the  usual  difference 
in  pressure  in  the  auricle  and  ventricle  at  the  time  when  the  auricle  should 
be  contracting.  With  the  auricle  paralyzed  the  murmur  is  more  likely  to  be 
heard  early  in  diastole.  Difference  in  rate  may  cause  marked  changes  in  the 
time  and  character  of  the  murmur. 

Sometimes  in  the  apex  region  a  sharp  first  sound  or  gallop  rhythm  may 
be  heard.  The  systolic  shock  may  be  present  after  the  disappearance  of  the 
thrill  and  the  characteristic  murmur.  If  partial  heart-block  occurs  a  com- 
plicated set  of  signs  results  as  the  auricle  is  contracting  more  often  than  the 
ventricle.  Under  treatment,  with  gradual  recovery  of  compensation,  probably 
with  increasing  vigor  of  contraction  of  the  right  ventricle  and  left  auricle, 
the  presystolic  murmur  reappears.  In  cases  seen  at  this  stage  the  nature  of 
the  valve  lesion  may  be  entirely  overlooked.  Auricular  fibrillation  is  the  rule 
in  the  arrhythmia  of  mitral  stenosis. 

Stenosis  of  the  mitral  valve  may  for  years  be  efficiently  compensated  by 
the  hypertrophy  of  the  right  ventricle.  Many  persons  with  the  characteristic 
signs  of  this  lesion  present  no  symptoms.  They  may  for  years  be  short  of 
breath  on  going  upstairs,  but  are  able  to  pass  through  the  ordinary  duties  of 
life  without  discomfort.  The  pulse  is  smaller  in  volume  than  normal,  and 
very  often  irregular  (auricular  fibrillation).  A  special  danger  is  the  recurring 
endocarditis.  Vegetations  may  be  whipped  off  into  the  circulation  and,  block- 
ing a  cerebral  vessel,  may  cause  hemiplegia  or  aphasia,  or  both.  This,  un- 
fortunately, is  not  an  uncommon  sequence  in  women.  Patients  with  mitral 
stenosis  may  survive  this  accident  for  an  indefinite  period. 


CHEONIC  VALVULAR  DISEASE  817 

Pressure  of  the  eElarged  auricle  on  the  left  recurrent  laryngeal  nerve, 
causing  paralysis  of  the  vocal  cord  on  the  corresponding  side,  has  been  de- 
scribed and  the  diagnosis  of  aneurism  of  the  arch  of  the  aorta  may  be  made. 
Fetterolf  and  ISTorris  conclude  that  it  is  not  due  to  the  pressure  of  the  left 
auricle  directly,  but  to  squeezing  of  the  nerve  between  the  pulmonary  artery 
and  the  aortic  arch,  and  that  the  paralysis  is  due  to  the  neuritis  so  excited. 

Failure  of  compensation  brings  in  its  train  the  group  of  symptoms  which 
have  been  discussed  under  cardiac  insufficiency.  Briefly  enumerated,  they  are : 
Eapid  and  irregular  action  of  the  heart,  shortness  of  breath,  cough,  signs  of 
pulmonary  engorgement,  and  very  frequently  hemoptysis.  Attacks  of  this 
kind  may  recur  for  years.  Bronchitis  or  a  febrile  attack  may  cause  shortness 
of  breath  or  slight  blueness.  Inflammatory  affections  of  the  lungs  or  pleura 
seriously  disturb  the  right  heart,  and  these  patients  stand  pneumonia  very 
badly.  Many,  perhaps  a  majority  of,  cases  of  mitral  stenosis  do  not  have 
dropsy.  The  liver  may  be  greatly  enlarged,  and  in  the  late  stages  ascites  is 
not  uncommon,  particularly  in  children. 

TRICUSPID  VALVE  DISEASE 

Tricuspid  Regurg^itation. — Occasionally  this  results  from  acute  or  chronic 
endocarditis  with  puckering;  more  commonly  the  condition  is  one  of  rela- 
tive insufficiency,  and  is  secondary  to  lesions  of  the  valves  on  the  left  side, 
particularly  of  the  mitral.  It  is  met  with  also  in  all  conditions  of  the  lungs 
which  cause  obstruction  to  the  circulation,  such  as  cirrhosis  and  emphysema, 
particularly  in  combination  with  chronic  bronchitis.  The  symptoms  are  those 
of  obstruction  in  the  lesser  circulation  with  venous  congestion  in  the  systemic 
veins,  already  described  with  mitral  insufficiency.     The  signs  are : 

(a)  Systolic  regurgitation  of  the  blood  into  the  right  auricle  and  the 
transmission  of  the  pulse  wave  into  the  veins  of  the  neck.  If  the  regurgita- 
tion is  slight  or  the  contraction  of  the  ventricle  is  feeble  there  may  be  no 
venous  throbbing,  but  in  other  cases  there  is  marked  systolic  pulsation  in  the 
cervical  veins.  It  may  be  seen  both  in  the  internal  and  the  external  vein,  par- 
ticularly in  the  latter.  Marked  pulsation  in  these  veins  occurs  only  when  the 
valves  guarding  them  become  incompetent.  Slight  oscillations  are  by  no 
means  uncommon,  even  when  the  valves  are  intact.  The  distention  is  some- 
times enormous,  particularly  in  the  act  of  coughing,  when  the  right  jugular  at 
the  root  of  the  neck  may  stand  out,  forming  an  extraordinarily  prominent 
ovoid  mass.  Occasionally  the  regurgitant  pulse  wave  may  be  widely  transmit- 
ted and  be  seen  in  the  subclavian  and  axillary  veins,  and  even  in  the  subcu- 
taneous veins  over  the  shoulder,  or  in  the  superficial  mammary  veins. 

Regurgitant  pulsation  through  the  tricuspid  orifice  may  be  transmitted  to 
the  inferior  cava,  and  so  to  the  hepatic  veins,  causing  a  systolic  distention  of 
the  liver.  This  is  best  appreciated  by  bimanual  palpation,  placing  one  hand 
over  the  fifth  and  sixth  costal  cartilages  and  the  other  in  the  lateral  region  of 
the  liver  in  the  mid-axillary  line.'  The  pulsation  may  be  readily  distinguished, 
as  a  rule,  from  the  impulse  from  the  ventricle  or  transmitted  from  the  aorta. 

(I))  The  second  important  sign  is  the  occurrence  of  a  systolic  murmur  of 
maximum  intensity  over  the  lower  sternum.  It  is  usually  a  soft,  low  murmur, 
often  to  be  distinguished  from  a  coexisting  mitral  murmur  by  difl:erences  in 


818  DISEASES  OF  THE  CIRCULATORY  SYSTEM 

quality  and  pitch,  and  may  be  heard  to  the  right  as  far  as  the  axilla.  Some- 
times it  is  very  limited  in  its  distribution. 

Together  these  two  signs  indicate  tricuspid  regurgitation.  In  addition,  the 
percussion  usually  shows  increase  in  the  area  of  dulness  to  the  right  of  the 
sternum,  and  the  impulse  in  the  lower  sternal  region  is  forcible.  In  the  great 
majority  of  cases  the  s3aiiptoms  are  those  of  the  associated  lesions.  In  fibrosis 
of  the  lung  and  in  chronic  emphysema  the  failure  of  compensation  of  the  right 
ventricle  with  insufficiency  of  the  tricuspid  not  infrequently  leads  to  gradual 
failure  with  cardiac  dropsy. 

Tricuspid  Stenosis. — The  condition  is  rare  both  clinically  and  anatomi- 
cally, and  it  is  not  often  recognized  during  life.  Of  26,000  medical  admissions 
in  the  Johns  Hopkins  Hospital  there  were  only' 8  with  either  clinical  or  post 
mortem  diagnosis  of  this  condition;  and  in  a  total  of  3,500  autopsies,  only  5 
cases  were  found,  all  in  females.  Of  a  total  of  195  collected  cases,  there  were 
141  females,  38  males,  16  sex  unknown.  In  a  majority  of  the  cases — 104 — the 
mitral  and  tricuspid  were  affected  together,  in  14  the  tricuspid  alone,  in  64  the 
tricuspid  and  aortic.  A  definite  history  of  rheumatism  was  present  in  only 
66  cases  (Futcher). 

The  diagnosis  is  not  often  made;  extreme  cyanosis  and  dyspnoea  are 
common,  and  toward  the  end  the  ordinary  signs  of  cardiac  failure.  Among 
the  important  physical  signs  are  presystolic  pulsation  in  the  jugular  veins 
and  in  the  enlarged  liver.  A  presystolic  thrill  may  be  felt  at  the  tricuspid 
area  with  a  marked  systolic  shock.  The  cardiac  dulness  is  greatly  increased 
to  the  right,  a  rumbling  presystolic  murmur  may  be  present  over  the  lower 
sternum  with  .an  extension  to  the  right  border.  This,  with  a  very  snappy 
first  sound,  great  increase  of  dulness  to  the  right,  and  chronic  breathlessness 
with  cyanosis,  are  the  important  features. 

PULMONARY  VALVE  DISEASE 

MuEMURS  in  the  region  of  the  pulmonary  valves  are  extremely  common; 
lesions  of  the  valves  are  exceedingly  rare.  Balfour  has  M^ell  called  the  pul- 
monic area  the  region  of  "auscultatory  romance."  A  systolic  murmur  is  heard 
here  under  many  conditions — (1)  very  often  in  health,  in  thin  chested  per- 
sons, particularly  in  children,  during  expiration  and  in  the  recumbent  pos- 
ture; (2)  when  the  heart  is  acting  rapidly,  as  in  fever  and  after  exertion;  (3) 
it  is  a  favorite  situation  of  the  cardio-respiratory  murmur;  (4)  in  anaemic 
states;  and  (5)  the  systolic  murmur  of  mitral  insufficiency  may  be  trans- 
mitted along  the  left  sternal  margin.  Actual  lesions  of  the  pulmonary  valves 
are  rare. 

Stenosis  is  almost  invariably  a  congenital  anomaly  and  constitutes  one 
of  the  most  important  of  the  congenital  cardiac  affections.  The  valve  seg- 
ments are  usually  united,  leaving  a  small,  narrow  orifice.  In  adults  cases  oc- 
casionally occur.  The  congenital  lesion  is  commonly  associated  with  patency 
of  the  ductus  Botalli  and  imperfection  of  the  ventricular  septum.  There  may 
also  be  tricuspid  stenosis.  Acute  endocarditis  not  infrequently  attacks  the 
sclerotic  valves. 

The  physical  signs  are  extremely  uncertain.  There  may  be  a  systolic  mur- 
mur with  a  thrill  heard  best  to  the  left  of  the  sternum  in  the  second  int  v 


CHRONIC  VALVULAE  DISEASE  819 

costal  space.  This  murmur  may  be  very  like  a  murmur  of  aortic  stenosis,  but 
is  not  transmitted  into  the  vessels.  Naturally  the  pulmonary  second  sound  is 
weak  or  obliterated,  or  may  be  replaced  by  a  diastolic  murmur.  Usually  there 
is  hypertrophy  of  the  right  heart. 

JPulmonary  Insufficiency. — This  rare  lesion  was  originally  described  by 
Morgagni.  Pitt  analysed  109  cases  from  the  Guy's  Hospital  Eeports,  of  which 
60  had  infectious  endocarditis,  18  were  due  to  a  dilated  pulmonary  artery,  14 
to  pulmonary  stenosis,  14  to  aortic  aneurism,  13  to  abnormality  in  the  num- 
ber of  the  valves,  and  6  unclassified.  Pitt  makes  two  groups,  one  with  a  rapid 
course,  sometimes  with  definite  symptoms  pointing  to  the  heart  but  the  signs 
to  general  sei^ticsemia.  In  the  second  group  the  cardiac  symptoms  are  marked, 
dyspnoea,  cough,  etc.,  and  the  physical  signs  are  definite. 

The  physical  signs  are  those  of  regurgitation  into  the  right  ventricle,  but, 
as  a  rule,  it  is  difficult  to  differentiate  the  murmur  from  that  of  aortic  in- 
sufficiency, though  the  maximum  intensity  may  be  in  the  pulmonary  area. 
The  absence  of  the  vascular  features  of  aortic  insufficiency  is  the  most  sug- 
gestive feature.  Both  Gibson  and  Graham  Steell  called  attention  to  the  pos- 
sibility of  leakage  through  these  valves  in  cases  of  great  increase  of  pressure 
in  the  pulmonary  artery,  and  to  a  soft  diastolic  murmur  heard  under  these 
circumstances. 

Combined  Valvular  Lesions. — A^alvular  lesions  are  seldom  single  or  pure; 
combined  lesions  are  more  common.  This  is  particularly  the  case  in  con- 
genital disease.  In  young  children  mitral  and  aortic  lesions,  the  result  of 
rheumatic  fever,  are  common.  Pure  mitral  insiifficiency  and  pure  mitral 
stenosis  may  exist  for  years,  but  in  time  the  tricuspid  becomes  involved. 
Aortic  valve  lesions  are  more  commonly  uncombined  than  mitral  lesions.  The 
added  lesion  may  be  hurtful  or  helpful.  The  stenosis  which  so  often  accom- 
panies the  endocarditic  variety  may  lessen  the  regurgitation  in  aortic  insuf- 
ficiency; and  a  progressive  narrowing  of  the  mitral  orifice  may  be  beneficial 
in  mitral  regurgitation. 

Prognosis  in  Valvular  Disease. — The  question  is  entirely  one  of  efficient 
compensation.  So  long  as  this  is  maintained  the  patient  may  suffer  no  incon- 
venience, and  even  with  the  most  serious  forms  of  valve  lesion  the  function  of 
the  heart  may  be  little,  if  at  all,  disturbed. 

Practitioners  who  are  not  adepts  in  auscultation  and  feel  unable  to  esti- 
mate the  value  of  the  various  heart  murmurs  should  remember  that  the  best 
judgment  may  be  gathered  from  inspection  and  palpation.  With  an  apex  beat 
in  the  normal  situation  and  a  regular  rhythm  the  auscultatory  phenomena 
may  be  practically  disregarded.  The  myocardium  is  more  important  than  the 
valve. 

A  murmur  per  se  is  of  little  or  no  moment  in  determining  the  prognosis 
in  any  given  case.  There  is  a  large  group  of  patients  who  present  no  other 
symptoms  than  a  systolic  murmur  heard  over  the  body  of  the  heart,  or  over 
the  apex,  in  whom  tlic  left  ventricle  is  not  hypertrophied,  the  heart  rhythm 
is  normal,  and  who  may  not  have  had  rheumatism.  Among  the  conditions  in- 
fluencing prognosis  are: 

(a)  Age. — Children  under  ten  are  bad  subjects.  Compensation  is  well 
effected,  and  they  are  free  from  many  of  the  influences  which  disturb  com- 
pensation in  adults.     The  coronary  arteries  are  healthy  and  nutrition  of  the 


820  DISEASES  OF  THE  CIECULATOEY  SYSTEM 

heart  muscle  can  be  readily  maintained.  Yet,  in  spite  of  this,  the  outlook  in 
cardiac  lesions  in  young  children  is  usually  bad.  The  valve  lesion  itself  is  apt 
to  be  rapidly  progressive,  and  the  limit  of  cardiac  reserve  force  is  early  reached. 
There  seems  to  be  proportionately  a  greater  degree  of  hypertrophy  and  dilata- 
tion. Among  other  causes  of  the  risks  of  this  period  are  insufficient  food  in  the 
poorer  classes,  the  recurrence  of  rheumatic  attacks,  and  the  existence  of  peri- 
cardial adhesions.  The  outlook  in  a  child  Avho  can  be  carefully  supervised 
and  prevented  from  damaging  himself  by  overexertion  is  better  than  in  one 
who  is  constantly  overtasking  his  circulation.  The  valvular  lesions  which  occur 
at,  or  subsequent  to,  the  period  of  puberty  are  more  likely  to  be  permanently 
and  eificiently  compensated.  Sudden  death  from  heart  disease  is  very  rare  in 
children. 

(h)  Sex. — Women  bear  valve  lesions,  as  a  rule,  better  than  men,  owing 
partly  to  the  fact  that  they  live  quieter  lives,  partly  to  the  less  common  in- 
volvement of  the  coronary  arteries,  and  to  the  greater  frequency  of  mitral 
lesions.  Pregnancy  and  parturition  are  disturbing  factors,  but  are  less  serious 
than  some  writers  would  have  us  believe. 

(c)  Yalve  xIefected. — The  relative  prognosis  of  the  different  valve  le- 
sions is  difficult  to  estimate  and  each  case  must  be  judged  on  its  own  merits. 
Aortic  insufficiency  is  unquestionably  the  most  serious;  yet  for  years  it  may 
be  perfectly  compensated.  Favorable  circumstances  in  any  case  are  a  moder- 
ate grade  of  hypertrophy  and  dilatation,  the  absence  of  all  symptoms  of  cardiac 
distress,  and  the  absence  of  extensive  arterio-sclerosis  and  of  angina.  The 
prognosis  rests  largely  with  the  condition  of  the  coronary  arteries.  Eheumatic 
lesions  of  the  valves,  inducing  insufficiency,  are  less  apt  to  be  associated  with 
endarteritis  at  the  root  of  the  aorta;  and  in  such  cases  the  coronary  arteries 
may  escape  for  years.  On  the  other  hand,  when  aortic  insufficiency  is  only  a 
part  of  an  arterio-sclerosis  at  the  root  of  the  aorta,  the  coronary  arteries  are 
almost  invariably  involved,  and  the  outlook  is  much  more  serious.  Sudden 
death  is  not  uncommon,  either  from  acute  dilatation  during  exertion,  or,  more 
frequently,  from  blocking  of  one  of  the  branches  of  the  coronary  arteries. 
The  liability  of  this  form  to  be  associated  with  angina  pectoris  also  adds  to  its 
severity.  Aortic  stenosis  is  comparatively  rare,  most  common  in  middle  aged 
or  elderly  men,  and  is,  as  a  rule,  well  compensated.  In  Broadbent's  series,  in 
which  autopsy  showed  definite  aortic  narrowing,  forty  years  was  the  average 
age  at  death,  and  the  oldest  was  but  fifty-three. 

In  mitral  lesions  the  outlook  on  the  whole  is  more  favorable  than  in 
aortic  insufficiency.  Mitral  insufficiency,  when  well  compensated,  carries  with 
it  a  better  prognosis  than  mitral  stenosis.  Except  aortic  stenosis,  it  is  the 
only  lesion  commonly  met  with  in  patients  over  three-score  years.  The  cases 
which  last  the  longest  are  those  in  which  the  valve  orifice  is  more  or  less  nar- 
rowed, as  well  as  incompetent.  There  is,  in  reality,  no  valve  lesion  so  poorly 
compensated  and  so  rapidly  fatal  as  that  in  Avhicli  the  mitral  segments  are 
gradually  curled  and  puckered  until  they  form  a  narrow  strip  around  a  wide 
mitral  ring — a  condition  specially  seen  in  children.  There  are  cases  of  mitral 
insufficiency  in  which  the  defect  is  thoroughly  balanced  for  thirty  or  even  forty 
years,  without  distress  or  inconvenience.  Even  with  great  hypertrophy  and 
the  apex  beat  almost  in  the  mid-axillary  line  the  compensation  may  be  most 


CHEOmC  A^ALVULAE  DISEASE  831 

effective.    Women  may  pass  safely  through  repeated  pregnancies^  though  here 
they  are  liable  to  accidents  associated  Avith  the  severe  strain. 

In  mitral  stenosis  the  prognosis  is  usually  regarded  as  less  favorable  but 
our  experience  places  this  lesion  almost  on  a  level,  particularly  in  women,  with 
mitral  insufficiency.  It  is  found  very  often  in  persons  in  perfect  health,  Avho 
have  had  neither  palpitation  nor  signs  of  heart-failure,  and  who  have  lived 
laborious  lives.  The  figures  given  by  Broadbent  indicate  that  the  date  of 
death  in  mitral  stenosis  is  comparatively  advanced.  Of  53  cases  from  the 
post  mortem  records  of  St.  Mary's  Hospital,  thirty-three  was  the  age  for 
males,  and  thirty-seven  or  thirty-eight  for  females.  These  women  pass 
through,  repeated  pregnancies  with  safety.  There  are,  of  course,  those  too 
common  accidents,  the  result  of  cerebral  embolism,  which  are  more  likely  to 
occur  in  this  than  in  other  forms. 

Hard  and  fast  lines  can  not  be  drawn  in  the  question  of  prognosis  in  val- 
vular disease.  The  outlook  depends  largely  on  the  condition  of  the  myocar- 
dium, which  in  large  measure  governs  the  situation.  With  evidence  of  mus- 
cular insufficiency  the  prognosis  is  always  grave.  The  etiological  factor  is  im- 
portant, thus  rheumatic  fever  or  syphilis  may  have  caused  serious  myocardial 
mischief.  EA-ery  case  must  be  judged  separately,  and  all  the  circumstances 
carefully  balanced.  The  development  of  auricular  fibrillation,  alternation  of 
the  heart,  etc.,  must  be  taken  into  account.  There  is  no  question  which  re- 
quires greater  experience  and  more  mature  judgment,  and  the  most  experienced 
are  sometimes  at  fault.  The  folloAving  conditions  justify  a  favorable  prog- 
nosis :  Good  general  health  and  good  habits ;  no  exceptional  liability  to  rheu- 
matic or  catarrhal  affections;  origin  of  the  valvular  lesion  independently  of 
degeneration ;  existence  of  the  valvular  lesion  without  change  for  over  three 
years;  sound  ventricles,  of  moderate  frequency,  and  general  regularity  of  ac- 
tion; the  absence  of  serious  forms  of  arrhythmia;  sound  arteries,  with  a  nor- 
mal tension :  and  freedom  from  pulmonary,  hepatic,  and  renal  congestion. 

Treatment. —  (a)  Stage  of  Compensation. — Medicinal  treatment  is  not 
necessary  and  is  often  hurtful.  A  very  common  error  is  to  administer  cardiac 
drugs,  such  as  digitalis,  on  the  discovery  of  a  murmur  or  of  hypertrophy.  If 
the  lesion  has  been  found  accidentally,  it  may  be  best  not  to  tell  the  patient, 
but  rather  an  intimate  friend.  Often  it  is  necessary  to  be  perfectly  frank  in 
order  that  the  patient  may  take  certain  preventive  measures.  He  should  lead 
a  quiet,  reg-ulated,  orderly  life,  free  from  excitement  and  worry,  and  the  risk 
of  sudden  death  makes  it  imperative  that  the  patient  suffering  from  aortic 
disease  should  be  specially  warned  against  overexertion  and  hurry.  An  ordi- 
nary Avholesome  diet  in  moderate  quantities  should  be  taken;  tobacco  may  be 
alloAved  in  moderation,  but  alcohol  should  be  interdicted  or  used  in  very  small 
amount.  Exercise  should  be  regulated  entirely  by  the  feelings  of  the  patient. 
So  long  as  no  cardiac  distress  or  palpitation  follows,  moderate  exercise  Avill 
prove  very  beneficial.  The  skin  should  be  kept  active  by  a  dail}^  bath.  Hot 
baths  should  be  avoided  and  the  Turkish  bath  forbidden.  In  the  case  of 
full-blooded,  somewhat  corpulent  individuals,  an  occasional  saline  p'urge 
should  be  taken.  Patients  with  valvular  lesions  should  not  go  to  very  high 
altitudes.  The  act  of  coition  has  serious  risks,  particularly  in  aortic  insuf- 
ficiency. Knowing  that  the  -causes  which  most  surely  and  povrerfully  disturb 
the  compensation  are  overexertion,  mental  worry,  and  malnutrition,  the  physi- 


822  DISEASES  OF  THE  CIECULATOEY  SYSTEM 

cian  should  give  suitable  instructions  in  each  case.  As  it  is  alwaj^s  better  to 
have  the  cooperation  of  an  intelligent  patient^,  he  should,  as  a  rule,  be  told  of 
the  condition,  but  in  this  matter  the  physician  must  be  guided  by  circum- 
stances, and  there  are  cases  in  which  reticence  is  the  wiser  policy. 

(&)  Stage  of  Beoken  Compensatiox. — The  break  may  be  immediate  and 
final,  as  when  sudden  death  results  from  acute  dilatation  or  from  blocking  of 
a  branch  of  the  coronary  artery,  or  it  may  be  gradual.  Among  the  first  indi- 
cations are  shortness  of  breath  on  exertion  or  attacks  of  nocturnal  dyspnoea. 
These  are  often  associated  with  impaired  nutrition,  particularly  with  anaemia, 
and  a  course  of  iron  or  change  of  air  may  suffice  to  relieve  the  symptoms. 

Irregularity  of  the  heart  is  not  necessarily  an  indication  of  failing  com- 
pensation but  demands  an  accurate  diagnosis  of  the  cause.  Serious  failure  of 
compensation  is  indicated  by  signs  of  dilatation,  marked  cyanosis,  gallop 
rhythm,  or  certain  forms  of  arrhythmia,  with  or  without  the  existence  of 
dropsy.  These  are  dependent  on  the  myocardium  and  the  same  measures  are 
to  be  carried  out  as  are  indicated  under  treatment  in  cardiac  insuificiency. 


V.     SPECIAL  PATHOLOGICAL  CONDITIONS 

I.     ANEURISM  OF  THE  HEART 

Aneurism  of  a  valve  results  from  acute  endocarditis,  which  produces  soft- 
ening or  erosion  and  may  lead  to  perforation  of  the  segment  or  to  gradual 
dilatation  of  a  limited  area  under  the  influence  of  the  blood  pressure.  The 
aneurisms  are  usually  spheroidal  and  project  from  the  ventricular  face  of 
an  aortic  valve.  They  are  much  less  common  on  the  mitral  segments.  They 
frequently  rupture  and  produce  extensive  destruction  and  insufficiency. 

Aneurism  of  the  walls  results  from  the  weakening  due  to  chronic  myocar- 
ditis, or  occasionally  follows  acute  mural  endocarditis,  which  more  commonlj^, 
however,  leads  to  perforation.  It  has  followed  a  stab  wound,  a  gumma  of  the 
ventricle,  and,  according  to  some  authors,  pericardial  adhesions.  The  left 
ventricle  near  the  apex  is  usually  the  seat,  this  being  the  situation  in  which 
fibrous  degeneration  is  most  common.  Of  the  90  cases  collected  by  Legg  59 
were  situated  here.  In  the  early  stages  the  anterior  wall  of  the  ventricle, 
near  the  septum,  sometimes  even  the  septum  itself,  is  slightly  dilated,  the  endo- 
cardium opaque,  and  the  muscular  tissue  sclerotic.  In  a  more  advanced  stage 
the  dilatation' is  pronounced  and  layers  of  thrombi  occiipy  the  sac.  Ultimately 
a  large  rounded  tumor  may  project  from  the  ventricle  and  attain  a  size  equal 
to  that  of  the  heart.  Occasionally  the  aneurism  is  sacculated  and  communi- 
cates with  the  ventricle  through  a  small  orifice.  The  sac  may  be  double,  as 
in  the  cases  of  Janeway  and  Sailer.  In  the  museum  of  Guy's  Hospital  there 
is  a  specimen  showing  the  wall  of  the  ventricle  covered  with  aneurismal  bulg- 
ings.    Eupture  occurred  in  7  of  the  cases  collected  by  Legg. 

The  symptoms  are  indefinite.  Occasionally  there  is  marked  bulging  in  the 
apex  region  and  the  tumor  may  perforate  the  chest  wall.  In  mitral  stenosis 
the  right  ventricle  may  bulge  and  produce  a  visible  pulsating  tumor  below  the 
left  costal  border,  which  has  been  mistaken  for  cardiac  aneurism.  When  the 
sac  is  large  and  produces  pressure  upon  the  heart  itself,  there  may  be  a  marked 


SPECIAL  PATHOLOGICAL  CONDITIONS  823 

disproportion  between  the  strong  cardiac  impulse  and  the  feeble  pulsation  in 
the  peripheral  arteries. 

II.     EUPTURE   OF  THE   HEART 

This  rare  event  is  usually  associated  with  fatty  infiltration  or  degenera- 
tion of  the  heart-muscle.  In  some  instances  acute  softening  in  consequence 
of -embolism  of  a  branch  of  the  coronary  artery,  suppurative  myocarditis,  or 
a  gummatous  growth  has  been  the  cause.  Of  100  cases  collected  by  Quain, 
fatty  degeneration  was  noted  in  77.  Two  thirds  of  the  patients  were  over 
sixty  years  of  age.  It  may  occur  in  infants.  Schaps  reports  a  case  in  an  in- 
fant of  four  months  associated  with  an  embolic  infarct  of  the  left  ventricle. 
Harvey,  in  his  second  letter  to  Eiolan  (1649),  described  the  case  of  Sir  Eob- 
ert  Darcy,  who  had  distressing  pain  in  the  chest  and  syncopal  attacks  with 
suffocation,  and  finally  cachexia  and  dropsy.  Death  occurred  in  one  of  the 
paroxysms.  The  wall  of  the  left  ventricle  of  the  heart  was  ruptured,  "hav- 
ing a  rent  in  it  of  size  sufficient  to  admit  any  of  my  fingers,  although  the  wall 
itself  appeared  sufficiently  thick  and  strong." 

The  rent  may  occur  in  any  of  the  chambers,  but  is  most  frequent  in  the 
left  ventricle  on  the  anterior  wall,  not  far  from  the  septum.  The  accident 
usually  takes  place  during  exertion.  There  may  be  no  preliminary  symptoms, 
but  without  any  warning  the  patient  may  fall  and  die  in  a  few  moments.  Sud- 
den death  occurred  in  71  per  cent,  of  Quain's  cases.  In  other  instances  there 
may  be  a  sense  of  anguish  and  suffocation,  and  life  may  be  prolonged  for  sev- 
eral hours.  In  a  Montreal  case,  the  patient  walked  up  a  steep  hill  after  the 
onset  of  the  symptoms,  and  lived  for  thirteen  hours.  A  case  is  on  record  in 
which  the  patient  lived  for  eleven  days. 

III.  NEW  GROWTHS  AND  PARASITES 

Primary  cancer  or  sarcoma  is  extremely  rare.  Secondary  tumors  may  be 
single  or  multiple,  and  are  usually  unattended  with  symptoms,  even  when  the 
disease  is  most  extensive.  In  one  case  in  the  wall  of  the  right  ventricle  a  mass 
was  found  which  involved  the  anterior  segment  of  the  tricuspid  valve  and 
partly  blocked  the  orifice.  The  surface  was  eroded  and  there  were  numerous 
cancerous  emboli  in  the  pulmonary  artery.  In  another  instance  the  heart  was 
greatly  enlarged,  owing  to  the  presence  of  innumerable  masses  of  colloid  cancer 
the  size  of  cherries.  The  mediastinal  sarcoma  may  penetrate  the  heart,  though 
it  is  remarkable  how  extensive  the  disease  of  the  mediastinal  glands  may  be 
without  involvement  of  the  heart  or  vessels. 

Cysts  in  the  heart  are  rare.  They  are  found  in  different  parts,  and  are 
filled  either  with  a  brownish  or  a  clear  fluid.     Blood  cysts  occasionally  occur. 

The  parasites  have  been  discussed,  but  it  may  be  mentioned  here  that  both 
the  Cysticercus  ce.llulosce  and  echinococcus  cysts  occur  occasionally. 

IV.  WOUNDS  AND  FOREIGN  BODIES 

Wounds  of  the  heart  may  be  caused  by  external  injuries,  as  stabs  and 
bullet  wounds,  by  foreign  bodies  passing  from  the  gullet  or  oesophagus,  or  by 
puncture  for  therapeutic  purposes. 


824  DISEASES  OF  THE  CIECULATOEY  SYSTEM 

(a)  Bullet  wounds  of  the  heart  are  common.  Eecovery  may  take  place, 
and  bullets  have  been  found  encysted  in  the  organ.  Stab  wounds  are  still 
more  common.  A  medical  student,  while  on  a  spree,  passed  a  pin  into  his 
heart.  The  pericardium  was  opened,  and  the  head  of  the  pin  was  found  out- 
side of  the  right  ventricle.  It  was  grasped  and  an  attempt  made  to  remove 
it,  but  it  was  withdrawn  into  the  heart  and,  it  is  said,  caused  the  patient  no 
further  trouble   (Moxon), 

(&)  Hysterical  girls  sometimes  swallow  pins  and  needles,  which,  passing 
through  the  oesophagus  and  stomach,  are  found  in  various  parts  of  the  body. 
A  remarkable  case  is  reported  by  Allen  J.  Smith  of  a  girl  from  whom  several 
dozen  needles  and  pins  were  removed,  chiefly  from  subcutaneous  abscesses. 
Several  years  later  she  developed  symptoms  of  chronic  heart  disease.  At  the 
post  mortem  needles  were  found  in  the  tissues  of  the  adherent  pericardium, 
and  between  thirty  and  forty  were  embedded  in  the  thickened  pleural  mem- 
branes of  the  left  side. 

(c)  Puncture  of  the  heart  (cardiocentesis)  has  been  recommended  as  a 
therapeutic  procedure.  The  proceeding  is  not  without  risk.  Hgemorrhage  may 
take  place  from  the  puncture,  though  it  is  not  often  extensive.  Sloane  has 
urged  its  use  in  all  cases  of  asphyxia  and  in  suffocation  by  drowning  and  from 
coal  gas.  The  successful  case  which  he  reports  illustrates  its  stimulating 
action. ' 

VI.     CONGENITAL  AFFECTIONS  OF  THE  HEART 

These  have  only  a  limited  clinical  interest,  as  in  a  large  proportion  of  the 
cases  the  anomaly  is  not  compatible  with  life,  and  in  others  nothing  can  be 
done  to  remedy  the  defect  or  even  to  relieve  the  symptoms. 

The  congenital  affections  result  from  interruption  of  the  normal  course 
of  development  or  from  inflammatory  processes — endocarditis;  sometimes  from 
a  combination  of  both. 

General  Anomalies. — Of  general  anomalies  of  development  the  follov/ing 
conditions  may  be  mentioned:  Acardia,  absence  of  the  heart,  which  has  been 
met  with  in  the  monstrosity  known  by  the  same  name;  double  heart,  which 
has  occasionally  been  found  in  extreme  grades  of  fetal  deformity;  dextro- 
cardia,  in  which  the  heart  is  on  the  right  side,  either  alone  or  as  part  of  a 
general  transposition  of  the  viscera ;  ectopia  cordis,  a  condition  associated 
with  fission  of  the  chest  wall  and  of  the  abdomen.  The  heart  may  be  situ- 
ated in  the  cervical,  pectoral,  or  abdominal  regions.  Except  in  the  abdominal 
variety,  the  condition  is  very  rarely  compatible  with  extra-uterine  life.  Occa- 
sionally, as  in  a  case  reported  by  Holt,  the  child  lives  for  some  months,  and 
the  heart  may  be  seen  and  felt  beating  beneath  the  skin  in  the  epigastric  re- 
gion.   This  infant  was  five  months  old  at  the  date  of  examination. 

Anomalies  of  the  Cardiac  Septa. — The  septa  of  both  auricles  and  ventricles 
may  be  defective,  in  which  case  the  heart  consists  of  but  tv/o  chambers,  the 
cor  hiloculare  or  reptilian  heart.  In  the  septum  of  the  auricles  there  is  a 
very  common  defect,  owing  to  the  fact  that  the  membrane  closing  the  fora- 
men ovale  has  failed  at  one  point  to  become  attached  to  the  ring,  and  leaves 
a  yalvular  slit  which  may  admit  the  handle  of  a  scalpel.  Neither  this  nor  the 
small  cribriform  perforations  of  the  meml^rane  are  of  any  significance. 


CONGENITAL  AFFECTIOXS  OF  THE  HEAET  825 

The  foramen  ovale  may  be  patent  without  a  trace  of  membrane  closing 
it.  In  some  instances  this  exists  Avith  other  serious  defects,  such  as  stenosis 
of  the  pulmonary  arteiy,  or  imperfection  of  the  Mnitricular  septum.  In 
others  the  patent  foramen  ovale  is  the  only  anomaly,  and  in  many  instances 
it  does  not  appear  to  have  caused  any  embarrassment,  having  been  found  in 
persons  who  have  died  of  various  affections.  The  ventricular  septum  may  be 
absent,  the  condition  known  as  trilocular  heart.  ]\Iuch  more  frequently  there 
is  a  small  defect  in  the  upper  portion  of  the  septum,  either  in  the  situation 
of  the  membranous  portion  known  as  the  "undefended  space"  or  in  the  region 
just  anterior  to  this.  This  is  frequently  associated  with  narrowing  of  the 
pulmonary  orifice  or  of  the  conus  arteriosus  of  the  right  ventricle. 

Apart  from  the  instances  in  association  with  narrowing  of  the  orifice  of 
the  palmonary  artery,  or  of  the  conus,  there  are  cases  in  which  defect  of  the 
memhranons  septum  is  the  only  lesion,  a  condition  not  incompatible  with 
long  and  fairly  active  life.  The  late  Professor  Brooks  of  the  Johns  Hopkins 
University  knew  from  early  manhood  that  he  had  heart  trouble,  but  he  ac- 
complished an  extraordinary  amount  of  work,  and  lived  to  be  about  60.  Im- 
perfect septum  was  the  only  lesion.  The  physical  signs  are  fairly  distinctive, 
with  usually  some  evident  enlargement  of  the  heart,  and  a  murmur  described 
by  Eoger  as  follows :  "It  is  a  loud  murmur,  audible  over  a  large  area,  and, 
commencing  with  systole,  is  prolonged  so  as  to  cover  the  normal  tic-tac.  It 
has  its  maximum,  not  at  the  base  to  the  right,  as  in  aortic  stenosis,  or  to  the 
left,  as  in  pulmonary  stenosis,  but  at  the  upper  third  of  the  precordial  region. 
It  is  central,  like  the  septum,  and  from  this  central  point  gradually  dimin- 
ishes in  intensity  in  every  direction.  The  murmur  does  not  vary  at  any  time, 
and  it  is  not  conducted  into  the  vessels."  In  some  cases  there  is  a  distinct 
systolic  intensification  of  this  loud  continuous  murmur. 

Anomalies  and  Lesions  of  the  Valves. — Numerical  anomalies  of  the  valves 
are  not  uncommon.  The  semilunar  segments  at  the  arterial  orifices  are  not 
infrequently  increased  or  diminished  in  number.  Supernumerary  segments 
are  more  frequent  in  the  pulmonary  artery  than  in  the  aorta.  Four,  or  some- 
times five,  valves  have  been  found.  The  segments  may  be  of  equal  size,  but,  as 
a  rule,  the  supernumerary  valve  is  small. 

Instead  of  three  there  may  be  only  two  semilunar  valves,  or,  as  it  is 
termed,  the  bicuspid  condition;  this  is  more  frequent  in  the  aortic  valve. 
Of  21  instances  only  2  occurred  at  the  pulmonary  orifice.  Two  of  the  valves 
have  united,  and  from  the  ventricular  face  show  either  no  trace  of  division 
or  else  a  slight  depression  indicating  where  the  union  has  occurred.  From  the 
aortic  side  there  is  usually  to  be  seen  some  trace  of  division  into  two  sinuses 
of  Valsalva.  There  has  been  a  discussion  as  to  the  origin  of  this  condition, 
whether  it  is  really  an  anomaly  or  due  to  endocarditis,  fetal  or  post-natal. 
The  combined  segment  is  usually  thickened,  but  the  fact  that  this  anomaly  is 
met  with  in  the  fetus  without  a  trace  of  sclerosis  or  endocarditis  shows  that  it 
may,  in  some  cases  at  least,  result  from  a  developmental  error. 

Clinically  this  is  a  very  important  congenital  defect,  owing  to  the  liability 
of  the  combined  valve  to  sclerotic  changes.  Except  two  fetal  specimens,  all 
of  a  series  showed  thickening  and  deformity,  and  in  15  of  those  reported  death 
resulted  directly  or  indirectly  from  the  lesion  (Osier). 


826  DISEASES  OF  THE  CIECULATOEY  SYSTEM 

The  little  fenestrations  at  the  margins  of  the  sigmoid  valves  have  no  sig- 
nificance; they  occur  in  a  considerable  proportion  of  all  bodies. 

Anomalies  of  the  auriculo-ventricular  valves  are  not  often  met  with. 

Eetal  exdocarditis  may  occur  either  at  the  arterial  or  auriculo-ven- 
tricular  orifices.  It  is  nearly  always  of  the  chronic  or  sclerotic  variety.  Very 
rarely,  indeed,  is  it  of  the  warty  or  verrucose  form.  There  are  little  nodular 
bodies,  sometimes  six  or  eight  in  number,  on  the  mitral  and  tricuspid  seg- 
ments— the  nodules  of  Albini — which  represent  the  remains  of  fetal  struc- 
tures, and  must  not  be  mistaken  for  endocardial  outgrowths.  The  little 
rounded,  bead  like  hgemorrhages  of  a  deep  purple  color,  which  are  very  com- 
mon on  the  heart  valves  of  children,  are  also  not  to  be  mistaken  for  the  prod- 
ucts of  endocarditis.  In  fetal  endocarditis  the  segments  are  usually  thickened 
at  the  edges,  shrunken,  and  smooth.  In  the  mitral  and  tricuspid  valves  the 
cusps  are  found  united  and  the  chordae  tendinese  are  thickened  and  shortened. 
In  the  semilunar  valves  all  trace  of  the  segments  has  disappeared,  leaving  a 
stiff  membranous  diaphragm  perforated  by  an  oval  or  rounded  orifice.  It  is 
sometimes  very  difficult  to  say  whether  this  condition  has  restilted  from  fetal 
endocarditis  or  is  an  error  in  development.  In  many  instances  the  processes 
are  combined ;  an  anomalous  valve  becomes  the  seat  of  chronic  sclerotic  changes, 
and,  according  to  Eauchfuss,  endocarditis  is  more  common  on  the  right  side 
of  the  heart  only  because  the  valves  are  here  more  often  the  seat  of  develop- 
mental errors. 

Lesioxs  at  the  Pulmonary  Oeifice. — Stenosis  of  this  orifice  is  one  of 
the  commonest  and  most  important  of  congenital  heart  affections.  A  slow 
endocarditis  causes  gradual  union  of  the  segments  and  narrowing  of  the  orifice 
to  such  a  degree  that  it  admits  only  the  smallest  sized  probe.  In  some  of  the 
cases  the  smooth  membranous  condition  of  the  combined  segments  is  such  that 
it  would  appear  to  be  the  result  of  faulty  development.  In  some  instances 
vegetations  occur.  The  condition  is  compatible  with  life  for  many  years, 
and  in  a  considerable  proportion  of  the  cases  of  congenital  heart  disease  above 
the  tenth  year  this  lesion  is  present.  With  it  there  may  be  defect  of  the  ven- 
tricular septum.  Pulmonary  tuberculosis  is  a  very  common  cause  of  death. 
Obliteration  or  atresia  of  the  pulmonary  orifice  is  a  less  frequent  but  more 
serious  condition  than  stenosis.  It  is  associated  with  persistence  of  the  ductus 
arteriosus,  together  with  patency  of  the  foramen  ovale  or  defect  of  the  ven- 
tricular septum  with  hypertrophy  of  the  right  heart.  Stenosis  of  the  conus 
arteriosus  of  the  right  ventricle  exists  in  a  considerable  proportion  of  the 
cases  of  obstruction  at  the  pulmonary  orifice.  At  the  outset  a  developmental 
error,  it  may  be  combined  with  sclerotic  changes.  The  ventricular  septum  is 
imperfect,  the  foramen  ovale  usually  open,  and  the  ductus  arteriosus  patent. 
The  lesions  at  the  pulmonary  orifice  constitute  the  most  important  group  of 
congenital  cardiac  affections.  Of  631  instances  of  various  congenital  anomalies 
analyzed  by  Maude  Abbott,  150  cases  came  under  this  category. 

Congenital  lesions  of  the  aortic  orifice  are  not  very  frequent. 
Eauchfuss  collected  24  cases  of  stenosis  and  atresia ;  stenosis  of  the  left  conus 
arteriosus  may  also  occur,  a  condition  not  incompatible  with  prolonged  life. 
Ten  of  the  16  cases  tabulated  by  Dilg  were  over  thirty  years  of  age. 

Transposition  of  the  large  arterial  trunks  is  a  not  uncommon 
anomaly.    There  may  be  neither  hypertrophy,  cyanosis,  nor  heart  murmur. 


COXGEXITAL  AFFECTIOXS  OF  THE  HEART       •        827 

Symptoms  of  Cong^enital  Heart  Disease. — Cyanosis  occurs  in  over  90  per 
cent,  of  the  cases^  and  forms  so  distinctive  a  feature  that  the  terms  "blue  dis- 
ease" and  "morbus  cseruleus"  are  practically  synonyms  for  congenital  heart- 
disease.  The  lividity  in  a  majority  of  cases  appears  only  within  the  first  week 
of  life,  and  may  be  general  or  confined  to  the  lips,  nose,  and  ears,  and  to  the 
fingers  and  toes.  In  some  instances  there  is  in  addition  a  general  dusky  suf- 
fusion, and  in  the  most  extreme  grades  the  skin  is  almost  purple.  It  may 
vary  a  good  deal  and  may  be  intense  only  on  exertion.  The  external  temper- 
ature is  low.  Dyspncea  on  exertion  and  cough  are  common  symptoms.  A 
great  increase  in  the  number  of  the  red  corpuscles  has  been  noted.  In  a  case 
of  Gibson's  there  were  above  eight  millions  of  red  blood  cells  per  c.  mm.  There 
may  be  nucleated  red  cells  and  great  variation  in  size  and  shape.  The  children 
rarely  thrive,  and  often  display  a  lethargy  of  both  mind  and  body.  The 
fingers  and  toes  are  clubbed  to  a  degree  rarely  met  with  in  any  other  affection. 
The  cause  of  the  cyanosis  has  been  much  discussed.  ]\Iorgagni  referred  it  to 
the  general  congestion  of  the  venous  system  due  to  obstruction.  Morrison's 
analysis  of  75  cases  of  congenital  heart  disease  shows  that  closure  of  the  pul- 
monary orifice  with  patency  of  the  foramen  ovale  and  the  ventricular  septum 
is  the  condition  most  frequently  associated  with  cyanosis,  and  he  concludes 
that  the  deficient  aeration  of  the  blood  owing  to  diminished  lung  function  is 
the  most  important  factor.  Another  view,  often  attributed  erroneously  to 
William  Hunter,  was  that  the  discoloration  was  due  to  the  admixture  in  the 
heart  of  venous  and  arterial  blood;  but  lesions  may  exist  which  permit  of  very 
free  mixture  without  producing  cyanosis.  The  question  of  the  cause  of  cyano- 
sis can  not  be  considered  as  settled.  Variot  made  the  suggestion  that  the 
cause  is  not  entirely  cardiac,  but  is  associated  with  disturbance  throughout  the 
whole  circulatory  system,  and  particularly  a  vaso-motor  paresis  and  malaera- 
tion  of  the  red  blood  corpuscles. 

Diagnosis. — In  the  case  of  children,  cyanosis,  with  or  without  enlargement 
of  the  heart,  and  the  existence  of  a  murmur,  are  sufficient,  as  a  rule,  to  de- 
termine the  presence  of  a  congenital  heart  lesion.  The  cyanosis  gives  us  no 
clew  to  the  precise  nature  of  the  trouble,  as  it  is  a  symptom  common  to  many 
lesions  and  it  may  be  absent  in  certain  conditions.  The  murmur  is  usually 
systolic.  It  is  not  always  present,  and  there  are  instances  of  complicated  con- 
genital lesions  in  which  the  examination  showed  normal  heart  sounds.  In  two 
or  three  instances  fetal  endocarditis  has  been  diagnosed  in  gravida  by  the  pres- 
ence of  a  rough  systolic  murmur,  and  the  condition  corroborated  subsequent 
to  the  birth  of  the  child.  Hypertrophy  is  present  in  a  majority  of  the  cases 
of  congenital  defect.  The  fatal  event  may  be  caused  by  abscess  of  the  brain. 
For  a  full  discussion  of  the  subject  the  student  is  referred  to  the  monograph  of 
Dr.  Maude  Abbott  in  Vol.  IV  of  our  "System  of  Medicine."  The  conclusions 
of  Hochsinger  are  as  follows : 

"(1)  In  childhood,  loud,  rough,  musical  heart  murmurs,  with  normal  or 
only  slight  increase  in  the  heart  dulness,  occur  only  in  congenital  heart  dis- 
ease. The  acquired  endocardial  defects  with  loud  heart  murmurs  in  young 
children  are  almost  always  associated  with  great  increase  in  the  heart  dul- 
ness. In  the  transposition  of  the  large  arterial  trunks  there  may  be  no  cyano- 
sis, no  heart  murmur,  and  an  absence  of  hypertrophy. 


828  DISEASES  OF  THE  CIECULATOEY  SYSTEM 

"(2)  In  young  children  heart  murmurs  with  great  increase  in  the  cardiac 
dulness  and  feeble  apex  beat  suggest  congenital  changes.  The  increased  dul- 
ness  is  chiefly  of  the  right  heart,  whereas  the  left  is  only  slightly  altered.  On 
the  other  hand,  in  the  acquired  endocarditis  in  children,  the  left  heart  is 
chiefly  affected  and  the  apex  beat  is  visible;  the  dilatation  of  the  right  heart 
comes  late  and  does  not  materially  change  the  increased  strength  of  the  apex 
beat. 

"(3)  The  entire  absence  of  murmurs  at  the  apex,  with  their  evident  pres- 
ence in  the  region  of  the  auricles  and  over  the  pulmonary  orifice,  is  always  an 
important  element  in  differential  diagnosis,  and  points  rather  to  septum  defect 
or  pulmonary  stenosis  than  to  endocarditis. 

'"(4)  An  abnormally  weak  second  pulmonic  sound  associated  with  a  dis- 
tinct sj'^stolic  murmur  is  a  symptom  which  in  early  childhood  is  only  to  be 
explained  by  the  assumption  of  o.  congenital  pulmonary  stenosis,  and  possesses 
therefore  an  importance  from  a  point  of  differeutial  diagnosis  which  is  not  to 
be  underestimated. 

"(5)  Absence  of  a  palpable  thrill,  despite  loud  murmurs  which  are  heard 
over  the  whole  prsecordial  region,  is  rare  except  with  congenital  defects  in  the 
septum,  and  it  speaks,  therefore,  against  an  acquired  cardiac  affection. 

"(6)  Loud,  especially  vibratory,  systolic  murmurs,  with  the  point  of  maxi- 
mum intensity  over  the  upper  third  of  the  sternum,  associated  with  a  lack  of 
marked  symptoms  of  hypertrophy  of  the  left  ventricle,  are  very  important  for 
the  diagnosis  of  a  persistence  of  the  ductus  Botalli,  and  can  not  be  explained 
by  the  assumption  of  an  endocarditis  of  the  aortic  valve." 

Escherich  suggests  that  the  systolic  basic  murmur  heard  sometimes  in  the 
newborn,  particularly  if  premature,  may  originate  in  the  ductus  Botalli  before 
its  closure. 

Treatment. — The  child  should  be  warmly  clad  and  guarded  from  all  cir- 
cumstances liable  to  excite  bronchitis.  In  the  attacks  of  urgent  dyspnoea  with 
lividity  blood  should  be  freely  let.  Saline  cathartics  are  also  useful.  Digitalis 
must  be  used  with  care;  it  is  sometimes  beneficial  in  the  later  stages.  When 
the  compensation  fails,  the  indications  for  treatment  are  those  of  muscular 
insufficiency  in  acquired  cardiac  disease. 


VII.     ANGINA  PECTORIS 

(Stenocardia,  Breast  Pang) 

Definition. — A  disease  characterized  by  paroxysmal  attacks  of  pain,  usually 
pectoral,  associated  with  vascular  changes. 

History. — In  1768  Heberden  described  a  "disorder  of  the  breast,^'  to  which 
he  gave  the  name  of  "Angina  Pectoris."  Before  this  date  Morgagni  and 
Rougnon  had  described  cases.  The  association  with  coronary  artery  disease 
was  early  shown  by  Jenner.  John  Hunter  died  in  an  attack.  The  connection 
with  aortitis  as  demonstrated  by  Corrigan  and  Allbutt,  the  recognition  of 
extra-pectoral  forms,  and  the  introduction  of  nitrites  in  treatment  by  Lauder 
Brunton  are  the  important  contributions  of  the  nineteenth  century. 

Etiology. — The  disease  is  not  nncommon  :  tliero  were  1,062  deaths  in  Eng- 


ANGINA  PECTOETS  829 

land  and  Wales  in  1916.  In  the  United  States  the  death  rate  is  increasing; 
there  were  5^914  deaths  in  the  registration  area  in  1917. 

It  is  a  rare  disease  in  hospitals;  a  case  a  year  is  about  the  average,  even  in 
the  large  metropolitan  hospitals.  It  is  a  disease  of  the  better  classes,  and  a 
consultant  in  active  work  may  see  a  dozen  or  more  cases  a  year. 

Age. — In  our  series  of  300  cases  there  were,  under  30,  9  cases;  between 
30  and  40,  42;  between  40  and  50,  60;  between  50  and  60,  93;  between  60 
and  70,  72 ;  between  70  and  80,  20 ;  above  80,  4. 

Sex. — Women  are  rarely  attacked.  Of  our  cases  256  were  men  and  44 
women, 

Eace. — As  mentioned,  the  disease  seems  to  be  relatively  more  frequent 
in  the  United  States.     Jews  are  particularly  prone,  42  of  our  300  cases. 

Occupation. — It  is  not  an  affection  of  the  working  classes.  The  life 
of  stress  and  strain,  particularly  of  worry,  seems  to  predispose  to  it,  and  this 
is  perhaps  why  it  is  so  common  in  our  profession.  In  our  series  of  300  cases 
there  were  38  physicians,  a  large  proportion.  From  John  Hunter  onward  a 
long  list  of  distinguished  physicians  have  been  its  victims,  among  whom  in 
recent  years  were  Charcot,  Nothnagel,  and  William  Pepper. 

Caedio-vascular  Disease. — In  persons  under  forty  syphilis  is  an  im- 
portant feature,  causing  an  aortitis,  often  limited  to  the  root  of  the  vessel. 
Whatever  the  cause,  arterio-sclerosis  predisposes  to  angina.  A  majority  of  the 
patients  have  sclerosis,  many  high  blood  pressure.  Business  men  leading  lives 
of  great  strain,  and  eating,  drinking,  and  smoking  to  excess,  form  the  large 
contingent  of  angina  cases.  Slight  attacks  may  occur  with  high  blood  pressure 
alone. 

Heredity. — The  disease  may  occur  in  members  of  three  generations,  as 
in  the  Arnold  family. 

Imitative  Features. — Outbreaks  of  angina-like  attacks  have  been  described. 
After  the  death  of  one  member  of  a  family  from  the  disease,  another  may 
have  somewhat  similar  attacks.  Two  of  his  physicians  had  angina  after 
Senator  Sumner's  fatal  attack.  One  of  them  died  within  two  weeks;  the 
other,  a  young  man,  recovered  completely. 

Pathology. — The  lesions  in  17  post  mortems  were  as  follows : 

(a)  Coronary  artery  disease  was  present  in  13  cases.  The  orifices  only 
may  be  involved  in  a  sclerotic  aortitis.  In  one  case  they  were  narrowed  to 
admit  only  a  bristle,  while  the  vessels  beyond  were  normal.  Blocking  of  a 
branch  with  a  fresh  thrombus,  or  with  an  embolus,  is  not  uncommon.  Dur- 
ing an  attack  an  infarct  may  soften,  with  perforation  of  the  ventricular  wall. 
Obliterative  endarteritis,  the  lesion  of  the  disease,  was  present  in  9  of  the 
cases.  In  elderly  subjects  the  coronary  vessels  may  be  calcified — the  condition 
found  by  Jenner  in  John  Hunter. 

(h)  Aortitis  was  present  in  four  of  the  cases,  in  syphilitic  subjects,  all 
under  40  years  of  age.  Corrigan  first  called  attention  to  this  lesion  in  angina, 
the  great  importance  of  which  has  been  emphasized  by  Clifford  AUbutt.  It  is 
usually  limited  to  the  supra-sigmoidal  area. 

(c)  In  a  few  instances  no  lesions  have  been  found.  In  one  case  of  the 
list  a  man  aged  26  had  attacks,  which  were  regarded  as  functional,  on  and  off 
for  two  years.  Death  occurred  after  a  series  of  paroxysms.  The  aorta  was 
small,  otherwise  there  were  no  changes. 


830  DISEASES  OF  THE  CIECULATORY  SYSTEM 

Pathogpenesis. — No  completely  satisfactory  explanation  of  the  phenomena 
of  the  attack  has  yet  been  offered.  It  has  been  regarded  as  a  neuralgia  of  the 
cardiac  nerves,  a  cramp  of  the  heart  muscle,  or  of  certain  parts  of  it,  or  an 
expression  of  tension  of  the  ventricular  walls.  The  view  of  Clifford  AUbutt 
that  the  pain  is  dependent  on  tension  of  the  first  portion  of  the  aorta  has  much 
to  recommend  it.  A  similar  pain  occurs  in  dilatation  of  the  aorta.  In  some 
ways  the  intermittent  claudication  theory  of  Allan  Burns  meets  the  case.  This 
may  be  defined  as  a  state  in  which  an  artery  admits  enough  blood  to  a  mus- 
cular structure  for  quiet  work,  but  not  enough  for  increased  work,  so  that 
the  contractile  function  of  the  muscle  is  disturbed  and  pain  results.  Burns 
remarked  that  ".  .  .  If  we  can  call  into  vigorous  action  a  limb  around  which 
we  have  with  moderate  tightness  applied  a  ligature,  we  find  that  then  the  mem- 
ber can  only  support  its  action  for  a  very  short  time,  for  now  the  supply  of 
energy  and  its  expenditure  do  not  balance  each  other.  ...  A  heart,  the  coro- 
nary arteries  of  which  are  cartilaginous  or  ossified,  is  nearly  in  a  similar  con- 
dition; it  can,  like  the  limb  begirt  with  a  moderately  tight  ligature,  discharge 
its  functions  so  long  as  its  action  is  moderate  and  equal.  Increase,  however, 
the  action  of  the  whole  body,  and  along  with  the  rest  that  of  the  heart,  and 
you  will  soon  see  exemplified  the  truth  of  what  has  been  said." 

Angina  results  from  an  alteration  in  the  working  of  the  muscle  fibres  of 
any  part  of  the  cardio-vascular  system,  whereby  painful  afferent  stimuli  are 
excited.  Cold,  emotion,  or  toxic  agents  interfering  with  the  orderly  action  of 
the  peripheral  circulation  increase  the  tension  in  the  heart  walls  or  in  the 
larger  central  mains,  causing  strain  and  a  type  of  contraction  capable  of  ex- 
citing in  the  involuntary  muscles  painful  afferent  stimuli.  In  disturbance  of 
this  all-important  Gaskellian  function,  in  the  stretching,  in-  the  alteration  of 
the  wall  tension  at  any  point,  sufficient  to  excite  a  pain-producing  resistance  to 
this  by  the  muscle  elements,  are  to  be  sought  an  explanation  of  the  phenomenon 
of  the  attack.  Spasm,  or  narrowing  of  a  coronary  artery,  or  of  one  branch, 
may  so  modify  the  action  of  a  section  of  the  heart  that  it  works  with  disturbed 
tension,  and  with  stretching  and  strain  sufficient  to  rouse  painful  sensations. 
Or  the  heart  may  be  in  the  same  state  as  the  leg  muscles  of  a  man  with  in- 
termittent claudication,  working  smoothly  when  quiet,  but  the  instant  an 
effort  is  made,  or  if  a  wave  of  emotion  touches  the  peripheral  vessels,  the 
normal  contraction  is  disturbed  and  a  crisis  of  pain  excited. 

Symptoms. — Classified  by  the  severity  of  the  attacks,  cases  may  be  grouped 
in  three  categories: 

(a)  Mildest  Form  (''Les  Formes  Frustes"  of  the  French). — There  is 
a  feeling  of  substernal  tension,  uneasiness,  or  distress,  rising  at  times  to  posi- 
tive pain,  usually  associated  with  emotion,  sometimes  with  exertion,  but  soon 
passing  off.  There  may  be  slight  pallor,  or  a  feeling  of  faintness.  When  ris- 
ing to  speak  in  public  there  may  be  a  feeling  of  substernal  tension — it  is  a 
common  experience — which  passes  off.  Muscular  effort,  as  in  climbing  a  hill 
or  a  stair,  may  bring  on  the  sensation.  In  the  high  pressure  life  a  man  may 
experience  for  weeks  or  months  this  sense  of  substernal  tension,  not  pain,  and 
without  accurate  localization  or  radiation,  and  not  increased  by  exercise  or 
emotion.  It  is,  as  one  patient  expressed  it,  a  "hot-box"  indicating  too  great 
pressure  and  too  high  speed.  It  is  away  after  the  night's  rest,  and  may  dis- 
appear entirely  when  the  "harness"  is  taken  off. 


ANGINA  PECTOEIS  831 

(b)  Mild  Form  (Angina  Minor). — Pain  in  the  heart  of  moderate  se- 
verity with  radiation  to  the  arm  is  met  with  in  nervous  persons,  in  tobacco 
smokers,  sometimes  following  the  acute  infections,  particularly  influenza.  The 
attacks  are  brought  on  by  emotion,  more  frequent  in  women,  and  never  fatal. 
Often  called  pseudo,  false,  functional,  or  toxic  angina,  the  difference  in  the 
character  of  the  attacks  may  be  one  of  degree  only.  The  conditions  under 
which  the  attacks  come  on  are  of  greater  importance  than  the  nature  of  the 
attack  itself.  There  may  be  marked  vaso-motor  disturbance,  with  cold,  numb, 
and  blue  extremities,  followed  by  praecordial  pain  and  a  feeling  of  faintness. 
In  persons  addicted  to  tea,  coffee,  and  tobacco  heart  pain  is  not  infrequent, 
sharp  and  shooting,  associated  with  palpitation,  or  severe  and  truly  anginal. 

(c)  Severe  Angina  {Angina  Major). — The  two  special  features  in  this 
group  are  the  existence  in  a  large  proportion  of  all  the  cases  of  organic  dis- 
ease of  heart  or  vessels  and  the  liability  to  sudden  death.  An  exciting  cause 
of  the  attack  can  usually  be  traced;  muscular  effort  is  the  most  common. 
Mental  emotion  is  a  second  potent  cause.  John  Hunter  used  to  say  that 
"his  life  was  in  the  hands  of  any  rascal  who  chose  to  worry  him,"  and  his 
fatal  attack  occurred  in  a  fit  of  anger.  A  third  very  common  excitant  is 
flatulent  distention  of  the  stomach.  Many  patients  are  very  sensitive  to  cold, 
and  the  chill  of  getting  out  of  bed  or  of  a  bath  may  bring  on  a  paroxysm. 

Phenomena  of  the  Attack. — During  exertion  or  intense  mental  emo- 
tion the  patient  is  seized  with  an  agonizing  pain  in  the  region  of  the  heart 
and  a  sense  of  constriction,  as  if  the  heart  had  been  seized  in  a  vice.  The 
pains  radiate  to  the  neck  and  down  the  arm,  and  there  may  be  numbness  of 
the  fingers  or  in  the  cardiac  region.  The  face  is  usually  pallid  and  may  as- 
sume an  ashy  gray  tint,  and  not  infrequently  a  profuse  sweat  breaks  out  over 
the  surface.  The  paroxysm  lasts  from  several  seconds  to  a  minute  or  two, 
during  which,  in  severe  attacks,  the  patient  feels  as  if  death  were  imminent. 
As  pointed  out  by  Latham,  there  are  two  elements  in  it,  the  pain — dolor  pec- 
toris— and  the  indescribable  feeling  of  anguish  and  sense  of  imminent  dis- 
solution— angor  animi.  There  are  great  restlessness  and  anxiety,  and  the 
patient  may  drop  dead  at  the  height  of  the  attack  or  faint  and  pass  away  in 
syncope.  The  condition  of  the  heart  during  the  attack  is  variable ;  the  pulsa- 
tions may  be  uniform  and  regular.  The  pulse  tension,  however,  is  usually 
increased,  but  it  is  surprising,  even  in  the  cases  of  extreme  severity,  how  slight- 
ly the  character  of  the  pulse  may  be  altered.  After  the  attack  there  may  be 
eructations,  or  the  passage  of  a  large  quantity  of  clear  urine.  The  patient 
usually  feels  exhausted,  and  for  a  day  or  two  may  be  badly  shaken;  in  other 
instances  in  an  hour  or  two  the  patient  feels  himself  again.  While  dyspnoea 
is  not  a  constant  feature,  the  paroxysm  is  not  infrequently  associated  with  it; 
there  is  wheezing  in  the  bronchial  tubes,  which  may  come  on  very  rapidly, 
and  the  patient  gets  short  of  breath. 

Death  may  occur  in  the  first  attack,  as  in  the  well  known  case  of  Thomas 
Arnold;  or  at  the  end  of  a  series  of  attacks,  the  so-called  status  angiosus. 
Paroxysms  may  occur  at  intervals  of  a  few  weeks  for  a  year  or  more  before 
the  fatal  attack. 

There  is  a  chronic  form  represented  by  12  cases  in  our  series,  in  which 
attacks  occur  irregularly.  John  Hunter's  first  seizure  was  in  1773,  and  he 
had  many  in  the  20  years  before  his  death.     Sometimes  life  is  a  terrible  bur- 


832  DISEASES  OF  THE  CIECULATOEY  SYSTEM 

den,  as  any  emotion  or  effort  may  bring  on  an  attack.  And,  lastly,  after 
paroxysms  of  great  severity  recurring  for  months,  or  even  for  so  long  as  two 
years,  complete  recovery  takes  place. 

ExTEA-PECTORAL  FEATURES  OF  Angina. — In  the  attack  the  pain  usually 
radiates  up  the  neck  and  down  the  left  arm.  As  the  studies  of  Mackenzie 
and  Head  have  shown  in  disease  of  the  heart  and  of  the  aorta,  the  pain  is 
referred  to  the  1st,  2d,  3d,  and  -ith  dorsal  areas;  and  in.  angina  it  may  be 
also  in  areas  of  the  distribution  of  the  oth  to  the  9th  dorsal  nerves.  The  pain 
may  begin  in  the  left  arm,  or  in  the  jaw,  even  in  the  front  teeth,  or  in  one 
testis.  Sometimes  the  pain  remains  in  these  distant  parts,  and  yet  the  attack 
presents,  as  noted  by  Heberden,  all  the  features  of  angina.  The  attack  may 
begin  with  agonizing  pain  in  the  left  leg  or  in  the  left  pectoral  muscle.  The 
entire  features  of  the  attack  may  be  sub-diaphragmatic — the  so-called  angina 
ahdominis.  In  at  least  twelve  of  our  series  the  pains  were  abdominal,  and,  as 
first  pointed  out  by  Leared,  gastralgia  may  be  diagnosed. 

The  pulmonary  features  are  remarkable.  A  condition  like  acute  emphy- 
sema may  come  on,  with  wheezing  and  an  inflated  state  of  the  lungs.  Acute 
oedema  may  follow  with  the  expectoration  of  large  quantities  of  a  thin,  bloody 
fluid.  The  blood  pressure,  may  be  extraordinarilv  high — 340  mm,  Hg  in  one 
case.  Cerebral  features  are  not  common,  but  unconsciousness  may  occur. 
Transient  monoplegia,  or  hemiplegia  and  aphasia,  may  occur. 

Prognosis. — In  men  under  40  syphilis  must  be  suspected,  and  with  appro- 
priate treatment  recovery  may  be  complete  (see  the  Lumleian  Lectures  (Osier), 
Lancet,  1910,  I).  In  men  in  the  5th  and  6th  decades  who  have  lived  the 
high  pressure  life  a  change  of  habits  may  bring  relief;  but,  as  Walshe  re- 
marked, "the  cardinal  fact  in  real  angina  is  its  uncertainty."  Even  after 
attacks  of  the  greatest  severity  recovery  is  possible.  The  circumstances  that 
bring  on.  an  attack  are  important.  Emotion  is  of  the  least  importance.  The 
angina  of  effort  that  follows  any  slight  exertion  is,  as  a  rule,  more  serious 
than  that  which  comes  on  spontaneously,  or  is  excited  by  emotion;  yet  one 
patient  who  could  never  dress  without  having  what  he  called  "angor  de 
toilette"  lived  for  11  years.  The  cardio-vascular  condition  is  of  the  first  im- 
portance in  prognosis.  Very  high  blood  pressure,  advanced  arterio-sclerosis, 
valvular  disease,  signs  of  myocardial  weakness  are  of  serious  import.  It  is 
to  be  remembered  that  a  large  proportion  of  all  cases  have  no  obvious  signs 
of  cardiac  disease;  and  the  coronary  arteries  may  be  extensively  diseased 
with  clear  heart  sounds  and  a  good  pulse.  In  women  the  forms  of  angina 
with  marked  vaso-motor  disturbance  as  a  rule  do  well,  and  when  neurotic  or 
hysterical  manifestations  are  prominent  the  outlook  is  good. 

There  are  three  modes  of  dying  in  angina — one,  as  Walshe  says,  "is  sud- 
den, instantaneous,  coeval  with  a  single  pang.''  The  functions  of  life  stop 
abruptly,  and  with  a  gasp  all  is  over.  Ventricular  fibrillation  may  be  the  cause. 
In  a  second  mode,  following  a  series  of  attacks,  the  heart  grows  weaker  and  the 
patient  dies  in  a  progressive  asthenia;  while  in  a  third  there  is  a  gradually 
induced  cardiac  insufficiency  with  dyspnoea. 

Treatment. — Prolonged  rest  is  important  and  every  effort  should  be  made 
to  reduce  anxiety  and  sources  of  irritation.  Factors  which  induce  an  attack 
should  be  avoided.  The  diet  should  be  simple  and  the  bowels  kept  freely  open. 
If  there  are  any  signs  of  myocardial  insufficiency  an  occasional  course  of  digi- 


ARTERIO-SCLEEOSIS  833 

talis  is  advisable.  Syphilitic  cases  require  active  treatment — arsphenamine 
in  the  subjects  under  40,  mercury  and  iodide  of  potassium  in  older  persons. 
In  the  neurotic  cases  with  a  recognition  of  the  basic  disturbance  in  the  vaso- 
motor system  a  rest  cure  and  hydrotherapy  are  indicated.  A  persistent  course 
of  wet  packs  is  often  helpful.  When  high  tension  is  present  the  nitrites  may 
be  given;  and  ergotin  grs.  ii  (0.13  gni.)  three  times  a  day  has  a  definite  value 
in  vaso-motor  instaljility.  In  the  severer  types  the  treatment  is  concerned 
with  the  attack  and  with  the  general  condition  afterward.  In  the  attack  in- 
halation of  nitrite  of  amyl,  introduced  by  Lauder  Brunton,  may  give  instant 
relief.  We  see  its  benefit  particularly  in  cases  with  widespread  arterial  con- 
striction. In  the  recurring  terrible  paroxysms  it  may  lose  its  effect,  but  many 
milder  forms  are  relieved  promptly,  and  it  gives  great  comfort  and  confidence 
to  the  patient  to  carry  the  pedes.  Morphia  should  be  used  freely  when  amyl 
nitrite  fails  and  when  the  attacks  recur  with  great  frequency.  As  Burney 
Yeo  pointed  out,  angina  patients  are  very  resistant  to  this  drug.  Chloroform 
may  have  to  be  used,  and  is  always  helpful,  never  harmful.  With  a  dusky 
cyanosis  and  asthma  like  breathing  oxygen  inhalations  may  be  given. 

For  the  general  condition,  if  high  tension  is  present,  iodide  of  potassium 
and  the  nitrites  in  all  forms  are  useful.  The  use  of  theobromine,  advocated 
by  Marchiafava,  grs.  xv  (1  gm.)  three  times  a  day,  is  sometimes  of  benefit. 


C.   DISEASES  OF  THE  ARTERIES 

I.    ARTERIO-SCLEROSIS 

(Arterio-capiUary  Fibrosis) 

The  conception  of  arterio-sclerosis  as  an  independent  affection — a  general 
disease  of  the  vascular  system — is  due  to  Gull  and  Sutton. 

Definition. — A  condition  of  thickening  of  the  arterial  coats,  with  degen- 
eration, diffuse  or  circumscribed.  The  process  leads,  in  the  larger  arteries,  to 
what  is  known  as  atheroma  and  to  endarteritis  deformans,  and  seriously  in- 
terferes with  the  normal  functions  of  various  organs. 

Etiology. — Among  the  important  factors  are  the  following: 

(a)  Hypertension. — The  blood  pressure,  the  tension  or  force  with  which 
the  blood  circulates,  depends  upon  five  factors :  The  heart  pump  supplies  the 
force;  the  elastic  coats  of  the  large  arteries  store  and  convert  an  intermittent 
into  a  continuous  stream;  the  small  arteries  act  as  sluices  or  taps  regulating 
the  control  to  different  parts;  the  capillary  bed  is  the  irrigation  field  over 
which  the  nutritive  fluid  is  distributed ;  and  the  drainage  system  is  represented 
l)y  the  veins  and  lymph  channels. 

Galen  first  grasped  the  fact  that  life  depends  upon  the  maintenance  of  a 
due  pressure  in  these  irrigation  fields :  "Many  canals  dispersed  througliout  all 
the  parts  of  the  body  convey  to  them  blood  as  those  of  a  garden  convey  mois- 
ture, and  the  intervals  separating  those  canals  are  wonderfully  disposed  by 
nature  in  such  a  way  that  they  should  neither  lack  a  sufficient  quantity  of 
blood  for  absorption,  nor  be  overloaded  at  any  time  with  an  excessive  supply." 

The   blood   pressure   varies   greatly   in   different   individuals,   and   in   the 


834  DISEASES  OF  THE  CIECULATORY  SYSTEM 

same  individual  under  varying  conditions.  The  normal  blood  pressure  is  from 
120  to  130  mm.  of  mercury,  but  in  persons  over  50  it  is  very  often  from  140 
to  160  mm.  A  permanent  pressure  above  the  latter  figure  may  be  called 
high,  but  there  are  great  regional  variations.  Permanently  low  blood  pressure 
may  be  met  with  in  asthenia  from  any  cause,  in  the  various  toxaemias  of  the 
infectious  diseases,  in  adrenal  insufficiency,  and  there  are  persons  in  apparently 
good  health  with  chronic  hypotension. 

High  tension  is  met  with  in  many  chronic  diseases,  in  various  forms  of 
cardiac  and  renal  disease,  in  lead  poisoning,  and  in  connection  with  general 
arterio-sclerosis.  The  relation  to  arterio-sclerosis  has  been  much  discussed. 
Briefly,  there  are  three  groups  of  cases:  (1)  First,  the  simple  high  tension 
without  signs  of  arterial  or  renal  disease — what  Clifford  Allbutt  calls  hyper- 
piesia.  In  this  well  recognized  condition,  met  with  in  individuals  otherwise 
healthy,  the  blood  pressure  is  permanently  high — above  180 — but,  so  far  as 
can  be  ascertained,  there  are  no  arterial,  cardiac,  or  renal  changes.  It  is  dif- 
ficult to  exclude  internal,  not  discernible  alterations  in  the  splanchnic  and 
other  vessels,  since  vascular  disease  may  be  very  localized.  But  clinically  the 
group  is  well  defined  and  very  important.  The  condition  is  met  with  most 
frequently  in  keen  business  men,  who  work  hard,  drink  hard,  and  smoke  hard. 

The  exact  cause  of  this  high  tension  we  do  not  know.  Some  have  attributed 
it  to  over-activity  of  the  adrenals,  but  it  is  much  more  likely  that  the  primary 
difficulty  is  somewhere  in  the  capillary  bed — in  that  short  space  in  which  the 
real  business  of  life  is  transacted.  However  produced,  the  important  point 
here  is  that  this  hypertension  itself  leads  to  arterio-sclerosis,  which  can  be 
produced  experimentally  by  the  injection  of  epinephrin  and  other  hypertensive 
substances. 

(2)  In  the  second  group  of  cases  the  high  tension  is  associated  with  an 
arterio-sclerosis  with  consecutive  cardiac  and  renal  disease. 

(3)  In  the  third  group  the  high  tension  is  secondary  to  forms  of  chronic 
nephritis  in  association  with  cardio-vascular  disease. 

(&)  As  an  INVOLUTION  process  arterio-sclerosis  is  an  accompaniment  of 
old  age,  and  is  the  expression  of  the  natural  wear  and  tear  to  which  the  tubes 
are  subjected.  Longevity  is  a  vascular  question,  which  has  been  well  expressed 
in  the  axiom  that  "a  man  is  only  as  old  as  his  arteries."  To  a  majority  of 
men  death  comes  primarily  or  secondarily  through  this  portal.  The  onset  of 
what  may  be  called  physiological  arterio-sclerosis  depends,  in  the  first  place, 
upon  the  quality  of  arterial  tissue  (vital  rubber)  which  the  individual  has 
inherited,  and  secondly  upon  the  amount  of  wear  and  tear  to  which  he  has 
subjected  it.  That  the  former  plays  a  most  important  role  is  shown  in  the 
cases  in  which  arterio-sclerosis  sets  in  early  in  life  in  individuals  in  whom  none 
of  the  recognized  etiological  factors  can  be  found.  Thus,  for  instance,  a  man 
of  thirty  may  have  the  arteries  of  a  man  of  sixty,  and  a  man  of  forty  may  pre- 
sent vessels  as  much  degenerated  as  they  should  be  at  eighty.  Entire  families 
sometimes  show  this  tendency  to  early  arterio-sclerosis — a  tendency  which  can 
not  be  explained  in  any  other  way  than  that  in  the  makeup  of  the  machine'  bad 
material  was  used  for  the  tubing.  More  commonly  the  arterio-sclerosis  re- 
suits  from  the  bad  use  of  good  vessels.  '  .'    '.'  - 

(c)  Intoxications. — Alcohol,  lead,  and  gout  play  an  impof^an't  role^i:^  " 
the  causation  of  arterio-sclerosis,  although  the  precise  mode  of  their  action 


AETEEIO-SCLEROSIS  .  835 

is  not  yet  very  clear.  They  may  act,  as  Traube  suggests,  by  increasing  the 
peripheral  resistance  in  the  smaller  vessels  and  in  this  way  raising  the  blood 
tension,  or  possibly,  as  Bright  taught,  they  alter  the  quality  of  the  blood  and 
render  more  difficult  its  passage  through  the  capillaries.  The  observations  of 
Cabot  throw  doubt  on  the  importance  of  alcohol  as  a  factor.  The  poisons  of 
the  acute  infections  may  produce  degenerative  changes  in  the  media  and  ad- 
ventitia.  Thayer  called  attention  to  the  frequency  of  arterial  changes  as  a 
sequence  of  typhoid  fever. 

{d)  Syphilis,  one  of  the  most  important  single  causes,  will  be  spoken  of 
under  morbid  anatomy. 

(e)  OvEEElTiNG. — This  plays  an  important  part  in  inducing  arterio- 
sclerosis. George  Cheyne's  advice,  quoted  at  page  441,  was  never  more  needed 
thr.n  by  the  present  generation. 

(/)  Stress  and  Strain. — There  are  men  in  the  fifth  decade  who  have  not 
had  syphilis  or  gout,  who  have  eaten  and  drunk  with  discretion,  and  in  whom 
none  of  the  ordinary  factors  are  present — men  in  whom  the  arterio-sclerosis 
seems  to  come  on  as  a  direct  result  of  a  high  pressure  life. 

{g)  Overwork  of  the  muscles,  which  acts  by  increasing  the  peripheral 
resistance  and  by  raising  the  blood  pressure. 

{h)  Eenal  Disease. — The  relation  between  the  arterial  and  kidney,  le- 
siops  has  been  much  discussed,  some  regarding  the  arterial  degeneration  as 
secondary,  others  as  primary.  There  are  two  groups  of  cases,  one  in  which 
the  arterio-sclerosis  is  the  first  change,  and  the  other  in  which  it  is  secondary 
to  a  primary  affection  of  the  kidneys. 

Morbid  Anatomy. — The  affection  is  met  with  most  frequently  in  the  aorta 
and  its  main  branches.  It  is  comparatively  less  frequent  in  the  mesenteric 
and  rare  in  the  pulmonary  arteries.     Several  forms  may  be  recognized: 

{a)  Nodular. — The  aorta  presents  in  the  early  stages,  from  the  ring  to 
the  bifurcation,  numerous  flat  projections,  yellowish  or  yellowish  white  in 
color,  and  situated  particularly  about  the  orifices  of  the  branches.  In  the 
early  stage  these  patches  are  scattered  and  do  not  involve  the  entire  intima. 
In  more  advanced  stages  the  patches  undergo  atheromatous  changes.  The  ma- 
trial  constituting  the  button  undergoes  softening  and  breaks  up  into  granular 
material,  consisting  of  molecular  debris — the  so-called  atheromatous  abscess. 
Klotz  has  called  attention  to  the  frequency  of  nodular  endarteritis  about  the 
orifices  of  the  intercostal  arteries  in  young  people,  usually  in  association  with 
acute  infections. 

(&)  Diffuse  Arterio-sclerosis. — In  this  form,  met  with  usually  in 
middle-aged  men,  or  younger  persons,  the  affection  is  widespread  throughout 
the  arteries.  In  the  aorta  the  media  shows  necrotic  and  hyaline  changes, 
while  the  intima  may  be  smooth  or  show  very  slight  thickenings — scattered 
elevated  areas  of  an  opaque  white  color,  some  of  which  undergo  atheromatous 
changes.  The  smaller  arteries  show  thickening  of  the  walls,  due  particularly 
to  increase  in  the  sub-endothelial  connective  tissue.  The  muscular  coat  may 
1)6  at  first  hypertrophied,  but  later  undergoes  hyaline  and  calcareous  changes. 
In  this  group  the  heart  hypertrophies  and  fibrous  myocarditis  is  often  present. 
The  aortic  valves  are  opaque  and  sclerotic.  The  kidneys  are  sclerotic,  may  be 
increased  in  size,  and  are  usually  very  firm.  In  places  the  surface  maybe 
rough,  or  present  atrophied  depressed  areas  of  a  deep  red  color. 


836  DISEASES  OF  THE  CIECULATOKY  SYSTE^^I 

(c)  Senile  Aeterio-sclerosis. — In  this  the  larger  arteries  are  dilated 
and  tortuous,  the  walls  thin  and  stiff,  and  the  smaller  vessels,  as  the  radials, 
converted  into  rigid  tubes  like  pipe-stems.  The  intima  of  the  aorta  may  be 
occupied  by  rough,  calcareous  plaques,  with  here  and  there  fissures  and  loss 
of  substance.  There  may  be  sub-eudothelial  softening  with  the  formation  of 
atheromatous  ulcers  on  which  thrombi  may  deposit ;  though,  as  a  rule,  there 
may  be  the  most  extreme  calcification  and  roughness  with  erosions  of  the 
aorta  without  thrombus  formation.  In  the  smaller  vessels,  as  the  radials, 
there  are  degeneration  and  calcification  of  the  media — the  so-called  Moncke- 
berg  type. 

The  SYPHILITIC  ARTERio-scLEROSis  is  usuallv  a  mesaortitis  with  definite 
characteristics.  Macroscopic-ally  it  may  be  limited  in  extent,  localized  at  the 
root  of  the  aorta,  or  about  the  orifice  of  an  aneurism,  or  there  is  a  band  of  an 
inch  in  width  on  some  portion  of  the  tube,  while  other  parts  of  the  aorta  and 
its  branches  are  normal.  In  other  instances  the  intima  is  involved,  not  with 
the  usual  plaque-like  areas  of  atheroma,  but  there  are  shallow  depressions  of 
a  bluish  tint,  and  short  transverse  or  longitudinal  puckerings,  sometimes  with 
a  stellate  arrangement;  or  the  intima  is  pitted  and  scarred  with  small  depres- 
sions and  linear  sulci.  Microscopically  the  most  important  changes  are  found 
in  the  media  and  adventitia :  (a)  perivascular  infiltration  of  the  vasa  vas- 
orum;  (&)  small-celled  infiltration  in  areas  of  the  media,  with  (c)  splitting, 
separation,  and  destruction  of  elastic  fibres  and  the  muscle  cells.  The  intima 
over  these  areas  may  be  perfectly  normal,  but  it  often  shows  signs  of  thicken- 
ing with  fatty  degeneration  and  the  production  of  hyaline.  Similar  changes 
have  been  described  by  Klotz  in  the  larger  blood  vessels  in  cases  of  congenital 
syphihs.  And,  lastly,  the  specific  nature  of  this  mesaortitis  has  been  deter- 
mined by  the  detection  of  the  spirochsetes.  Other  forms  affecting  the  smaller 
vessels  have  been  referred  to  under  syphilis. 

Sclerosis  of  the  pulmoxart  artery  is  met  with  in  various  conditions. 

(1)  AYith  high  tension,  particularly  in  emphysema  and  mitral  disease,  the 
sclerosis  may  be  marked,  the  main  branches  may  be  dilated,  and  the  valves 
thickened  and  incompetent.  (2)  Gummatous  arteritis  has  been  met  with 
(Warthin).  (3)  Primary  sclerosis  is  not  uncommon  in  India  (Leonard 
Eogers).  Aneurismal  dilatation  may  be  present.  Syphilis  is  a  factor  in 
some  cases.  Dyspncea,  cyanosis,  polycythsemia,  repeated  haemoptysis,  angina 
with  enlargement  of  the  heart,  and  chronic  passive  congestion  are  features. 
Our  South  American  colleagues  call  it  "A^^erza's  disease." 

In  many  caces  of  arterio-sclerosis  the  condition  is  not  confined  to  the 
arteries,  but  extends  not  only  to  the  capillaries  but  also  to  the  veins,  and  may 
properly  be  termed  an  angio-sderosis. 

Sclerosis  of  the  veins — plilebo-sderosis — is  not  at  all  an  uncommon 
accompaniment  of  arterio-sclerosis.  It  is  seen  in  conditions  of  heightened 
blood  pressure,  as  in  the  portal  system  in  cirrhosis  of  the  liver  and  in  the 
pulmonary  veins  in  mitral  stenosis.  The  affected  vessels  are  usually  dilated, 
and  the  intima  shows,  as  in  the  arteries,  a  compensatory  thickening,  which  is 
particularly  marked  in  those  regions  in  which  the  media  is  thinned.  The 
new-formed  tissue  in  the  endophlebitis  may  undergo  hyaline  degeneration, 
and  is.  sometimes  extensively  calcified.     Without  existing  arterio-sclerosis  the 


ABTERIO-SCLEROSrS  837 

peripheral  veins  may  be  sclerotic,  iisiially  in  conditions  of  debility,  but  not  in- 
frequently in  young  persons. 

Symptoms. — Increased  Texsiox. — The  pressure  with  which  the  blood 
flows  in  the  arteries  depends  upon  the  degree  of  peripheral  resistance  and  the 
force  of  the  ventricular  contraction.  A  high-tension  pulse  may  exist  with 
very  little  arterio-sclerosis ;  but,  as  a  rule,  when  the  condition  has  been  per- 
sistent, the  sclerosis  and  high  tension  are  found  together.  On  the  other  hand, 
a  very  low  or  normal  tendon  may  be  present  in  extremely  sclerotic  vessels. 

General  Symptoms. — The  early  symptoms  are  interesting.  Stengel  has 
called  attention  to  the  pallor,  and  there  may  be  dyspeptic  symptoms.  It  is 
remarkable  with  what  rapidity  the  disease  may  progress.  The  peripheral 
arteries  may  stiffen  and  grow  old  in  a  couple  of  years. 

The  combination  of  heightened  blood  pressure,  a  palpable  thickening  of  the 
arteries,  hypertrophy  of  the  left  ventricle,  and  accentuation  of  the  aortic  second 
sound  are  signs  pathognomonic  of  arterio-sclerosis.  From  this  period  of  es- 
tablishment the  course  may  be  very  varied.  For  years  the  patient  may  have 
good  health,  and  be  in  a  condition  analogous  to  that  of  a  person  with  a  well 
compensated  valvular  lesion.  There  may  be  no  renal  symptoms,  or  there  may 
be  the  passage  of  a  larger  amount  of  urine  than  normal,  with  transient  albu- 
minuria, and  now  and  then  hyaline  tube  casts.  The  subsequent  history  is  ex- 
traordinarily diverse,  depending  upon  the  vascular  territory  in  which  the 
sclerosis  is  most  advanced,  or  upon  the  accidents  which  are  so  liable  to  happen, 
and  the  symptoms  may  be  cardiac,  cerebral,  renal,  etc.  In  some  cases  there 
is  a  rapid  loss  of  weight. 

(a)  Cardiac. — Involvement  of  the  coronary  arteries  may  lead  to  various 
symptoms — thrombosis  with  sudden  death,  fibroid  degeneration  of  the  heart, 
aneurism  of  the  heart,  rupture,  and  angina  pectoris.  The  last  is  not  uncom- 
mon, and  the  organic  variety  is  almost  always  associated  with  arterio-sclerosis. 
A  second  important  group  of  cardiac  symptoms  results  from  the  dilatation 
which  finally  gets  the  better  of  the  hypertrophy.  The  patient  presents  all  the 
symptoms  of  cardiac  insufficiency  and  when  he  comes  under  observation  for 
the  first  time  the  clinical  picture  is  that  of  chronic  valvular  disease,  and  a 
loud  blowing  murmur  at  the  apex  may  throw  the  practitioner  off  his  guard.- 
Many  cases  terminate  in  this  way. 

(&)  The  cerebral  symptoms  are  varied  and  important,  and  embrace  thosQ 
of  many  degenerative  diseases,  acute  and  chronic  (which  follow  sclerosis  of  the 
smaller  branches),  and  cerebral  hsemorrhage.  Syphilis  should  always  be  con- 
sidered in  these  cases.  Transient  hemiplegia,  monoplegia,  or  aphasia  may 
occur  in  advanced  arterio-sclerosis.  The  attacks  are  very  characteristic,  often 
brief,  lasting  twenty-four  hours  or  less.  Eecovery  may  be  perfect.  Eecur- 
rence  is  the  rule,  and  a  patient  may  have  a  score  or  more  attacks  of  apha- 
sia, or  in  a  couple  of  years  there  may  be  half  a  dozen  transient  hemiplegia 
attacks  or  one  or  two  monoplegias,  or  paraplegia  for  a  day  or  two.  These 
cases  seem  best  explained  on  the  view  of  transient  spasm  as  suggested  by  Pea- 
body.  Vertigo  occurs  frequently,  and  may  be  simple,  or  associated  with  slow 
pulse  and  syncopal  or  epileptiform  attacks — the  Stokes-iidams  syndrome. 

(c)  Renal  symptoms  supervene  in  a  large  number  of  the  cases.  A  sclero- 
sis, patchy  or  diffuse,  is  present  in  a  majority  of  the  cases  at  the  time  of 
autopsy,  and  the  condition  is  practically  that  of  contracted  kidney.     It  is  seen 


838  DISEASES  OF  THE  CIECULATOEY  SYSTEM 

typically  in  the  senile  form,  and  not  infrequently  develops  early  in  life  as  a 
direct  sequence  of  the  diffuse  variety.  It  is  often  difficult  to  decide  clinically 
(and  the  question  is  one  upon  v^^hich  good  observers  might  not  agree  in  a 
given  case)  whether  the  arterial  or  the  renal  disease  has  been  primary. 

{d)  Abdominal  Arteriosclerosis. — It  is  believed  to  be  associated  particu- 
larly with  overeating  and  chronic  overtaxing  of  the  stomach  and  intestines. 
The  condition  is  not  uncommon,  and  the  sclerosis  of  the  splanchnic  vessels  may 
be  advanced  out  of  all  proportion  to  that  elsewhere.  The  symptoms  are  in- 
definite, sometimes  resembling  those  of  the  ordinary  neurosis  with  marked 
constipation,  features  that  are  by  no  means  certainly  associated  with  sclerosis; 
on  the  other  hand,  there  is  much  more  reason  to  connect  the  attacks  of  severe 
abdominal  pain,  the  gastric  crises  of  lead  and  of  tabes  with  spasm  of  the 
vessels  in  this  condition.  There  are  cases  of  angina  pectoris  with  abdominal 
pain  which  may  be  due  to  angiospasm  of  the  sclerotic  vessels. 

(e)  Among  other  events  in  arterio-sclerosis  may  be  mentioned  gangrene 
of  the  extremities,  due  either  directly  to  endarteritis  or  to  the  dislodgment 
of  thrombi.     Sudden  transient  paralysis  of  the  legs  may  occur. 

(/)  Sclerosis  of  the  Vessels  of  the  Legs. — The  main  symptom  is  pain  in 
the  legs,  after  walking  for  a  few  minutes  or  on  walking  fast,  which  may  pull 
the  patient  "up  short"  or  gradually  reach  a  point  at  which  motion  is  im- 
possible. The  patient  rarely  falls  and  after  resting  for  a  few  minutes  he  can 
again  walk.  The  attacks  are  similar  to  those  of  angina  pectoris;  as  one  in- 
telligent man  expressed  it — "there  is  no  difference  in  the  sensation,  it  is  only 
in  the  place."  .  Cramp  of  the  muscles  may  occur,  and  aggravate  the  pain, 
sometimes  in  paroxysms  of  very  severe  intensity,  or  nocturnal  cramp  may  be 
troublesome.  Numbness,  tingling  and  sensations  of  cold  are  common,  and 
when  dependent  the  feet  may  become  deeply  congested.  The  posterior  tibials 
and  dorsal  arteries  of  the  feet  may  be  felt  as  hard  cords  without  pulsation  and 
phlebosclerosis  is  common. 

Intermittent  lameness  or  claudication^  the  dysbasia  angio-sclerotica  of 
Erb,  the  crural  angina  of  Walton,  is  associated  with  arterio-sclerosis.  In  the 
horse,  in  which  the  intermittent  lameness  was  first  described  by  Bouley,  ver- 
minous aneurisms  are  present  in  the  aorta  or  the  iliac  arteries.  In  man  Char- 
cot described  the  condition  in  1856  in  an  old  soldier  who  was  not  able  to  walk 
for  more  than  a  quarter  of  an  hour  without  severe  cramps  in  the  legs.  The 
post  mortem  showed  a  traumatic  aneurism  of  one  iliac  artery.  The  loss  of 
function  and  the  pain  in  the  muscles  are  due  to  the  relative  ischaemia.  Of  127 
cases  there  were  only  7  in  women  (Erb).  Hebrews  seem  more  frequently  af- 
fected.   Syphilis,  alcohol,  and  tobacco  are  common  factors. 

Thromho-angeitis  obliterans  (Buerger)  is  an  acute  inflammatory  lesion 
with  occlusion  thrombosis,  probably  due  to  infection.  There  is  excruciating 
pain  in  the  foot  and  leg,  worse  at  night.  The  feet  are  blue  and  congested,  and 
the  skin  clammy  with  decreased  sensitiveness  to  heat  and  cold.  There  may 
be  atrophy  of  the  toes  with  dark  colored  skin  and  sometimes  gangrene.  Pul- 
sation in  the  vessels  of  the  affected  leg  is  decreased  or  absent. 

Treatment. — In  the  late  stages  the  conditions  must  be  treated  as  they 
arise  in  connection  with  the  various  viscera.  In  the  early  stages,  before  any 
local  symptoms  are  manifest,  the  patient  should  be  enjoined  to  live  a  quiet, 
well  regulated  life,  avoiding  excesses  in  food  and  drink.    It  is  well  to  reduce 


AOETITIS  839 

the  intake  of  salt.  It  is  usually  best  to  explain  frankly  the  condition  of  affairs, 
and  so  gain  his  intelligent  cooperation.  Special  attention  should  be  paid  to 
the  state  of  the  bowels  and  urine,  and  the  secretion  of  the  skin  should  be  kept 
active  by  daily  baths.  Alcohol  in  all  forms  should  be  prohibited,  and  the  food 
restricted  to  plain,  wholesome  articles.  The  use  of  mineral  waters  or  a  resi- 
dence every  year  at  one  of  the  mineral  springs  is  usually  serviceable.  If  there 
has  been  a  syphilitic  history  the  persistent  use  of  iodide  of  potassium  is  in- 
dicated; indeed,  even  in  the  non-syphilitic  cases  it  seems  to  do  good.  It  is  best 
given  in  small  doses,  grains  v  to  x  (0.3  to  0.6  gm.).  Whenever  the  blood 
pressure  is  high  nitroglycerine  or  sodium  nitrite  may  be  given  to  relieve  symp- 
toms rather  than  with  any  hope  of  essentially  influencing  the  disease.  For  in- 
termittent claudication  not  much  can  be  done.  In  the  thrombo-angeitis  ob- 
literans small  doses  of  thyroid  extract  may  be  given.  Injections  of  300-500 
c.  c.  of  salt  solution  subcutaneously  may  be  tried. 

In  cases  which  come  under  observation  for  the  first  time  with  dyspnoea, 
slight  lividity,  and  signs  of  cardiac  insufficiency,  venesection  is  indicated.  In 
some  instances,  with  very  high  tension,  striking  relief  is  afl'orded  by  the  ab- 
straction of  10  to  20  ounces  of  blood.  Cardiac  failure,  renal  symptoms,  etc., 
require  the  usual  treatment. 

II.    AORTITIS 

Acute  Aortitis. — This  is  much  more  common  than  is  usually  recognized. 
It  may  occur  in  the  acute  infections  but  most  especially  in  septicaemia  and 
rheumatic  fever,  particularly  in  children  who  have  aortic  endocarditis.  Of 
greatest  importance  is  its  occurrence  in  syphilis. 

Pathology. — The  process  may  be  diffuse  or  most  evident  in  slightly  raised 
areas  which  at  first  are  soft  and  later  harder  and  with  a  yellow  tinge.  The 
first  portion  of  the  arch  is  most  often  affected  and  this  may  involve  the  orifices 
of  the  coronary  arteries.  If  the  aorta  was  previously  diseased,  all  stages  of 
atheroma  may  be  found. 

Symptoms. — Pain  is  common,  usually  referred  to  the  upper  part  of  the 
sternum  and  sometimes  radiating  into  the  arms.  There  may  be  dyspnoea  and 
a  sense  of  thoracic  oppression.  In  the  syphilitic  form,  pain  is  the  outstanding 
symptom.  In  the  other  forms  the  pain  is  merged  in  the  symptoms  of  the  pri- 
mary condition,  especially  in  the  acute  infections. 

Signs. — There  may  be  marked  pulsation  in  the  neck,  especially  in  the 
suprasternal  notch,  where  the  aorta  may  be  seen  and  felt,  and  in  the  first  and 
second  interspaces.  There  is  dulness  over  the  manubrium  and  in  the  first  two 
interspaces,  both  to  right  and  left.  The  second  sound  may  have  a  musical 
bell-like  quality,  sometimes  very  characteristic.  The  syphilitic  form  as  a  rule 
shows  in  addition  the  signs  of  aortic  insufficiency. 

Diagnosis.— The  main  requisite  is  that  the  condition  be  kept  in  mind.  It 
is  unrecognized  because  not  considered.  If  there  is  any  doubt  the  X-ray  ex- 
amination should  decide.  A  positive  Wassermann  reaction  or  other  evidence 
of  syphilis  gives  the  diagnosis  of  this  form. 

Prognosis, — The  condition  in  itself  probably  does  not  shorten  life  but  may 
lead  to  permanent  damage  of  the  aortic  orifice.  In  the  syphilitic  forms  the 
degree  of  this  depends  greatly  on  early  diagnosis  and  proper  treatment. 


840  DISEASES  OF  THE  CIECULATORY  SYSTEM 

The  treatment  is  that  of  the  etiological  condition. 

Chronic  Aortitis. —  (Dilatation  of  the  Aorta). — This  is  a  common  con- 
dition, frequently  overlooked.  The  diffuse  dilatation  is  sometimes  described 
under  aneurism  but  deserves  separate  mention.  It  was  first  described  by 
Hodgson  in  1815  as  '"preternatural  permanent  enlargement  of  the  cavity  of 
an  artery."  It  is  often  associated  with  aortic  insufficiency,  which  the  French 
term  maladie  de  Hodgson. 

Etiology. — It  is  much  more  common  in  males  and  the  colored  race  shows 
a  relatively  high  incidence.  There  are  several  special  groups:  (1)  As  a  re- 
sult of  infection  and  acute  aortitis  a  permanent  dilatation  remains.  Two  dis- 
eases are  particularly  concerned,  rheumatic  fever  and  syphilis.  (2)  As  part 
of  a  general  arterio-sclerosis  in  which  the  aorta  is  specially  involved.  The 
influence  of  syphilis  and  hard  muscular  work  is  important  in  this  form.  (3) 
In  the  aged  it  is  common  as  part  of  an  advanced  arterial  degeneration. 

Pathology. — The  extent  of  dilatation  varies  greatly  and  may  involve 
only  a  portion  of  the  arch,  extend  throughout  the  whole  extent  of  the  aorta  or 
only  to  where  the  aorta  passes  through  the  diaphragm.  The  orifices  and  part 
of  the  vessels  given  off  from  the  aorta  may  be  involved  in  the  dilatation. 
Thrombus  formation  in  the  aorta  may  occur.  The  aorta  shows  all  grades  of 
gross  atheromatous  change. 

Symptoms. — There  are  several  groups :  ( 1 )  Latent  cases,  especially  in 
the  aged.  (2)  In  many  cases  those  due  to  associated  cardiac  disease  pre- 
dominate, with  the  features  of  myocardial  insufficiency  or  of  aortic  insuffi- 
ciency, (3)  A  group  with  features  suggestive  of  angina  pectoris,  not  surprising 
in  view  of  the  disease  of  the  first  part  of  the  aorta.  The  pain  may  radiate 
down  either  arm  or  sometimes  down  both.  The  common  complaints  are  of 
pain,  dyspnoea,  and  cough. 

Signs. — The  neck  may  be  full  with  distended  veins  and  a  collar  of  pul- 
sation above  the  clavicles  and  sternum.  Pulsation  in  the  suprasternal  notch 
is  common.  The  manubrium  may  be  lifted  and  pulsation  in  the  upper  two  in- 
terspaces is  often  seen.  The  order  of  frequency  is  second  right,  second  left, 
first  right  and  first  left  interspace.  This  pulsation  is  usually  diffuse  and  can 
rarely  be  felt  distinctly.  The  aorta  may  be  felt  above  the  sternum  or  with  the 
finger  behind  it.  Dulness  is  very  important,  over  the  manubrium  and  adjoin- 
ing interspaces.  It  is  continuous  with  the  heart  dulness  in  most  cases  but 
not  always.  The  width  of  the  dulness  in  the  first  interspaces  may  be  8  to 
14  cm.  and  the  extent  may  vary  from  time  to  time.  On  auscultation  the  second 
sound  often  has  an  amphoric  bell-like  quality,  which  is  diagnostic  if  present. 
The  murmur  of  an  associated  aortic  insufficiency  may  have  the  same  quality. 
The  blood  pressure  is  low  in  the  majority.  Arterio-sclerosis  is  usually  and 
aortic  insufficiency  (relative  or  permanent)  often  present.  The  pressure 
signs  are  practically  the  same  as  in  aneurism,  inequality  of  the  pupils,  laryn- 
geal paralysis,  tracheal  tug,  inequality  of  the  radial  pulses,  and  dysphagia. 

Diagnosis. — The  main  point  is  to  know  of  the  condition  and  look  for  it. 
The  diagnosis  from  aneurism  or  displacement  of  the  aorta  is  difficult  in  a  few 
cases;  the  X-ray  examination  will  decide.  The  pain  suggests  angina  pectoris 
but  it  is  rarely  so  severe,  often  lasts  for  a  considerable  time,  and  is  not  often 
caused  by  exertion.  In  fact  mild  exertion  often  relieves  the  pain.  Sweating  is 
very  rare. 


ANEUEISM  8^1 

Teeatmext. — A  quiet  even  life  with  avoidance  of  strain,  pliysical  or 
mental,  a  limited  diet,  open  bowels,  and  the  treatment  of  symptoms  are  the 
main  points.  If  syphilis  is  responsible,  thorough  treatment  should  be  given 
but  usually  the  damage'  is  done  and  beyond  repair.  Yaso-dilators  are  useful 
for  the  pain. 

III.     ANEURISM 

Definition. — A  tumor  containing  fluid  or  solid  blood  in  direct  communica- 
tion with  the  cavity  of  the  heart,  the  surface  of  a  valve,  or  the  lumen  of  an 
artery. 

History.— Galen  knew  external  aneurism  well,  and  in  the  second  century 
A.  D.,  Antyllos  devised  his  operation  of  incising  and  emptying  the  sac  in- 
closed between  ligatures.  Internal  aneurism  was  recognized  by  Fernelius  in 
the  16th  century,  and  Vesalius  was  very  familiar  with  it.  Ambroise  Pare  sug- 
gested the  relation  of  aneurism  to  syphilis,  which  was  insisted  upon  in  the 
great  monograph  of  Lancisi  in  1728.  Morgagni  in  1761  described  very  fully 
the  symptoms  and  morbid  anatomy.  The  modern  views  date  from  the  studies 
of  Helmstedter  and  Koster,  who  showed  that  the  primary  change  was  in  the 
media.  The  researches  of  Eppinger,  Thoma,  and  Welch  emphasized  the  im- 
portance of  these  changes  in  the  media,  particularly  as  brought  about  by 
syphilis. 

Classification. — The  following  classification  may  be  adopted: 

I.  True  aneueism  (aneurisma  verum  or  aneurisma  spontaneum),  in  which 
one  or  more  of  the  coats  of  the  vessel  form  the  wall  of  the  tumor:  (a)  Dila- 
tation-an&urism — (1)  Limited  to  a  certain  portion  of  the  vessel,  fusiform, 
cylindroid;  (2)  extending  over  a  whole  artery  and  its  branches — cirsoid  an- 
eurism. (&)  Circumscribed  saccular  aneurism,  which  is  the  common  form 
of  aneurism  of  the  aorta,  (c)  Dissecting  aneurism,  with  splitting  of  the 
media,  and  occasionally  with  the  formation  of  a  new  tube  lined  with  intimal 
endothelium. 

II.  False  aneueism,  following  a  wound  or  the  rupture  of  an  artery,  or 
of  a  true  aneurism,  causing  a  diffuse,  or  circumscribed,  hgematoma. 

III.  Aeterio-venous  aneurism,  either  with  direct  communication  between 
an  artery  and  vein,  or  with  the  intervention  of  a  sac,  varicose  aneurism. 

IV.  Special  forms,  as  the  parasitic,  erosion,  traction,  and  mycotic. 
Etiolo^. — Predisposing  Causes. — Age. — i^early  one  half  of  the  deaths 

in  England  and  Wales  from  aneurism  in  males  occur  between  the  ages  of  30 
and  45.  In  the  young  and  in  the  very  old  the  disease  is  rare,  but  it  may  occur 
at  any  age.    Congenital  aneurism  has  been  described. 

Sex. — Males  are  attacked  much  more  frequently  than  females — 5  to  1. 

Eace  and  Locality. — The  disease  is  more  common  in  Great  Britain  than 
on  the  Continent.  Among  about  19,000  post  mortems  at  Vienna  there  were 
230  cases  of  aneurism,  while  among  18,678  at  Guy's  Hospital  there  were  325 
cases.  It  is  more  common  in  the  negroes  of  the  Southern  States  of  America 
than  among  the  whites.  Of  345  admissions  for  aneurism  to  the  medical  wards 
of  the  Hopkins  Hospital  132  were  in  colored  and  213  in  white  patients — a  ratio 
of  1  to  1.6,  while  the  "ratio  of  colored  to  white  in  the  hospital  at  large  was 
1  to  5.     In  India  aneurism  is  rare,  though  syphilis  and  arterial  disease  are 


843  DISEASES  OF  THE  CIECULATOEY  SYSTEM 

common.  Possibly,  as  Eogers  suggests,  the  low  blood  pressure  in  the  natives 
may  have  something  to  do  with  this  comparative  immunity. 

Occupation. — Soldiers,  sailors,  draymen,  iron  and  steel  workers,  and  dock 
workers  are  particularly  prone.  In  soldiers  and  sailors,  who  are  peculiarly 
liable,  the  disease  is  in  direct  proportion  to  the  prevalence  of  syphilis. 

Determining  Causes. — These  are  three  in  number : 

I.  The  Acute  Infections. — In  the  specific  fevers  areas  of  degeneration  are 
common  in  the  aorta.  Fortunately  in  most  instances  they  are  confined  to  the 
intima,  but  occasionally,  as  Thayer  pointed  out  in  typhoid  fever,  the  changes 
may  be  in  the  media.  The  infection  with  which  aneurism  is  especially  con- 
nected is  syphilis — a  fact  recognized  in  the  eighteenth  century  by  Lancisi  and 
by  Morgagni,  and  dwelt  upon  specially  in  1876  by  Francis  H.  Welch,  of  the 
British  Army.  All  recent  figures  show  a  very  high  percentage  of  syphilis  and 
it  is  rare  not  to  find  a  positive  Wassermann  reaction  in  an  aneurismal  patient 
under  fifty.  The  lesion,  a  mesaortitis,  has  been  described  under  arterio-scle- 
rosis.  Other  infections  play  a  very  minor  role.  With  rheumatic  fever,  pneu- 
monia, and  septicaemia,  the  mycotic  aneurism  may  be  associated. 

II.  The  second  determining  factor  is  strain,  particularly  the  internal 
strain  associated  with  sudden  and  violent  muscular  efi^ort.  The  media  is  the 
protecting  coat  of  the  artery,  and  during  a  violent  effort,  as  in  lifting  or  jump- 
ing, laceration  or  splitting  of  the  intima  may  occur  over  a  weak  spot.  If  small 
this  leads  to  a  local  bulging  of  the  media  and  the  gradual  production  of  a  sac, 
or  the  tear  of  the  intima  may  heal  completely,  or  a  dissecting  aneurism  may 
form.  In  other  instances  a  widespread  mesaortitis  leads  to  a  gradual,  dif- 
fuse distention  of  the  artery.  This  type  of  aneurism,  frequently  seen  in  the 
aged,  may  follow  ordinary  chronic  atheroma. 

III.  Occasional  Causes. —  (a)  Embolism:  The  emboli  may  consist  of 
vegetations  or  calcified  fragments  from  the  valves.  This  form,  often  multiple, 
is  met  with  in  infective  endocarditis,  in  which  the  emboli  probably  pass  to  the 
vasa  vasorum,  causing  mesaortitis  with  weakening  of  the  wall;  but  in  the 
smaller  vessels  the  aneurisms  are  caused  by  the  direct  lodgment  of  the  emboli 
which  infect  and  weaken  the  wall.  (&)  External  Injury :  A  blow  on  the  chest, 
a  sudden  fall,  or  the  jar  of  an  accident  may  cause  a  rupture  of  the  intima  over 
a  weak  spot  in  the  aorta,  with  the  production  of  a  dissecting  or  sacculated 
aneurism,  (c)  External  Erosion:  A  tuberculous  focus  may  involve  the  wall 
of  the  aorta ;  or  a  bullet  lodged  near  the  wall  of  an  artery  may  weaken  it  and 
be  followed  by  aneurism,  {d)  In  the  horse  there  is  a  parasitic  aiieurism. 
common  in  the  mesenteric  vessels,  due  to  growth  in  them  of  the  Strongylu^ 
armatus.  (e)  Thoma  described  a  "traction"  aneurism  at  the  concavity  of  the 
arch  at  the  point  of  insertion  of  the  ductus  Botalli. 

Morbid  Anatomy  and  Pathology. — NtfMBEE, — Usually  there  is  one  aneu- 
rism, but  three  or  four  or  even  a  dozen  may  be  present.  Multiple  cup-shaped 
tumors  in  the  aorta  are  always  syphilitic.  The  mycotic  are  usually  multiple, 
and  in  the  peripheral  vessels  there  may  be  a  dozen  or  more. 

Form. — There  are  two  great  types — one  in  which  the  lumen  of  the  vessel 
is  dilated,  and  the  other  in  which  a  limited  section  of  the  wall  gives  way  with 
the  formation  of  a  sac.  Typical  cylindrical  and  spindle  shaped  aneurisms  are 
seen  in  the  aorta  and  in  the  vessels  of  the  second  and  third  dimensions.  The 
sacculated  form  is  the  more  common.     They  are  either  flat,  saucer-shaped,  or 


ANEURISM  843 

cup-shaped,  or  sometimes  beyond  a  very  narrow  orifice  is  a  cylindrical  tumor 
of  variable  size,  from  a  pin's  head  in  the  smaller  vessels,  as  in  the  brain,  to  a 
huge  sac  which  may  fill  one  half  of  the  chest. 

Vessels  Affected. — Of  a  series  of  551  cases  studied  by  Crisp,  the  tho- 
racic aorta  was  involved  in  175,  the  abdominal  aorta  in  59,  the  femoral-iliac 
in  66,  the  popliteal  in  137,  the  innominate  in  20,  the  carotids  in  25,  subcla- 
vians  in  23,  axillary  in  18.  The  other  smaller  vessels  are  rarely  attacked.  Of 
late  years  aneurism  of  the  external  vessels  appears  to  have  become  much  less 
frequent. 

I.     ANEUEISM   or   THE   AORTA 

A.  Aneurism  of  the  Thoracic  Aorta. — For  purposes  of  discussion  this  part 
of  the  vessel  may  be  divided  into  the  sinuses  of  Valsalva,  ascending,  trans- 
verse, and  descending  portions. 

(a)  Aneurism  of  the  sinuses  of  Valsalva,  a  common  and  important 
variety,  is  met  with  most  frequently  in  young  syphilitic  subjects.  There  may 
be  pouching  of  one  or  of  all  three  sinuses ;  the  aortic  ring  is  apt  to  be  involved 
and  one  or  more  of  the  valves  rendered  incompetent.  The  special  features  are : 
(1)  It  is  often  latent,  causing  sudden  death  by  perforation  into  the  pericar- 
dium. (2)  It  is  a  medico-legal  aneurism  met  with  most  frequently  in  coro- 
ner's cases.  (3).  Angina  pectoris  is  not  uncommon  and  may  be  the  only  symp- 
tom. (4)  Aortic  insufficiency  is  often  associated  with  it.  (5)  In  a  majority 
of  all  cases  syphilitic  mesaortitis  is  present. 

(&)  Aneurism  of  the  Ascending  Arch. — Along  the  convex  border  an- 
eurism frequently  arises  and  may  grow  to  a  large  size,  either  passing  out  into 
the  right  pleura  or  forward,  pointing  at  the  second  or  third  interspace,  erod- 
ing the  ribs  and  sternum,  and  producing  large  external  tumors.  In  this  situ- 
ation the  sac  may  compress  the  superior  vena  cava,  causing  engorgement  of 
the  vessels  of  the  head  and  arm;  sometimes  it  compresses  only  the  subclavian 
vein,  and  causes  enlargement  and  oedema  of  the  right  arm.  Perforation  may 
take  place  into  the  superior  vena  cava,  of  which  accident  Pepper  and  Griffith 
collected  29  cases.  In  rare  instances,  when  the  aneurism  springs  from  the 
concave  side  of  the  vessels,  the  tumor  may  appear  to  the  left  of  the  sternum. 
Large  aneurisms  in  this  situation  may  cause  much  dislocation  of  the  heart, 
pushing  it  down  and  to  the  left,  and  sometimes  compressing  the  inferior  vena 
cava,  and  causing  swelling  of  the  feet  and  ascites.  The  right  recurrent  laryn- 
geal nerve  is  often  compressed.  The  innominate  artery  is  rarely  involved. 
Death  commonly  follows  from  rupture  into  the  pericardium,  the  pleura,  or  into 
the  superior  cava;  less  commonly  from  rupture  externally,  sometimes  from 
syncope. 

(c)  Aneurism  of  the  Transverse  Arch. — The  direction  of  growth  is 
most  commonly  backward,  but  the  sac  may  grow  forward,  erode  the  sternum, 
and  form  a  large  tumor.  The  sac  presents  in  the  middle  line  and  to  the  right 
of  the  sternum  much  more  often  than  to  the  left,  which  occurred  in  only  4  of 
35  aneurisms  in  this  situation  (0.  A.  Browne).  Even  when  small  and  pro- 
ducing no  external  tumor  it  may  cause  marked  pressure  signs  in  its  growth 
backward  toward  the  spine,  involving  the  trachea  and  the  oesophagus,  and  giv- 
ing rise  to  cough,  often  of  a  paroxysmal  character,  and  dysphagia.  The  left 
recurrent  laryngeal  is  often  involved  in  its  course  round  the  arch.     A  small 


844  DISEASES  OF  THE  CIRCrLATORY  SYSTEM 

aneurism  from  the  lower  or  posterior  wall  of  the  arch  may  compress  a  bronchus, 
inducing  bronchorrhoea,  gradual  bronchiectasis,  and  suppuration  in  the  lung — 
a  process  which  not  infrequently  causes  death  in  aneurism,  and  a  condition 
which  at  the  ]\Iontreal  General  Hospital  we  were  in  the  habit  of  terming  "an- 
eurismal  phthisis."  Occasionally  enormous  aneurisms  arise  in  this  situation^ 
and  grow  into  both  pleurae,  extending  between  the  manubrium  and  the  verte- 
brse ;  they  may  persist  for  years.  The  sac  may  be  evident  at  the  sternal  notch. 
The  innominate  artery,  less  commonly  the  left  carotid  and  subclavian,  may  be 
involved,  and  the  radial  or  carotid  pulse  absent  or  retarded.  Sometimes  the 
thoracic  duct  is  compressed. 

The  ascending  and  transverse  portions  of  the  arch  are  not  infrequently  in- 
volved together,  usually  without  the  branches;  the  tumor  gTows  upward,  or 
upward  and  to  the  right. 

(d)  Aneurism  of  the  Descending  Portion  or  the  Arch. — It  is  not 
infrequently  the  traction  aneurism  of  Thoma.  The  sac  projects  to  the  left 
and  backward,  and  often  erodes  the  vertebrse  from  the  third  to  the  sixth  dor- 
sal, causing  great  pain  and  sometimes  compression  of  the  spinal  cord.  Dys- 
phagia is  common.  Pressure  on  a  bronchus  may  induce  bronchiectasis,  with 
retention  of  secretions,  and  fever.  A  tumor  may  appear  externally  in  the 
region  of  the  scapula,  and  attain  an  enormous  size.  Death  not  infrequently 
occurs  from  rupture  into  the  pleura,  or  the  sac  may  grow  into  the  lung  and 
cause  haemoptysis. 

(e)  Aneurism  or  the  Descending  Thoracic  Aorta. — This  is  the  least 
common  situation  of  aortic  aneurism.  The  larger  number  occur  close  to  the 
diaphragm,  the  sac  lying  upon  or  to  the  left  of  the  bodies  of  the  lower  dorsal 
vertebrae,  which  are  often  eroded.  It  is  frequently  latent,  in  3  of  14  cases 
(Osier),  and  is  often  overlooked;  pulmonary  and  pleural  symptoms  are  com- 
mon. Pain  in  the  back  is  severe;  dysphagia  is  not  infrequent.  The  sac  may 
reach  an  enormous  size  and  form  a  subcutaneous  tumor  in  the  left  back. 

Physical  Signs. — Inspection. — A  good  light  is  essential;  cases  are  often 
overlooked  owing  to  a  hasty  inspection.  The  face  is  often  suffused,  the  con- 
junctiva injected,  and  veins  of  the  chest  and  of  one  arm  engorged.  "One 
pupil  may  be  enlarged.  In  many  instances  inspection  is  negative.  On  either 
side  of  the  sternum  there  may  be  abnormal  pulsation,  due  to  dislocation  of 
the  heart,  to  deformity  of  the  thorax,  or  to  retraction  of  the  lung.  Three  sorts 
of  pulsation  may  be  seen  in  the  chest:  (1)  A  general  shock,  such  as  is  seen 
in  the  violent  throbbing  of  the  heart  or  of  an  aneurism.  In  anemia,  in  neuras- 
thenia, and  in  great  hypertrophy  this  widespread  shock  may  suggest  aneurism. 
(2)  A  diffuse  impulse  localized  in  a  certain  part  of  the  chest,  which  may  be 
caused  by  a  deep-seated  aneurism  but  which  is  met  with  also  in  tumors,  in 
pulsating  pleurisy,  and  in  a  few  cases  without  evident  cause  (see  "Modern 
Medicine,"  Vol.  IV).  (3)  The  punctate,  heaving  true  aneurismal  impulse 
which  when  of  any  extent  is  visibly  expansile.  It  is  seen  .most  frequently 
above  the  level  of  the  third  rib  to  the  right  of  the  sternum,  in  the  second  left 
interspace,  over  the  manubrium,  and  behind  in  the  left  interscapular  region. 
When  the  innominate  is  involved  the  throbbing  may  be  seen  at  the  right  sterno- 
clavicular joint  and  above  it.  An  external  tumor  is  present  in  many  cases, 
projecting  either  through  the  upper  part  of  the  sternum  or  to  the  right,  some- 
times involving  the  sternum  and  costal  cartilages  on  both  sides,  forming  a 


ANEUEISM  845 

swelling  the  size  of  a  cocoauut  or  even  larger.  The  skin  is  thin,  often  blood 
stained,  or  it  may  have  ruptured,  exposing  the  laminae  of  the  sac.  The  apex 
beat  may  be  much  dislocated,  particularly  when  the  sac  is  large.  It  is  more 
commonly  a  dislocation  from  pressure  than  from  enlargement  of  the  heart 
itself. 

Palpation. — The  area  and  degree  of  pulsation  are  best  determined  by 
palpation.  When  the  aneurism  is  deep  seated  and  not  apparent  externally, 
the  bimanual  method  should  be  used,  one  hand  upon  the  spine  and  Jthe  other 
on  the  sternum.  There  may  be  only  a  diffuse  impulse.  When  the  sac  has  per- 
forated the  chest  wall  the  impulse  is,  as  a  rule,  forcible,  slow,  heaving,  and 
expansile,  and  has  the  same  qualities  as  a  forcible  apex  beat.  The  resistance 
may  be  very  great  if  there  are  thick  laminae  beneath  the  skin ;  more  rarely  the 
sac  is  soft  and  fluctuating.  The  hand  upon  the  sac,  or  on  the  region  in  which 
it  is  in  contact  with  the  chest  wall,  may  feel  a  diastolic  shock,  often  of  great 
intensity,  which  forms  one  of  the  valuable  physical  signs  of  aneurism.  A  sys- 
tolic thrill  is  sometimes  present.  The  pulsation  may  sometimes  be  felt  in  the 
suprasternal  notch. 

Percussion. — The  small  and  deep  seated  aneurisms  are  in  this  respect 
negative.  In  the  larger  tumors,  as  soon  as  the  sac  reaches  the  chest  wall,  there 
is  produced  an  area  of  abnormal  dulness,  the  position  of  which  depends  upon 
the  part  of  the  aorta  affected.  Aneurisms  of  the  ascending  arch  groAV  forward 
and  to  the  right,  producing  dulness  on  one  side  of  the  manubrium;  those 
from  the  transverse  arch  produce  dulness  in  the  middle  line,  extending  toward 
the  left  of  the  sternum,  while  aneurisms  of  the  descending  portion  most  com- 
monly produce  dulness  in  the  left  interscapular  and  scapular  regions.  The  per- 
cussion note  is  flat  and  gives  a  feeling  of  increased  resistance. 

Auscultation. — Adventitious  sounds  are  not  always  to  be  heard.  Even 
in  a  large  sac  there  may  be  no  murmur.  Much  depends  upon  the  thickness  of 
the  laminge  of  fibrin.  An  important  sign,  particularly  if  heard  over  a  dull 
region,  is  a  ringing,  accentuated  second  sound,  a  phenomenon  rarely  missed 
in  large  aneurisms  of  the  aortic  arch.  A  systolic  murmur  may  be  present; 
sometimes  a  double  murmur,  in  which  case  the  diastolic  bruit  is  usually  due 
to  associated  aortic  insufficiency.  The  systolic  murmur  alone  is  of  little  mo- 
ment in  the  diagnosis  of  aneurism.  A  continuous  humming  top  murmur  with 
systolic  intensification  is  heard  when  the  aneurism  communicates  with  the 
vena  cava  or  the  pulmonary  artery. 

Among  OTHER  physical  signs  of  importance  are  retardation  of  the  pulse 
in  the  arteries  beyond  the  aneurism,  or  in  those  involved  in  the  sac.  There 
may,  for  instance,  be  a  marked  difference  between  the  right  and  left  radial, 
both  in  volume  and  time.  The  blood  pressure  on  the  two  sides  may  be  un- 
equal. A  physical  sign  of  large  thoracic  aneurism  is  obliteration  of  the  pulse 
in  the  abdominal  aorta  and  its  branches.  Attention  was  called  to  this  in  a 
patient  who  was  stated  to  have  aortic  insufficiency.  There  was  a  well-marked 
diastolic  murmur,  but  in  the  femorals  and  in  the  aorta  no  trace  of  pulsation 
could  be  found,  and  not  the  slightest  throbbing  in  the  abdominal  aorta  or  in 
the  peripheral  arteries  of  the  leg.  The  circulation  was,  however,  unimpaired 
in  them  and  there  was  no  dilatation  of  the  veins.  A  careful  examination  of 
the  patient's  back  showed  what  neither  the  patient  nor  an :  of  his  physicians 
had  noticed,  that  he  bad  a  very  large  area  of  pulsation  in  the  left  scapular 


846  DISEASES  OF  THE  CIECULATOEY  SYSTEM 

region.  The  sac  probably  was  large  enough  to  act  as  a  reservoir  annihilating 
the  ventricular  systole,  and  converting  the  intermittent  into  a  continuous 
stream. 

A  remarkable  condition  suggestive  of  pneumothorax  may  be  caused  by  com- 
pression of  one  bronchus  by  the  sac  (Newton  Pitt).  The  air  is  inspired  be- 
yond the  obstruction,  but  has  difficulty  in  getting  out,  so  that  the  lung  is 
gradually  distended,  causing  enlargement  of  the  side  with  a  hyperresonant 
note  on  percussion,  and  on  auscultation  absence  of  breath  sounds.  The  X-ray 
picture  may  alone  decide  the  diagnosis. 

The  tracheal  tugging,  a  valuable  sign  in  deep-seated  aneurisms,  was  de- 
scribed by  Surgeon-Major  Oliver,  who  gave  the  following  directions:  "Place 
the  patient  in  the  erect  position,  and  direct  him  to  close  his  mouth  and  ele- 
vate his  chin  to  almost  the  full  extent;  then  grasp  the  cricoid  cartilage  be- 
tween the  finger  and  thumb,  and  use  steady  and  gentle  upward  pressure  on  it, 
when,  if  dilatation  or  aneurism  exists,  the  pulsation  of  the  aorta  will  be  dis- 
tinctly felt  transmitted  through  the  trachea  to  the  hand."  The  tug  is  usually 
felt  more  easily  if  the  chin  is  held  down.  This  is  a  sign  of  great  value  in  the 
diagnosis  of  deep-seated  aneurisms,  though  it  may  occasionally  be  felt  in  tu- 
mors and  in  the  extreme  dynamic  dilatation  of  aortic  insufficiency.  It  may 
be  visible  in  the  thyroid  cartilage.    The  trachea  may  be  pushed  to  one  side. 

Occasionally  a  systolic  murmur  may  be  heard  in  the  trachea,  as  pointed 
out  by  David  Drummond,  or  even  at  the  patient's  mouth,  when  opened.  This 
is  either  the  sound  conveyed  from  the  sac,  or  is  produced  by  the  air  as  it  is 
driven  out  of  the  wind  pipe  during  the  systole.  Feeble  respiration  in  one 
lung  is  a  common  effect  of  pressure. 

Symptoms.— Broadbent  made  the  useful  division  of  aneurisms  of  symp- 
toms -and  aneurisms  of  phi/sical  signs;  the  former  is  more  commonly  seen 
when  the  transverse  arch  is  involved,  the  latter  when  the  ascending  portion. 
There  may  be  no  symptoms.  A  man  may  present  a  tumor  which  has  eroded 
the  chest  wall  without  pain  or  any  discomfort  but  this  is  rare. 

An  important  but  variable  feature  in  thoracic  aneurism  is  pain,  which  is 
particularly  marked  in  deep  seated  tumors.  It  is  usually  paroxysmal,  sharp, 
and  lancinating,  often  very  severe  when  the  tumor  is  eroding  the  vertebrae,  or 
perforating  the  chest  wall.  In  the  latter  case  after  perforation  the  pain  may 
cease.  Anginal  attacks  are  not  uncommon,  particularly  in  aneurisms  at  the 
root  of  the  aorta.  Frequently  the  pain  radiates  down  the  left  arm  or  up  the 
neck,  sometimes  along  the  upper  intercostal  nerves.  Superficial  tenderness 
may  be  felt  in  the  skin  over  the  heart  or  over  the  left  sternomastoid  muscle. 
Cough  results  either  from  the  direct  pressure  on  the  trachea,  or  is  associated 
with  bronchitis.  The  expectoration  in  these  instances  is  abundant,  thin,  and 
watery;  subsequently  it  becomes  thick  and  turbid.  Paroxysmal  cough  of  a 
peculiar  brazen,  ringing  character  is  a  characteristic  symptom  in  some  cases, 
particularly  when  there  is  pressure  on  the  recurrent  laryngeal  nerves,  or  the 
cough  may  have  a  peculiar  wheezy  quality — the  "goose  cough." 

Dyspnoea,  which  is  common  in  cases  of  aneurism  of  the  transverse  portion, 
is  not  necessarily  associated  with  pressure  on  the  recurrent  laryngeal  nerves, 
but  may  be  due  directly  to  compression  of  the  trachea  or  the  left  bronchus.  It 
may  occur  with  marked  stridor.    Loss  of  voice  and  hoarseness  are  consequences 


ANEURISM  847 

of  pressure  on  the  recurrent  laryngeal,  usually  the  left,  inducing  either  a 
spasm  in  the  muscles  of  the  left  vocal  cord  or  paralysis. 

Paralysis  of  an  abductor  on  one  side  may  be  present  without  any  symp- 
toms. It  is  more  particularly,  as  Semon  states,  when  the  paralytic  contrac- 
tures supervene  that  the  attention  is  called  to  laryngeal  symptoms. 

HcEmorrhage  in  thoracic  aneurism  may  come  from  (a)  the  soft  granula- 
tions in  the  trachea  at  the  point  of  compression,  in  which  case  the  sputum  is 
blood  tinged,  but  large  quantities  of  blood  are  not  lost;  (&)  from  rupture, 
of  the  sac  into  the  trachea  or  a  bronchus;  (c)  from  perforation  into  the  lung 
or  erosion  of  the  lung  tissue.  The  bleeding  may  be  profuse,  rapidly  proving 
fatal,  and  is  a  common  cause  of  death.  It  may  persist  for  weeks  or  months, 
in  which  case  it  is  simply  haemorrhagic  weeping  through  the  sac,  which  is 
exposed  in  the  trachea.  In  some  instances,  even  after  a  very  profuse  haemor- 
rhage, the  patient  recovers  and  may  live  for  years.  A  man  with  well-marked 
thoracic  aneurism,  who  had  several  brisk  hgemorrhages,  died  four  years  after, 
having  in  the  meantime  enjoyed  average  health.  Death  from  hajmorrhage  is 
relatively  more  common  in  aneurism  of  the  third  portion  of  the  arch  and  of 
the  descending  aorta. 

Difficulty  of  swallowing  is  a  comparatively  rare  symptom,  and  may  be  due 
either  to  spasm  or  to  direct  compression.  The  sound  should  never  be  passed 
in  these  cases,  as  the  oesophagus  may  be  almost  eroded  and  perforation  of  the 
sac  has  taken  place. 

Heart  Symptoms. — Pain  is  often  anginal  in  character,  and  is  most  common 
when  the  root  of  the  aorta  is  involved.  The  heart  is  hypertrophied  in  less 
than  one-half  of  the  cases.  The  aortic  valves  are  sometimes  incompetent, 
either  from  disease  of  the  segments  or  stretching  of  the  aortic  ring. 

Among  other  signs,  venous  compression  may  involve  one  subclavian  or  the 
superior  vena  cava.  A  curious  phenomenon  in  intrathoracic  aneurism  is  the 
clubbing  of  the  fingers  and  incurving  of  the  nails  of  one  hand,  of  which  two 
examples  were  without  any  special  distention  or  signs  of  venous  engorgement. 
Tumors  of  the  arch  may  involve  the  pulmonary  artery,  producing  compres- 
sion, or  in  some  instances  adhesion  of  the  pulmonary  segments  and  insuf- 
ficiency of  the  valve ;  or  the  sac  may  rupture  into  the  artery,  which  happened ' 
in  two  cases,  producing  instantaneous  death. 

Pupil  Signs. — These  may  be  due  to,  first,  pressure  on  the  sympathetic, 
which  may  cause  dilatation  of  one  pupil  from  irritation,  contraction  when 
the  nerve  is  paralyzed.  Flushing  of  the  side  of  the  face  and  ear,  increased 
temperature,  and  sweating  may  be  present.  Secondly,  as  Ainley  Walker  and 
Wall  have  shown,  the  anisocoria  is  most  frequently  due  to  vascular  conditions 
— with  low  blood  pressure  in  one  carotid  the  pupil  on  that  side  is  dilated,  with 
high  pressure  contracted,  and  in  26  cases  of  aneurism  they  found  a  relation 
between  the  state  of  the  pupil  and  the  arteries  on  the  same  side.  Thirdly,  in 
some  cases  the  anisocoria  is  a  syphilitic  manifestation. 

An  X-ray  examination  should  be  made  in  all  doubtful  cases.  The  fluoro- 
scope  gives  an  accurate  picture  of  the  situation,  the  size,  and  the  relation  to 
the  heart.  Even  a  small  sac  may  be  seen.  The  diagnosis  may  rest  upon  it 
alone  in  cases  in  which  scarcely  a  physical  sign  was  present.  Sailer  and 
Pfahler  have  shown  that  a  condition  of  tortuosity  of  the  aorta,  due  to  arterio- 


848  DISEASES  OF  THE  CIECULATORY  SYSTEM 

sclerosis,  may  exist,  suggesting  very  strongly  the  presence  of  aneurism,  par- 
ticularly on  examination  with  the  fluoroscope. 

The  clinical  picture  of  aneurism  of  the  aorta  is  extremely  varied.  Many 
cases  present  characteristic  symptoms  and  no  physical  signs,  while  others  have 
well-marked  physical  signs  and  few  or  no  symptoms. 

Diagnosis. — Aneurism  of  the  aorta  may  be  confounded  with:  (a)  The 
violent  throbbing  impulse  of  the  arch  in  aortic  insufficiency. 

(&)  Simple  Dynamic  Pulsation. — This  is  common  in  the  abdominal  aorta, 
but  is  rare  in  the  arch.  A  case  which  came  under  the  care  of  William  Mur- 
ray and  Bramwell  presented,  without  any  pain  or  pressure  symptoms,  pulsa- 
tion and  dulness  over  the  aorta.  The  condition  gradually  disappeared  and 
was  thought  to  be  neurotic. 

(c)  Dilatation  of  the  arch  which  has  many  of  the  features  of  aneurism. 
The  X-ray  examination  may  be  required  to  decide  the  diagnosis. 

(d)  In  curvature  of  the  spine  there  may  be  great  displacement  of  the 
aorta,  so  that  it  pulsates  forcibly  to  the  right  of  the  sternum. 

(e)  Solid  Tumors. — When  the  tumor  projects  externally  and  pulsates  the 
difficulty  may  be  considerable.  In  tumor  the  heaving,  expansile  pulsation  is 
absent,  and  there  is  not  that  sense  of  force  and  power  which  is  so  striking  in 
the  throbbing  of  a  perforating  aneurism.  There  is  not  to  be  felt,  as  in  aortic 
aneurism,  the  shock  of  the  heart  sounds,  particularly  the  diastolic  shock.  Aus- 
cultatory sounds  are  less  definite,  as  large  aneurisms  may  occur  without  mur- 
murs; and,  on  the  other  hand,  murmurs  may  be  heard  over  tumors.  The 
greatest  difficulty  is  in  the  deep  seated  thoracic  tumors,  and  here  the  diagnosis 
may  be  impossible.  The  physical  signs  may  be  indefinite.  The  ringing  aortic 
second  sound  is  of  great  importance  and  is  rarely,  if  ever,  heard  over  tumor. 
Tracheal  tugging  is  here  a  valuable  sign.  Pressure  phenomena  are  less  com- 
mon in  tumor.  The  general  appearance  of  the  patient  in  aneurism  is  much 
better  than  in  tumor,  in  which  there  may  be  cachexia  and  enlargement  of  the 
glands  in  the  axilla  or  in  the  neck.  The  result  of  the  Wassermann  reaction 
is  of  aid.  Occasionally  cancer  of  the  oesophagus  may  simulate  aneurism,  pro- 
ducing pressure  on  the  left  bronchus. 

(/)  Pulsating  Pleurisy. — In  cases  of  empyema  necessitatis,  if  the  project- 
ing tumor  is  in  the  neighborhood  of  the  heart  and  pulsates,  the  condition 
may  be  mistaken  for  aneurism.  The  absence  of  the  heaving,  firm  distention 
and  of  the  diastolic  shock  would,  with  the  history  and  the  existence  of  pleural 
effusion,  determine  the  nature  of  the  case.  If  necessary,  puncture  may  be 
made  with  a  fine  needle.  In  a  majority  of  the  cases  of  pulsating  pleurisy  the 
throbbing  is  diffuse  and  widespread,  moving  the  whole  side.  The  X-ray  study 
is  of  value. 

Prognosis.— The  outlook  is  always  grave.  Life  may  be  prolonged  for 
some  years,  but  the  patients  are  in  constant  jeopardy.  Spontaneous  cure  is 
not  very  infrequent  in  the  small  sacculated  tumors  of  the  ascending  and 
thoracic  portions.  The  cavity  becomes  filled  with. lamina  of  firm  fibrin,  which 
become  more  and  more  dense  and  hard,  the  sac  shrinks  considerably,  and  finally 
lime  salts  are  deposited  in  the  old  fibrin.  The  laminae  of  fibrin  may  be  on  a 
level  with  the  lumen  of  the  vessel,  causing  complete  obliteration  of  the  sac. 
The  cases  which  rupture  externally,  as  a  rule,  run  a  rapid  course,  although  to 
this  there  are  exceptions ;  the  sac  may  contract,  become  firm  and  hard,  and  the 


ANEURISM  849 

patient  may  live  for  five,  or  even  for  ten  or  twenty  years.  The  cases  which  last 
longest  are  those  in  which  a  saccular  aneurism  has  projected  from  the  ascend- 
ing arch.  One  patient  in  Montreal  had  been  known  to  have  aneurism  for 
eleven  years.  The  aneurism  may  be  enormous,  occupying  a  large  area  of  the 
chest,  and  yet  life  be  prolonged  for  many  years.  One  of  the  most  remarkable 
instances  is  the  case  of  dissecting  aneurism  reported  by  Graham.  The  patient 
was  invalided  after  the  Crimean  War  with  aneurism  of  the  aorta,  and  for 
years  was  under  the  observation  of  J.  H.  Eichardson,  of  Toronto,  under  whose 
care  he  died  in  1885.  The  autopsy  showed  a  healed  aneurism  of  the  arch, 
with  a  dissecting  aneurism  extending  the  whole  length  of  the  aorta,  which 
formed  a  double  tube. 

Treatment. — In  a  large  proportion  of  the  cases  tliis  can  only  be  palliative. 
Still  in  every  instance  measures  should  be  taken  which  are  known  to  promote 
clotting  and  consolidation  within  the  sac.  In  any  large  series  of  cured  aneu- 
risms a  considerable  majority  of  the  patients  have  not  been  known  to  be  sub- 
jects of  the  disease,  but  the  obliterated  sac  has  been  found  accidentally  at 
the  post  mortem. 

The  most  satisfactory  plan  in  early  cases,  when  it  can  be  carried  out  thor- 
oughly, is  the  modified  Valsalva  method  advised  by  Tufnell,  of  Dublin,  the 
essentials  of  which  are  rest  and  a  restricted  diet.  The  rest  should,  as  far  as 
possible,  be  absolute.  The  reduction  of  the  daily  number  of  heart  beats,  when 
a  patient  is  recumbent  and  without  exertion,  amounts  to  many  thousands,  and 
is  one  of  the  principal  advantages  of  this  plan.  Mental  quiet  should  also  be 
enjoined.  The  diet  advised  by  Tufnell  is  extremely  rigid — for  breakfast,  2 
ounces  of  bread  and  butter  and  2  ounces  of  milk  or  tea;  dinner,  3  ounces  of 
mutton  and  3  of  potatoes  or  bread  and  4  ounces  of  claret;  supper,  2  ounces  of 
bread  and  'butter  and  2  ounces  of  tea.  This  low  diet  diminishes  the  blood 
volume  and  is  thought  also  to  render  the  blood  more  fibrinous.  "Total  per 
diem,  10  ounces  of  solid  food  and  8  ounces  of  fluid,  and  no  more."  This 
treatment  should  be  pursued  for  several  months,  but,  except  in  persons  of  a 
good  deal  of  mental  stamina,  it  is  impossible  to  carry  it  out  for  more  than  a 
few  weeks  at  a  time.  It  is  a  form  of  treatment  adapted  only  to  the  saccular 
form,  and  in  cases  of  large  sacs  communicating  with  the  aorta  by  a  compara- 
tively small  orifice  the  chances  of  consolidation  are  fairly  good.  Unquestion- 
ably rest  and  the  restriction  of  the  liquids  are  the  important  parts  of  the  treat- 
ment, and  a  greater  variety  and  quantity  of  food  may  be  allowed  with  ad- 
vantage. If  this  plan  can  not  be  thoroughly  carried  out,  the  patient  should 
be  advised  to  live  a  very  quiet  life,  moving  about  with  deliberation  and  avoid- 
ing all  sudden  mental  or  bodily  excitement.  The  bowels  should  be  kept  regu- 
lar, and  constipation  and  straining  carefully  avoided.  Of  medicines,  iodide  of 
potassium  is  of  great  value.  It  may  be  given  in  doses  of  from  10  to  20  grains 
(0.6  to  1.3  gm.)  three  times  a  day.  Larger  doses  are  not  necessary.  The  most 
striking  efi^ect  of  the  iodide  is'  the  relief  of  pain.  The  evidence  is  conclusive 
that  the  syphilitic  casc^^  are  more  benefited  by  it  than  the  non-syphilitic.  All 
these  measures  have  little  value  unless  the  sac  is  of  a  suitable  form  and  size. 
The  large  tumors  with  wide  mouths  commimicating  with  the  ascending  por- 
tion of  the  aorta  may  be  treated  on  the  most  approved  plans  for  months  with- 
out the  slightest  influence  other  than  reduction  in  the  intensity  of  the  throb- 
bing.   A  patient  with  a  tumor  projecting  into  the  right  pleura  remained  on  the 


850  DISEASES  OF  THE  CIECULATOEY  SYSTEM 

most  rigid  Tufnell  treatment  for  more  than  one  hundred  days,  during  which 
time  he  took  potassium  iodide  faithfully.  The  pulsations  were  greatly  reduced 
and  the  area  of  dulness  diminished,  and  we  congratulated  ourselves  that  the  sac 
was  probably  consolidating.  Sudden  death  followed  rupture  into  the  pleura, 
and  the  sac  contained  only  fluid  blood,  not  a  shred  of  fibrin.  In  cases  in 
which  the  tumor  is  large,  or  in  which  there  seems  little  prospect  of  consolida- 
tion, it  is  perhaps  better  to  advise  a  man  to  go  on  quietly  with  his  occupa- 
tion, avoiding  excitement  and  worry.  Our  profession  has  offered  many  ex- 
amples of  good  work,  thoroughly  and  conscientiously  carried  out,  by  men  with 
aneurism  of  the  aorta,  who  wisely  preferred,  as  did  the  late  Hilton  Fagge, 
to  die  in  harness. 

Surgical  Measures. — Consolidation  may  be  promoted  in  the  sac  by  the 
combination  of  wiring  and  electrolysis.  Moore,  in  186 J:,  first  wired  a  sac, 
putting  in  78  feet  of  fine  wire.  Death  occurred  on  the  fifth  day.  Corradi 
proposed  the  combined  method  of  wiring  with  electrolysis,  which  was  first 
used  by  Burresi  in  1879.  H.  A.  Hare  has  done  the  operation  33  times  with- 
out any  accident.  He  emphasizes  the  importance  of  employing  a  gold  platinum 
wire  without  too  much  spring  (silver  is  not  suitable),  of  using  the  positive 
pole  in  the  aneurism  and  of  not  giving  too  strong  a  current  (5  milliamperes 
at  the  beginning,  gradually  increased  to  50,  and  then  decreased  to  5  again, 
the  current  being  passed  for  about  50  minutes).  In  nearly  all  of  Hare's 
patients  there  was  marked  benefit,  the  duration  of  which  was  variable.  One 
patient  lived  for  nine  years.  The  decrease  in  the  size  of  the  aneurism  is  often 
marked  but  the  relief  of  pain  is  the  most  striking  feature.  The  most  favorable 
cases  are  those  in  which  the  aneurism  is  sacculated,  which  can  usually  be  de- 
termined by  the  X-rays.  The  sudden  filling  by  clot  of  an  aneurism  of  the 
coeliac  axis  of  the  superior  mesenteric  artery  may  result  fatally  from  infarct 
of  the- intestine. 

Other  Coxditioxs. — Pressure  on  veins  causing  engorgement,  particularly 
of  the  head  and  arms,  is  sometimes  promptly  relieved  by  free  venesection,  and, 
at  any  time  during  the  course  of  a  thoracic  aneurism,  if  attacks  of  dyspnoea 
with  lividity  supervene,  bleeding  may  be  resorted  to  with  great  benefit.  In 
the  final  stages  morphia  is,  as  a  rule,  necessary.  Dyspnoea,  if  associated  with 
cyanosis,  is  best  relieved  by  bleeding.  Chloroform  inhalations  may  be  neces- 
sary. The  question  of  tracheotomy  sometimes  comes  up  in  the  cases  of  ur- 
gent dyspnoea.  If  it  can  be  shown  by  laryngoscopic  examination  that  it  is 
due  to  bilateral  abductor  paralysis  the  trachea  may  be  opened,  but  this  is  ex- 
tremely rare,  and  in  nearly  every  instance  the  urgent  dyspnoea  is  caused  by 
pressure  about  the  bifurcation.  ^Yhen  the  sac  appears  externally  and  grows 
large,  an  ice  bag  or  a  belladonna  plaster  may  be  applied  to  allay  the  pain  but 
wiring  with  electrolysis  is  most  useful  for  this.  In  some  instances  an  elastic 
support  may  be  used  with  advantage,  and  a  physician  with  an  enormous  ex- 
ternal aneurism  in  the  right  mammary  region  f.or  many  months  obtained  great 
relief  by  an  elastic  support,  passing  over  the  shoulder  and  under  the  arm  of 
the  opposite  side. 

The  nitrites  may  be  given  if  the  blood  pressure  is  high,  but  rest  and  diet, 
restriction  of  the  fluids,  and  free  purgation  are  usually  more  effectual  than 
drugs  in  reducing  blood  pressure. 

B.     Aneurism  of  the  Abdominal  Aorta. — Of  233  cases  collected  by  Nixon, 


A:N"EUEISM  851 

207  were  in  males,  26  in  females;  121  were  between  the  ages  of  twenty-five 
and  forty-five.  Xixon  reports  a  case  in  a  syphilitic  girl  of  twenty.  There 
were  16  cases  among  16,000  admissions  at  the  Johns  Hopkins  Hospital. 

Pathology. — The  sac  is  most  common  jnst  below  the  diaphragm  in  the 
neighborhood  of  the  coeliac  axis.  The  tumor  may  be  fusiform  or  sacculated, 
and  it  is  sometimes  multiple.  Projecting  backward,  it  erodes  the  vertebrae  and 
may  cause  numbness  and  tingling  in  the  legs  and  finally  paraplegia,  or  it  may 
pass  into  the  thorax  and  burst  into  the  pleura.  More  commonly  the  sac  is 
on  the  anterior  wall  and  projects  forward  as  a  definite  tumor,  which  may  be 
either  in  the  middle  line  or  a  little  to  the  left.  The  tumor  may  project  in 
the  epigastric  region  (which  is  most  common),  in  the  left  hypochondrium,  in 
the  left  flank,  or  in  the  lumbar  region.  When  high  up  beneath  the  pillar  of 
the  diaphragm  it  may  attain  considerable  size  without  being  very  apparent  on 
palpation.  When  it  ruptures  into  the  retro-peritoneal  tissues  a  tumor  in  the 
flank  may  be  formed  gradually,  which  enlarges  with  very  little  pulsation.  It 
may  be  mistaken  for  a  rapidly  growing  sarcoma  or  for  appendicitis,  and  an 
operation  may  be  performed. 

The  symptoms  are  chiefly  pain,  very  often  of  a  neuralgic  nature,  passing 
round  to  the  sides  or  localized  in  the  back,  and  more  persistent  and  intense 
than  in  any  other  variety  of  aneurism.  Gastric  symptoms,  particularly  vom- 
iting, may  be  early  and  deceptive  features.  Eetardation  of  the  pulse  in  the 
femoral  artery  is  a  very  common  symptom. 

Diagnosis  and  Physical  Signs. — Inspection  may  show  marked  pulsation  in 
the  epigastric  region,  sometimes  a  definite  tumor.  A  thrill  is  not  uncommon. 
The  pulsation  is  forcible,  expansile,  and  sometimes  double  when  the  sac  is 
large  and  in  contact  with  the  pericardium.  On  palpation  a  definite  tumor 
can  he  felt.  Though  usually  fixed,  the  aneurism  may  be  freely  movable.  If 
large,  there  is  some  degree  of  dulness  on  percussion,  which  usually  merges  with 
that  of  the  left  lobe  of  the  liver.  On  auscultation,  a  systolic  murmur  is,  as  a 
rule,  audible,  and  is  sometimes  best  heard  at  the  back.  A  diastolic  murmur 
is  occasionally  present,  usually  very  soft  in  quality.  No  pulsation,  however 
forcible,  no  thrill,  however  intense,  no  murmur,  however  loud,  justifies  the 
diagnosis  of  abdominal  aneurism  unless  there  is  a  definite  tumor  which  can 
he  grasped  and  which  has  an  expansile  pulsation.  Attention  to  this  rule  will 
save  many  errors.  The  throbhing  abdominal  aorta  was  well  described  by  Mor- 
gagni  and  Laennec,  and  called  by  Allan  Burns  the  "preternatural  pulsation  in 
the  epigastrium."  It  is  met  with  (a)  in  nervous  women  often  associated  with 
enteroptosis  and  pain,  and  sometimes,  as  Morgagni  pointed  out,  with  vomiting 
of  blood,  (b)  In  anaemia  particularly  after  severe  haemorrhage,  in  which  the 
throbbing  may  shake  the  patient  and  the  bed.  (c)  In  aortic  insufficiency. 
(d)  In  sclerosis  of  the  abdominal  aorta.  A  common  mistake  is  to  regard  this 
throbbing  aorta  as  aneurism.  The  vessel  may  appear  dilated  and  even  may  be 
grasped  in  the  hand.  Very  frequently  a  tumor  of  the  pylorus,  of  the  pancreas, 
or  of  the  left  lobe  of  the  liver  is  lifted  with  each  impulse  of  the  aorta  and 
may  be  confounded  with  aneurism.  The  absence  of  the  forcible  expansile  im- 
pulse and  the  examination  in  the  knee  elbow  position,  in  which  the  tumor,  as 
a  rule,  falls  forward,  and  the  pulsation  is  not  then  communicated,  suffice  for 
differentiation. 

Prognosis. — The  outlook  is  bad  but  a  few  cases  heal  spontaneously.   Death 


853  DISEASES  OF  THE  CTBCULATORY  SYSTEM 

may  result  from  (a)  complete  obliteration  of  the  lumen  by  clots;  (h)  com- 
pression paraplegia;  (c)  rupture  (which  occurred  in  152  of  the  233  cases  in 
Nixon's  series)  either  into  the  pleura,  retroperitoneal  tissues,  peritoneum,  or 
the  intestines,  most  commonly  into  the  duodenum;  (d)  embolism  of  the  su- 
perior mesenteric  artery,  producing  intestinal  infarction. 

The  treatment  is  the  same  as  in  thoracic  aneurism.  When  the  aneurism 
is  low  down  pressure  has  been  successfully  applied  in  a  case  by  Murray,  of 
Newcastle.  It  must  be  kept  up  for  many  hours  under  chloroform.  The  plan 
is  not  without  risk,  as  patients  have  died  from  bruising  and  injury  of  the  sac. 
Nine  cases  in  our  series  were  treated  surgically.  In  two  the  wiring  and 
electrolysis  were  followed  by  great  improvement ;  one  man  lived  for  three  years. 

C.  Dissecting  Aneurism. — The  majority  of  aneurisms  of  the  aorta  begin 
with  a  split  or  crack  of  the  intima  over  a  spot  of  syphilitic  mesaortitis.  Once 
this  split  has  started  the  aorta  may  rupture  in  all  its  coats,  or  an  aneurism 
may  form  at  the  site,  or  the  fracture  of  the  intima,  though  large  and  often 
circumferential,  may  heal ;  or  the  blood  may  extend  between  the  coats,  separat- 
ing  them  for  many  inches,  or  in  the  entire  extent,  forming  a  dissecting  aneu- 
rism; and,  lastly,  such  a  dissecting  aneurism  may  heal  perfectly. 

EuPTURE  OF  THE  AORTA  is  not  Very  infrequent,  as  medico-legal  work  in- 
dicates. Usually  there  is  agonizing  pain  with  features  of  shock,  and  death 
may  take  place  instantly;  but  in  fully  half  of  the  cases  there  are  two  very 
characteristic  stages,  the  first  corresponding  to  the  rupture  of  the  inner  coats, 
the  second  eight  to  ten  hours,  or  as  long  as  fifteen  or  sixteen  days  later,  to 
fatal  rupture  of  the  external  layer. 

Dissecting  aneurism  is  not  very  common.  There  were  only  two  cases  in 
16  years  at  the  Hopkins  Hospital,  where  aneurism  may  be  said  to  be  excep- 
tionally frequent.  The  primary  split  is  most  frequently  in  the  arch,  not  far 
above  the  valves,  and  is  in  the  form  of  a  transverse,  or  vertical,  clean  cut  in- 
cision, as  if  made  with  a  ra^or.  The  extent  of  the  separation  of  the  coats  is 
variable.  If  the  adventitia  is  reached,  rupture  is  certain  to  take  place,  as  only 
the  structures  of  the  middle  coat  can  resist  for  any  time  the  pressure  of  the 
blood.  The  blood  may  pass  for  three  or  four  or  more  inches,  separating  the 
media,  and  then  burst  internally  or  externally.  In  other  cases  the  dissection 
reaches  from  the  ascending  arch  to  the  bifurcation  of  the  aorta,  even  passing 
down  the  iliac  and  femorals  into  the  smaller  vessels  of  the  leg.  The  splitting 
of  the  coats  may  reach  to  all  the  subdivisions  of  the  aorta.  The  symptoms  are 
those  spoken  of  under  rupture;  but  a  very  remarkable  condition  may  follow,, 
leading  to : 

Healed  Dissecting  Aneurism. — The  earlier  observers  of  this  remark- 
able condition  regarded  it  as  an  anatomical  anomaly  of  a  double  aorta.  Adami 
collected  39  cases,  in  a  majority  of  which  there  was  no  advanced  disease  of 
the  aorta  itself.  The  outer  tube  formed  by  the  dissecting  aneurism  may 
extend  the  entire  length  of  the  aorta,  occupying  the  full  extent  of  the  circum- 
ference. The  most  extraordinary  feature  is  that  the  outer  tube  may  present 
a  perfectly  smooth  and  natural  appearance,  and  be  lined  with  a  new  intima. 
The  condition  may  last  for  many  years. 


ANEUEISM  853 


II.     ANEURISM  OF   THE  BRANCHES  OF  THE  ABDOMINAL  AORTA 

The  coeliac  axis  is  itself  not  infrequently  involved  in  aneurism  of  the 
first  portion  of  the  abdominal  aorta.  Of  its  branches,  the  splenic  artery  is 
occasionally  the  seat  of  aneurism.  This  rarely  causes  a  tumor  large  enough 
to  be  felt;  sometimes^  however,  the  tumor  is  of  large  size.  In  a  case  in  a 
man,  aged  thirty,  who  had  an  illness  of  several  months'  duration,  the  severe 
epigastric  pain  and  vomiting  led  to  a  diagnosis  of  gastric  ulcer.  There  was 
a  deep  seated  tumor  in  the  left  hypochondriac  region,  the  dulness  of  which 
merged  with  that  of  the  spleen.  There  was  no  pulsation,  but  it  was  thought 
on  one  occasion  that  a  bruit  was  heard.  The  chief  symptoms  were  vomiting, 
severe  epigastric  pain,  occasional  hsematemesis,  and  finally  severe  haemorrhage 
from  the  bowels.  An  aneurism  of  the  splenic  artery  the  size  of  a  cocoanut  was 
situated  between  the  stomach  above  and  the  transverse  colon  below,  and  ex- 
tended to  the  right  as  far  as  the  level  of  the  navel.  The  sac  contained  densely 
laminated  fibrin.  It  had  perforated  the  colon.  Of  39  instances  of  aneurism 
on  the  branches  of  the  abdominal  aorta  collected  by  Lebert,  10  were  of  the 
splenic  artery. 

Of  aneurism  of  the  hepatic  artery  Rolland  collected  40  cases  (1908), 
of  which  24  were  extra-hepatic.  In  Eolland's  case  there  were  three  sacs — all 
intra-hepatic.  Eupture  took  place  in  32  cases — in  16  into  the  peritoneal  cavity, 
in  13  into  the  bile  passages.  The  sac  is  rarely  large,  but  in  the  case  of  Woll- 
mann's  it  was  as  large  as  a  child's  head.  Cholelithiasis  and  duodenal  ulcer  are 
the  conditions  for  which  it  is  most  likely  to  be  mistaken.  In  Eoss  and  Osier's 
case  the  liver  was  enlarged,  with  symptoms  of  pyaemia. 

Aneurism  of  the  superior  mesenteric  artery  is  not  very  uncommon.  The 
diagnosis  is  scarcely  possible  from  aneurism  of  the  aorta.  Plugging  of  the 
branches  or  of  the  main  stem  may  cause  infarction  of  the  bowel. 

Renal  Artery. — Henry  Morris  collected  21  instances  of  aneurism,  12  of 
which  arose  from  injury.  Many  of  them  were  false.  Pulsation  and  a  bruit 
are  not  always  present.  Four  cases  were  operated  upon ;  three  recovered.  In 
a  case  of  Keen's  the  tumor  and  the  kidney  were  removed  together. 

Pulmonary  Artery. — Primary  aneurism  of  the  trunk  is  very  rare. 
The  forms  are :  (a)  Of  the  trunk  and  main  branches  Henschen  to  1906  col- 
lected 42  cases;  and  Possett  (1909)  added  nine.  Most  of  the  patients  were 
in  the  third  and  fourth  decades,  and  ■syphilis  is  the  important  factor.  Warthin 
demonstrated  spirochsetes  in  atherosclerosis  with  aneurism.  (5)  Acute  embolic 
aneurism,  which  may  be  multiple  in  connection  with  septic  thrombi  in  the 
veins  or  endocarditis  of  the  right  side  of  the  heart,  (c)  The  small  aneurisms 
in  the  walls  of  pulmonary  cavities,  already  considered. 

111.     ARTERIO-VENOUS  ANEURISM 

In  this  form,  known  to  Galen,  but  first  accurately  described  by  the  great 
William  Hunter,  there  is  abnormal  communication  between  an  artery  and  a 
vein.  When  a  tumor  lies  between  the  two  it  is  known  as  varicose  aneurism; 
Avhen  there  is  a  direct  communication  without  tumor  the  vein  is  chiefly  dis- 
tended and  tlio  condition  is  known  as  aneurismal  vari.v. 


854  DISEASES  OF  THE  CIECULATOEY  SYSTEM 

While  it  may  occur  in  the  aorta,  it  is  much  more  common  in  the  periph- 
eral arteries  as  a  result  of  stab  or  gunshot  wounds. 

An  aneurism  of  the  ascending  portion  of  the  arch  may  open  directly  into 
the  vena  cava.  Twenty-nine  cases  of  this  lesion  were  analyzed  by  Pepper 
and  Griffith.  Cyanosis,  oedema,  and  great  distention  of  the  veins  of  the  upper 
part  of  the  body  are  the  most  frequent  symptoms,  and  develop,  as  a  rule,  with 
suddenness.  Of  the  physical  signs  a  thrill  is  present  in  some  cases.  A  con- 
tinuous murmur  with  systolic  intensification  is  of  great  diagnostic  value. 
Thurnam  (Medico-Chirurgical  Transactions,  1840)  gave  the  first  accurate 
account  of  this  murmur  and  of  this  characteristic  type  of  cyanosis.  There  is 
only  one  condition  with  which  it  could  be  confounded,  viz.,  the  remarkable 
cyanosis  of  the  upper  part  of  the  body  which  follows  crushing  accidents  to 
the  thorax.  Perforation  between  the  aorta  and  pulmonary  artery  causes  very 
much  the  same  symptoms.  In  a  few  cases  an  aneurism  of  the  abdominal  aorta 
perforates  the  inferior  vena  cava — oedema  and  cyanosis  of  the  legs  and  lower 
half  of  the  body,  and  the  distinctive  thrill  and  murmur  are  present. 

In  the  arterio -venous  aneurisms  which  follow  stab  and  bullet  wounds  of 
the  subclavian,  axillary,  carotid,  femoral,  and  popliteal  arteries  the  clinical 
features  are  most  characteristic.  First,  the  veins  enlarge  as  the  arterial  blood 
flows  under  high  pressure  into  them.  The  affected  limb  may  be  greatly 
swollen  and  in  a  young  person  may  lengthen,  and  the  growth  of  hair  is  in- 
creased. Secondly,  a  strong  thrill  is  felt,  of  maximum  intensity  at  the  site  of 
the  aneurism,  but  sometimes  to  be  felt  at  the  most  distant  parts  of  a  limb. 
Thirdly,  the  characteristic  contmuous  murmur  with  systolic  intensification  is 
heard.  In  the  external  arteries  the  condition  may  persist  for  years  before 
disability  is  caused  by  enlargement  of  the  veins  and  swelling  of  the  limb. 
Surgical  treatment  by  a  skilled  operator  is  indicated. 

Periarteritis  Nodosa 

An  inflammatory  lesion  of  the  smaller  arteries,  beginning  in  the  outer 
coats,  with  hyaline  degeneration  of  the  media,  and  formation  of  secondary 
aneurisms  with  thrombosis  and  rupture.  The  nodular  syphilitic  arteritis 
should  not  be  included  in  this  group.  Described  first  by  Kussma.ul  and  Maier, 
it  has  been  made  the  subject  of  special  study  of  late  years  by  Dickson,  Long- 
cope,  Lamb,  and  Klotz.     Some  42  cases  are  on  record.  . 

The  etiology  is  uncertain.  Most  of  the  cases  are  in  males  of  middle  age 
and  syphilis  has  been  noted  in  a  few  cases.  The  disease  appears  to  be  a  sub- 
acute infection  with  forms  of  staphylococci  and  streptococci  (Klotz).  The 
smaller  arteries  are  involved,  the  branches  of  the  cceliac  axis,  the  mesenteric, 
the  renal,  hepatic,  coronary,  and  more  rarely  those  of  the  skin,  lungs  and  brain. 
The  nodular  tumors  vary  in  numbers  from  a  dozen  or  more  to  many  hun- 
dreds and  are  usually  visible  to  the  naked  eye.  Th'ey  differ  in  structure  from 
the  other  forms  of  nodular  arteritis,  the  syphilitic  and  mycotic.  The  sub- 
cutaneous nodules  present  in  eight  cases  led  to  the  diagnosis  in  two. 

The  disease  runs  a  course  wifh  mild  fever,  weakness,  anaemia,  muscular 
and  joint  pains,  epigastric  pain,  vomiting,  diarrhoea  and  purpura.  Tonsillitis 
has  not  infrequently  preceded  the  attack.  The  duration  is  from  a  few  weeks 
to  three  or  four  months.     Eecovery  has  occurred. 


SECTION  XI 
DISEASES  OF  THE   DUCTLESS  GLANDS 

Introduction. — Disturbances  in  the  endocrine  glands  may  be  due  to 
hyper-,  hypo-  or  dysfunction.  The  results  may  be  shown  in  various  ways: 
(1)  the  features  caused  by  disturbance  in  the  gland  specially  involved,  (3) 
secondary  disturbances  in  other  endocrine  glands,  as  they  are  all  bound  to- 
gether, causing  a  polyglandular  syndrome,  and  (3)  involvement  of  the  vege- 
tative nervous  system  and,  through  this,  widespread  influence  on  many  organs. 
There  seem  to  be  special  relations  between  certain  glands,  which  may  take 
the  form  of  inhibition  or  of  stimulation.  It  is  evident  that  the  polyglandular 
syndromes  may  present  very  complex  problems. 


I.    DISEASES  OF  THE  SUPRARENAL  BODIES  AND 
CHROMAFFIN  SYSTEM 

Introduction. — Of  the  two  parts  of  the  suprarenal  bodies,  (1)  the  medul- 
lary belongs  to  what  is  known  as  the  chromaffin  system,  which  includes  a  simi- 
lar tissue  scattered  in  the  sympathetic  ganglia  and  the  carotid  glands,  and  (2) 
the  cortex  with  an  epithelial  origin  and  belonging  to  the  interrenal  system.  The 
chromaffin  bodies  produce  an  internal  secretion,  epinephrine  the  chief  func- 
tion of  which  is  to  maintain  the  blood  pressure  and  the  sympathetic  tonus, 
though  this  is  disputed  by  some  workers,  e.  g.,  Vincent.  In  some  way  it  also 
controls  the  pigment  metabolism  of  the  skin  and  possibly  the  muscular  vigor. 
Disturbance  in  function  of  the  medullary  portion  of  the  suprarenal  bodies  is 
known  only,  through  the  remarkable  disease  described  by  Addison.  Beyond 
this  all  is  debatable,  and  much  visionary.  The  function  of  the  cortical  part- 
of  the  gland  is  unknown,  but  that  it  bears  some  relation  to  the  sexual  organs 
is  shown  by  the  sex  anomalies  that  develop  with  tumors  of  these  parts  and  by 
the  enlargement  during  pregnancy.  Hyperplasia  of  the  cortex  or  tumor  for- 
mation may  be  associated  with  precocious  sexual  development  and  hypo- 
plasia with  infantilism.  The  interrenal  system  produces  cholin  which  lowers 
blood-pressure. 

Glycosuria  is  caused  by  the  injection  of  epinephrin,  and  in  animals  a  form 
of  arterio-sclerosis,  probably  due  to  the  high  blood  pressure.  Many  theoretical 
conceptions  have  been  entertained  of  the  relation  between  a  defect  of  the 
adrenal  secretion  and  asthenic  affections,  and  it  is  suggested  that  adrenal  insuf- 
ficiency plays  an  important  role  in  acute  infections,  in  tuberculosis,  and  many 
wasting  diseases,  with  which  it  is  interesting  to  note  that  increased  pigmenta- 
tion may  be  associated. 

855 


856  DISEASES  OF  THE  DUCTLESS  GLANDS 

I.    ADDISON'S   DISEASE 

Definition. — A  disease  characterized  by  muscular  and  vascular  asthenia, 
gastro-intestinal  disturbance,  and  pigmentation  of  the  skin;  due  either  to 
tuberculosis  or  atrophy  of  the  adrenals,  or  to  degenerative  changes  in  the  chro- 
maffin system  generally. 

The  recognition  of  the  disease  is  due  to  Addison  of  Guy's  Hospital,  whose 
monograph  on  "The  Constitutional  and  Local  Effects  of  Disease  of  the  Supra- 
renaL  Capsules"  was  published  in  1855. 

Etiology. — The  disease  is  rare.  Only  17  cases  were  seen  in  21  years  in 
the  L^nited  States  (Osier).  In  large  clinics  a  year  or  more  may  pass  without 
a  case.  Males  are  more  frequently  attacked  than  females.  In  Greenhow's 
analysis  of  183  cases,  119  were  males  and  64  females.  The  majority  of  cases 
occur  between  the  twentieth  and  fortieth  years.  A  congenital  case  has  been 
described,  in  which  the  child  lived  for  eight  weeks,  and  post  mortem  the  adre- 
nals were  found  to  be  large  and  cystic.  In  a  few  cases  a  blow  on  the  abdomen 
or  back  has  preceded  the  onset.  A  certain  number  of  cases  have  been  asso- 
ciated with  Pott's  disease.  An  increase  in  the  disease  in  France  was  re- 
ported during  the  recent  war. 

Morbid  Anatomy. — There  is  rarely  emaciation  or  ansemia.  Eolleston  thus 
summarizes  the  condition  of  the  suprarenal  bodies  in  Addison's  disease: 

"1.  The  fibro-caseous  lesion  due  to  tuberculosis — far  the  commonest  con- 
dition found.  2.  Simple  atrophy.  3.  Chronic  interstitial  inflammation  lead- 
ing to  atrophy.  4.  Malignant  disease  invading  the  capsules,  including  Addi- 
son's case  of  malignant  nodule  compressing  the  suprarenal  vein.  5.  Blood 
extravasated  into  the  suprarenal  bodies.  6.  No  lesion  of  the  suprarenal  bodies 
themselves,  but  pressure  or  inflammation  involving  the  semilunar  ganglia. 

"The  first  is  the  only  common  cause  of  Addison's  disease.  The  others, 
with  the  exception  of  simple  atrophy,  may  be  considered  as  very  rare." 

The  nerve-cells  of  the  semilunar  ganglia  have  been  found  degenerated  and 
deeply  pigmented,  and  the  nerves  sclerotic.  The  ganglia  are  not  uncom- 
monly entangled  in  the  cicatricial  tissue  about  the  adrenals.  The  chromaffin 
cells  in  the  sympathetic  ganglia  and  in  the  abdominal  |)lexuses  generally  dis- 
appear. The  cases  of  extensive  destruction  of  the  glands  without  Addison's 
disease  are  explained  by  a  persistence  of  the  chromaffin  structures  elsewhere, 
while  extensive  involvement  of  the  extra-capsular  chromaffin  system  may 
itself  be  sufficient  to  cause  the  symptoms,  the  adrenals  themselves  being  intact. 

Few  changes  of  importance  are  found  in  other  organs.  The  spleen  is 
occasionally  enlarged ;  the  thymus  may  be  persistent  and  the  lymph  nodes  and 
tonsils  enlarged  as  in  status  lymphaticus.  The  other  organs  show  only  the 
alterations  associated  with  a  protracted  illness. 

Symptoms. — In  the  words  of  Addison,  the  characteristic  symptoms  are 
"ansemia,  general  languor  or  debility,  remarkable  feebleness  of  the  heart's 
action,  irritability  of  the  stomach,  and  a  peculiar  change  of  color  in  the 
skin."  The  onset  is,  as  a  rule,  insidious.  The  feelings  of  weakness  usually 
precede  the  pigmentation.  In  other  instances  the  gastro-intestinal  symptoms, 
the  weakness,  and  the  pigmentation  come  on  together.  There  are  a  few  cases 
in  which  the  whole  process  is  acute,  following  a  shock  or  some  special  depres- 
sion.    There  are  three  important  symptoms : 


DISEASES  OF  THE  SIIPRAEENAL  BODIES  857 

(a)  Pigmentation  of  the  Skin. — This,  as  a  rule,  first  attracts  the 
attention  of  the  patient's  friends.  The  grade  of  coloration  ranges  from  a 
light  yellow  to  a  deep  brown,  or  even  black.  In  typical  cases  it  is  diffuse, 
but  always  deeper  on  the  exposed  parts  and.  in  the  regions  where  the  normal 
pigmentation  is  more  intense,  as  the  areolae  of  the  nipples  and  about  the 
genitals ;  also  Avherever  the  skin  is  compressed  or  irritated,  as  by  the  waist- 
band. At  first  it  may  be  confined  to  the  face  and  hands.  Occasionally  it 
is  absent.  Patches  showing  atrophy  of  pigment,  leucoderma,  may  occur.  The 
pigmentation  occurs  on  the  mucous  membranes  of  the  mouth,  conjunctivae, 
and  vagina  but  it  is  not  distinctive  as  it  has  been  found  in  chronic  gastric 
disease  and  is  common  in  the  negro.  A  patchy  pigmentation  of  the  serous 
membranes  has  often  been  found.  Over  the  diffusely  pigmented  skin  there 
may  be  little  mole  like  spots  of  deeper  pigmentation,  and  upon  the  trunk, 
particularly  on  the  lower  abdomen,  it  may  be  "ribbed"  like  the  sand  on 
the  seashore. 

(6)  Gastro-intestinal  Symptoms. — The  disease  may  set  in  with  attacks 
of  nausea  and  vomiting,  spontaneous  in  character.  Toward  the  close  there 
may  be  pain  with  retraction  of  the  abdomen,  and  even  features  suggestive 
of  peritonitis.  A  marked  anorexia  may  be  present.  The  gastric  symptoms 
are  variable  throughout  the  course;  occasionally  they  are  absent.  Attacks  of 
diarrhoea  are  frequent  and  come  on  without  obvious  cause. 

(c)  Asthenia,  the  most  characteristic  feature,  may  be  manifested  early 
as  a  feeling  of  inability  to  carry  on  the  ordinary  occupation,  or  the  patient 
may  complain  constantly  of  feeling  tired.  The  weakness  is  specially  marked 
in  the  muscular  and  cardio-vascular  systems.  There  may  be  an  extreme 
degree  of  muscular  prostration  in  an  individual  apparently  well  nourished, 
whose  muscles  feel  firm  and  hard.  The  cardio-vascular  asthenia  is  mani- 
fest in  a  feeble,  irregular  action  of  the  heart,  which  may  come  on  in  par- 
oxysms, in  attacks  of  vertigo,  or  of  syncope,  in  one  of  which  the  disease  may 
prove  fatal.  The  blood  pressure  is  low,  falling  to  70  or  80  mm.  of  Hg.  Head- 
ache is  a  frequent  symptom ;  convulsions  occasionally  occur.  Pain  in  the  back 
may  be  an  early  and  important  symptom. 

Anemia,  a  symptom  specially  referred  to  by  Addison,  is  not  common.  In 
a  majority  of  the  patients  the  blood  count  is  normal.  The  sugar  content  of 
the  blood  has  been  found  to  be  low  in  some  cases.  McMunn  described  an 
increase  in  the  urinary  pigments,  and  a  pigment  has  been  isolated  of  very 
much  the  same  character  as  the  melanin  of  the  skin. 

The  mode  of  termination  is  by  syncope,  which  may  occur  even  early  in 
the  disease,  by  gradual  progressive  asthenia,  or  by  the  development  of  tuber- 
culous lesions.  A  noisy  delirium  with  urgent  dyspnoea  may  precede  the  fatal 
event. 

Diag^nosis. — Pigmentation  of  the  skin  is  not  confined  to  Addison's  disease. 
The  following  conditions  may  give  rise  to  an  increase  in  the  pigment;  some 
of  which,  e.  g.,  a  and  h,  are  due,  as  in  Addison's  disease,  to  disturbance  in  the 
chromaffin  system. 

(a)  Abdominal  growths — tubercle,  cancer,  or  lymphoma.  In  tuberculosis 
of  the  peritoneum  pigmentation  is  not  uncommon. 

(h)  Pregnancy,  in  which  the  discoloration  is  usually  limited  to  the  face, 


858  DISEASES  OF  THE  DUCTLESS  GLANDS 

the  so-called  m,asque  des  femmes  enceintes.     Uterine  disease  is  a  common 
cause  of  a  patchy  melasma. 

(c)  HcemochromMosisy  associated  with  cirrhosis  of  the  liver,  pigmentation 
of  the  skin,  and  diabetes. 

(d)  In  overworked  persons  of  constipated  habit  there  may  be  a  patchy 
staining  of  the  face  and  forehead. 

(e)  The  vagabond's  discoloration,  caused  by  the  irritation  of  lice  and  dirt, 
may  reach  a  high  grade,  and  has  been  mistaken  for  Addison's  disease. 

(/)  In  rare  instances  there  is  deep  discoloration  of  the  skin  in  melanotic 
cancer,  so  general  that  it  has  been  confounded  with  melasma  supn'arenale. 

(g)   In  certain  cases  of  exophthalmic  goitre  abnormal  pigmentation  occurs. 

(/i)  In  a  few  rare  instances  the  pigmentation  in  scleroderma  may  be  gen- 
eral and  deep. 

(i)  In  the  face  there  may  be  an  extraordinary  degree  of  pigmentation  due 
to  innumerable  small  black  comedones.  If  not  seen  in  a  very  good  light,  the 
face  may  suggest  argyria.  Pigmentation  of  an  advanced  grade  may  occur  in 
chronic  ulcer  of  the  stomach  and  in  dilatation  of  the  organ. 

(/)   Argyria  has  sometimes  been  mistaken  for  Addison's  disease. 

{h)  Arsenic  may  cause  a  most  intense  pigmentation  of  the  skin. 

(?)  With  arterio-sclerosis  and  chronic  heart-disease  there  may  be  marked 
melanoderma. 

(m)  In  pernicious  ancemia  the  pigmentation  may  be  extreme,  most  com- 
monly due  to  the  prolonged  administration  of  arsenic. 

{n)  There  is  a  form  of  deep  pigmentation,  usually  in  women,  which  per- 
sists for  years  without  any  special  impairment  of  health.  The  pigmentation 
is  a  little  more  leaden  than  is  usual  in  Addison's  disease. 

(o).  In  ochronosis  there  may  be  a  deep  melanotic  pigmentation  of  the 
face  and  hands. 

{p)  In  von  Eecklinghausen's  disease  the  pigmentation  may  be  uniform 
and  suggestive  of  adrenal  disease. 

In  any  case  of  unusual  pigmentation  these  various  conditions  must  be 
sought  for;  the  diagnosis  of  Addison's  disease  is  scarcely  justifiable  without 
the  asthenia.  In  many  instances  it  is  difficult  early  in  the  disease  to  arrive 
at  a  definite  conclusion.  The  occurrence  of  fainting  fits,  of  nausea,  and  gas- 
tric irritability  are  important  indications.  As  the  lesion  of  the  capsules  is 
almost  always  tuberculous,  in  doubtful  cases  the  tuberculin  test  may  be  used. 

Prognosis. — The  disease  is  usually  fatal.  The  cases  in  which  the  bronzing 
is  slight  or  does  not  occur  run  a  more  rapid  course.  There  are  occasionally 
acute  cases  which,  with  great  weakness,  vomiting,  and  diarrhoea,  prove  fatal 
in  a  few  weeks.  In  a  few  cases  the  disease  is  much  prolonged,  even  to  six  or 
ten  years.  In  rare  instances  recovery  has  taken  place,  and  periods  of  improve- 
ment, lasting  many  months,  may  occur; 

Treatment. — When  asthenia  appears  the  patient  should  be  confined  to  bed 
and  sudden  efforts  and  muscular  exercise  should  not  be  allowed.  Eatal  syn- 
cope may  occur  at  any  time.  E(^r  the  debility  arsenic  and  strychnia  are  useful ; 
for  the  diarrhoea  large  doses  of  bismuth,  and  for  the  irritability  of  the  stom- 
ach very  simple  diet  and  alkalies.  The  diet  should  be  light  and  nutritious; 
sugar  should  be  given  freely.    As  the  disease  is  nearly  always  tuberculous  an 


DISEASES  OF  THE  SUPRAEENAL  BODIES  859 

open  air  treatment  may  be  carried  out.     Tuberculin  may  be  tried  cautiously, 
particularly  if  the  case  is  seen  early. 

Operation  has  been  suggested.  The  lesion  is  usually  localized,  and  it 
should  not  be  a  difficult  matter  to  remove  the  diseased  glands;  but,  so  far 
as  we  know,  in  animals  this  is  always  a  fatal  procedure,  and  in  any  case,  unless 
there  were  supernumerary  adrenals  and  a  considerable  portion  of  the  extra- 
capsular chromaffin  intact,  the  operation  would  be  useless. 

Adrenal  Therapy. — Evidently  the  relation  of  Addison's  disease  to  the 
adrenals  is  not  the  same  as  that  of  myxoedema  to  the  thyroid  gland,  in  which 
the  insufficiency  is  promptly  relieved  by  the  administration  of  thyroid  prepa- 
rations. The  tuberculous  nature  of  the  lesions  in  most  of  the  cases  of  Addi- 
son's disease  is  an  obstacle,  and  there  is  usually  widespread  involvement  of  the 
sympathetic  system.  There  is  now  a  large  series  of  cases  treated  with  various 
preparations,  but  only  a  very  few  with  satisfactory  results.  In  only  three  of 
our  patients  was  there  marked  improvement.  In  one,  all  the  severer  symp- 
toms disappeared,  the  pigmentation  cleared  up,  and  the  patient  died  subse- 
quently of  an  acute  infection,  which  apparently  had  nothing  to  do  with  the 
disease.  The  adrenals  were  found  sclerotic  but  not  tuberculous.  The  dried . 
gland  may  be  given  in  doses  of  from  5  to  20  grains  (0.3  to  1.3  gm.)  three 
times  a  day.  Epinephrin  may  be  used  hypodermically  in  doses  of  TTLv-xv 
(0.3-1  c.  c.)  of  the  1-1000  solution.    "The  results  should  be  watched  carefully. 

II.     OTIIEE  AFFECTIONS  OF  THE  SUPEAEENAL  GLANDS 

Lesions  of  the  Adrenal  Cortex. — Eemarkable  changes  in  the  secondary 
sexual  characters  have  been  associated  with  tumors  and  other  lesions  of  this 
part — the  so-called  suprarenal  genital  syndrome.  Pseudo-hermaphroditism 
has  been  found  in  connection  with  hyperplasia  of  the  cortex,  as  in  a  case  in 
which  the  internal  organs  were  those  of  a  female  but  the  external  had  male 
characters.  The  reverse  may  occur.  Premature  puberty,  with  the  development 
of  the  secondary  sexual  characters,  may  appear  as  early  as  the  fifth  or  sixth 
year.  After  puberty  the  presence  of  a  tumor  may  lead  to  the  remarkable  con- 
dition known  in  women  as  virilismus  or  hirsutismus,  in  which  a  growth  of  hair 
occurs  on  the  face,  the  voice  becomes  masculine,  and  the  muscular  strength 
may  increase.  Later,  as  the  signs  of  tumor  develop,  there  are  emaciation, 
pigmentfition,  and  mental  changes. 

Hyper-  and  Hypo-function  of  the  Adrenals. — The  state  of  our  physiolog- 
ical knowledge  is  at  present  far  too  uncertain  to  make  it  worth  while  to  discussi 
the  clinical  vagaries  which  have  been  grouped  under  the  terms  hyper-  and  hypo- 
epinephrinaemia.  The  suggestion  of  Sergent  that  the  vaso-constrictor  skin 
reflex,  causing  tho  "white  line,"  is  an  evidence  of  adrenal  insufficiency  has 
not  been  generally  supported  but  in  some  cases  of  asthenia  and  low  blood 
pressure,  which  show  the  "white  line/'  the  response  to  the  administration  of 
epinephrin  is  prompt.  That  certain  disturbances  come  under  these  headings 
can  not  be  doubted  but  much  experimental  work  and  many  observations  are 
necessary  before  they  can  be  accurately  stated. 

Haemorrhage. — Acute  hiemorrhagic  adrenalitis  presents  a  picture  some- 
what resembling  acute  pancreatitis — a  sudden  onset  with  pain,  vomiting,  pro- 
found prostration  and  death  within  a  few  days.     In  other  cases  convulsions 


860  DISEASES  OF  THE  DUCTLESS  GLANDS 

occur  or  the  patient  falls  into  a  typhoid  state  with  profound  asthenia.  In 
children  the  disease  may  be  associated  with  purpura,  both  cutaneous  and 
visceral. 

Tumors. — Both  carcinoma  and  sarcoma  have  been  described.  They  are 
apt  to  undergo  fatty  degeneration  and  hasmorrhage,  so  that  they  may  form 
very  large  cysts.  In  children  excessive  development  of  the  genitals  with 
hair  and  fat  has  been  found,  as  noted  by  Bullock  and  Sequeira,  who  collected 
a  number  of  cases.  On  this  account  a  suggestion  has  been  made  that  the 
adrenal  cortex  has  an  hormonic  internal  secretion  which  influences  sexual 
development.  Eobert  Hutchison  described  a  remarkable  syndrome  in  chil- 
dren of  adrenal  tumor,  exophthalmos,  and  cranial  tumors;  and  William 
Pepper  (tertius)  described  a  form  characterized  by  rapid  growth,  diffuse  in- 
volvement of  the  liver,  and  great  distention  of  the  abdomen  without  ascites 
or  jaundice. 

Carotid  Glands. — Situated  at  the  bifurcation  of  the  carotid  arteries,  these 
bodies,  each  about  the  size  of  a  grain  of  wheat,  belong  to  the  chromaffin  group. 
Their  function  is  unknown.  They  are  of  interest  as  the  seat  of  tumors,  benign 
at  first  but  which  may  become  malignant,  at  the  level  of  the  top  of  the  thyroid 
cartilage. 

II.     DISEASES  OF  THE  THYMUS  GLAND 

The  thymus  in  structure  has  little  resemblance  to  the  other  ductless  glands, 
with  the  exception  of  the  epiphysis  cerebri,  and  must  be  classed  as  an  epithelial 
rather  than  as  a  lymphoid  organ  (Pappenheimer). 

At  birth  the  thymus  gland  weighs  about  12  grams; "from  the  first  to  the 
fifth  year  about  23  grams;  from  the  sixth  to  the  tenth  year  about  26  grams; 
from  the  eleventh  to  the  fifteenth  year  about  37y2  grams,  and  from  the  six- 
teenth to  the  twentieth  year  about  251/2  grams,  after  which  it  undergoes  a 
gradual  atrophy  (Hammar).  Involution  not  taking  place,  a  "persistent 
thymus"  remains. 

The  function  of  the  gland  is  not  known.  There  is  an  obscure  relationship 
between  the  thymus  and  the  sexual  glands.  After  castration  N.  Patton  found 
persistency  and  hypertrophy  of  the  gland.  A  disturbance  of  the  normal  de- 
velopment of  the  bones,  particularly  in  ossification,  also  occurs  (Basch)  and 
there  is  an  increase  in  the  excitability  of  the  nerves.  The  nature  of  the  in- 
ternal secretion  is  unknown.  Many  experiments  have  been  made  with  extract 
from  the  gland,  but  without  definite  results. 

I.     HYPEETEOPHY   OF   THE    THYMUS 

The  size  of  the  gland  varies  so  greatly  that  it  is  not  easy  to  define  the  limits 
between  persistency  and  enlargement.  Between  the  manubrium  sterni  and  the 
vertebral  column  in  an  infant  of  eight  inonths  the  distance  is  only  2.2  cm. 
(Jacobi),  so  that  it  is  easy  to  understand  how  an  enlarged  gland  may  induce 
what  Warthin  calls  "thymic  tracheostenosis."  There  would  appear  to  be,  as 
this  author  suggests,  three  groups  of  cases : 

(a)  Thymic  stridor,  either  congenital  or  developing  soon  after  birth,  vary- 
ing in  intensity  and  aggravated  by  crying  and  coughing. 


DISEASES  OF  TPIE  THYMUS  GLAND  8G1 

(b)  Thymic  asthma,  sometimes  known  as  Kopp's  or  Miller's  asthma,  is  an 
exaggerated  and  more  persistent  form  of  the  stridor.  While  much  dispute 
exists  as  to  this  form,  there  can  be  no  doubt  as  to  its  occurrence,  as  there 
are  cases  in  which  complete  relief  has  followed  removal  of  the  gland.  Olivier 
collected  39  cases  of  thymectomy  with  24  recoveries. 

(c)  Lastly,  in  some  cases  sudden  death  has  occurred,  usually  in  connec- 
tion with  the  condition  of  lymphatism  about  to  be  described. 

Persistence  of  the  gland  has  been  met  with  in  many  affections,  such  as 
Graves'  disease,  Addison's  disease,  acromegaly,  myasthenia  gravis,  rick3ts, 
etc.  Many  observers  regard  the  association  of  an  enlargement  with  Graves' 
disease  as  more  than  accidental  and  as  a  sort  of  compensatory  process. 

II.     ATROPHY  OF  THE  THYMUS 

This  is  met  with  accidentally  in  children  who  show  no  special  pathological 
changes,  especially  as  Euhrah  has  shown,  in  marasmus  and  the  chronic  wast- 
ing disorders  of  children.  Of  other  morbid  conditions,  haemorrhages  are  not 
uncommon.  Mediastinal  tumors  may  originate  in  the  remnants  of  the  thymus ; 
dermoid  tumors  and  cysts  have  also  been  met  with;  tuberculosis  and  syphilis 
of  the  gland  are  occasionally  seen.  The  condition  described  by  Dubois  in  con- 
genital syphilis,  in  which  there  are  fissure  like  cavities  in  the  gland  filled  with 
a  purulent  fluid,  is  probably  post  mortem  softening. 

III.     STATUS    THYMICO-LYMPHATICUS 

(Lymphatism) 

Definition. — A  combination  of  constitutional  anomalies  among  which  are 
hyperplasia  of  the  lymphoid  tissues  and  of  the  thymus,  hypoplasia  of  the  car- 
dio-vascular  system,  and  peculiarities  of  configuration. 

Formerly  the  condition  was  regarded  as  specially  important  in  young  chil- 
dren, but  it  is  found  both  in  children  and  adults.  In  Bellevue  Hospital,  457 
cases  were  found  among  .5,652  autopsies  (8  per  cent.).  Of  these  only  92  were 
below  the  age  of  twenty  years  (Symmers).  The  eases  in  adults  have  received 
much  attention  and  present  a  definite  picture. 

The  results  of  the  condition  are  various;  among  them  are:  (1)  The  liabil- 
ity to  sudden  death.  This  may  be  from  several  causes,  (a)  Anaphylaxis. 
Xecrosis  occurs  in  the  lymphoid  tissues  with  resulting  sensitization.  With 
further  necrosis  a  fatal  attack  may  result,  (b)  Cerebral  hcemorrhage.  The 
hypoplastic  arteries  rupture  easily,  as  from  slight  trauma,  which  is  a  point 
of  medico-legal  importance,  (c)  In  young  children  sudden  death  may  result 
from  pressure  of  the  enlarged  gland  ("thymic  death"),  but  this  is  probably 
very  rare.  (2)  Increased  susceptibility  to  acute  infections  and  decreased  re- 
sistance to  them.  This  applies  particularly  to  endocarditis,  pneumonia,  cere- 
bro-spinal  fever  and  sepsis.  (3)  In  women  there  is  increased  danger  in  child- 
birth. (4)  Psychical  Instability.  The  subjects  form  a  considerable  proportion 
of  cases  of  drug  addiction  and  suicide. 

Patholo^. — Symmers  describes  two  forms — status  lymphaticus  and  re- 
cessive status  lymphaticus.     The  former  shows  well-developed  changes  in  the 


862  DISEASES  OF  THE  DUCTLESS  GLANDS 

lymphoid  tissues  and  occurs  at  an  age  when  these  structures  are  active.  The 
recessive  form  shows  atrophic  changes  in  the  lymphoid  structures  which  vary 
with  the  time  of  involution.  Of  249  cases,  118  were  instances  of  status  lyni- 
phaticus,  89  of  the  recessive  form  and  42  were  border-line  cases,  tending 
toward  recession.  In  the  status  lymphaticus  form  the  thymus  was  hyper- 
plastic, the  average  weight  being  about  25  gm.  No  instance  was  found  of 
death  being  due  to  pressure  from  the  thymus.  Histologically  the  thymus 
showed  hyperplasia,  which  may  be  extreme.  Necrotic  changes  were  marked 
in  the  lymph  nodes  and  this  was  especially  marked  in  the  case  of  sudden  death 
from  slight  causes.  This  is  regarded  by  Symmers  as  being  in  close  relation 
to  anaphylaxis. 

Symptoms. — Children  with  lymphatism  are  often  fat,  may  be  anaemic  and 
flabby  but  are  usually  regarded  as  in  good  health.  The  tonsils  are  enlarged 
and  adenoids  are  present.  They  have  little  resistance  to  infections  and  are 
easily  upset  by  trifling  ailments.  They  are  often  subject  to  nasal  catarrh, 
mouth  breathing  is  common,  and  vaso-motor  changes  are  frequent.  The  blood 
may  show  a  marked  lymphocytosis.  The  enlarged  thymus  may  be  shown  by 
dulness  over  the  upper  sternum  and  to  each  side  of  it  which  shifts  upward 
with  extreme  retraction  of  the  head  (Boggs).  There  may  be  bulging  or  the 
gland  may  be  felt  in  the  episternal  notch.  The  X-ray  shadow  may  be  dis- 
tinct. In  these  cases  there  may  be  attacks,  often  after  a  fit  of  temper  or  a 
crying  spell,  in  which  the  child  shows  noisy  breathing,  stridor  and  cyanosis. 
Respiration  may  stop  for  some  seconds  or  death  may  occur. 

After  puberty  the  condition  is  easily  recognized.  In  males  the  main  points 
are  (1)  A  slender  thorax,  rounded  arms  and  thighs,  and  a  suggestion  of  the 
feminine  type.  (3)  A  soft  delicate  skin.  (3)  A  scanty  growth  of  hair  on 
the  face,  especially  on  the  upper  lip  and  chin,  and  in  the  axillge,  with  the 
pubic  hair  showing  the  feminine  distribution.  (4)  The  external  genitals 
may  be  poorly  developed ;  some  are  cryptorchids.  ( 5 )  The  cervical  and  axillary 
glands  may  be  palpable.  In  females  the  main  features  are  ( 1 )  A  slender 
thorax  and  extremities.  (2)  A  soft  delicate  skin.  (3)  Scanty  axillary  and 
pubic  hair.     (4)  Hypoplasia  of  the  genital  organs. 

Diagnosis. — Suspected  cases  should  be  carefully  examined  before  trifling 
operations.  The  enlargement  of  the  superficial  glands  of  the  tonsillar  tissues 
and  of  the  spleen  is  easily  determined.  The  adult  forms  are  readily  recognized 
from  the  general  characteristics. 

Treatment.— -In  children  it  is  well  to  reduce  the  sugar  and  starch  in  the 
diet  to  a  minimum,  giving  skim  milk,  eggs,  meat,  green  vegetables  and  fruits. 
A  general  tonic  treatment  with  iron  and  arsenic  should  be  given.  A  large 
thymus  causing  compression  may  require  removal  but  treatment  by  the 
X-ray  is  often  successful.     In  the  adult  forms  there  is  no  special  treatment. 


III.     DISEASES  OF  THE  THYROID  GLAND 

I.     CONGESTION 

At  puberty,  in  girls,  often  at  the  onset  of  menstruation,  the  gland  en- 
larges; in  certain  women  the  neck  becomes  fuller  at  each  menstruation,  and  it 
was  an  old  idea  that  the  gland  enlarged  at  or  after  defloration.     The  slight 


DISEASES  OF  THE  THYROID  GLAND  863 

enlargement  at  puberty  may  persist  for  months  and  cause  uneasiness,  but,  as 
a  rule,  it  disappears  completely.  From  mechanical  causes,  as  tight  collars  or 
repeated  crying,  the  gland  may  swell  for  a  short  time.  Slight  enlargement 
is  common  in  acute  infections. 

II.     THYEOIDITIS 

Etiology. — Inflammation  of  the  gland,  which  is  nearly  always  secondary 
to  some  infection,  may  be  simple  or  purulent.  It  is  most  frequent  in  typhoid 
fever,  small-pox,  measles,  pneumonia,  rheumatic  fever,  and  mumps.  Epi- 
demics of  thyroiditis  have  been  reported.  It  is  a  rare  disease  in  ordinary 
hospital  practice,  and  did  not  occur  in  our  series  of  1,500  cases  of  typhoid 
fever. 

Symptoms. — The  whole  gland  may  be  involved,  or  only  one  lobe.  There 
are  swelling,  pain  on  pressure,  redness  over  the  afl^ected  part,  and,  when  sup- 
puration occurs,  softening  or  fluctuation.  Often  the  acute  inflammation  sub- 
sides spontaneously.  Myxcedema  has  followed  destruction  of  the  entire  gland 
by  acute  supjDuration. 

A  remarkable  sclerotic  thyroiditis  has  been  described  by  Riedel  and  is 
sometimes  called  after  his  name.  It  is  important,  as,  in  the  rapidity  of  its 
evolution  and  in  the  production  of  a  diffuse  tumor  involving  the  wdiole  gland, 
the  clinical  picture  may  resemble  cancer.  The  gland  becomes  firmly  fixed 
to  the  surrounding  parts  and  serious  effects  may  be  produced  by  compression 
of  the  trachea  and  the  recurrent  laryngeal  nerves.  The  cut  section  of  the 
gland  is  white  and  smooth,  and  shows  a  dense  fibrous  tissue. 

III.     TUMOES  OF  THE  THYROID 

Of  these  the  most  important  are :  (a)  Infective  granulomata — tuberculo- 
sis, actinomycosis,  and  syphilis.  Cases  are  very  rare.  Tuberculosis  may  be 
mistaken  for  exophthalmic  goitre.  Swelling  of  the  gland  has  been  seen  in 
recent  syphilitic  infection,  and  gummata  may  occur  in  the  congenital  form. 
(&)  Adenomata,  simple  or  malignant.  The  latter  may  cause  extensive  metas- 
tases, as  in  the  case  reported  by  Haward,  in  which  tumors  resembling  thyroid 
tissue  occurred  in  the  lungs  and  various  bones,  (c)  Cancer  and  sarcoma, 
which  are  rare,  have  a  surgical  interest. 

IV.     ABERRANT    AND   ACCESSORY   THYROIDS 

In  various  places,  from  the  root  of  the  tongue  to  the  arch  of  the  aorta, 
fragments  of  thyroidal  tissue  have  been  found.  These  aberrant  portions  of 
the  gland  are  very  apt  to  enlarge  and  undergo  cystic  degeneration.  In  the 
mediastinum  they  may  form  large  tumors,  and  in  the  pleura  an  accessory 
cystic  thyroid  may  occupy  the  upper  portion,  and  a  case  was  reported  by  F. 
A.  Packard,  in  which  the  cystic  gland  filled  nearly  the  entire  side.  The 
so-called  lingual  thyroid  is  not  uncommon,  varying  in  size  from  a  hemp  seed 
to  a  pea,  usually  free  in  the  deep  muscles  of  the  tongue,  or  attached  to  the 
hyoid  bone.    When  enlarged  the  lingual  goitre  may  form  a  tumor  of  consider- 


864  DISEASES  OF  THE  DUCTLESS  GLANDS 

able  size.    The  true  thyroid  gland  has  been  absent,  and  removal  of  the  lingual 
goitre  has  been  followed  by  myxoedema. 

V.     GOITRE 

{Struma,  Bronchocele) 

Definition. — A  chronic  enlargement  of  the  thyroid  gland,  of  unknown 
origin,  occurring  sporadically  or  endemically. 

Distribution. — Goitre  in  the  LTnited  States  is  perhaps  most  common  in 
the  region  of  the  Great  Lakes.  In  an  investigation  in  Michigan,  Dock  found 
a  large  number  of  cases  and  the  disease  is  not  uncommon  in  Lower  Canada. 
In  England  it  is  common  in  certain  regions;  the  Thames  valley,  the  Dales, 
Derbyshire,  Sussex,  and  Hampshire.  It  is  very  prevalent  about  Oxford  and 
the  upper  Thames  valley.  In  Switzerland,  in  the  mountains  of  Germany  and 
Austria,  the  mountainous  districts  of  France,  and  in  the  Pyrenees  the  disease 
is  very  prevalent.  In  regions  of  Central  Asia,  in  the  Abyssinian  mountains, 
and  in  the  Himalayas  there  are  many  foci  of  the  disease. 

Etiology. — The  disease  is  rarely  congenital  except  in  very  goitrous  dis- 
tricts. Cases  are  most  common  at  or  about  puberty,  and  the  tendency  dimin- 
ishes after  the  twentieth  year.  Women  are  much  more  frequently  attacked 
than  men,  in  a  proportion  of  6  or  8  to  1. 

^In  its  endemic  form  the  disease  occurs  at  every  latitude  and  in  every  alti- 
tude, in  valleys  and  in  plains,  and  in  various  climates.  It  seems  to  be  much 
less  prevalent  by  ^the  seashore. 

The  cause  is  obscure.  The  water  in  goitrous  districts  is  hard,  rich  in  lime 
and  magnesia,  poor  in  iodine,  and  (so  Eedin  affirms  of  the  Swiss  waters)  with 
a  high  degree  of  radio-activity.  Others  speak  of  a  "miasma"  of  the  soil  which 
gets  into  the  drinking  water.  McCarrison  in  Kashmir  found  that-  the  specific 
agent  could  be  killed  by  boiling  the  water  and  that  it  did  not  pass  a  Berkefeld 
filter.  He  produced  goitre  in  himself  and  in  others  by  the  daily  consumption 
of  the  residue  of  the  filter,  but  the  residue  when  boiled  was  harmless.  The 
disease  was  transmitted  to  goats  who  drank  water  contaminated  by  goitre  pa- 
tients. There  are  "goitre  springs"  and  "goitre  wells."  These  and  other  facts 
strongly  suggest  a  specific  organism ;  and  this  view  is  supported  by  the  remark- 
able outbreaks  of  acute  goitre  in  schools,  lasting  for  a  few  months  and  disap- 
pearing. In  one  such  outbreak  161  boys  among  350  and  245  girls  among  381 
were  attacked  (Guillaume). 

Morbid  Anatomy. — Usually  the  whole  gland  is  involved,  but  one  lol)e  only 
may  be  attacked.  When  the  enlargement  is  uniform,  and  the  appearance  of 
the  gland  natural,  it  is  spoken  of  as  parenchymatous  goitre;  when  the  blood 
vessels  are  very  large,  vascular  goitre.  In  both  forms  there  is  an  increase  in 
the  colloid  material  of  the  follicles.  Degenerations  of  various  kinds  are  com- 
mon, particularly  cystic,  in  which  there  are  many  large  and  small  cavities 
with  colloid  contents.  In  some  of  these  cystic  forms  there  are  papillary  in- 
growths into  the  alveoli.  Sometimes  the  cysts  contain  blood  and  extensive 
haemorrhages  occur  in  the  gland. 

Symptoms. — When  small  a  goitre  is  not  inconvenient,  but  when  large 
pressure  symptoms  may  cause  the  patient  to  seek  relief.     The  windpipe  may 


DISEASES  OF  THE  THYEOID  GLAXD  865 

be  flattened  from  i^ressure,  usually  of  an  enlarged  isthmus,  or  it  is  narrowed 
by  circular  compression.  The  symptoms  are  more  or  less  marked  stridor  and 
cough,  which  may  persist  for  years  without  special  aggravation.  They  may 
be  present  with  very  large  glands,  or  with  the  small  encircling  goitre,  or  with 
the  goitre  which  passes  deeply  beneath  the  sternum.  Pressure  on  the  recur- 
rent nerves  may  cause  attacks  of  dyspno-a,  particularly  at  night,  and  the  voice 
may  be  altered.  Pressure  on  the  vagus  is  not  common.  Sometimes  there  is 
difficulty  in  swallowing,  and  the  veins  of  the  neck  may  be  compressed.  The 
heart  is  often  involved,  either  from  pressure  on  the  vagi,  or  there  is  dilatation 
associated  with  dyspnoea.  This  is  sometimes  spoken  of  as  the  "goitre  heart" 
in  contra-distinction  to  the  cardiac  condition  in  Graves'  disease. 

Prognosis. — ]\Iauy  cases  in  the  young  get  vrell;  too  often  in  goitrous  dis- 
tricts the  tumor  persists.  It  may  disappear  on  leaving  the  district.  Many 
cases  get  well  without  medical  treatment,  but  when  pressure  symptoms  occur 
surgery  gives  relief. 

Treatment. — In  goitrous  districts  the  drinking  water  should  be  boiled. 
Simple  goitre  can  be  prevented  by  small  doses  of  iodine.  Iodine  in  some  form 
is  used  extensively,  and  often  is  curative.  Its  effect  is  to  stimulate  the  gland 
to  healthy  action.  In  young  people  2  to  5  grains  (0.13  to  0.3  gm.)  of  potas- 
sium or  sodium  iodide  may  be  given  daily.  Iodine  injections  into  the  gland 
are  not  advisable.  Iodine  may  be  applied  externally  as  an  ointment  (5  per 
cent.).  The  X-rays  have  been  tried  with  success.  When  the  gland  is  large, 
surgical  measures  are  indicated. 

YI.     HYPOTHYEOIDISM 

(Cretinism  and  Myxedema) 

Definition. — A  constitutional  affection  due  to  the  loss  of  function  of  the 
thyroid  gland,  characterized  clinically  by  a  myxoedematous  condition  of  the 
subcutaneous  tissues  and  mental  failure,  and  anatomically  by  atrophy  of  the 
thyroid  gland. 

History. — As  early  as  1859  Schiff  had  noted  that  in  the  dog  removal  of 
the  gland  was  followed  by  certain  symptoms.  Gull  described  "A  cretinoid 
change  in  women,"  and  in  the  eighties  the  observations  of  Ord  and  other 
English  physicians  separated  a  well  defined  clinical  entity  called  "myx- 
oedema." 

Kocher  (in  1883)  reported  that  30  of  his  first  100  thyroidectomies  had 
been  followed  by  a  very  characteristic  picture,  to  which  he  gave  the  name 
"cachexia  strumipriva,"  an  observation  which  had  already  been  made  in  the 
previous  year  by  the  Peverdins,  who  also  had  recognized  the  relation  of  this 
change  to  the  disease  known  as  "myxcedema."  The  researches  of  Horsley, 
and  the  investigation  of  the  Committee  of  the  Clinical  Society  of  London, 
made  it  clear  that  the  changes  following  complete  removal  of  the  gland, 
cachexia  strumipriva,  niyxoedema,  and  the  sporadic  cretinism,  were  one  and 
the  same  disease,  due  to  the  loss  of  the  function  of  the  thyroid  gland.  Schiff 
and  Horsley  demonstrated'  that  animals  could  be  saved  by  the  transplantation 
of  the  glands.  Lastly  came  the  discovery  of  George  Murray  and  Howitz 
that  fci'ding  A\itli  the  tliyroid  extract  replaced  the  ghiiid  function,  and  cured 


866  DISEASES  OF  THE  DUCTLESS  GLANDS 

the  disease.  The  first  patient  given  thyroid  by  Murray  in  1891  died  in  1919, 
aged  74,  from  heart  disease.  The  activitv  of  the  gland  is  connected  with 
the  metabolism  of  iodine. 

Kendall  has  isolated  the  active  principle  which  he  terms  thyroxin  and 
which  contains  65  per  cent,  of  iodine.  It  is  an  amino-acid  which  enters  into 
reaction  and  is  regenerated  so  that  it  can  repeat  the  process.  It  acts  as  does 
thyroid  extract  in  myxoedema.  There  is  a  quantitative  relation  between  thy- 
roxin and  the  rate  of  basal  metabolism. 

The  outcome  of  a  host  of  researches  has  been  the  recognition  of  the  enor- 
mous importance  of  the  internal  secretion  of  the  gland,  which  is  essential 
for  normal  growth  in  childhood,  and  has  a  marked  influence  on  metabolism.  It 
stimulates  both  vegetative  nervous  systems. 

Clinical  Forms. — There  are  three  groups  of  cases — cretinism,  myxoedema 
proper,  and  operative  myxoedema.  To  Felix  Semon  is  due  the  credit  of  recog- 
nizing that  these  were  one  and  the  same  condition  and  all  due  to  loss  of  func- 
tion of  the  thyroid  gland. 

Cretinism. — Two  forms  are  recognized — the  sporadic  and  the  endemic. 
In  the  sporadic  form  the  gland  may  be  congenitally  absent,  or  is  atrophied 
after  one  of  the  specific  fevers,  or  the  condition  develops  with  goitre.  The 
disease  is  not  very  uncommon;  the  histories  of  58  cases  were  collected  in 
a  few  years  in  the  United  States  and  Canada  (Osier).  It  is  more  common 
in  females  than  in  males — 35  in  the  series. 

Morbid  Anatomy.- — Absence  of  the  gland,  or  complete  fibrous  atrophy, 
is  the  common  condition.  Goitre  with  any  trace  of  gland  tissue  is  rare.  In 
the  sporadic  form  sometimes  the  hypophysis  and  thymus  have  been  found  en- 
larged. Arrest  of  development,  a  brachycephalic  skull  in  the  endemic,  and  a 
dolichocephalic  in  the  sporadic  form,  are  the  chief  skeletal  changes. 

Symptoms. — In  the  congenital  cases  the  condition  is  rarely  recognized 
before  the  infant  is  six  or  seven  months  old.  Then  it  is  noticed  that  the  child 
does  not  grow  so  rapidly  and  is  not  bright  mentally.  The  tongue  looks  large 
and  hangs  out  of  the  mouth.  The  hair  may  be  thin  and  the  skin  very  dry. 
Usually  by  the  end  of  the  first  year  and  during  the  second  year  the  signs  be- 
come very  marked.  The  face  is  large,  looks  bloated,  the  eyelids  are  puffy 
and  swollen ;  the  alse  nasi  are  thick,  the  nose  looks  depressed  and  flat.  Denti- 
tion is  delayed,  and  the  teeth  which  appear  decay  early.  The  abdomen  is 
swollen,  the  legs  are  thick  and  short,  and  the  hands  and  feet  are  undeveloped 
and  pudgy.  The  face  is  pale  and  sometimes  has  a  waxy,  sallow  tint.  The 
fontanelles  remain  open;  there  is  muscular  weakness,  and  the  child  can  not 
support  itself.  In  the  supraclavicular  regions  there  are  large  pads  of  fat. 
The  child  does  not  develop  mentally  and  may  lapse  into  imbecility. 

In  cases  in  which  the  atrophy  of  the  gland  follows  a  fever  the  condition 
may  not  come  on  until  the  fourth  or  fifth  year,  or  later.  This  is  really,  as 
Parker  determined,  a  juvenile  myxoedema.  In  a  few  of  the  sporadic  forms 
cretinism  develops  with  an  existing  goitre.  It  may  retard  development,  bodily 
and  mental,  without  ever  progressing  to  complete  imbecility. 

Endemic  Cretinism. — This  occurs  wherever  goitre  is  very  prevalent,  as  in 
parts  of  Switzerland,  Savoy,  Tyrol,  and  the  Pyrenees.  It  formerly  prevailed 
in  parts  of  England.  The  clinical  features  are  the  same  as  in  the  sporadic 
form,  stunted  growth  and  feeble  mind,  plus  goitre.     To  some  poison  in  the 


DISEASES  OF  THE  THYEOID  GLAND  867 

water — mineral  or  organic — the  thyroid  changes  have  been  attributed,  but 
whatever  the  toxic  agent  may  be,  it  is  the  interference  with  the  function  of 
the  gland  that  leads  to  the  cretinous  change  in  the  body. 

The  diagnosis  is  very  easy  after  one  has  seen  a  case,  or  good  illustrations. 
Infants  a  year  or  so  old  sometimes  become  flabby,  lose  their  vivacity,  or  show 
a  protuberant  abdomen,  and  lax  skin  with  slight  cretinoid  appearance.  These 
milder  forms,  as  they  have  been  termed,  are  probably  due  to  transient  func- 
tional disturbance  in  the  gland. 

Myxcedema  of  Adults  (Gull's  Disease). — Women  are  much  more  fre- 
quently affected  than  men — in  a  ratio  of  6  to  1.  The  disease  may  affect  several 
members  of  a  family,  and  it  may  be  transmitted  through  the  mother.  In  some 
instances  there  has  been  first  the  appearance  of  exophthalmic  goitre.  Though 
most  common  in  women,  it  seems  to  have  no  special  relation  to  menstruation 
or  pregnancy;  the  symptoms  of  myxcedema  may  disappear  during  pregnancy 
or  may  develop  post  partum.  Myxcedema  and  exophthalmic  goitre  may  occur 
in  sisters.  It  is  not  so  common  in  America  as  in  England.  In  sixteen 
years  only  10  cases  were  seen  in  Baltimore,  7  of  which  were  in  the  hospital. 
C.  P.  Howard  collected  100  American  cases,  of  which  86  were  in  women. 
The  symptoms,  as  given  by  Ord,  are  marked  increase  in  the  general  bulk  of 
the  body,  a  firm,  inelastic  swelling  of  the  skin,  which  does  not  pit  on  pres- 
sure; dryness  and  roughness,  which  tend  with  the  swelling  to  obliterate  in 
the  face  the  Knes  of  expression;  imperfect  nutrition  of  the  hair;  local  tume- 
faction of  the  skin  and  subcutaneous  tissYies,  particularly  in  the  supraclavicular 
region.  Perspiration  is  often  much  decreased.  The  physiognomy  is  altered 
in  a  remarkable  way :  the  features  are  coarse  and  broad,  the  lips  thick,  the 
nostrils  broad  and  thick,  and  the  mouth  is  enlarged.  Over  the  cheeks,  some- 
times the  nose,  there  is  a  reddish  patch.  There  is  a  striking  slowness  of 
thought  and  of  movement.  The  memory  becomes  defective,  the  patients  grow 
irritable  and  suspicious,  and  there  may  be  headache.  In  some  instances  there 
are  delusions  and  hallucinations,  leading  to  a  final  condition  of  dementia.  The 
gait  is  heavy  and  slow.  The  temperature  may  be  below  normal.  The  patients 
often  suffer  in  cold  weather.  The  functions  of  the  heart,  lungs,  and  abdominal 
organs  are  normal.  Haemorrhage  sometimes  occurs.  Albuminuria  is  some- 
times present,  more  rarely  glycosuria.  Death  is  usually  due  to  some  intercur- 
rent disease,  most  frequently  tuberculosis  (Greenfield).  The  thyroid  gland 
is  diminished  in  size  and  may  become  completely  atrophied  and  converted 
into  a  fibrous  mass.  The  subcutaneous  fat  is  abundant,  and  in  one  or  two 
instances  a  great  increase  in  the  mucin  has  been  found.  The  larynx  is  also, 
involved. 

The  basal  metabolism  is  reduced  20  to  40  per  cent,  below  the  normal. 

The  course  is  slow  but  progressive,  and  extends  over  ten  or  fifteen  years. 
A  condition  of  acute  and  temporary  myxcedema  may  develop  in  connection 
with  enlargement  of  the  thyroid  in  young  persons.  Myxcedema  may  follow 
exophthalmic  goitre.  In  other  instances  the  symptoms  of  the  two  diseases 
have  been  combined.  In  one  case  a  young  man  became  bloated  and  increased 
in  weight  enormously  during  three  months,  then  had  tachycardia  with  tremor 
and  active  delirium,  and  died  within  six  months  of  the  onset  of  the  symptoms. 

Operative  Myxcedema;  Cachexia  Strumipriva. — Horsley  showed  that 
complete  removal  of  the  thyroid  in  monkeys  was  followed  by  the  production 


868  DISEASES  OF  THE  DUCTLESS  GLANDS 

of  a  condition  similar  to  that  of  myxoedema  and  sometimes  associated  with 
spasms  or  tetanoid  contractures,  and  followed  by  apathy  and  coma.  An  identi- 
cal condition  sometimes  follows  extirpation  of  the  thyroid  in  man.  The  dis- 
ease follows  only  a  certain  number  of  total  and  a  much  smaller  proportion  of 
partial  removals  of  the  thyroid  gland.  Of  408  cases,  in  69  the  operative 
myxoedema  occurred  (Kocher).  If  a  small  fragment  of  the  thyroid  remains, 
or  if  there  are  accessory  glands,  which  in  animals  are  very  common,  the  symp- 
toms do  not  develop.  Operative  myxoedema  is  very  rare  in  i\.merica.  A  few 
years  ago  only  two  cases  were  found,  one  of  which,  McGraw's,  referred  to  in 
previous  editions  of  this  work,  has  since  been  cured. 

The  diagnosis  of  myxoedema  is  easy,  as  a  rule.  The  general  aspect  of  the 
patient — the  subcutaneous  swelling  and  the  pallor — ^suggests  nephritis,  which 
may  be  strengthened  by  the  discovery  of  tube  casts  and  of  albumin  in  the 
urine;  but  the  solid  character  of  the  swelling,  the  exceeding  dryness  of  the 
skin,  the  yellowish  white  color,  the  low  temperature,  the  loss  of  hair,  and 
the  dull,  listless  mental  state  should  suffice  to  differentiate  the  conditions.  In 
mild  cases  the  result  of  thyroid  administration  may  be  an  aid  in  diagnosis.  In 
dubious  cases  not  too  much  stress  should  be  laid  upon  the  supraclavicular 
swellings.  There  may  be  marked  fibro-fatty  enlargements  in  this  situation  in 
healthy  persons,  the  supraclavicular  pseudo-lipomata  of  Verneuil. 

Hypothyroidism  should  be  considered  in  children  who  are  dull  and  back- 
ward, in  women  who  have  symptoms  suggesting  a  premature  menopause,  in 
obesity,  and  in  those  with  constipation  the  cause  for  which  is  obscure. 

Treatment. — The  patients  suffer  in  cold  and  improve  greatly  in  warm 
weather;  They  should  therefore  be  kept  at  an  even  temperature,  and  should, 
if  possible,  move  to  a  warm  climate  during  the  winter  months.  Eepeated 
warm'  baths  with  massage  are  useful.  Our  art  has  made  no  more  brilliant  ad- 
vance than  in  the  cure  of  these  disorders  due  to  disturbed  function  of  the 
thyroid  gland.  That  we  can  to-day  rescue  children  otherwise  doomed  to  help- 
less idiocy — that  we  can  restore  to  life  the  hopeless  victims  of  myxoedema — 
is  a  triumph  of  experimental  medicine  for  which  we  are  indebted  very  largely 
to  Victor  Horsley  and  his  pupil  Murray.  Transplantation  of  the  gland  was 
first  tried ;  then  Murray  used  an  extract  subcutaneously.  Hector  Mackenzie  in 
London  and  Howitz  in  Copenhagen  introduced  the  method  of  feeding.  We 
now  know  that  the  gland  is  efficacious  in  a  majority  of  all  the  cases  of  myx- 
oedema in  infants  or  adults.  It  makes  little  difference  how  the  gland  is 
administered.  The  dried  gland  is  the  most  convenient.  It  is  well  to  begin 
with  the  Thyroideum  siccum  U.  S.  P.  1  grain  (0.065  gm.)  three  times  a  day. 
The  dose  may  be  increased  gradually  until  the  patient  takes  10  or  15  grains 
(0.6  gm.  to  1  gm.)  in  the  day.  Care  should  be  taken  to  be  sure  of  the  strength 
of  the  preparation  which  is  given.  In  many  cases  there  are  no  unpleasant 
symptoms;  in  others  there  are  irritation  of  the  skin,  restlessness,  rapid  pulse, 
and  delirium;  in  rare  instances  tonic  spasms,  the  condition  to  which  the  term 
thyroidism  is  applied.  The  results,  as  a  rule,  are  most  astounding- — unparal- 
leled by  anything  in  the  whole  range  of  curative  measures.  Within  six  weeks 
a  poor,  feeble-minded,  toad-like  caricature  of  humanity  may  be  restored  to 
mental  and  bodily  health.  Loss  of  weight  is  one  of  the  first  and  most  striking 
effects;  one  patient  lost  over  30  pounds  within  six  weeks.  The  skin  becomes 
moist,  tbe  urine  is  increased,  the  perspiration  returns,  the  temperature  rises. 


DISEASES  OF  THE  THYKOID  GLAND  869 

the  pulse  rate  quickens,  and  the  mental  torpor  lessens.  Ill  effects  are  rare. 
Two  or  three  cases  M'ith  old  heart  lesions  have  died  during  or  after  the  treat- 
ment; in  one  a  temporary  condition  of  Graves'  disease  was  induced. 

The  treatment,  as  Murray  suggests,  must  he  carried  out  in  two  stages — 
one,  early,  in  which  full  doses  are  given  until  the  cure  is  effected;  the  other, 
the  permanent  use  of  small  doses  sufficient  to  preserve  the  normal  metabolism. 
In  the  cases  of  cretinism  it  seems  to  be  necessary  to  keep  up  the  treatment 
indefinitely  as  relapse  may  follow  the  cessation  of  the  use  of  the  extract. 

VII.     HYPERTHYEOIDISM;    EXOPHTHALMIC  GOITRE 

{Graves',  Basedow's,  or  Parry's  Disease) 

Definition. — A  disease  characterized  by  goitre,  exophthalmos,  tachycardia, 
and  tremor,  associated  with  a  perverted  or  hyperactive  state  of  the  thyroid 
gland  and  increased  activity  of  the  vegetative  nervous  system. 

A  distinction  should  be  made  between  hyperthyroidism  and  Graves'  dis- 
ease. Not  all  the  cases  of  over-activity  of  the  gland  go  on  to  exophthalmic 
goitre,  but  it  is  probable  that  the  possibility  of  this  progress  exists.  It  may  be 
difficult  to   classify  some  of  the  borderline  cases. 

Historical  Note. — In  the  posthumous  writings  of  Caleb  Hillier  Parry 
(1825)  is  a  description  of  8  cases  of  Enlargement  of  the  Thyroid  Gland  in 
Connection  with  Enlargement  or  Palpitation  of  the  Heart.  In  the  first  case, 
seen  in  1786,  he  also  described  the  exophthalmos:  "The  eyes  were  protruded 
from  their  sockets,  and  the  countenance  exhibited  an  appearance  of  agitation 
and  distress,  especially  in  any  muscular  movement."  The  Italians  claim  that 
Flajani  described  the  disease  in  1800.  Moebius  states  that  his  original  ac- 
count is  meagre  and  inaccurate,  and  bears  no  comparison  with  that  of  Parry. 
If  the  name  of  any  physician  is  to  be  associated  with  the  disease,  imdoubtedly 
it  should  be  that  of  the  distinguished  old  Bath  physician.  Graves  described 
the  disease  in  1835  and  Basedow  in  1840. 

Etiolo^. — Age. — In  Sattler's  collection  of  3,4:77  cases  only  184  were 
under  the  age  of  sixteen.  Sex — In  England  and  America  the  proportion  of 
females  is  greatly  in  excess,  as  much  probably  as  20  to  1,  but  in  Sattler's  col- 
lected cases  the  ratio  was  5.4  to  1,  which  would  indicate  marked  differences  in 
different  countries. 

The  exciting  factors  are  probably  varied.  The  acute  infections,  local  in- 
fections, thyroiditis,  profound  nervous  disturbance,  worry,  mental  shock,  a 
severe  fright,  and  changes  in  the  vegetative  nervous  system,  may  be  responsible. 

A  strong  family  predisposition  may  exist  and  five  or  six  members  may  be 
affected. 

Pathology. — The  essential  change  consists  in  increased  activity  of  the 
gland,  Avhich  enlarges  as  a  result  of  hyperplasia  and  shows  increased  vascu- 
larity. The  normal  colloid  is  greatly  reduced  or  absent.  The  epithelial  cells 
of  the  follicles  show  proliferation  and  the  lymph-adenoid  tissue  is  increased. 
These  changes  may  occur  only  in  limited  areas  of  the  gland  tissue.  The  en- 
largement occasiojially  results  in  mechanical  disturbance.  The  increased  se- 
cretion causes  definite  results:  (1)  There  is  a  great  increase  in  metabolism; 
(2)  other  endocrine  glands  are  affected,  and  (;5)  tlie  vegetative  nervous  system 


870  DISEASES  OF  THE  DUCTLESS  GLANDS 

is  stimulated.  The  active  principle — thyroxin — has  been  isolated  by  Kendall. 
In  many  cases  there  is  enlargement  of  the  thymus,  which  may  play  a 
part  in  the  lymphocytosis  nsually  found  (30-60  per  cent.)  with  decrease  in 
the  neutrophiles.  Myxcedema  may  develop  in  the  late  stages,  and  there  are 
transient  oedema  and  in  a  few  cases  scleroderma,  which  indicate  that  the  nutri- 
tion of  the  skin  is  involved. 

Anatomical  Changes. — In  rare  instances  the  thyroid  gland  has  been  stated 
to  be  normal.  In  the  majority  of  cases  there  is  active  hyperplasia  of  the  gland, 
with  enlarged  and  newly  formed  follicles,  and  an  increase  in  the  lymphoid 
tissue  of  the  gland  stroma.  Involuntary  and  regressive  changes  are  common; 
the  hyperplasia  may  cease  and  the  gland  returns  to  the  colloid  state.  Finally, 
in  certain  cases,  atrophy  of  the  cell  elements  takes  place. 

The  iodine  content  of  the  gland  bears  a  direct  relationship  to  the  amount 
of  colloid;  the  gland  in  hyperplasia  has  the  lowest  percentage,  the  pure  colloid 
glands  the  highest. 

Symptoms. — Acute  and  chronic  forms  may  be  recognized.  In  the  acute 
form  the  disease  may  arise  with  great  rapidity.  In  a  patient  of  J.  H.  Lloyd's, 
of  Philadelphia,  a  woman,  aged  thirty-nine,  who  had  been  considered  perfectly 
healthy,  but  whose  friends  had  noticed  that  for  some  time  her  eyes  looked 
rather  large,  was  suddenly  seized  with  intense  vomiting  and  diarrhoea,  rapid 
action  of  the  heart,  and  great  throbbing  of  the  arteries.  The  eyes  were  promi- 
nent and  the  thyroid  gland  was  much  enlarged  and  soft.  The  gastro-in- 
testinal  symptoms  continued,  the  pulse  became  more  rapid,  the  vomiting  was 
incessant,  and  the  patient  died  on  the  third  day  of  the  illness.  The  acute  cases 
show  marked  toxaemia  but  are  not  always  associated  with  delirium. 

More  frequently  the  onset  is  gradual  and  the  disease  is  chronic.  There 
are  four  characteristic  symptoms — tachycardia,  exophthalmos,  enlargement 
of  the  thyroid,  and  tremor. 

Taciitcaedia. — Eapid  heart  action  is  the  most  constant  phenomenon. 
The  pulse  rate  at  first  may  be  not  more  than  95  or  100,  but  when  the  disease 
is  established  it  may  be  from  140  to  160,  or  even  higher.  The  increase  is  most 
marked  in  the  sympathicotonic  cases.  Irregularity  is  not  common,  except 
toward  the  close.  In  a  well  developed  case  the  visible  area  of  cardiac  pulsation 
is  much  increased,  the  action  is  heaving  and  forcible,  and  the  shock  of 
the  heart  sounds  is  well  felt.  The  large  arteries  at  the  root  of  the  neck  throb 
forcibly.  There  is  visible  pulsation  in  the  peripheral  arteries.  The  capillary 
pulse  is  readily  seen,  and  there  are  few  diseases  in  which  one  may  see  at  times 
with  greater  distinctness  the  venous  pulse  in  the  veins  of  the  hand.  The 
throbbing  pulsation  of  the  arteries  may  be  felt  even  in  the  finger  tips.  Vascu- 
lar erythema  is  common — the  face  and  neck  are  flushed  and  there  may  be  a 
widespread  erythema  of  the  body  and  limbs.  Murmurs  are  usually  heard,  a 
loud  apex  systolic  and  loud  bruits  at  the  base  and  over  the  manubrium.  The 
heart  sounds  may  be  very  intense.  In  rare  instances  they  may  be  heard  at 
some  distance  from  the  patient;  according  to  Graves,  as  far  as  four  feet.  At- 
tacks of  acute  dilatation  may  occur  with  dyspnoea,  cough,  and  a  frothy  bloody 
expectoration. 

Exophthalmos. — A  characteristic  facial  aspect  is  given  by  the  staring 
expression,  caused  in  part  by  protrusion  of  the  eyeballs,  but  more  particularly 
by  retraction  of  the  lids  exposing  the  sclerae.     The  exophthalmos,  which  may 


DISEASES  OF  THE  THYROID  GLAND  871 

be  unilateral,  usually  follows  '{he  vascular  disturbance.  The  protrusion  may 
become  very  great  and  the  eyr  may  even  be  dislocated  from  the  socket,  or  both 
eyes  may  be  destroyed  by  po^nophthalmitis.  The  vision  is  normal.  Graefe 
noted  that  when  the  eyeball  h  moved  downward  the  upper  lid  does  not  follow 
it  as  in  health.  This  is  known  as  Graefe's  sign.  The  palpebral  aperture  is 
wider  than  in  health,  owing  to  spasm  or  retraction  of  the  upper  lid.  The  pa- 
tient winks  less  frequently  than  in  health  (Stellwag's  sign).  There  is  marked 
tremor  of  the  lids  and  they  contract  spasmodically  in  advance  of  the  elevating 
eyeball.  Moebius  called  attention  to  the  lack  of  convergence  of  the  two  eyes. 
The  majority  of  the  eye  signs  are  autonomic  in  origin.  Changes  in  the  pupils 
and  in  the  optic  nerves  are  rare.    Pulsation  of  the  retinal  arteries  is  common. 

Enlargement  of  the  thykoid  is  the  rule.  It  may  be  general  or  in  only 
one  lobe,  and  is  rarely  so  large  as  in  ordinary  goitre.  It  niay  be  absent.  The 
swelling  is  firm,  but  elastic.  There  are  rarely  pressure  signs.  The  vessels 
are  usually  much  dilated,  and  the  whole  gland  may  be  seen  to  pulsate.  A 
thrill  may  be  felt  on  palpation  and  on  auscultation  a  systolic  murmur.  A 
double  murmur  is  common  and  is  pathognomonic  (Guttmann). 

Tremor  is  the  fourth  cardinal  symptom,  and  was  really  first  described  by 
Basedow.  It  is  involuntary,  fine,  about  eight  to  the  second.  It  is  of  great 
importance  in  the  diagnosis  of  the  early  cases. 

Other  features  are  angemia,  emaciation,  and  slight  fever.  The  blood  shows 
lymphocytosis.  Attackn  of  vomiting  and  diarrhoea  may  occur.  The  latter  may 
be  very  severe  and  distressing,  recurring  at  intervals.  The  greatest  complaint 
is  of  the  forcible  throbbing  in  the  arteries,  often  accompanied  with  unpleasant 
flushes  of  heat  and  profuse  perspirations.  An  erythematous  flushing  is  com- 
mon. Pruritus  may  be  a  severe  and  persistent  symptom.  Multiple  telan- 
giectases have  been  described.  Solid,  infiltrated  oedema  is  not  uncommon  and 
may  be  transitory.  A  remarkable  myxoedematous  state  may  supervene.  Pig- 
mentary changes  are  common  and  may  be  patchy  or  generalized.  The  co- 
existence of'  sclerod'"  rma  and '  Graves'  disease  has  been  frequently  noticed. 
Irritability  of  temper,  change  in  disposition,  and  great  mental  depression 
occur.  An  important  complication  is  acute  mania,  in  which  the  patient  may 
die  in  a  few  days.  Weakness  of  the  muscles  is  not  uncommon,  particularly 
a  feeling  of  "giving  way"  of  the  legs.  If  the  patient  holds  the  head  down 
and  is  asked  to  look  up  without  raising  the  head,  the  forehead  remains 
smooth  and  is  not  wrinkled,  as  in  a  normal  individual  (Joffroy).  A  feature 
of  interest  noted  by  Charcot  is  the  great  diminution  in  the  electrical  resistance, 
which  may  be  due  to  the  saturation  of  the  skin  with  moisture  owing  to  the 
vaso-motor  dilatation  (Hirt).  Bryson  noted  that  the  chest  expansion  may 
be  greatly  diminished.  The  emaciation  may  be  extreme.  Glycosuria  and 
albuminuria  are  not  infrequent  and  true  diabetes  may  occur. 

The  basal  metabolism  (minimal  heat  production)  shows  a  marked  increase 
and  this,  is  an  important  aid  in  diagnosis.  In  very  severe  cases  the  increase 
may  be  75  per  cent,  or  over,  in  severe  cases  50  to  75  per  cent.,  and  in  milder 
forms  from  20  to  50  per  cent. 

The  course  is  usually  chronic,  lasting  several  years.  After  persisting  for 
six  months  or  a  year  the  symptoms  may  disappear.  There  are  remarkable 
instances  in  which  the  symptoms  have  come  on  with  great  intensity,  following 
fright,  and  have  disappeared  again  in  a  few  days. 


872  DISEASES  OF. THE  DUCTLESS  GLANDS 

Prognosis. — Statistics  are  misleading  as  only  the  severe  cases  come  muler 
hospital  treatment.  Sattler  estimates  the  mortality  at  11  per  cent.  In  Hale 
White's  series  it  was  81  in  211  eases.  In  the  hands  of  competent  surgeons 
the  mortality  from  operation  is  low  and  the  results  are  excellent. 

Diagnosis. — The  typical  cases  are  easily  recognized  but  the  difficulty 
comes  with  the  partially  developed  forms  and  hyperthyroidism.  The  patient 
should  be  kept  at  rest  and  carefully  studied.  If  the  giving  of  thyroid  extract 
(gr.  i-ii,  0.06-0.12  gm.)  or  iodine  for  a  few  days  increases  the  symptoms  and 
pulse  rate,  it  is  significant.  The  test  of  Goetsch  which  consists  in  the  re- 
sponse to  the  injection  of  epinephrin  (0.5  c.  c.)  is  sometimes  of  value.  An 
increase  in  the  pulse  rate  and  blood-pressure  and  aggravation  of  the  general 
symptoms  are  the  important  points.  It  may  aid  in  the  diagnosis  froih  early 
tuberculosis  which  may  show  features  suggestive  of  hyperthyroidism.  Certain 
signs  should  suggest  the  possibility  of  hyperthyroidism :  ( 1 )  tachycardia, 
(2)  rapid  emaciation  without  evident  cause,  (3)  diarrhoea  without  evident 
cause,  (1)  lymphocytosis,  and  (5)  a  neurasthenic  condition  otherwise  difficult 
to  explain.     Increase  in  the  basal  metabolism  is  very  important. 

Treatment. — It  is  usually  well  to  try  medical  treatment  before  surgery  is 
considered.  Halfway  measures  should  not  be  considered;  the  patient  should 
be  in  bed,  at  absolute  rest  and  excitement  and  irritation  avoided.  Any  causes 
of  worry  should  be  corrected  if  possible.  Long  hours  of  sleep  should  be 
secured  by  sedatives  if  necessary.  Any  focus  of  infection  should  be  treated. 
Tobacco,  alcohol,  tea  and  coffee  should  be  forbidden.  In  the  diet,  milk,  but- 
termilk and  foods  prepared  with  milk  should  figure  largely.  Cereals,  eggs, 
butter,  bread  or  toast,  vegetables  and  fruits  may  be  given.  Meat  broths  and 
meat  are  not  to  be  given;  small  amounts  of  chicken  may  be  taken  occasionally. 
Water  should  be  taken  freely,  best  as  distilled  water,  but,  if  not  available, 
boiled  water.  An  icebag  should  be  applied  over  the  heart.  Of  internal  reme- 
dies, belladonna,  ergot  and  sodium  phosphate  seem  helpful  in  some  cases.  The 
application  of  the  X-rays  is  sometimes  useful  and  is  worth  a  trial. 

Surgical  Trmtment. — Operation  is  indicated,  (1)  when  there  are  com- 
pression signs,  (2)  when  there  is  no  gain  under  a  proper  trial  of  medical  treat- 
ment and  (3)  when  medical  treatment  causes  improvement  but  there  is  not 
complete  recovery.  Severe  toxaemia  is  usually  a  contra-indication  to  surgery. 
Eemoval  of  part  of  the  thyroid  gland  offers  the  best  hope  of  permanent 
cure.  It  is  remarkable  with  what  rapidity  all  the  symptoms  may  disappear 
after  partial  thyroidectomy.  A  second  operation  may  be  necessary  in  severe 
eases.  Tying  of  the  arteries  may  be  enough.  Excision  of  the  superior  cervical 
ganglia  of  the  sympathetic  has  one  beneficial  result,  viz.,  the  production  of 
slight  ptosis,  which  obviates  the  staring  character  of  the  exophthalmos. 


IV.     DISEASES  OF  THE  PARATHYROID  GLANDS 

The  parathyroid  bodies  occur,  as  a  rule,  in  two  pairs  on  either  side  of  the 
lateral  lobes  of  the  thyroid  gland;  small  ovoid  structures  from  G  to  8  mm, 
in  length.  They  have  an  internal  secretion  supplementing  that  of  the  thyroid 
gland  and  controlling  calcium  metabolism.  Following  their  removal  in  ani- 
mals there  are  twitching,  spasms  of  the  voluntary  muscles,  gradual  paralysis 


DISEASES  OP  THE  PARATHYROID  GLANDS  S73 

with  dyspnoea,  and  death  from  exhaustion.  These  sometimes  disappear  when 
a  saline  extract  of  the  parathyroid  is  injected  into  a  vein,  or  if  the  parathyroid 
glands  are  fed  or  transplanted.  The  association  of  tetany  with  the  dis- 
turbance of  the  function  of  the  parathyroid  seems  definitely  established. 
MacCallum  has  shown  the  importance  of  the  function  of  these  glands  in  con- 
trolling calcium  metabolism,  and  it  is  possible  that  in  impoverishment  of 
the  tissues  in  this  ingredient  is  to  be  sought  the  cause  of  the  great  excitability 
of  the  nervous  system  and  of  tetany. 

These  studies  have  thrown  great  light  upon  various  spasmodic  disorders 
of  children,  and  some  have  gone  so  far  as  to  embrace  such  conditions  as  laryn- 
gismus, infantile  convulsions,  and  tetany  under  the  term  "spasmophilia." 
These  glands  have  also  hormonic  relations,  as  yet  not  thoroughly  understood, 
with  the  other  ductless  glands,  and  have  some  influence  on  carbohydrate 
metabolism.  The  experimental  association  of  the  glands  with  tetany  is  suffi- 
cient warrant  for  treating  this  disease  here,  though  some  regard  the  relation- 
ship to  spontaneous  tetany  as  doubtful. 

TETANY 

Definition. — Hyperexcitability  of  the  neuro-muscular  system  with  bilateral 
chronic  or  intermittent  spasms  of  the  muscles  of  the  extremities.  There  are 
definite  changes  in  the  calcium  metabolism,  possibly  due  to  disturbance  in 
the  functions  of  the  parathyroid  glands. 

Etiology. — It  occurs  in  epidemic  form,  particularly  in  the  spring,  the 
so-called  "rheumatic"  tetany,  sometimes  with  slight  fever  and  behaves  like 
an  acute  infection.  It  may  occur  in,  or  follow,  the  infections,  typhoid  fever, 
measles,  etc.  In  medical  wards  it  is  not  uncommon.  Of  8  cases  reported  by 
C.  P.  Howard,  4  were  associated  with  dilatation  of  the  tomach,  2  with  hyper- 
acidity, 1  with  chronic  diarrhoea,  and  1  with  lactation.  In  adults  the  gastro- 
intestinal group  is  the  most  common.  It  may  follow  successive  pregnancies — 
the  "nurse's  contracture"  of  Trousseau. 

In  children  it  is  common  with  rickets  (so  much  so  that  many  regard  it 
as  a  feature  of  the  disease)  and  in  gastro-intestinal  affections  of  artificially 
fed  infants  associated  with  wasting.  Laryngo-spasm  and  child  crowing  are 
usually  manifestations  of  tetany. 

The  fact  that  tetany  may  follow  removal  of  the  thyroid  (tetania  strumi- 
priva)  led  to  the  experimental  studies  showing  a  supposed  relationship  of 
the  disease  to  the  parathyroid  gland.  Removal  of  these  bodies  is  followed  by 
tetany,  and  in  animals  transplantation  of  living  parathyroids  cures  experi- 
mental tetany;  indeed,  there  are  cases  of  human  tetany  that  have  been  cured 
by  transplantation.  Where  no  disease  of  the  glands  has  been  found  a  para- 
thyroid insufficiency  is  assumed. 

The  relation  of  the  disease  to  calcium  metahaUsm  has  been  studied  by 
W.  G.  MacCallum  and  others,  and  the  hyperexcitability  of  the  nervous  system 
is  thought  to  be  due  to  excessive  loss  of  the  lime  salts.  On  the  other  hana 
Noel  Paton  believes  that  the  error  in  metabolism  is  an  intoxication  caused  by 
guanidin  compounds.  That  there  is  a  striking  reduction  in  the  calcium  con- 
tent of  the  blood  in  tetany  as  shown  by  MacCallum  has  been  confirmed  by 
Howland  and  Marriott  in  clinical  cases   (falling  from  the  normal  10  to  11 


874  DISEASES  OF  THE  DUCTLESS  GLANDS 

mgms.  per  100  c.  c.  to  an  average  of  5.6  mgms.)  ;  but  these  wjiters  conclude 
that  the  cause  of  the  calcium  cleficienc}^  is  not  yet  explained  and  that  the 
parathyroid  theory  lacks  confirmation. 

Morbid  Anatomy. — Atrophy,  haemorrhages,  adenomas,  cysts  and  inflamma- 
tions have  been  fomid  in  the  parathyroids,  but  the  glands  have  been  found 
normal  in  fatal  cases. 

Symptoms. — The  tonic  spasms  occur  chiefly  in  the  upper  extremities;  the 
arms  are  flexed  across  the  chest  with  the  hands  in  the  so-called  "obstetric" 
position,  the  proximal  phalanges  flexed,  the  middle  and  distal  extended  with 
the  thumb  contracted  in  the  palm.  The  legs  are  extended  with  plantar  flexion 
of  the  feet  and  toes.  The  nuiscles  of  the  face  are  not  so  often  involved,  but 
there  may  be  trismus  and  spasm  of  the  muscles  of  expression. 

Laryngo-spasm  may  occur  with  noisy  inspiration.  The  spasms  may  last 
only  for  a  few  hours  or  the  condition  may  persist  for  days  or  weeks,  recurring 
in  paroxysms.  Contracture  of  the  back  muscles  is  rare;  occasionally  there 
are  general  convulsions.  There  is  not  often  pain.  The  pulse  may  be  quick- 
ened and  the  temperature  raised.  Disturbance  of  sensation  is  rare.  In 
chronic  cases,  the  skin  looks  tense  or  drawn,  there  may  be  oedema,  the  hair 
falls  out,  and  the  teeth  may  subsequently  show  defects  in  the  enamel.  Peri- 
nuclear cataract  may  follow  a  prolonged  attack. 

Certain  additional  features  are  present: 

TroiLSseaus  sign  is  thus  described  by  him — "So  long  as  the  attack  is  not 
over,  the  paroxysm  may  be  reproduced  at  will.  This  is  effected  by  simply 
compressing  the  affected  parts,  either  in  the  direction  of  their  principal  nerve 
trunks,  or  over  their  blood  vessels  so  as  to  impede  the  arterial  or  venous 
circulation."  The  spasm  is  really  caused  by  pressure  on  the  nerves.  It  may 
be  elicited  months,  or  even  years,  after  an  attack.     It  is  not  always  present. 

ChvosteVs  phenomenon  depends  on  an  increased  excitability  of  the  motor 
nerves.  A  slight  tap  on  the  facial  will  throw  the  muscles  into  spasm, 
sometimes  only  limited  groups.  It  is  sometimes  seen  in  debilitated  children 
who  have  not  had  tetany. 

Erh's  phenomenon  is  due  to  increased  electrical  excitability  of  the  motor 
nerves.  In  normal  infants  a  cathodal  opening  contraction  is  not  caused  by 
a  current  of  less  than  5  milliamperes ;  contraction  is  obtained  in  tetany  with 
much  less.  Anodal  hyperexcitability  is  also  present,  especially  in  latent 
tetany,  but  it  may  occur  in  normal  infants  and  in  other  conditions. 

Diagnosis. — The  disease  is  readily  recognized.  Between  the  attacks,  or 
even  long  after,  the  signs  just  described  may  be  obtained.  The  common  carpo- 
pedal  spasm  of  debilitated  infants  is  regarded  by  some  as  mild  tetany.  The 
predisposing  factors,  gastro-intestinal  disease,  thyroidectomy,  pregnancy,  etc., 
should  be  borne  in  mind.  There  is  rarely  any  difficulty  in  differentiating 
tetanus,  epilepsy  or  functional  cramps. 

Prognosis. — Post-operative  cases  may  prove  fatal.  Death  in  the  gastro- 
intestinal forms  is  usually  from  the  primary  conditions.  Eecovery  is  the  rule 
in  children. 

Treatment. — In  children  the  condition  with  which  the  tetany  is  associated 
should  be  treated.  Baths  and  cold  sponging  are  recommended  and  often  re- 
lieve the  spasm  as  promptly  as  in  child-crowing.  Bromide  of  potassium  may 
be  tried.     In   severe   cases  chloroform  inhalations   mav  be   given,     "\rassage. 


DISEASES  OF  THE  PITTTTTAKY  BODY  875 

electricity,  and  the  spinal  icebag  have  also  been  used  with  success.  Cases, 
however,  may  resist  all  treatment,  and  the  spasms  recur  for  many  years.  The 
thyroid  extract  should  be  tri^d. 

Calcium  therapy  has  proved  very  efficacious  in  doses  of  gr.  v-xv  (0.3-1  gm.) 
of  the  lactate  every  three  or  four  hours.  The  symptoms  are  promptly  relieved, 
but  the  drug  must  be  continued  for  some  weeks. 

In  gastric  tetany,  especially  when  due  to  dilatation  of  the  stomach,  the 
mortality  is  high,  and  recovery  without  operative  interference  is  rare.  Eegu- 
lar,  systematic  lavage  with  large  quantities  of  saline  or  mildly  antiseptic 
solutions  is  sometimes  beneficial. 


V.     DISEASES  OF  THE  PITUITARY  BODY 

The  hypophysis  cerebri  consists  of  two  lobes,  (a)  an  anterior  lobe,  originat- 
ing from  the  roof  of  the  pharynx  and  composed  of  large  granular  epithelial 
cells  arranged  in  columns  surrounded  by  large  venous  spaces  into  which  their 
secretion  discharges;  and  (&)  a  smaller  posterior  lobe  w^hich  arises  from  the 
floor  of  the  third  ventricle  and  is  composed  (1)  of  a  central  neuroglial  portion 
(pars  nervosa)  and  (2)  an  investment  of  epithelial  cells  (pars  intermedia). 
The  secretion  of  the  posterior  lobe  is  supposed  by  som.e  to  find  its  way  into 
the  cerebro-spinal  fluid. 

Complete  experimental  removal  of  the  gland  is  fatal  (Paulesco).  Partial 
removal  leads,  in  young  animals,  to  a  stunting  of  growth,  to  adiposity  and 
failure  of  sexual  development,  in  adult  animals  to  adiposity  and  genital  dys- 
trophy (Cushing). 

Modern  knowledge  of  the  functions  of  the  gland  began  with  the  studies 
of  Marie  on  its  relation  to  acromegaly  and  gigantism.  Then  Schafer  and 
Oliver  discovered  that  injection  of  an  extract  of  the  gland  caused  a  rise  in 
blood  pressure.  Since  these  observations  an  enormous  amount  of  work  has 
been  done,  and  we  now  appreciate  the  remarkable  influence  of  this  small  struc- 
ture upon  the  processes  of  development  and  metabolism.  Briefly,  the  anterior 
lobe  influences  growth  and  development,  and  is  necessary  to  life ;  the  posterior 
lobe  influences  the  metabolism  of  the  carbohydrates  and  fats. 

Disturbances  in  the  function  of  the  pituitary  gland  are  not  clearly  grouped 
into  the  effects  of  deficiency  and  excess,  though  one  can  differentiate  states  of 
hyper-  and  hypopituitarism.  The  hypophysis  appears  to  be  closely  related  to 
other  glands  of  internal  secretion  and  involvement  of  any  member  of  the 
series  causes  a  readjustment  in  the  activity  of  the  others.  Owing  to  the 
situation  of  the  gland  it  is  very  liable  to  feel  the  effect  of  pressure  from  neigh- 
boring or  even  distant  lesions,  so  that  disturbance  of  function  may  be  due  not 
only  to  a  primary  involvement,  but  to  secondary  compression.  As  a  result  of 
experimental  work  and  clinical  studies  Cushing  prefers  to  group  the  conditions 
associated  with  disturbance  of  the  function  of  the  gland  under  the  term 
"dyspituitarism"  and  recognizes  a  number  of  gi'oups: 

(a)  Cases  of  tumor  growth  shoAving  signs  of  distortion  of  neighboring 
ntructures,  and  the  constitutional  effects  of  altered  glandular  activity.  The 
X-rays  show  changes  in  the  configuration  of  the  pituitary  fossa;  there  are 
pressure  signs  on  the  adjacent  cranial  nerves,  bi-temporal  hemianopia,  optic 


876  DISEASES  OF  THE  DUCTLESS  GLANDS 

atrophy,  and  oculomotor  palsies.  L'ncinate  fits  are  not  unnsual.  Epistaxis 
is  common  and  cerebro-spinal  rhinorrhoea  may  occur.  The  constitutional 
effects  vary  from  primary  over-activity  to  glandular  under-activity. 

(h)  Cases  in  which  the  neighborhood  manifestations  are  pronounced  but 
the  constitutional  features  are  slight.  The  characteristic  regional  signs  of 
tumor  are  marked,  but  there  may  be  slight  or  very  transient  evidence  of  dis- 
turbed glandular  activity,  perhaps  only  disturbed  carbohydrate  metabolism 
with  adiposit)'. 

(c)  Cases  in  which  the  neighborhood  manifestations  are  absent  or  slight, 
though  the  glandular  symptoms  are  unmistakable.  The  gland  is  not  so  large 
as  to  cause  regional  symptoms.  There  are  skeletal  changes  either  of  over- 
or  undergrowth.  Disturbance  of  carbohydrate  metabolism  is  a  matter  of 
modified  posterior  lobe  activity,  whether  occurring  as  a  lowering  of  the 
assimilation  limit,  so  often  associated  with  the  early  stages  of  acromegaly, 
or  a  great  increase  in  tolerance,  as  characterizes  all  grades  of  hypopituitarism. 
In  posterior  lobe  insufficiency  there  is  a  tendency  to  the  deposition  of  fat, 
subnormal  temperature,  drowsiness,  slow  pulse,  dry  skin,  loss  of  hair,  and 
an  extraordinary  high  tolerance  for  sugars.  Most  cases  of  acromegaly  fall 
in  this  group  and  show  at  first  evidences  of  hyperpituitarism,  and  later  of 
insufficiency.  In  the  adult,  adiposity,  high  sugar  tolerance,  subnormal  tem- 
perature, psychic  manifestations,  and  sexual  infantilism  of  the  reversive  type 
indicate  hypopituitarism  and  may  exist  without  the  regional  symptoms  of 
tumor. 

(d)  Hypophysial  symptoms  may  be  shown  by  patients  with  internal  hydro- 
cephalus from  any  cause,  probably  by  interference  with  the  passage  of  the 
posterior  lobe  secretion  into  the  cerebro-spinal  fluid,  and  this  obstructive 
dyspituitarism  may  result  from  any  lesion,  inflammatory  or  neoplastic,  in  the 
neighborhood  of  the  third  ventricle. 

These  are  the  most  important  of  the  groups  to  which  Cushing  refers,  but 
there  are  also  cases  with  manifestations  indicating  involvement  of  other  in- 
ternal secretions  together  with  that  of  the  hypophysis,  and  a  large  group  in 
which  transient  hypophysial  s3'mptoms  occur,  as.  in  pregnancy,  cranial  injuries 
and  infectious  diseases. 

It  is  quite  clear  that  disturbances  in  the  function  of  the  pituitary  gland 
may  lead  to  remarkable  changes  in  growth;  liyperpituitarism  may  lead  to 
gigantism,  when  the  process  antedates  ossification  of  the  epiphyses — the  Lau- 
nois  type ;  to  acromegaly  when  it  is  of  later  date ;  hypopituitarism  to  adiposity, 
with  skeletal  and  sexual  infantilism  when  the  process  originates  in  child- 
hood— the  Frohlich  type;  to  adiposity  and  sexual  infantilism  of  the  reversive 
type  when  originating  in  the  adult. 

Much  has  been  done  to  clear  the  subject,  but  much  remains,  particularly 
to  clear  up  the  relations  of  the  various  types  of  infantilism  which  have  been 
described — the  Lorain,  the  Brissaud,  the  pancreatic,  the  intestinal — to  the 
different  internal  secretions.  One  condition  merits  separate  consideration, 
that  differentiated  clearly  by  Marie  and  known  as  acromegaly.  (The  student 
is  referred  to  Hastings  Gilford's  "Disorders  of  Post-natal  Growth,*'  to  Vin- 
cent's "Innere  Secretion."  Ergeh.  d.  Phys.,  IX  and  X,  and  to  Cushiug's  work, 
"The  Pituitary  Gland  and  Its  Disorders,'"'  J.  B.  Lippincott  Co.,  1912.) 


DISEASES  OF  THE  PITUITAEY  BODY  877 

ACROMEGALY 

Definition. — A  dystrophy  characterized  by  increase  in  size  of  the  face  and 
extremities  associated  with  perverted  function  of  the  anterior  lobe  of  the 
pituitary  gland. 

The  essence  of  the  disease  is  a  dystrophy  of  hypophysial  origin  (Marie), 
which,  if  it  antedates  ossification  of  the  epiphyses,  leads  to  gigantism,  and  in 
the  adult  leads  to  over-growth  of  the  skeleton  and  other  changes  which  we 
know  as  acromegaly. 

Etiology. — It  is  a  rare  disease,  and  rather  more  frequent  in  women.  It 
affects  particularly  persons  of  large  size.  Twenty  per  cent,  of  acromegalics 
are  above  six  feet  in  height  when  the  symptoms  begin,  and  fully  40  per  cent, 
of  giants  are  acromegalics  (Sternberg).  Trauma,  the  infections,  and  emo- 
tional shock  have  preceded  the  onset  of  the  disease. 

Pathology. — Practically  all  of  the  cases  show  changes  in  the  pituitary 
gland,  hyperplasia,  adenoma,  fibroma,  or  sarcoma,  causing  distention  of  the 
sella  turcica  and,  in  the  late  stages,  pressure  on  surrounding  structures;  the 
symptoms  are  in  part  due  to  disturbance  of  the  function  of  the  gland,  and 
in  part  to  the  pressure  on  the  adjacent  parts. 

The  bones  show  the  most  striking  changes;  there  is  a  general  enlargement 
of  the  extremities,  but  the  skeleton  on  the  whole  is  more  or  less  affected. 
The  enlargement,  due  to  a  periosteal  growth,  is  most  evident  in  the  hands  and 
feet.  The  bones  of  the  face  are  always  involved.  The  orbital  arches,  frontal 
prominences,  zygoma,  malar,  and  nasal  bones  are  all  increased  in  size,  the 
lower  jaw  is  elongated,  thickened,  and  the  teeth  separated.  The  X-ray  picture 
shows  very  characteristic  changes  in  the  sella  turcica.  The  skin  and  sub- 
cutaneous tissues  are  thickened  and  the  hypertrophy  is  seen  in  the  soft  parts 
of  the  face  as  well. 

The  brain  has  been  found  large,  but  the  most  important  changes  are 
those  due  to  pressure  at  the  base.  The  internal  organs  have  been  found 
enlarged,  and  in  Osborne's  case  the  heart  weighed  2  lbs.  9  oz. 

Symptoms. — When  the  pituitary  gland  is  involved  in  tumor  growth,  which 
is  the  common  condition  in  acromegaly,  the  symptoms  may  be  grouped  into 
those  due  to  the  mechanical  effects  and  those  associated  with  perversion  of 
the  secretion  of  the  gland. 

(a)  Eegional  Symptoms. — Headache  is  common,  usually  frontal,  and 
often  very  severe.  Somnolence  has  been  noted  in  many  cases,  and  may  be 
the  first  symptom.  Ocular  features  occur  in  a  large  proportion  of  the  cases, 
bitemporal  hemianopia,  optic  atrophy,  and,  in  the  late  stages,  pressure  on 
the  third  nerve  and  the  abducens.  One  eye  only  may  be  affected.  Exophthal- 
mos may  occur.  Deafness  is  not  infrequent.  Irritability  of  temper,  marked 
change  in  the  disposition,  groat  depression,  and  progressive  dementia  have 
been  noted.     Epistaxis  and  rhinorrhoea  may  be  present. 

'(b)  Symptoms  due  to  the  perversion  of  the  internal  secretion 
itself  form  the  striking  features  of  the  disease.  The  patient's  friends  first 
notice  a  gradual  increase  in  the  features,  which  become  heavy  and  thick;  or 
the  patient  himself  may  notice  that  he  takes  a  larger  size  of  hat,  or  with  the 
progressive  enlargement  of  the  hands  a  larger  size  of  gloves.  The  enlarge- 
ment of  the  extremities  does  not  interfere  with  their  free  use. 


878  DISEASES  OF  THE  DUCTLESS  GLANDS 

The  iaypertrophy  is  general^  involving  all  the  tissues,  and  gives  a  curious 
spadelike  character  to  the  hands.  The  Hues  on  the  palms  are  much  deepened. 
The  wrists  may  be  enlarged,  but  the  arms  are  rarely  affected.  The  feet 
are  involved  like  the  hands  and  are  uniformly  enlarged.  The  big  toe,  however, 
may  be  much  larger  in  proportion.  The  nails  are  usually  broad  and  large,  but 
there  is  no  curving,  and  the  terminal  phalanges  are  not  bulbous.  The  joints 
may  be  painful  and  neuralgia  is  common.  The  head  increases  in  volume, 
but  not  as  much  in  proj^ortion  as  the  face,  which  becomes  much  elongated 
and  enlarged  in  consequence  of  the  increase  in  the  size  of  the  superior  and 
inferior  maxillary  bones.  The  latter  in  particular  increases  greatly  in  size, 
and  often  projects  below  the  upper  jaw.  The  alveolar  processes  are  widened 
and  the  teeth  are  often  separated.  The  soft  parts  also  increase  in  size, 
and  the  nostrils  are  large  and  broad.  The  eyelids  are  sometimes  greatly 
thickened,  and  the  ears  enormously  hypertrophied.  The  tongue  in  some 
instances  becomes  greatly  enlarged.  Late  in  the  disease  the  spine  may  be 
affected  and  the  back  bowed — kyphosis.  The  bones  of  the  thorax  may  slowly 
and  progressively  enlarge.  With  this  gradual  increase  in  size  the  skin  of  the 
hands  and  face  may  appear  normal.  Sometimes  it  is  slightly  altered  in  color, 
coarse,  or  flabby,  but  it  has  not  the  dry,  harsh  appearance  of  the  skin  in 
myxoedema.     The  muscles  are  sometimes  wasted. 

Also  associated  with  disturbance  of  the  function  of  the  gland  is  the  diabetes 
noticed  in  many  cases,  which  is  common  in  the  early  stages;  in  the  advanced 
stages  there  is  an  extraordinary  high  tolerance  for  sugar.  Symptoms  on  the 
part  of  other  ductless  glands  are  common.  Goitre  is  of  frequent  occurrence. 
Myxoedema  or  a  flabby  obesity  may  occur  late.  Amenorrhea  is  an  early  symp- 
tom in. women.     Impotence  is  common  in  advanced  cases  in  men. 

Treatment. — The  use  of  extracts  of  the  gland  has  been  extensively  tried 
but  with  practically  no  results.  Surgical  treatment  has  been  carried  out  in 
a  number  of  cases,  the  chief  indication  being  to  give  relief  to  the  local  pressure 
symptoms  when  there  is  marked  glandular  enlargement.  Partial  removal  of 
the  growth  or  the  evacuation  of  a  cyst  under  favorable  circumstances  may 
save  the  optic  nerves  from  complete  pressure  atrophy. 


VI.     DISEASES  OF  THE  PINEAL  GLAND 

"That  there  is  a  small  gland  in  the  brain  in  which  the  soul  exercises 
its  functions  more  particularly  than  in  the  other  parts"  was  the  opinion  of 
Descartes;  and  for  more  than  two  and  a  half  centuries  this  was  the  type 
of  our  knowledge  of  the  functions  of  the  pineal  gland.  What  we  know  now 
is  derived  chiefly  from  clinical  cases.  But  the  nature  of  the  internal  secre- 
tion is  unknoAvn ;  Barker,  indeed,  believes  that  the  pressure  exerted  by  tumors 
of  the  gland  may  explain  the  symptoms. 

Disease  of  the  gland,  usually  tumor,  may  cause  ( 1 )  pressure  symptoms, 
due  to  internal  hydrocephalus,  (2)  focal  symptoms,  due  to  involvement  of 
the  cranial  nerves,  particularly  those  of  the  eyes,  (3)  features  believed  to  be 
due  to  disturbance  of  the  internal  secretion,  as  premature  puberty,  carbohydrate 
tolerance,  obesitv  and  increase  in  the  growth  of  hair. 


INFANTILISM  879 


VII.     DISEASES  OF  THE  SEX  GLANDS 

The  endocrine  part  of  the  testicle  is  represented  by  the  interstitial  cells  of 
Leydig  and  of  the  ovary  by  the  interstitial  cells  and  the  cells  of  the  corpus 
hiteum.  The  secretions  influence  the  development  of  the  secondary  sexual 
characters.  Hyper-function  causes  premature  sexual  development  in  both  sexes. 
■Hypof unction  is  shown  (1)  in  eunuchs,  in  whom  there  is  complete  loss  of  the 
glands,  and  (2)  in  eunochoids,  in  whom  there  is  insufficiency  of  the  glands. 
In  eunuchs  there  is  lack  of  genital  development,  the  body  is  large  and  fat, 
there  is  scanty  growth  of  hair,  and  the  psychical  state  is  altered.  In  females 
whose  ovaries  are  removed  after  puberty  the  features  of  the  artificial  meno- 
pause appear.  Eunochoids  differ  according  as  the  insufficiency  occurred  be- 
fore or  after  puberty.  There  is  usually  involvement  of  other  glands,  espe- 
cially the  pituitary,  with  a  polyglandular  syndrome.  The  ^individuals  are 
usually  tall  and  fat  with  absence  of  secondary  sexual  characters.  The  genitals 
show  hypoplasia  and  sterility,  with  disturbance  of  the  sexual  function,  is  the 
rule.  In  treatment,  various  combinations  of  glandular  extracts  may  be 
used,  especially  testicular  and  pituitary  in  the  male  and  ovarian  in  the  female. 


VIII.     INFANTILISM 

Definition. — A  disturljunce  in  growth  characterized  by  persistence  of  in- 
fantile characters  and  a  general  retardation  of  development,  bodily  and 
mental. 

Etiology. — It  is  not  possible  to  make  a  satisfactory  classification  of  the 
causes  or  of  the  cases  of  infantilism — in  some  no  cause  is  evident,  in  others 
the  failure  in  development  has  followed  obvious  disease,  and  there  are  cases 
directly  dependent  upon  loss  of  some  internal  secretion. 

I.  Cachectic  infantilism  is  by  no  means  uncommon,  as  any  serious 
chronic  malady  may  delay  sexual  development.  For  example,  the  children 
affected  Avith  hoohworm  disease  may  reach  the  age  of  20  or  older  before  the 
change  from  the  infantile  to  the  adult  state.  Syphilis  is  a  very  common  cause. 
In  regions  in  which  malaria  is  very  prevalent  delayed  sexual  development  is 
not  uncommon  in  children,  and  we  see  it  not  infrequently  in  cases  of  con- 
genital heart  disease.  There  is  also  a  toxic  infantilism  due  to  the  slow  and 
prolonged  action  of  alcohol  and  tobacco. 

II.  'idiopathic  Infantilism  (So-called  Lorain  Type). — 'Tn  this  variety 
the  figure  is  so  small  that,  at  first  sight,  it  looks  like  that  of  a  child.  When 
the  patient  is  stripped,  however,  his  outlines  are  seen  to  be  those  of  an  adult, 
and  not  those  of  childhood.  The  head  is  proportionately  small,  and  the  trunk 
well  formed ;  for  the  shoulders  are  broad  compared  to  the  hips,  and  the  bony 
prominences  and  the  muscles  stand  out  distinctly.  We  have  before  us  a 
miniature  man  (or  woman,  as  the  case  may  be),  and  not  one  who  has  retained 
the  characteristics  of  childhood  beyond  the  proper  time.  There  is,  indeed,  no 
growth  of  facial,  pubic  or  axillary  hair,  yet  the  genital  organs,  though  small, 
are  well  shaped  and  quite  large  enough  for  the  size  of  the  body.  The  intelli- 
gence in  both  sexes  is  generallv  nnrniar'   (John  Thomson). 


880  DISEASES  OF  THE  DUCTLESS  GLANDS 

The  cause  of  this  form  is  probably  associated  with  perversion  of  the 
pituitary  secretions.  It  has  also  been  called  an  "angioplastic  infantilism/' 
in  the  belief  that  it  was  due  to  a  defect  of  development  of  the  vascular  system. 

m.  The  Hormonic  Type. — Here  we  are  on  safer  ground,  as  we  know  def- 
initely of  several  varieties  directly  dependent  upon  disturbance  of  the  internal 
secretions.     The  most  important  of  these  are: 

(a)  Thyroidal  or  Cretinoid  Infantilism. — This  has  been  described. 

(b)  The  Frohlich  type,  dystrophia  adiposo-genitalis,  associated  with  a 
tumor  of  the  pituitary  region,  is  characterized  by  great  obesity  and  genital 
hypoplasia.  The  s}Tnptoms  are  due  to  a  secretory  deficit,  for  they  are  capable 
of  experimental  reproduction  by  partial  glandular  extirpation  in  animals 
(Cushing).  There  are  adult  and  infantile  types,  just  as  there  are  in  myx- 
cedema ;  in  the  former  the  individual  becomes  fat  and  the  sexual  organs  revert 
to  the  preadolescent  state.  The  Brissaud  type  is  in  all  probability  due  to 
hypopituitarism.  A  round,  chubby  face,  under-developed  skeleton,  prominent 
abdomen,  large  layer  of  fat  over  the  whole  body,  rudimentary  sexual  organs, 
no  growth  of  hair  except  on  the  head,  and  absence  of  the  second  dentition, 
are  some  of  the  prominent  features  of  this  form,  which  Brissaud  attributed 
to  hypothyroidism,  but  which  appears  more  likely  to  be  due  to  dyspituitarism. 

(c)  Pancreatico-intestinal  Type. — Bramwell,  Herter,  Ereedman,  and 
others  have  reported  cases  of  infantilism  associated  with  intestinal  changes. 
Bramwell  thought  the  pancreas  was  at  fault,  and  his  cases  improved  remark- 
ably under  treatment  with  pancreatic  extract.  In  Herter's  case  there  were 
looseness  of  the  bowels,  often  fatty  stools,  and  a  change  in  the  flora  of  the 
intestine  with  a  rise  in  the  ethereal  sulphates  in  the  urine. 

rV.  Progeria. — Under  this  term  Hastings  Gilford  described  a  condition 
in  children  of  incomplete  development  (infantilism)  with  premature  decay. 
-The  facial  appearance,  the  attitude,  the  loss  of  hair,  wasting  of  the  skin,  are 
those  of  old  age,  and  post  mortem  extensive  fibroid  changes  are  found, 
particularly  in  the  arteries  and  kidneys.  The  condition  is  probably  associated 
with  unknown  changes  in  the  internal  secretions. 


IX.     DISEASES  OF  THE  SPLEEN 

I.     GENERAL    REMARKS 

Though  a  ductless  gland,  the  spleen  is  not  known  to  have  an  internal  secre- 
tion, and  its  functions  are  as  yet  ill  understood.  It  is  not  an  organ  essential 
to  life.  In  the  fetus  it  takes  part  in  the  formation  of  the  red  blood  corpuscles, 
and  as  it  contains  hsematoblasts,  it  is  possible  that  in  the  adult  this  function 
may  be  exercised  to  some  extent,  particularly  in  cases  of  severe  anemia. 

Haemolysis  is  generally  believed  to  be  its  special  function,  a  view — not 
held  by  all  physiologists — based  upon  the  presence  of  a  large  percentage  of 
organic  compounds  of  iron,  the  deposit  in  the  organ  of  blood  pigments  in  vari- 
ous diseases,  the  presence  of  many  macrophages  containing  red  blood  cor- 
puscles, and  upon  the  evidence,  after  removal  of  the  spleen,  of  compensatory 
haemolysis  in  many  newly  formed  hsmo-lymph  glands  (Warthin). 

Removal  of  the  spleen,  an  operation  practised  by  the  ancients  in  the  belief 
that  it  improved  the  wind  of  runners,  is  not,  as  a  rule,  followed  by  serious 


DISEASES  OF  THE  SPLEEN  881 

effects.  There  may  be  slight  eosinophilia  and  temporary  anaemia,  and  later 
there  is  usually  slight  leucocytosis,  with  relative  increase  of  the  lymphocytes. 
In  infections  the  organ  enlarges  and  micro-organisms  are  present  in  large 
numbers.  It  has  been  supposed  to  play  some  part  in  the  processes  of  immunity 
and  phagocytosis  goes  on  actively  in  the  organ.  In  experimental  anaemia 
caused  by  various  hsemolytic  agents  the  spleen  enlarges,  and  in  these  conditions 
Bunting  and  Norris  found  evidence  of  vicarious  blood  formation.  Chronic 
splenomegaly  may  be  present  with  little  disturbance  of  health. 

II.     MOVABLE  SPLEEN 

Movable  or  wandering  spleen  is  seen  most  frequently  in  women  the  sub- 
jects of  enteroptosis.  It  may  be  present  without  signs  of  displacement  of 
other  organs.  It  may  be  found  accidentally  in  individuals  who  present  no 
symptoms  whatever.  In  other  cases  there  are  dragging,  uneasy  feelings  in  the 
back  and  side.  All  grades  are  met  with,  from  a  spleen  that  can  be  felt  com- 
pletely below  the  margin  of  the  ribs  to  a  condition  in  which  the  tumor-mass 
impinges  upon  the  pelvis;  indeed,  the  organ  has  been  found  in  an  inguinal 
hernia !  In  the  large  majority  of  all  cases  the  spleen  is  enlarged.  Sometimes 
it  appears  that  the  enlargement  has  caused  relaxation  of  the  ligaments;  in 
other  instances  the  relaxation  seems  congenital,  as  movable  spleens  have  been 
found  in  different  members  of  the  same  family.  Possibly  traumatism  may 
account  for  some  of  the  cases.  Apart  from  the  dragging,  uneasy  sensations 
and  the  worry  in  nervous  patients,  wandering  spleen  causes  very  few  serious 
symptoms.  Torsion  of  the  pedicle  may  produce  a  serious  condition,  leading  to 
great  swelling  of  the  organ,  high  fever,  or  even  to  necrosis.  A  young  woman 
was  admitted  to  H.  A.  Kelly's  ward  with  a  tumor  supposed  to  be  ovarian, 
but  which  proved  to  be  a  wandering,  moderately  enlarged  spleen.  She  was 
transferred  to  the  medical  ward,  where  she  had  suddenly  great  pain  in  the 
abdomen,  a  large  swelling  in  the  left  flank,  and  much  tenderness.  Halsted 
operated  and  found  an  enormously  enlarged  spleen  in  a  condition  of  necrosis. 
He  laid  it  open  freely,  and  large  necrotic  masses  of  spleen  tissue  discharged 
for  some  time.     She  made  a  good  recovery. 

The  diagnosis  of  a  wandering  spleen  is  usually  easy  unless  the  organ  be- 
comes fixed  and  is  deformed  by  adhesions  and  perisplenitis.  The  shape  and 
the  sharp  'margin  with  the  notches  are  the  points  to  be  specially  noted. 

The  treatment  is  important.  Occasionally  the  organ  may  be  kept  in  posi- 
tion by  a  properly  adapted  belt  and  a  pad  under  the  left  costal  margin.  Ee- 
moval  of  the  displaced  organ  has  been  advised  and  carried  out  in  many  cases, 
and  is  not  a  very  serious  operation.  It  is,  however,  as  a  rule  unnecessary.  In 
two  cases  of  enlarged  spleen,  with  great  mobility,  causing  much  discomfort 
and  uneasiness,  Halsted  completely  relieved  the  condition  by  replacing  the 
spleen,  packing  it  in  position  with  gauze,  and  allowing  firm  adhesions  to 
take  place.  More  than  eighteen  months  after  the  operation  the  organ  had 
remained  in  position. 

III.     EUPTURE  OF  THE  SPLEEN 

This  is  of  interest  in  connection  with  the  spontaneous  rupture  in  cases  of 
acute  enlargement  during  typhoid  fever  or  malaria,  which  is  very  rare.    Hup- 


882  DISEASES  OF  THE  DUCTLESS  GLANDS 

ture  of  a  malarial  spleen  may  follow  a  blow,  a  fall,  or  exploratory  pmicture. 
In  India  and  in  Mauritius  rupture  of  the  spleen  is  stated  to  be  common.  Fatal 
hsemorrhage  may  follow  puncture  of  a  swollen  spleen  with  a  hypodermic  needle. 
Occasionally  the  rupture  results  from  the  breaking  of  an  infarct  or  of  an 
abscess.  The  symptoms  are  those  of  hsemorrhage  into  the  peritoneum,  and 
the  condition  demands  immediate  laparotomy. 

IV.  INFARCT  CYSTS  AND  TUBEECULOSLS  OF  THE  SPLEEN 

Emboli  in  the  splenic  arteries  causing  infurcts  may  be  infective  or  simple 
and  are  seen  most  frequently  in  ulcerative  endocarditis  and  septic  conditions. 
Infarcts  may  also  follow  the  formation  of  thrombi  in  the  branches  of  the 
splenic  artery  in  cases  of  fever.  They  are  not  very  infrequent  in  typhoid. 
In  a  few  instances  the  infarcts  have  follov/ed  thrombosis  in  the  splenic  veins. 
They  are  chiefly  of  pathological  interest.  Infarct  of  the  spleen  may  be  sus- 
pected in  cases  of  septicaemia  or  pyaemia  when  there  are  pain  in  the  splenic 
region,  tenderness  on  pressure,  and  slight  swelling  of  the  organ ;  a  well-marked 
friction  rub  is  occasionally  heard.  Occasionally  in  the  infective  infarcts  large 
abscesses  are  formed,  and  in  rare  instances  the  whole  organ  may  be  converted 
into  a  sac  of  pus. 

Tumors  of  the  spleen,  hydatid  and  other  cysts  of  the  organ,  and  gummata 
are  rare  conditions  of  anatomical  interest.  In  Hodgkin's  disease  the  organ 
may  be  enlarged  and  smooth,  or  irregular  from  the  presence  of  nodular  tumors. 

Cysts  are  rare ;  the  senior  author  saw  but  two,  one  an  echinoeoccus,  and  the 
other  a  double  cjst  of  the  hilus.  The  latter  probably  arise  from  a  hematoma 
subcapsular  or  in  the  hilus.  They  have  been  successfully  removed.  Very 
small  cysts  are  not  infrequent  in  connection  with  polycystic  disease  of  the 
liver  and  the  kidneys.  A  dermoid  cyst  has  been  described.  The  diagnosis 
of  cysts  is  not  often  made;  the  mass  is  usually  irregular  in  the  region  of  the 
spleen,  but  the  splenic  outlines  are  marked.  In  the  case  with  two  cysts  at 
the  hilus,  the  tumor  was  very  movable  and  irregular,  and  operation  was  urged 
on  the  grounds  of  mechanical  discomfort,  and  increase  in  size.  Musser  col- 
lected notes  of  21  operations,  all  successful,  in  cysts  of  this  sort. 

Primary  tuberculosis  is  rare.  Winternitz  collected  51  cases  in  1912.  In 
some  cases  the  symptoms  resemble  those  of  an  acute  infection,  with  pain  in 
the  splenic  region  and  enlargement  of  the  organ.  In  the  chronic  cases  there 
is  progressive  enlargemeat  of  the  spleen,  often  with  cyanosis  and  sometimes 
with  polycythaemia.     Splenectomy  has  been  successful  in  some  cases. 

V.     PRIMAEY  SPLENOMEGALY  WITH   AN.EMIA 

(Splenic  Ana'mla,  Banirs   Disea^ie) 

Definition. — A  primary  disease  of  the  spleen  of  unknown  origin,  character- 
ized by  ]:>rogressive  enlargement,  attacks  of  anaemia,  a  tendency  to  haemorrhage, 
and  in  some  cases  a  secondary  cirrhosis  of  the  liver,  with  jaundice  and  ascites. 
That  the  spleen  itself  is  the  seat  of  the  disease  is  shown  by  the  fact  that  com- 
plete recovery  follows  its  removal. 

History. — The  name  "splenic  anaemia'"  was  applied  to  a  group  of  cases  by 


DISEASES  OF  THE  SPLEEis^  883 

Griesinger  in  18GU.  H.  C.  Wood,  in  1871,  described  cases  as  the  splenic  form 
of  pseudo-leukaemia.  The  real  study  of  the  disease  was  initiated  by  Banti  in 
1883.  In  France  the  condition  was  called  "primitive  splenomegaly,"  and 
many  different  types  have  been  described.  Here  we  shall  deal  only  with  the 
form  referred  to  in  the  definition  as  splenic  anemia  and  Banti's  disease. 

Etiology. — In  the  majority  of  cases  the  enlargement  of  the  spleen  comes 
on  without  any  recognizable  cause.  In  a  few  cases  malaria  has  been  present, 
but  in  the  greater  number  the  first  thing  noticed  has  been  the  mechanical 
inconvenience  of  the  big  spleen.  Males  are  more  frequently  attacked  than 
females.  It  is  a  disease  of  young  and  middle  life,  the  majority  of  cases  occur- 
ring before  the  fortieth  year.  Some  hold  that  syphilis  is  important  in  the 
etiology.  It  is  also  met  with  in  young  children.  Some  of  the  cases  of 
infantile  splenic  anaemia  of  von  Jaksch  and  of  the  Italian  writers  belong  to 
this  disease. 

Morbid  Anatomy. — The  spleen  is  greatly  enlarged,  coming  perhaps  next 
to  the  size  of  the  leuksemic  organ.  It  is  very  firm,  the  capsule  is  thickened, 
the  texture  of  the  gland  very  tough  and  firm,  and  the  whole  in  a  state  of 
advanced  fibrosis.  Banti  described  a  proliferation  of  the  endothelial  cells  of 
the  venous  sinuses  of  the  pulp.  The  blood  vessels  in  the  neighborhood  of 
the  spleen  may  be  very  large,  particularly  the  vasa  brevia,  and  the  splenic 
vein  itself  and  the  portal  vein  may  be  enormously  dilated,  and  show  atheroma 
and  calcification.  The  lymphatic  glands  are  not  involved.  Hyperplasia  of 
the  bone  marrow  has  been  found,  but  no  other  changes  of  special  importance. 

The  cases  of  the  Gaucher  type,  primitive  endothelioma  of  the  spleen,  do 
not  belong  in  this  group. 

Symptoms, — The  disease  is  extraordinarily  chronic;  eight  of  our  cases  had 
a  longer  duration  than  ten  years.  Usually  the  first  feature  to  attract  atten- 
tion is: 

Splenomegaly. — The  enlargement  is  uniform,  smooth,  painless,  usually 
reaches  to  the  navel,  very  often  to  the  anterior  superior  spine,  and  the  organ 
may  occupy  the  whole  of  the  left  half  of  the  abdomen.  It  may  exist  for  years 
without  any  symptoms  other  than  the  inconvenience  caused  by  the  distention 
of  the  abdomen.     Following  an  infarct  pain  may  be  present. 

Ancemia. — Sooner  or  later  the  patients  become  anemic.  The  attack  may 
develop  with  rapidity,  and  in  children  a  severe  and  even  fatal  form  may 
follow  in  a  few  weeks.  More  commonly  the  pallor  is  gradual  and  the  patient 
may  come  under  observation  for  the  first  time  with  swelling  of  the  feet,  short- 
ness of  breath,  and  all  the  signs  of  advanced  anaemia.  The  blood  picture  is 
that  of  a  secondary  anaemia  with  a  very  low  color  index  and  a  marked 
leucopenia.  The  red  blood  corpuscles  may  fall  as  low  as  two  million  and  in 
an  average  of  a  series  of  uncomplicated  cases  the  leucocyte  count  was  under 
3,500  per  c.  mm.  There  are  no  special  changes  in  the  differential  count. 
Following  a  severe  hemorrhage  there  may  be  a  rise  in  the  leucocytes.  Some 
patients  have  permanent  slight  anaemia  of  the  secondary  type;  others  remain 
very  well  except  for  recurring  attacks  of  anaemia,  of  great  severity,  which  may 
be  independent  of  haemorrhage. 

Hcemorrhages. — Bleeding,  usually  haematemesis,  may  be  a  special  feature  of 
the  disease  and  occur  at  intervals  for  many  years.  One  of  our  patients  had 
recurring  attacks  for  twelve  years,  and  one  at  the  London  Hospital  for  fifteen 


884  DISEASES  OF  THE  DUCTLESS  GLANDS 

years  (Hutchison).  In  such  cases  the  diagnosis  of  ulcer  of  the  stomach  may 
be  made.  The  bleeding  may  be  of  great  severity.  On  several  occasions  one 
of  our  patients  was  brought  into  the  hospital  completely  exsanguine;  in  two 
the  haemorrhage  proved  directly  fatal ;  in  a  third  the  hgemorrhage  proved  fatal 
ten  days  after  a  successful  removal  of  the  spleen.  The  bleeding  comes,  as  a 
rule,  from  oesophageal  varices.  Malsena  may  be  present.  Hsematuria  and 
purpura  may  occur. 

Ascites. — Usually  a  terminal  event,  it  may  be  due  to  the  enlarged  spleen 
itself  or  to  secondary  cirrhosis  of  the  liver.  When  due  to  the  liver,  it  is 
associated  with  slight  jaundice. 

Jaundice. — Icterus  has  been  a  rare  symptom  in  our  cases.  Enlargement 
of  the  spleen  may  persist  for  many  years  without  any  consecutive  change  in 
the  liver.  One  patient  with  splenomegaly  and  repeated  hgemorrhages  had 
more  than  twelve  years  of  good  health  after  splenectomy.  Slight  Jaundice 
may  persist  for  years,  sometimes  with  enlargement  of  the  liver,  in  others 
with  distinct  reduction  in  its  volume,  and  in  either  case  with  a  progressive 
cirrhosis — the  features  to  which  Banti  called  special  attention. 

Course. — It  is  extraordinarily  chronic.  Some  cases  never  progress  to  the 
stage  of  Banti's  disease.  A  patient  may  for  ten  or  twelve  years  have  a  large 
spleen  causing  no  inconvenience,  then  an  attack  of  anemia  may  occur,  from 
which  recovery  gradually  takes  place;  or  the  first  symptom  may  be  ascites  or 
a  severe  hemorrhage  from  the  stomach.  As  a  rule,  the  anaemia  becomes  more 
or  less  chronic,  with  marked  exacerbations,  and  in  the  later  stages  cirrhosis 
of  the  liver  with  jaundice  and  ascites  develops. 

Diagnosis. — Here  may  be  mentioned  a  series  of  forms  of  splenomegaly 
which  differ  essentially  from  splenic  anaemia. 

SPLiENOMEGALY     WITH     ACHOLURIC    HiEMOLYTIC     JAUNDICE. — This    type, 

first  described  by  Minkowski  and  sometimes  called  after  his  name,  is  usually 
a  familial  form,  often  hereditary.  It  is  consistent  with  good  health  through- 
out life,  and  there  may  be  no  symptoms.  Characteristic  features  are:  (a)  its 
familial  form;  (h)  chronic  enlargement  of  the  spleen;  (c)  good  health;  (d) 
chronic  slight  jaundice;  (e)  presence  of  urobilin  in  the  urine,  but  absence  of 
bile  pigment.  In  a  few  instances  gall  stone  colic  has  been  present,  due  to 
small  calculi.  The  red  blood  corpuscles  have  an  increased  fragility,  the  cause 
of  which  is  unknown,  but  this  is  an  essential  feature.  In  the  familial  form 
good  health  is  the  rule,  but  in  the  acquired  form  the  patient  often  becomes 
anaemic  and  is  very  ill.     Cures  have  been  reported  after  splenectomy. 

Splenomegaly  of  the  Gaucher  Type  (Primary  Endothelioma) . — This 
familial  disease  was  described  by  Gaucher  in  1883.  It  shows  splenomegaly, 
moderate  anemia,  leucocytes  normal  or  low,  and  a  brown  or  yellowish  brown 
pigmentation  of  the  skin.  The  liver  is  enlarged  but  there  is  no  jaundice. 
The  spleen  contains  large  endothelial  cells.  Splenectomy  may  be  beneficial 
but  is  not  always  curative. 

Splenomegaly  with  Primary  Pylethrombosis. — Cases  have  been  re- 
ported of  enlarged  spleen  in  connection  with  phlebitis  of  the  splenic  and 
portal  veins,  and  such  cases  closely  resemble  Banti's  disease.  The  spleen  is 
very  large  and  there  are  jaundice  and  ascites  with  moderate  anemia.  The 
recognition  of  the  pylethrombosis  is  only  made  post  mortem. 

Hepatic  Splenomegaly. — Three  varieties  of  cirrhosis  of  the  liver  may 


DISEASES  OF  THE  SPLEEN  885 

lead  to  great  enlargement  of  the  spleen  with  an?emia  and  a  symptom-complex 
resembling  that  of  splenic  ansemia. 

(a)  Alcoholic  Cirrhosis. — With  recurring  haemorrhages,  a  consecutive  an- 
semia, ascites,  and  an  unusually  large  spleen,  the  condition  may  simulate 
closely  the  last  stage  of  splenic  anaemia.  The  history,  particularly  the  late 
appearance  of  the  hepatic  changes,  may  be  the  most  important  point.  In  the 
cases  in  which  we  have  been  in  doubt  the  difficulty  has  arisen  from  an  im- 
perfect history  and  from  the  presence  of  recurring  haemorrhages. 

(&)  Syphilitic  Cirrhosis. — Great  enlargement  of  the  spleen  may  occur  with 
hepatic  syphilis,  congenital  or  acquired.  Toward  the  close  the  picture  is 
similar  to  Banti's  disease — slight  jaundice,  ascites,  big  spleen,  recurring 
haemorrhages,  and  marked  anemia.  Syphilis  may  cause  marked  enlargement 
Tvithout  involvement  of  the  liver. 

(c)  In  a  few  cases  of  hypertrophic  cirrhosis,  as  in  Hanot's  form  and  in 
hsemochromatosis,  the  spleen  may  be  greatly  enlarged,,  and  when  ascites  and 
haemorrhages  occur,  the  clinical  picture  may  be  like  that  of  splenic  anaemia. 

Splenomegaly  in  Pernicious  Anemia. — Sometimes  the  spleen  is  greatly 
enlarged,  reaching  to  the  navel,  but,  as  a  rule,  the  blood  findings  enable  one 
to  make  the  diagnosis. 

Tropical  Splenomegaly. — Kala-azar  can  be  distinguished  by  the  presence 
of  the  Leishman-Donovan  bodies  in  the  spleen.  There  are  big  spleens  with 
anaemia  in  the  Tropics  which  are  not  Kala-azar,  and  the  experience  of  some 
of  the  physicians  in  Cairo  indicates  that  some  of  these  are  of  the  ordinary 
splenic  ansemia  type,  in  which  removal  of  the  organ  cures  the  disease. 

The  cause  of  the  enlarged  spleen  in  leukaemia  and  erythraemia  is  deter- 
mined by  the  blood  examination;  in  Hodgkin's  disease,  carcinoma,  amyloid 
disease  and  infective  endocarditis,  other  features  usually  prevent  error. 

Treatment. — There  is  only  one  means  of  radical  cure — removal  of  the 
spleen.  This  should  be  done  as  early  as  possible,  but  if  there  is  severe  anemia 
the  usual  treatment  for  this  should  be  given  and  the  effort  made  to  improve 
the  blood  condition  before  operation.  When  marked  hepatic  changes  have 
occurred,  operation  is  usually  contra-indicated.  In  the  cases  too  far  ad- 
vanced for  operation  the  treatment  is  that  of  any  severe  anemia  and  with 
cirrhosis  of  the  liver  and  ascites  the  usual  measures  should  be  adopted.  If 
there  is  any  evidence  of  syphilis  active  treatment  for  that  should  be  given. 


SECTIOIST  XII 

DISEASES  OF  THE  NERVOUS  SYSTEM 

A.    GENERAL  INTRODUCTION 

The  Neurone. — Its  Structure. — The  nervous  system  is  a  combination  of 
units  called  neurones,  each  composed  of  a  receptive  cell  body  and  of  con- 
ductors— namely,  protoplasmic  processes  or  dendrites,  and  the  axis-cylinder 
process  or  axone.  The  dendrites  conduct  impulses  toward  the  cell  body  (cellu- 
lipetal  conduction)  and  the  axones  conduct  them  away  from  the  cell  (celluli- 
fugal  conduction).  Depending  upon  whether  the  axones  conduct  impulses 
in  a  direction  away  from  or  toward  the  cerebrum  they  are  called  efferent  or 
afferent.  The  axis-cylinder  process  gives  off  at  varying  intervals  lateral 
branches  called  collaterals,  running  at  right  angles,  and  these,  and  finally  the 
axis-cylinder  process  itself,  split  up  at  their  terminations  into '  many  fine 
fibres,  forming  the  end  brushes.  These,  known  as  arborizations,  surround  the 
body  of  one  or  more  of  the  many  other  cells,  or  interlace  with  their  proto- 
plasmic processes.  Thus,  the  terminals  of  the  axone  of  one  neurone  are 
related  to  the  dendrites  and  cell  bodies  of  other  neurones  by  contact  or  by 
concrescence. 

Function  of  the  Neurone. — The  function  of  the  neurone  is  to  conduct 
nervous  impulses.  Eeduced  to  its  simplest  form,  the  mode  of  action  may  be 
represented  by  two  cells,  one  of  which,  reacting  to  the  environment,  conducts 
impulses  inward,  whereas  the  other,  awakened  by  this  afferent  impulse,  con- 
ducts an  impulse  outward.  This  reflex  response  Marshall  Hall  showed  to  be 
the  fundamental  principle  of  action  of  the  nervous  system.  The  environment 
acts  on  the  afferent  neurones  through  special  sense  organs,  so  that  a  variety 
of  afferent  impulses,  olfactory,  visual,  auditory,  gustatory,  tactile,  painful, 
thermic,  muscular,  visceral,  and  vascular,  may  be  originated.  The  efferent 
neurones  convey  impulses  outward  to  non-nervous  tissues,  to  the  skeletal, 
visceral,  and  vascular  muscles  and  to  the  secretory  glands,  whose  activities 
are  thus  augmented  or  inhibited.  The  most  important  reflex  centres  lie  in 
the  bulbo-spinal  axis.  The  situation  of  the  vascular  and  respiratory  centres 
in  the  bulb  makes  it  the  vital  centre  of  the  body.  In  the  spinal  cord  the  loca- 
tion of  many  reflex  centres,  particularly  those  for  the  muscle  tendons  and 
for  some  of  the  viscera,  is  represented  in  the  table  on  page  891.  The  visceral 
mechanism  is  almost  wholly  regulated  by  the  bulbo-spinal  axis,  and  its  reac- 
tions are  usually  unperceived.  In  conditions  of  disease  the  visceral  reflexes 
may  "rise  into  consciousness,'^  and  at  such  times  referred  pains  and  areas  of 
tenderness  are  produced  in  the  skin-fields  of  the  spinal  segments  corresponding 
to  the  centre  for  registration  of  the  visceral  reflex. 

Degeneration  and  Eegeneration  of  the  Neurone. — The  nutrition  of 

886 


GENERAL  IXTRODITCTTOX  887 

the  neurone  depends  upon  the  condition  of  the  cell  body,  and  this  in  turn 
upon  the  activity  of  the  nucleus.  If  the  cell  is  injured  the  processes  degen- 
erate, or  the  processes  separated  from  the  cell  degenerate.  Though  the  nerve 
cells  cease  to  multiply  soon  after  birth,  they  nevertheless  retain  remarkable 
powers  of  growth  and  repair.  Injury  to  the  cell  body  may  not  be  recovered 
from,  but  if  tlie  axone  be  severed  and  degeneration  take  place  in  consequence, 
it  may  under  favorable  circumstances  be  replaced  by  sprouts  from  the  central 
stump,  and  its  function  be  regained.  Even  the  peripheral  section,  independ- 
ently of  the  cell  bod}^,  may  have  the  power  of  regeneration.  It  is  probable, 
however,  that  both  factors  play  a  part  in  the  regeneration — namely,  the  dowji 
growth  of  the  axone  from  the  central  end  of  the  divided  nerve  as  well  as 
the  changes  in  the  jjeriphery,  which  are  most  marked  in  the  cells  of  the 
sheath  of  Schwann. 

Cell  Systems. — The  cell  l:)odies  of  the  neurones  are  collected  more  or  less 
closely  together  in  the  gray  matter  of  the  brain  and  spinal  cord  and  in  the 
ganglia  of  the  peripheral  nerves.  Their  processes,  especially  the  axis-cylinder 
processes,  run  for  the  most  part  in  the  white  tracts  of  the  brain  and  spinal 
cord  and  in  the  peripheral  nerves.  In  this  way  the  different  parts  of  the 
central  nervous  system  are  brought  into  relation  with  each  other  and  with  the 
rest  of  the  body.  Eurthermore,  the  axis-cylinder  processes  arising  from  cells 
subserving  similar  functions  are  collected  together  into  bundles  or  tracts, 
and  though  in  many  cases  the  course  of  these  tracts  and  the  functions  which 
they  possess  are  extremely  complicated  and  as  yet  have  not  been  completely 
unravelled,  nevertheless  some  of  them  are  simple  and  fairly  well  understood. 
By  the  study  of  degenerations  resulting  from  injury  or  from  the  toxins  of 
certain  diseases  which  possess  an  affinity  for  one  or  another  of  these  individual 
tracts  or  .systems,  it  has  been  possible  to  trace  the  course  of  certain  of  them. 
Fortunately  for  the  clinician,  the  best  understood  and  the  simplest  system  in 
its  arrangement  is  that  which  conveys  motor  impulses  from  the  cortex  to 
the  periphery — the  so-called  pyramidal  tract. 

The  Motor  System. — Motor  impulses  starting  in  the  left  side  of  the  brain 
cause  contractions  of  muscles  on  the  right  side  of  the  body,  and  those  from 
the  right  side  of  the  brain  in  muscles  of  the  left  side  of  the  body.  Leaving 
out  of  consideration  some  few  exceptions,  it  may  be  stated  as  a  general  rule 
that  the  motor  path  is  crossed,  and  that  the  crossing  takes  place  in  the  upper 
segment  (Figs.  12  and  13).  Every  muscular  movement,  even  the  simplest, 
requires  the  activity  of  many  neurones.  In  the  production  of  each  move- 
ment special  neurones  are  brought  into  play  in  a  definite  combination,  and 
acting  in  this  combination  specific  movement  is  the  result.  In  other  words,  all 
the  movements  of  the  hodj  are  represented  in  the  central  nervous  system  by 
combinations  of  neurones — that  is,  they  are  localized.  Muscular  movements 
are  localized  in  every  part  of  the  motor  path,  so  that  in  cases  of  disease  of  the 
nervous  system  a  study  of  the  motor  defect  often  enables  one  to  fix  upon 
tlie  site  of  the  process,  and  it  would  lie  hard  to  over-estimate  the  importance  of 
a  thorough  knowledge  of  such  localization.  A  voluntary  motor  impulse  start- 
ing from  the  brain  cortex  must  pass  through  at  least  two  neurones  before  it 
can  reach  the  muscles,  and  we  therefore  speak  of  the  motor  tract  as  being 
composed  of  two  segments — an  upper  and  a  loAver. 

The  Lower  MoTori  SegiA[ex'P. — Tlie  neurones  of  the  lower  segment  have 


888 


DISEASES  OF  THE  NEEVOUS  SYSTEM 


Fig.  12. — Diagram  op  Motor  Path  from  Left  Brain, 
The  upper  segment  is  black,  the  lower  red.  The  nuclei  of  the  motor  cerebral  nerves 
are  shown  in  red  on  the  right  side;  on  the  left  side  the  cerebral  nerves  of  that  side 
are  indicated.  A  lesion  at  1  would  cause  upper  segment  paralysis  in  the  arm  of  the 
opposite  side — cerebral  monoplegia;  at  2,  upper  segment  paralysis  of  the  whole  opposite 
side  of  the  body— hemiplegia;  at  3,  upper  segment  paralysis  of  the  opposite  face,  arm, 
and  leg,  and  lower  segment  paralysis  of  the  eye  muscles  on  the  same  side — crossed 
paralysis;  at  4,  upper  segment  paralysis  of  opposite  arm  and  leg,  and  lower  segment 
paralysis  of  the  face  and  the  external  rectus  on  the  same  side — crossed  paralysis; 
at  5,  upper  segment  paralysis  of  all  muscles  below  lesion,  and  lower  segment  paralysis 
of  muscles  represented  at  level  of  lesion— spinal  paraplegia;  at  6,  lower  segment 
paralysis  of  muscles  localized  at  seat  of  lesion— anterior  poliomyelitis.  (Van  Gehuch- 
ten,  modified.) 


GEISTEEAL  INTEODUCTION 


889 


the  cell  bodies  and  their  'protoplasmic  processes  m  the  different  levels  of  the 
ventral  horns  of  the  spinal  cord  and  in  the  motor  nuclei  of  the  cerebral  nerves. 
The  axis-cylinder  processes  of  the  lower  motor  neurones  leave  the  spinal 
cord  in  the  ventral  roots  and  run  in  the  peripheral  nerves,  to  be  distributed 
to  all  the  muscles  of  the  body,  where  they  end  in  arborizations  in  the  motor 
end  plates.  These  neurones  are  direct — that  is,  their  cell  bodies,  their 
processes,  and  the  muscles  in  which  they  end  are  all  on  the  same  side  of 
the  body. 


Pig.  13. — Diagram  of  Motor  Path  from  Each  Hemisphere,  Showing  the  Crossing 
OF  THE  Path,  Which  Takes  Place  in  the  Upper  Segment  Both  for  the  Cranial 
AND  Spinal  Nerves.     (Van  Gehuchten,  colored.) 


The  ventral  roots  of  the  spinal  cord  are  collected,  from  above  down,  into 
small  groups,  which,  after  joining  with  the  dorsal  roots  of  the  same  level  of 
the  cordy  leave  the  spinal  canal  between  the  vertebrae  as  'the  spinal  nerves. 
That  part  of  the  cord  from  which  the  roots  forming  a  single  spinal  nerve 
arise  is  called  a  segment,  and  corresponds  to  the  nerve  which  arises  from 
it  and  not  to  the  vertebra  to  which  it  may  be  opposite.  With  the  exception  of 
the  cervical  region,  in  which  all  the  nerve  roots  but  the  eighth  emerge  from 
above  the  vertebrae,  the  roots  of  each  segment  for  the  remainder  of  the  cord 
leave  the  spinal  canal  below  the  vertebra  of  corresponding  number,  and  con- 
sequently, owing  to  the  fact  that  during  growth  the  bony  canal  lengthens 
much  more  than  the  cord  itself,  the  more  tailward  one  goes  the  greater  is 
the  discrepancy  in  position  between  each  spinal  segment  and  its  particular 
vertebra.  This  must  be  borne  in  mind  when  determining  upon  the  site  of 
a  lesion  known  to  occupy  a  given  segment,  for  it  may  lie  far  above  the  vertebra 
of  like  number  and  name.  A  chart  has  been  prepared  from  numerous  measure- 
ments by  Eeid  showing  the  level  of  the  various  segments  of  the  cord  in  rela- 
tion to  the  spines  of  the  vertebrae.     The  axis-cylinder  processes  which  go  to 


890  DISEASES  OF  THE  NEEVOUS  SYSTEM 

make  up  any  one  peripheral  nerve  do  not  necessarily  .arise  from  the  same 
segment  of  the  spinal  cord;  in  fact,  most  peripheral  nerves  contain  processes 
from  several  often  quite  widely  separated  segments.  Most  of  the  long  striped 
muscles,  furthermore,  having  originated  in  the  embryo  from  more  than  one 
myatome,  are  innervated  from  more  than  one  segment. 

Our  knoAvledge  of  the  localization  of  the  muscular  movements  in  the  gray 
matter  of  the  lower  motor  segment  is  far  from  complete,  but  enough  is  known 
to  aid  materially  in  determining  the  site  of  a  spinal  lesion.  The  following 
table,  in  which  is  included  for  each  of  the  spinal  segments  the  centres  of  repre- 
sentation for  the  more  im^Dortant  skeletal  muscles,  the  main  reflex  centres, 
and  the  main  location  of  the  segmental  skin-field,  has  been  prepared  from  the 
studies  of  Starr,  Edinger,  Wichmann,  Sherrington,  Bolk,  and  others  (pages 
891,  893  and  893). 

The  Upper  Motor  Segment  and  Motor  Areas  of  the  Cortex. — The 
cell  bodies  of  the  upper  motor  neurones  are  found  in  the  brain  cortex  lying 
for  the  most  part  in  a  strip  anterior  to  the  fissure  of  Eolando,  and  it  is  in 
this  region  that  we  find  the  movements  of  the  body  again  represented. 

True  motor  responses  are  elicited  only  by  stimulation  anterior  to  the 
Eolandic  fissure;  practically  no  point  over  the  ascending  frontal  convolution 
fails  to  respond  to  stimulation.  There  is  but  slight  extension  of  the  motor 
cortex  on  to  the  paracentral  lobule  of  the  mesial  surface  of  the  brain.  Move- 
ments are  obtainable  not  only  from  the  exposed  part  of  the  convolution,  but 
also  from  its  hidden  surface  to  the  very  depths  of  the  Eolandic  sulcus.  There 
is  an  area  of  representation  for  the  trunk  between  the  centres  for  the  leg 
and  arm,  and  also  for  the  neck  between  those  of  the  arm  and  face.  The 
superior  and  inferior  genua  are  the  landmarks  which  indicate  the  situation 
of  these  small  areas  of  representation  for  trunk  and  neck.  These  results  have 
in  large  measure  been  confirmed  by  Gushing  by  unipolar  electrical  stimulation 
of  the  human  cortex.  From  above  down  the  motor  areas  occur  in  the  follow- 
ing order:  leg,  trunk,  arm,  neck,  head  (Fig.  14).  Those  of  the  leg  and  arm 
occupy  the  upper  half  of  the  convolution,  and  that  for  the  head,  including 
movements  of  the  face,  jaws,  tongue,  and  larynx,  the  lower  half. 

The  speech  centres  are  indicated  in  the  diagram  (Fig.  14)  in  accordance 
with  the  generally  accepted  views :  that  for  motor  speech  occupies  the  posterior 
part  of  the  left  third  frontal  or  Broca's  convolution.  It  is  a  disputed  point 
whether  or  not  there  is  a  separate  centre  presiding  over  the  movements  em- 
ployed in  writing.  Some  have  assumed  such  a  centre  to  be  present  in  the 
second  frontal  convolution  as  indicated  on  the  diagram.  The  conjugate 
movement  of  head  and  eyes  to  the  opposite  side  has  commonly  been  found 
in  apes  to  follow  stimulation  of  the  external  surface  of  the  frontal  lobe. 
Similarly  movements  of  the  eyes  may  be  elicited  from  the  occipital  cortex, 
but  probably  none  of  these  reactions  are  comparable  to  the  more  simple  move- 
ments through  the  pyramidal  tract  which  follow  stimulation  of  the  ascending 
frontal  convolution. 

The  axis-cylinder  processes  of  the  upper  motor  neurones  after  leaving  the 
gray  matter  of  the  motor  cortex  pass  into  the  white  matter  of  the  brain  and 
form  part  of  ihe  corona  radiata.  They  converge  and  pass  between  the  basal 
ganglia  in  the  internal  capsule.  Here  the  motor  axis-cylinders  are  collected 
into  a  compact  bundle — the  pyramirla]  tract — occupying  the  knee  and  anterior 


GEXEKAL  TXTT^ODrCTTOX 


891 


Localization  of  the  Functio^xs  in  the  Segments  of  the  Spinal  Cokd 


Skin-Fields  (cf. 

Segment. 

Striped  Muscles. 

Reflex. 

Figs.  18  ant)  19). 

I,  II  and 

Splenius  capitis. 

Hypochondrium  (?). 

Back  of  head  to  ver- 

III C. 

Hyoid  muscles. 

Sudden  inspiration  pro- 

tex. 

Sterno-mastoid. 

duced  by  sudden 

Neck  (upper  part). 

Trapezius. 

pressure  beneath  the 

Diaphragm  (C  III-V). 

lower  border  of  ribs 

Levator  .scapulae  (C  III-V). 

(diaphragmatic). 

IV  C. 

Trapezius. 

Dilatation  of  the  pupil 

Neck  (lower  part  to 

Diaphragm. 

produced    by    irrita- 

.second rib). 

Levator  scapula^. 

tion  of  neck.    Reflex 

Upper  shoulder. 

Scaleni  (C  IV-T  I). 

through  the  sympa- 

Teres minor. 

thetic  (C  IV-T  I). 

Supraspinatus. 

Rhomboid. 

vc 

Diaphragm. 

Scapular  (C  V-T  I). 

Outer  side  of  shoul- 

Teres minor. 

Irritation  of  skin  over 

der  and  upper  arm 

Supra   and   infra    spinatus    (C 

the  scapula  produces 

over    deltoid    re- 

V-VI). 

contraction     of    the 

gion. 

Rhomboid. 

scapular  muscles. 

Subscapularis. 

Supinator    longus    and 

Deltoid. 

biceps. 

Biceps. 

Tapping  their  tendons 

Brachialis  anticus. 

produces    flexion    of 

Supinator  longus  (C  V-VII). 

forearm. 

Supinator  brevis  (C  V-VII). 

Pectoralis  (clavicular  part). 

Serratus  magnus. 

VI  c. 

Teres  minor  and  major. 

Triceps.      Tapping   el- 

Outer side  of  fore- 

Infraspinatus. 

bow  tendon  produces 

arm,     front     and 

Deltoid. 

extension  of  forearm. 

back. 

Biceps. 

Posterior  wrist.     Tap- 

Outer    half    of 

Brachialis  anticus. 

ping  tendons  causes 

hand  (?). 

Supinator  longus. 

extension  of  hand  (C 

Supinator  brevis. 

VI-VII). 

Pectoralis  (clavicular  part). 

Serratus  magnus  (C  V-VIII). 

Coraco-brachialis. 

Pronator  teres. 

Triceps  (outer  and  long  heads). 

Extensors  of  wrist  (C  VI-VIII). 

VII  c. 

Teres  major. 

Scapulo-humeral.   Tap- 

Inner side  and  back 

Subscapularis. 

ping  the  inner  lower 

of  arm  and  fore- 

Deltoid (posterior  part). 

edge  of  scapula  causes 

arm. 

• 

Pectoralis  major  (costal  part). 

adduction  of  the  arm. 

Radial    half    of    the 

Pectoralis  minor. 

Anterior    wrist.      Tap- 

hand. 

Serratus  magnus. 

ping  anterior  tendons 

Pronators  of  wrist. 

causes  flexion  of  wrist 

Triceps. 

(C  VII-VIII). 

Extensors  of  wrist  and  fingers. 

Flexors  of  wrist. 

Latissimus  dorsi  (C  VI-VIII). 

892  DISEASES  OF  THE  NEEVOUS  SYSTEM 

Localization  of  the  Functions  in  the  Segments  of  the  Spinal  Cord  {Continued) 


Segment. 

Striped  Muscles 

Reflex. 

Skin-Fields  (cf. 
Figs.  18  and  19). 

VIII  C. 

Pectoralis  major  (costal  part). 
Pronator  quadratus. 
Flexors  of  wrist  and  fingers. 
Latissimus. 

Radial    lumbricales    and    inter- 
ossei. 

Palmar.   Stroking  palm 
causes  closure  of  fin- 
gers. 

Forearm  and  hand, 
inner  half. 

IT. 

Lumbricales  and  interossei. 
Thenar  and   hypothenar   emi- 
nences (C  VII-T  I). 

Upper  arm,  inner 
half. 

II  to 
XII  T. 

Muscles  of  back  and  abdomen. 
Erectores  spinae  (T  I-LV). 
Intercostals  (T  I-T  XII). 
Rectus  abdominis  (T  V-T  XII). 
External  oblique  (T  V-XII). 
Internal  oblique  (T  VII-L  I). 
Transversalis  (T  VII-L  I). 

Epigastric.    Tickling 
mammary  region 
causes  retraction  of 
epigastrium    (T  IV- 
VII). 

Abdominal.      Stroking 
side  of  abdomen 
causes  retraction  of 
belly  (T  IX-XII). 

Skin  of  chest  and 
a,bdomen  in  ob- 
lique dorso-ventral 
zones.  The  nipple 
lies  between  the 
zone  of  T  IV  and 
TV.  The  umbil- 
icus lies  in  the 
field  of  T  X. 

IL. 

Lower  part  of  external  and  in- 
ternal oblique  and  transver- 
salis. 

Quadratus  lumborum  (L  I-II). 

Cremaster. 

Psoas  major  and  minor  (?). 

Cremasteric.     Stroking 
inner  thigh  causes  re- 
traction  of   scrotum 
(L  I-II). 

Skin  over  lowest  ab- 
dominal zone  and 
groin. 

II  L. 

Psoas  major  and  minor. 

Iliacus. 

Pectineus. 

Sartorius  (lower  part). 

Flexors  of  knee  (Remak). 

Adductor  longus  and  brevis. 

Front  of  thigh. 

IIIL. 

Sartorius  (lower  part). 
Adductors  of  thigh. 
Quadriceps  femoris  (L  II-L  IV). 
Inner  rotators  of  thigh. 
Abductors  of  thigh. 

Patellar  tendon.     Tap- 
ping   tendon    causes 
extension  of  leg. 
"Knee-jerk." 

Front  and  inner  side 
of  thigh. 

IV  L. 

Flexors  of  knee  (Ferrier). 
Quadriceps  femoris. 
Adductors  of  thigh. 
Abductors  of  thigh. 
Extensors  of  ankle  (tibialis  anti- 

cus). 
Glutei  (medius  and  minor). 

Gluteal.    Stroking  but- 
tock causes  dimpling 
in  fold  of  buttock  (L 
IV-V). 

Mainly  inner  side  of 
thigh  and  leg  to 
ankle. 

VL. 

Flexors    of    knee    (ham-string 
muscles)  (L  IV-S  II). 

Outward  rotators  of  thigh. 

Glutei. 

Flexors  of  ankle  (gastrocnemius 
and  soleus)  (L  IV-S  II). 

Extensors  of  toes  (L  IV-S  I). 

Peronsei. 

Back  of  leg,  and  pare 
of  foot. 

GENEKAL  INTEODUCTION 


893 


Localization  of  the  Functions  in  the  Segments  op  the  Spinal  Cord  (Continued) 


Segment. 

Striped  Muscles. 

Reflex. 

Skin-Fields  (cf. 
Figs.  18  and  19). 

I  to 
IIS. 

Flexors  of  ankle  (L  V-S  II). 

Long  flexor  of  toes  (L  V-S  II). 

Peronsei. 

Intrinsic  muscles  of  foot. 

Foot  reflex.  Extension 
of  Achilles  tendon 
causes  flexion  of  ankle 
(S  I-II).  Ankle- 
clonus. 

Plantar.  Tickling  sole 
of  foot  causes  flexion 
of  toes  or  extension 
of  great  toe  and 
flexion  of  others. 

Back  of  thigh,  leg 
and    foot;    outer 
side. 

Ill  to 

VS. 

Perineal  muscles. 
Levator  and  sphincter  ani   (S 
I-III). 

Vesical  and  anal  re- 
flexes. 

Skin    over    sacrum 

and  buttock. 
Anus. 
Perineum.  Genitals. 

Fig.  14. — Diagrammatic  Representation  of  Cortical  Localization  in  the  Left 
Hemisphere,  Showing  the  Speech  Centres. 
The  motor  areas  determined  by  unipolar  faradic  excitation  of  the  anthropoid  cortex 
(Sherrington  and  Griinbaum)  are  here  shown  stippled  in  red  and  lie  anterior  to  the 
Eolandic  fissure.  The  sensory  areas  presumably  lie  posterior  to  tliis  fissure  and  are 
roughly  indicated  in  blue  without  accurate  delineation.  Lying  as  it  does  on  the  upper 
surface  of  the  hemisphere,  the  leg  area  should  not  be  visible  on  a  lateral  view  sucli 
as  is  given  here. 


894 


DISEASES  OF  THE  NEEVOL'S  SYSTEM 


two-thirds  of  the  posterior  limb  of  the  internal  capsule.  The  order  in  which 
the  movements  of  the  opposite  side  of  the  body  are  represented  at  this  level;, 
as  learned  from  experimental  observations  on  apes,  is  given  in  Fig.  15. 

After  passing  through  the  internal  capsule  the  fibres  of  the  pyramidal 
tract  leave  the  hemisphere  by  the  crus,  of  which  they  occupy  about  the  middle 
three-fifths  (Fig.  16).  The  movements  of  the  tongue  and  lips  are  repre- 
sented nearest  the  middle  line. 

As  soon  as  the  tract  enters  the  crus,  some 
of  its  axis-cylinder  processes  leave  it  and  cross 
the  middle  line  to  end  in  arborizations  about 
the  ganglion  cells  in  the  nucleus  of  the  third 
Qerve  on  the  opposite  side ;  and  in  this  way,  as 
the  pyramidal  tract  passes  down,  it  gives  off' 
at  different  levels  fibres  which  end  in  th^ 
nuclei  of  all  the  motor  cerebral  nerves  on  the 
opposite  side  of  the  body.  Some  fibres,  how- 
ever, go  to  the  nuclei  of  the  same  side.  From 
the  crus  the  pyramidal  tract  runs  through  the 
pons  and  forms  in  the  medulla  oblongata  the 
pyramid,  which  gives  its  name  to  the  tract. 
At  the  lower  part  of  the  medulla,  after  the 
fibres  goingtothe  cerebral  nerves  have  crossed 
the  middle  line,  a  large  proportion  of  the  re- 
maining fibres  cross,  decussating  with  those 
from  the  opposite  pyramid,  and  pass  into  the 
opposite  side  of  the  spinal  cord,  forming  the 
crossed  pyramidal  tract  of  the  lateral  column 
(fasciculus  cerebro-spinalis  lateralis)  (Fig. 
17,  1).  The  smaller  number  of  fibres  which 
do  not  at  this  time  cross  descend  in  the  ven- 
tral column  of  the  same  side,  forming  the  di- 
rect pyramidal  tract,  or  Tiirck's  column 
(fasciculus  cerebro-spinalis  ventralis)  (Fig. 
17,  2). 

x\t  every  level  of  the  spinal  cord  axis-cylinder  processes  leave  the  crossed 
pyramidal  tract  to  enter  the  ventral  horns  and  end  about  the  cell  bodies  of 
the  lower  motor  neurones.  The  tract  diminishes  in  size  from  above  down- 
ward. The  fibres  of  the  direct  pyramidal  tract  cross  at  different  levels  in 
the  ventral  white  commissure,  and  also,  it  is  believed,  end  about  cells  in  the 
ventral  horns  on  the  opposite  side  of  the  cord.  This  tract  usually  ends  about 
the  middle  of  the  thoracic  region  of  the  cord. 

The  Sensory  System. — The  path  for  sensory  conduction  is  more  compli- 
cated than  the  motor  path,  and  in  its  simplest  form  is  composed  of  at  least 
three  sets  of  neiu'ones,  one  above  the  other.  The  cell  bodies  of  the  lowest  neu- 
rones are  in  the  ganglia  on  the  dorsal  roots  of  the  spinal  nerves  and  the  gan- 
glia of  the  sensory  cerebral  nerves.  These  ganglion  cells  have  a  special  form, 
having  apparently  but  a  single  process,  which,  soon  after  leaving  the  cell, 
divides  in  a  T-shaped  manner,  one  portion  rmuiing  into  the  central  nervous 
system  juid  the  otboi'  to  tlie  peri[)1i(M'y  of  the  body.      FmluTological  and  com- 


FiG.  15. — Diagram  of  Motor  and 

Sensory  Eepresentation  in  the 

Internal  Capsule. 

NL.,     Lenticular     nucleus.     NC, 

Caudate      nucleus.      THO.,      Optic 

thalamus.      The    motor    paths    are 

red  and  black,  the  sensory  are  blue. 


GENEEAL  INTRODUCTION 


895 


parative  anatomical  studies  have  made  it  seem  probable  that  the  peripheral 
sensory  fibre,  the  process  which  conducts  toward  the  cell,  represents  the  proto- 
plasmic processes,  while  that  which  conducts  away  from  the  ceU  is  the  axis- 
cylinder    process.     In    the    peripheral    sensory    nerves    we    have,    then,    the 


Fig.  16. — Diagram  of  Motor  and  Sensory  Paths  in  Crura. 

dendrites  of  the  lower  sensory  neurones.  These  start  in  the  periphery  of  the 
body  from  their  various  specialized  end  organs.  The  axis-cylinder  processes 
leave  the  ganglia  and  enter  the  spinal  cord  by  the  dorsal  roots  of  the  spinal 
nerves.     After  entering  the  cord  each   axis-cylinder  process  divides  into  an 


Fig.  17. — Diagram  of  Cross-section  cp  the  Spinal  Cord,  Showing  Motor,  Red,  and 

Sensory,  Blue,  Paths. 

1,  Lateral  pyramidal  tract.  2,  Veutral  pyramidal  tract.  3,  Dorsal  columns.  4,  Di- 
rect cerebellar  tract.  .^5,  Ventrolateral  ground  hundlos.  G,  Yentro-lateral  ascending 
tract  of  Gowers.     (Van  Celiuchten,  colored.) 

ascending  and  a  descending  branch,  which  run  in  the  dorsal  fasciculi.  The 
descending  branch  runs  but  a  short  distance,  and  ends  in  the  gray  matter  of 
the  same  side  of  the  cord.  It  gives  off  a  number  of  collaterals,  wliich  also 
end  in  the  gray  matter.     The  ascending  branch  may  end  in  the  gray  matter 


856  DISEASES  OF  THE  NERVOUS  SYSTEM 

soon  after  entering,  or  it  may  run  in  the  dorsal  fasciculi  as  far  as  the  medulla, 
to  end  about  the  nuclei  there.  In  any  case  it  does  not  cross  the  middle  line. 
The  lower  sensory  neurone  is  direct. 

The  cells  about  which  the  axis-cylinder  processes  and  their  collaterals  of 
the  lower  sensory  neurone  end  are  of  various  kinds.  They  are  known  as  sen- 
sory neurones  of  the  second  order.  In  the  first  place,  some  of  them  end  about 
the  cell  bodies  of  the  lower  motor  neurones,  forming  the  path  for  reflexes. 
They  also  end  about  cells  whose  axis-cylinder  processes  cross  the  middle  line 
and  run  to  the  opposite  side  of  the  brain.  In  the  spinal  cord  these  cells  are 
found  in  the  different  parts  of  the  gray  matter,  and  their  axis-cylinder  proc- 
esses run  in  the  opposite  ventro-lateral  ascending  tract  of  Gowers  (Fig.  15,  6) 
and  in  the  ground  bundles  (fasciculus  lateralis  proprius  and  fasciculus  ven- 
tralis  proprius). 

In  the  medulla  the  nuclei  of  the  dorsal  fasciculi  (nucleus  fasciculi  gracilis 
and  nucleus  fasciculi  cuneati)  contain  for  the  most  part  cells  of  this  character. 
Their  axis-cylinder  processes,  after  crossing,  run  toward  the  brain  in  the 
medial  lemniscus  or  bundle  of  the  fillet ;  certain  of  the  longitudinal  bundles  in 
the  formatio  reticularis  also  represent  sensory  paths  from  the  spinal  cord  and 
medulla  toward  higher  centres.  The  fibres  of  the  medial  lemniscus  or  fillet 
do  not,  however,  run  directly  to  the  cerebral  cortex.  They  end  about  cells  in 
the  ventro-lateral  portion  of  the  optic  thalamus,  and  the  tract  is  continued  on 
by  way  of  another  set  of  neurones,  which  send  processes  to  end  in  the  cortex 
of  the  posterior  central  and  parietal  convolutions.  This  is  the  most  direct 
path  of  sensory  conduction,  but  by  no  means  the  only  one.  The  peripheral 
sensory  neurones  may  also  end  about  cells  in  the  cord  whose  axones  run  but 
a  short -distance  toward  the  brain  before  ending  again  in  the  gray  matter,  and 
the  path,  if  path  it  can  be  called,  is  made  up  of  a  series  of  these  superimposed 
neurones.  The  gray  matter  of  the  cord  itself  is  also  believed  to  offer  paths  of 
sensory  conduction.  All  these  paths  reach  the  tegmentum  and  optic  thalamus, 
and  thence  are  distributed  to  the  cortex  along  with  the  other  sensory  paths. 
There  may  also  be  paths  of  sensory  conduction  through  the  cerebellum  by  way 
of  the  direct  cerebellar  tract  and  Gowers'  bundle. 

From  this  short  summary  it  is  evident  that  the  possible  paths  for  the  con- 
duction of  afferent  impulses  are  many,  and  become  more  complex  as  the  various 
tracts  approach  the  brain  where  our  knowledge  of  them  is  somewhat  indefinite. 
The  anatomical  arrangement  of  the  two  lower  orders  of  sensory  neurones  is, 
however,  sufficiently  well  understood  to  be  of  great  clinical  value.  We  have 
seen  in  the  case  of  the  motor  neurones  that  the  distribution  of  the  peripheral 
nerves  to  the  muscles,  owing  largely  to  the  interlacing  into  plexuses  of  the 
neurones  from  the  various  spinal  units,  is  quite  different  from  that  of  the  ven- 
tral roots  themselves,  and  the  same  rule  holds  true  for  the  peripheral  nerve 
and  dorsal  root  distribution  for  the  cutaneous  areas.  The  cutaneous  fields 
corresponding  to  the  peripheral  nerves  are  well  known,  and  although  our 
knowledge  of  the  exact  site  and  outline  of  some  of  the  segmental  skin-fields, 
represented  by  the  dorsal  roots,  is  less  accurately  established,  nevertheless  they 
are  sufficiently  well  understood  to  be  of  aid  in  determining  the  segmental  level 
pf  spinal  cord  and  of  dorsal  root  lesions.     Information  concerning  the  topogra- 


GENEEAL  INTRODUCTION  897 

phy  in  the  adult  of  these  skin  units  or  dermatomes  has  been  obtained  from 
various  sources;  from  morphological  studies;  from  anatomical  dissections; 
from  physiological  experimentation,  particularly  in  Sherrington's  hands ;  from 
the  study  of  anaesthesias  in  clinical  cases  after  traumatic  injuries  to  the  cord, 
and  from  Head's  studies  of  the  distribution  of  the  cutaneous  lesions  in  herpes 
zoster,  and  of  the  areas  of  referred  pain  and  tenderness  in  visceral  disease. 
The  diagrams  on  pages  898  and  899  embody  the  results  of  many  of  these  ob- 
servations. 

The  cutaneous  sensory  impressions  are  in  man  conducted  toward  the  brain, 
probably  on  the  opposite  side  of  the  cord — that  is,  the  path  crosses  to  the 
opposite  side  soon  after  entering  the  cord.  Muscular  sense,  on  the  other  hand, 
is  conducted  on  the  same  side  of  the  cord  in  the  fasciculus  of  GoU,  to  cross 
above  by  means  of  the  axones  of  sensory  neurones  of  the  second  order  in  the 
medulla. 

Sensory  Areas  of  the  Brain. — There  are  probably  two  sensory  cen- 
tres— one  in  the  optic  thalamus,  the  other  in  a  considerable  area  of  the  cerebral 
cortex.  The  thalamus  plays  a  three-fold  part.  Here  all  the  afferent  paths 
terminate;  secondly,  it  contains  a  mass  of  gray  matter  Avhich  forms  the 
centre  for  certain  fundamental  elements  of  sensation,  particularly  those  capable 
of  evoking  pleasure  and  discomfort  and  consciousness  of  changes  of  state. 
Thirdly,  in  the  lateral  part  of  the  thalamus  is  the  centre  through  which  the 
cortex  influences  the  essential  thalamic  centre,  controlling  and  checking  its 
activity.  On  their  way  from  the  periphery  to  the  cortex  afferent  impulses 
pay  toll  to  the  co-ordinate  mechanisms  of  the  spinal  cord  and  the  cerebellum. 
At  the  thalamic  junction  they  are  re-grouped  to  act  upon  the  two  terminal 
centres.  One  of  these,  the  essential  organ  of  the  optic  thalamus,  responds  to 
all  those  elements  which  evoke  consciousness  of  an  internal  change  in  state, 
more  particularly  pleasure  and  discomfort.  Sensory  impulses,  then,  pass  by 
way  of  the  internal  capsule  to  the  cortex,  and  in  the  main  five  groups  of 
sensory  impulses  are  distributed  in  this  way:  (1)  those  underlying  postural 
recognition,  and  the  appreciation  of  passive  movement  and  weight;  (2)  the 
impulses  underlying  the  recognition  of  tactile  differences;  (3)  those  upon 
which  depends  the  recognition  of  size  and  space;  (4)  those  which  enable  us 
to  localize  the  spot  stimulated;  and  (5)  thermal  impulses  (Head  and  Holmes). 

These  afferent  materials  are  combined  in  the  cortex  with  each  other  and 
with  other  sense  impressions  in  intellectual  processes.  The  cortical  area  con- 
cerned is  that  situated  between  the  pre-central  fissure  and  the  occipital  lobe. 

The  paths  for  the  conduction  of  the  stimuli  which  underlie  the  special 
senses  are  given  in  the  section  upon  the  cerebral  nerves,  and  it  is  only  neces- 
sary here  to  refer  to  what  is  known  of  the  cortical  representation  of  these  senses. 

Visual  impressions  are  localized  in  the  occipital  lobes.  The  primary  visual 
centre  is  on  the  mesial  surface  in  the  cuneus,  especially  about  the  calcarine 
fissure,  and  here  are  represented  the  opposite  visual  half -fields.  Some  authors 
believe  that  there  is  another  higher  centre  on  the  outer  surface  of  the  occipital 
lobe,  in  which  the  vision  of  the  opposite  eye  is  chiefly  represented.  However 
this  may  be,  most  authors  hold  that  the  angular  gyrus  of  the  left  hemisphere 
is  a  part  of  the  brain  in  which  are  stored  the  memories  of  the  meaning  of 
letters,  words,  figures,  and,  indeed,  of  all  seen  objects.  This  is  designated  as 
the  visual  speech  centre  on  the  diagram  (Fig.  14), 


898 


DISEASES  OF  THE  KEEVOUS  SYSTEM 


Fig.  18.-~Anterior  Aspect  of  the  Segmental  Skin  Fields  op  the  Body,  Combined 
FROM  THE  Studies  op  Head,  Kocher,  Starr,  Thorbusn,  Edinger,  Sherrington, 

WiCHMANN,   SBIFPER,    BOLK,    CtJSHING,    AND   OTHERS. 

Heavy  lines  represent  levels  of  fusion  of  dermatomes  and  the  preaxiul  and  postaxial 
lines  of  the  limbs. 


GENERAL  INTRODUCTION 


899 


Fig.  19.— Posterior  Aspect  of  the  Segmental  Skin  Fields  of  the  Body. 


900  DISEASES  OF  THE  NERVOUS  SYSTEM 

Auditory  impressions  are  localized  for  the  most  part  in  the  first  temporal 
convolution  and  the  transverse  temporal  gyri,  and  it  is  in  this  region  in  the 
left  hemisphere  that  the  memories  of  the  meanings  of  heard  words  and  sounds 
are  stored.  Musical  memories  are  localized  somewhat  in  front  of  those  for 
words.  The  cortical  centres  for  smell  include  a  part  of  the  base  of  the  frontal 
lobe,  the  uncus,  and  perhaps  the  gyrus  hippocampi.  The  centres  for  taste 
are  supposed  to  be  situated  near  those  for  smell,  but  we  possess  as  yet  no 
definite  information  about  them. 

Topical  Diagnosis. — The  successful  diagnosis  of  the  position  of  a  lesion 
in  the  nervous  system  depends  upon  a  careful  examination  into  all  the 
symptoms  present,  and  then  endeavoring  with  the  help  of  anatomy  and 
physiology  to  determine  the  place,  a  disturbance  at  which  might  produce 
these  symptoms.  The  abnormalities  of  motion  are  usually  the  most  important 
localizing  symptoms,  both  on  account  of  the  ease  with  which  they  can  be 
demonstrated,  and  also  because  of  the  comparative  accuracy  of  our  knowledge 
of  the  motor  path. 

Lesions  in  any  part  of  the  motor  path  cause  disturbances  of  motion.  If 
destructive,  the  function  of  the  part  is  abolished,  and  as  the  result  there  is 
paralysis.  If,  on  the  other  hand,  the  lesion  is  an  irritative  one,  the  structures 
are  thrown  into  abnormal  activity,  which  produces  abnormal  muscular  con- 
traction. The  character  of  the  paralysis  or  of  the  abnormal  muscular  contrac- 
tion varies  with  lesions  of  the  upper  and  lower  segment,  the  variations  depend- 
ing, first,  upon  the  anatomical  position  of  the  two  segments;  and,  secondly, 
upon  the  symptoms  which  are  the  result  of  secondary  degeneration  in  each  of 
the  segments. 

{a)  Lesions  op  the  Lower  or  Spino-muscular  Segment. — Destructive 
Lesions. — The  nutrition  of  all  parts  of  a  neurone  depends  upon  their  con^ 
nection  with  its  healthy  cell  body;  if  the  cell  body  be  injured,  its  processes 
undergo  degeneration,  or  if  a  portion  of  a  process  be  separated  from  the  cell 
body,  that  part  degenerates  along  its  whole  length.  This  so-called  secondary 
degeneration  plays  a  very  important  role  in  the  symptomatology. 

In  the  lower  motor  segment  the  degeneration  not  ouly  affects  the  axis- 
cylinder  processes  which  run  in  the  peripheral  nerves,  but  also  the  muscle  fibres 
in  which  the  axis-cylinder  processes  end.  The  degeneration  of  the  nerves  and 
muscles  is  made  evident,  first  by  the  muscles  becoming  smaller  and  fiabby, 
and,  secondly,  by  change  in  their  reaction  to  electrical  stimulation.  The  de- 
generated nerve  gives  no  response  to  either  the  galvanic  or  the  faradic  current,' 
and  the  muscle  does  not  respond  to  faradic  stimulation,  but  reacts  in  a  charac- 
teristic manner  to  the  galvanic  current.  The  contraction,  instead  of  being 
sharp,  quick,  lightning-like,  as  in  that  of  a  normal  muscle,  is  slow  and  lazy; 
and  is  often  produced  by  a  weaker  current,  and  the  anode-closing  contraction 
may  be  greater  than  the  cathode-closing  contraction.  This  is  the  reaction  of 
degeneration,  but  it  is  not  always  present  in  the  classical  form.  The  essential 
feature  is  the  slow,  lazy  contraction  of  the  muscle  to  the  galvanic  current,  and 
when  this  is  present  the  muscle  is  degenerated. 

The  myotatic  irritability,  or  muscle  refiex,  and  the  muscle  tonus  depend 
upon  the  integrity  of  the  reflex  arc,  of  which  the  lower  motor  segment  is  the 
efferent  limb,  and  in  a  paralysis  due  to  lesion  of  this  segment  the  muscle 


GENEEAL  INTEODUCTION  901 

reflexes    (tendon  reflexes)   are  abolished  and  there  is  a  diminished  muscular 
tension. 

Lower  segment  paralyses  have  for  their  characteristics  degenerative  atrophy 
with  the  reaction  of  degeneration  in  the  affected  muscles,  loss  of  their  reflex 
excitability,  and  a  diminished  muscular  tension.  These  are  the  general  char- 
acteristics, but  the  anatomical  relations  of  this  segment  also  give  certain 
peculiarities  in  the  distribution  of  the  paralyses  which  help  to  distinguish 
them  from  those  which  follow  lesions  of  the  upper  segment,  and  which  also 
aid  in  determining  the  site  of  the  lesion  in  the  lower  segment  itself.  The 
cell  bodies  of  this  segment  are  distributed  in  groups,  from  the  level  of  the 
peduncles  of  the  brain  throughout  the  whole  extent  of  the  spinal  cord  to  its 
termination  opposite  the  second  lumbar  vertebra,  and  their  axis-cylinder  proc- 
esses run  in  the  peripheral  nerves  to  every  muscle  in  the  body;  so  that  the 
component  parts  are  more  or  less  widely  separated  from  each  other,  and  a 
local  lesion  causes  paralysis  of  only  a  few  muscles  or  groups  of  muscles,  and 
not  of  a  whole  section  of  the  body,  as  is  the  case  where  lesions  affect  the  upper 
segment.  The  muscles  which  are  paralyzed  indicate  whether  the  disease  is  in 
the  peripheral  nerves  or  spinal  cord;  for  the  muscles  are  represented  differ- 
ently in  the  peripheral  nerves  and  in  the  spinal  cord.  Sensory  symptoms, 
which  may  accompany  the  paralysis,  are  often  of  great  assistance  in  making  a 
local  diagnosis.  Thus,  in  a  paralysis  with  the  characteristics  of  a  lesion 
of  the  lower  motor  segment,  if  the  paralyzed  muscles  are  all  supplied  by  one 
nerve,  and  the  anaesthetic  area  of  the  skin  is  supplied  by  that  nerve,  it  is  evi- 
dent that  the  lesion  must  be  in  the  nerve  itself.  On  the  other  hand,  if  the 
muscles  paralyzed  are  not  supplied  by  a  single  nerve,  but  are  represented  close 
together  in  the  spinal  cord,  and  the  anaesthetic  area  corresponds  to  that  sec- 
tion of  the  cord  (see  table),  it  is  equally  clear  that  the  lesion  must  be  in  the 
cord  itself  or  in  its  nerve  roots. 

Irritative  Lesions  of  the  Lower  Motor  Segment. — Lesions  of  this  segment 
cause  comparatively  few  symptoms  of  irritation.  The  fibrillary  contractions 
which  are  so  common  in  muscles  undergoing  degeneration  are  probably  due  to 
stimulation  of  the  cell  bodies  in  their  slow  degeneration,  as  in  progressive  mus- 
cular atrophy,  or  to  irritation  of  the  axis-cylinder  processes  in  the  peripheral 
nerves,  as  in  neuritis.  Lesions  which  affect  the  motor  roots  as  they  leave  the 
central  nervous  system  may  cause  spasmodic  contractions  in  the  muscles  sup- 
plied by  them.  Certain  convulsive  paroxysms,  of  which  laryngismus  stridu- 
lus is  a  type,  and  to  which  the  spasms  of  tetany  also  belong,  are  believed  to 
be  due  to  abnormal  activity  in  the  lower  motor  centres.  These  are  the  "lowest 
level  fits"  of  Hughlings  Jackson.  Certain  poisons,  as  strychnia  and  that  of 
tetanus,  act  particularly  upon  these  centres. 

The  lower  motor  segment  may  be  involved  in  all  diseases  involving  the 
peripheral  nerves  in  cerebral  and  spinal  meningitis,  in  injuries,  in  haemor- 
rhages and  tumors  of  the  medulla  and  cord  or  their  membranes,  in  lesions  of 
the  gray  matter  of  the  segment,  in  anterior  poliomyelitis,  progressive  muscular 
atrophy,  bulbar  paralysis,  ophthalmoplegia,  syringomyelia,  etc. 

(&)  Lesions  of  the  Upper  Motor  Segment. — Destructive  lesions  cause 
paralysis,  as  in  the  lower  motor  segment,  and  here  again  the  secondary  degen- 
eration which  follows  the  lesion  gives  to  the  paralysis  its  distinctive  character- 


902  DISEASES  OF  THE  A^ERVOUS  SYSTEM 

istics.  In  this  case  the  jaaralysis  is  accompanied  by  a  spastic  condition,  shown 
in  an  exaggeration  of  muscle  reflex  and  an  increase  in  the  tension  of  the 
muscle.  It  is  not  accurately  known  how  the  degeneration  of  the  pyramidal 
fibres  causes  this  excess  of  the  muscle  reflex.  The  usual  explanation  is  that 
under  normal  circumstances  the  upper  motor  centres  are  constantly  exerting 
a  restraining  influence  upon  the  activity  of  the  lower  centres,  and  that  when 
the  influence  ceases  to  act,  on  account  of  disease  of  the  pyramidal  fibres,  the 
lower  centres  take  on  increased  activity,  which  is  made  manifest  by  an  exag- 
geration of  the  muscle  reflex. 

The  neurones  composing  each  segment  of  the  motor  path  are  to  be  con- 
sidered as  nutritional  units,  and  therefore  the  secondary  degeneration  in  the 
upper  segment  stops  at  the  beginning  of  the  lower.  For  this  reason  the  mus- 
cles paralyzed  from  lesions  in  the  upper  segment  do  not  undergo  degenerative 
atrophy,  nor  do  they  show  any  marked  change  in  their  electrical  reactions. 

The  separate  parts  of  the  upper  motor  segment  lie  much  more  closely 
together  than  do  those  of  the  lower  segment,  and  therefore  a  small  lesion 
may  cause  paralysis  in  many  muscles.  This  is  more  particularly  true  in  the 
internal  capsule,  where  all  the  axis-cylinder  processes  of  this  segment  are  col- 
lected into  a  compact  bundle — the  pyramidal  tract.  A  lesion  in  this  region 
usually  causes  paralysis  of  most  of  the  muscles  on  the  opposite  side  of  the 
body — that  is,  hemiplegia.  The  pyramidal  tract  continues  in  a  compact  bun- 
dle, giving  ofl:  fibres  to  the  motor  nuclei  at  different  levels;  a  lesion  anywhere 
in  its  course  is  followed  by  paralysis  of  all  the  muscles  whose  spinal  centres 
are  situated  below  the  lesion.  When  the  disease  is  above  the  decussation,  the 
paralysis  is  on  the  opposite  side  of  the  body;  when  below,  the  paralyzed  mus- 
cles are  on  the  same  side  as  the  lesion.  Above  the  internal  capsule  the  path  is 
somewhat  more  separated,  and  in  the  cortex  the  centres  for  the  movements  of 
the  different  sections  of  the  body  are  comparatively  far  apart,  and  a  sharply 
localized  lesion  in  this  region  may  cause  a  more  limited  paralysis,  affecting 
a  limb  or  a  segment  of  a  limb — the  cerebral  monoplegias;  but  even  here  the 
paralysis  is  not  confined  to  an  individual  muscle  or  group  of  muscles,  as  is 
commonly  the  case  in  lower  segment  paralysis  (see  Eig.  12  and  explanation). 

To  sum  up,  the  paralyses  due  to  lesions  of  the  upper  motor  segment  are 
widespread,  often  hemiplegic;  the  paralyzed  muscles  are  spastic  (the  tendon 
reflexes  exaggerated),  they  do  not  undergo  degenerative  atrophy,  and  they  do 
not  present  the  degenerative  reaction  to  electrical  stimulation. 

Irritative  Lesions  of  the  Upper  Motor  Segment. — Our  knowledge  of  such  ■ 
lesions  is  confined  for  the  most  part  to  those  acting  on  the  motor  cortex.  The 
abnormal  muscular  contractions  resulting  from  lesions  so  situated  have  as 
their  type  the  localized  convulsive  seizures  classed  under  Jacksonian  or  cortical 
epilepsy,  which  are  characterized  by  the  convulsion  beginning  in  a  single  mus- 
cle or  group  of  muscles  and  involving  other  muscles  in  a  definite  order,  de- 
pending upon  the  position  of  their  representation  in  the  cortex.  For  instance, 
such  a  convulsion,  beginning  in  the  muscles  of  the  face,  next  involves  those  of 
the  arm  and  hand,  and  then  the  leg.  The  convulsion  is  usually  accompanied 
by  sensory  phenomena  and  followed  by  a  weakness  of  the  muscles  involved. 

A  majority  of  lesions  of  the  motor  cortex  are  both  destructive  and  irrita- 
tive— i.  e.,  they  destroy  the  nerve  cells  of  a  certain  centre,  and  either  in  their 


GENEEAL  TXTKODFCTIOX  903 

growth  or  by  their  presence  throw  into  al)iiormal  activity  those  of  the  sur- 
rounding centres. 

The  upper  motor  segment  is  involved  in  nearly  all  the  diseases  of  the 
brain  and  spinal  cord,  especially  in  injuries,  tumors,  abscesses,  and  haemor- 
rhages; transverse  lesions  of  the  cord;  syringomyelia,  progressive  muscular 
atrophy,  bulbar  jiaralysis,  etc.  One  lesion  often  involves  both  the  upper  and 
the  lower  motor  segments,  and  there  is  paralysis  in  the  different  parts  of  the 
body,  with  the  characteristics  of  each.  Such  a  combination  enables  us  in 
many  cases  to  make  an  accurate  local  diagnosis. 

Lesions  in  the  optic  path  and  in  the  different  speech  centres  also  give 
localizing  symptoms,  which  should  always  be  looked  for. 

(c)  Lesioxs  of  the  Sensoey  Path. — Here  again  the  lesion  may  be 
either  irritative  or  destructive.  Irritative  lesions  cause  abnormal  subjective 
sensory  impression — parsesthesia,  formication,  a  sense  of  cold  or  constriction, 
and  pain  of  every  grade  of  intensity.  The  character  of  the  sensory  symptoms 
gives  very  little  indication  as  to  the  position  of  the  irritating  process.  In- 
tense pain  is,  as  a  rule,  a  symptom  of  a  lesion  in  the  peripheral  sensory  neu- 
rones, but  it  may  be  caused  by  a  disease  of  the  sensory  path  within  the  central 
nervous  system. 

The  exact  distribution  of  symptoms  gives  more  accurate  data,  for  if  they 
are  confined  to  the  distribution  of  a  peripheral  nerve  or  of  a  sj^inal  segment 
the  indication  is  plain.  If  one  side  of  the  body  is  more  or  less  completely 
affected,  the  lesion  is  somewhere  within  the  brain,  etc. 

Destructive  Lesions. — A  complete  destruction  of  the  sensory  paths  from 
any  part  of  the  body  would  of  course  deprive  that  part  of  sensation  in  all  its 
qualities.  This  occurs  most  frequently  from  injury  to  the  peripheral  sensory 
neurones  within  the  peripheral  nerves,  and  the  area  of  anaesthesia  depends 
upon  the  nerve  injured.  Complete  transverse  lesion  of  the  cord  canses  com- 
plete anaesthesia  below  the  inj.ury. 

Unilateral  lesions  of  the  cord,  medulla,  dorsal  part  of  the  pons,  tegmentum, 
thalamus,  internal  capsule,  and  cortex  cause  disturbances  of  sensation  on  the 
opposite  side  of  the  body;  here  again  the  extent  of  the  defect  more  than  its 
character  helps  us  to  determine  the  position  of  the  lesion.  Hemiantesthesia 
involving  the  face  as  well  as  the  rest  of  the  body  can  only  occur  above  the 
place  where  the  sensory  paths  from  the  fifth  nerve  have  crossed  the  middle 
line  on  their  way  to  the  cortex.  This  is  in  the  upper  part  of  the  pons.  From 
this  point  to  where  they  leave  the  internal  capsule  the  sensory  paths  are  in 
fairly  close  relation,  and  are  at  times  involved  in  a  very  small  lesion.  Above 
the  internal  capsule  the  paths  diverge  quickly,  and  for  this  reason  only  an 
extensive  lesion  can  involve  them  all,  and  in  lesions  of  this  part  we  are  more 
apt  to  have  the  sensory  disturbances  confined  to  one  or  another  region  of  the 
body.  Unilateral  lesions  of  the  thalamus,  pons,  medulla,  and  cord  usually 
cause  sensory  disturbances  on  the  same  side  of  the  body,  as  well  as  those  on 
the  opposite  side.  These  are  due  to  the  involvement  of  the  sensory  paths  as 
they  enter  the  central  nervous  system  at  or  a  little  below  the  site  of  the 
lesion  and  before  the  axones  of  the  sensory  neurones  of  the  second  order  have 
crossed  the  middle  line.  The  area  of  disturbed  sensation  on  the  same  side  is 
limited  to  the  distribution  of  one  or  more  spinal  segments  and  often  indicates 


904  DISEASES  OF  THE  NEEVOUS  SYSTEM 

accurately  the  position  and  extent  of  the  diseased  process.  As  a  rule,  destruc- 
tive lesions  of  the  central  nervous  system  do  not  involve  all  the  paths  of 
sensory  conduction,  and  the  loss  of  sensation  is  not  complete.  It  is  often 
astonishing  how  very  slight  the  sensory  disturbances  are  which  result  from 
an  extensive  lesion.  Sensation  may  be  diminished  in  all  of  its  qualities,  or, 
what  is  more  common,  certain  qualities  may  be  afEected  while  others  are 
normal.  Thus,  the  sense  of  pain  and  temperature  may  be  lost  while  that  of 
touch  remains  normal,  as  is  often  the  case  in  diseases  of  the  spinal  cord,  or 
there  may  be  simply  a  loss  of  the  muscular  sense  and  of  the  stereognostic  sense 
(the  complex  sensory  impression  which  enables  one  to  recognize  an  object 
placed  in  the  hand),  as  occurs  frequently  from  lesions  of  the  cortex.  Occa- 
sionally pain  sensation  persists  with  loss  of  tactile  and  thermic  sensations. 
Almost  every  other  combination  has  been  described.  It  is  the  distribution 
more  than  the  character  of  the  sensory  defect  that  is  of  importance,  and  often 
the  distribution  gives  but  uncertain  indication  of  the  position  of  the  lesion. 
The  combination  of  the  sensory  defect  with  different  forms  of  paralysis  gives 
the  most  certain  diagnostic  signs. 

Sympathetic  Nervous  System  (Involuntary,  Vegetative,  Visceral,  Auto- 
nomic).— This  system  innervates  the  pupils,  non-striped  muscles,  glands,  vis- 
cera, heart  and  blood  vessels,  and  genital  organs.  It  is  outside  the  control  of 
the  will  but  can  be  influenced  by  the  central  nervous  system,  especially  by 
emotional  stimuli. 

This  involuntary  or  vegetative  nervous  system  consists  of  two  parts  which 
are  distinct  anatomically  and  antagonistic  physiologically. 

1.  Sympathetic  proper   (thoracico-lumbar). 

2.  Para-sympathetic  {a)   cranio-bulbar  and  (&)  sacral. 

There  is  some  confusion  in  the  use  of  the  term  "autonomic"  which  was 
applied  by  Langley  to  the  whole  vegetative  system,  but  is  also  used  to  desig- 
nate the  para-sympathetic  alone. 

The  fibres  of  the  sympathetic  proper  arise  from  cells  in  the  intermedio-lat- 
eral  region  of  the  cord  (preganglionic),  pass  by  the  anterior  roots  to  end  in 
ganglia  which  in  turn  send  fibres  (postganglionic)  to  the  terminations  in 
smooth  muscle,  the  heart,  blood  vessels,  sweat  glands,  secreting  glands,  etc. 
The  receptor  (afferent)  elements  are  concerned  with  visceral  sensations  and 
referred  visceral  pain.  The  excitor  (efferent)  elem.ents  form  synapses  in  the 
ganglia  and  in  this  way  one  fibre  may  stimulate  a  number  of  cells.  From 
these  cells  the  postganglionic  fibres  pass  directly  to  their  destinations.  The 
ganglia  act  as  "distributing  stations"  and  form  a  series  in  front  of  the  verte- 
bral column,  one  on  each  side.  In  the  neck  there  are  three  ganglia  in  each 
chain,  connected  with  the  cord  through  the  first  and  second  thoracic  roots. 
In  the  thoracic,  lumbar  and  sacral  regions  there  is  a  ganglion  for  each  nerve 
root. 

The  para-sympathetic  system  (often  termed  autonomic  or  system  of  the 
"extended  vagus")  has  the  ganglia  placed  more  peripherally.  In  the  cranio- 
bulbar  portion,  fibres  pass  from  the  mid-brain  to  the  ciliary  ganglion,  con- 
stricting the  pupil,  from  the  medulla  secretory  fibres  go  to  the  submaxillary 
glands  and  by  the  vagus  inhibitory  fibres  go  to  the  heart,  constrictor  to  the 
bronchi,  motor  to  the  oesophagus,  stomach  and  intestines,  and  secretory  to  the 


IXTEODUCTION"  905 

stomach  and  intestines.  The  vagus  nerve  is  the  most  important  constituent 
of  the  para-sympathetic  system.  From  the  sacral  portion  by  the  pelvic  nerve 
fibres  go  to  the  descending  colon,  rectum,  anus,  bladder  and  genital  system. 
The  vegetative  system  lias  three  plexuses,  cardiac,  solar  and  hypogastric,  which 
receive  fibres  from  both  systems. 

When  the  sympathetic  and  para-sympathetic  supply  the  same  structure, 
their  influences  are  antagonistic.  Thus  the  sympathetic  dilates  the  pupil,  the 
other  contracts  it ;  the  sympathetic  increases  the  heart  rate,  the  other  slows  it ; 
the  sympathetic  inhibits  the  movements  of  the  gastro-intestinal  tract,  the  other 
increases  them.  In  conditions  of  health  there  is  a  balance  between  the  two 
systems.  To  describe  the  resulting  condition  when  this  balance  is  disturbed  the 
term  sympathicotonia  and  vagotonia  are  employed,  depending  on  whicli.  sys- 
tem is  over-active.  In  the  diagnosis  of  this  the  effects  of  certain  drugs  are 
important.  Thus  the  sympathetic  system  is  stimulated  by  epinephrin  (1  c.  c. 
of  1-1000  solution)  with  resulting  tremor,  rigor,  a  sense  of  cold,  glycosuria  and 
a  rise  in  blood  pressure.  The  para-sympathetic  system  is  stimulated  by  pilo- 
carpine (gr.  1/20-1/6,  0.003-0.01  gm.)  with  resulting  salivation,  nausea, 
sweating,  flushing  and  a  fall  in  blood  pressure.  Atropine  (gr.  1/100-1/50, 
0.00065-0.001  gm.)  paralyses  the  para-sympathetic  system  with  resulting  dry- 
ness of  the  mouth  and  throat,  palpitation  and  oppression. 

Clinically  among  the  features  of  vagotonia  are  small  pupils,  salivation, 
flushing,  sweating,  clammy  hands  and  feet,  dermographia,  bradycardia,  irregu- 
larity of  respiration,  hyperacidity,  cardio-  and  pylorospasm,  spastic  constipa- 
tion, and  sphincter  contraction.  Among  those  of  sympathicotonia  are,  dilated 
pupils,  prominence  of  the  eyes,  dryness  of  the  mouth  and  dry  skin.  Actually  it 
is  found  that  many  patients  show  features  suggestive  of  disturbance  in  both 
systems.  Some  show  vagotonia  at  one  time  and  sympathicotonia  later.  The 
sympathetic  system  stands  in  close  relation  to  the  endocrine  glands  and  its 
stimulation  may  cause  increased  activity  of  the  adrenal  and  thyroid  glands 
particularly. 


B.    SYSTEM  DISEASES^ 

I.     INTRODUCTION 

There  are  certain  diseases  of  the  nervous  system  which  are  confined,  if 
not  absolutely,  still  in  great  part,  to  definite  tracts  (combinations  of  neurones) 
which  subserve  like  functions.  These  tracts  are  called  systems,  and  a  disease 
which  is  confined  to  one  of  them  is  a  system  disease.  If  more  than  one  system 
is  involved,  the  process  is  called  a  combined  system  disease.  Just  what  dis- 
eases should  be  classed  under  these  names  has  given  rise  to  much  discussion 
but  to  very  little  agreement.  We  can  not  speak  positively ;  our  knowledge  is 
not  sufficiently  accurate,  either  in  regard  to  the  exact  limits  of  the  sys- 
tems themselves,  or  to  the  nature  and  extent  of  the  morbid  process  in  the 
several  diseases. 

It  may  be  said  that  the  nervous  system  is  composed  of  two  great  systems 


906  DISEASES  OF  THE  NEEVOUS  SYSTEM 

of  neurones,  the  afferent  or  sensory  system  and  the  efferent  or  motor  system, 
and  the  connections  between  them,     (See  General  Introduction.) 

Tabes  dorsalis  is  a  disease  confined  at  its  onset  to  the  afferent  system,  and 
progressive  muscular  atrophy  is  one  of  the  efferent  system.  Several  theories 
have  been  advanced  to  explain  why  a  disease  should  be  limited  to  a  definite 
system  of  neurones.  One  view  is  based  upon  the  idea  that  in  certain  individ- 
uals one  or  the  other  of  these  systems  has  an  innate  tendency  to  undergo  de- 
generation; another  assumes  that  neurones  with  a  similar  function  have  a 
similar  chemical  construction  (which  differs  from  that  of  neurones  with  a 
different  function),  and  this  is  taken  to  explain  why  a  poison  circulating  in 
the  blood  should  show  a  selective  action  for  a  single  functional  system  of 
neurones. 


II.    DISEASES  OF  THE  AFFERENT  OR  SENSORY  SYSTEM 

I.     TABES    DOKSALIS 

{Locomotor  Ataxia;  Posterior  Spinal  Sclerosis) 

Definition. — An  affection  characterized  clinically  by  sensory  disturbances, 
incoordination,  trophic  changes,  and  involvement  of  the  special  senses,  par- 
ticularly the  eyes.  Anatomically  there  are  found  degenerations  of  the  root 
fibres  of  the  dorsal  columns  of  the  cord,  of  the  dorsal  roots,  and  at  times  of 
the  spinal  ganglia  and  peripheral  nerves.  Degenerations  have  been  described 
in  the  brain,  particularly  the  cortex  cerebri,  in  the  ganglion  cells  of  the  cord, 
and  in  the  endogenous  fibres  of  the  dorsal  columns. 

Etiology. — It  is  a  widespread  disease,  more  frequent  in  cities  than  in  the 
country.  The  relative  proportion  may  be  judged  from  the  fact  that  of  16,562 
cases  in  the  neurological  dispensary  of  the  Johns  Hopkins  Hospital  there  were 
201  cases  of  tabes.  Males  are  attacked  more  frequently  than  females,  the 
proportion  ■  being  nearly  10  to  1.  The  disease  is  not  very  uncommon  in  the 
negro  in  the  United  States.  It  is  a  disease  of  adult  life,  the  great  majority 
of  cases  occurring  between  the  thirtieth  and  fiftieth  years.  There  are  a  good 
many  cases  of  the  existence  of  the  disease  in  both  husband  and  wife,  and  a  few 
in  which  the  children  were  also  affected.  Occasionally  cases  are  seen  in  young 
men,  and  it  may  occur  in  children  with  congenital  syphilis.  Syphilis  is  the 
important  cause.  There  is  evidence  which  suggests  that  certain  strains  of  the 
Treponema  are  particularly  likely  to  attack  the  nervous  system.  The  interval 
between  the  syphilitic  infection  and  the  first  symptoms  of  tabes  is  variable. 
Five  to  fifteen  years  is  the  period  in  one-half  the  cases.  Intervals  from  two 
to  twenty-five  years  occur. 

•  Morbid  Anatomy  and  Pathology. — Posterior  spinal  sclerosis,  although  the 
most  obvious  gross  change,  is  not  an  "adequate  description.  The  dorsal  fibres 
are  of  two  kinds,  those  with  their  cell  bodies  outside  the  cord  in  the  spinal 
ganglia,  the  so-called  exogenous,  or  root  fibres,  and  those  which  arise  from 
cells  within  the  cord,  the  endogenous  fibres.  These  two  sets  occupy  fairly 
well-determined  regions,  and  a  study  of  early  cases  of  tabes  has  shown  that  ic 


DISEASES  OF  THE  AFFEEENT  OE  SENSOEY  SYSTEM     907 

is  the  exogenous  or  root  fibres  that  are  first  affected.  The  fibres  of  the  dorsal 
roots  enter  the  cord  in  two  divisions,  an  external  and  an  internal;  the  former 
is  composed  of  fibres  of  small  calibre,  which,  in  the  cord,  make  up  Lissauer's 
tract,  and  occupy  the  space  between  the  apex  of  the  dorsal  cornua  and  the 
periphery  of  the  cord,  and  really  do  not  form  part  of  the  dorsal  columns.  They 
are  short,  soon  entering  the  gray  matter,  and  do  not  seem  to  be  affected,  or 
only  slightly  so,  in  early  cases. 

The  larger  fibres  enter  the  cord  by  the  internal  division,  just  medial  to  the 
cornua,  in  what  is  known  as  the  root  entry  zone.  Some  enter  the  gray  matter 
of  the  spinal  cord  almost  directly  and  others  after  a  longer  course,  while  still 
others  run  in  the  cord  to  the  medulla,  to  end  in  the  nuclei  of  the  dorsal  col- 
umns. As  the  fibres  of  every  spinal  nerve  enter  the  cord  between  the  dorsal 
cornua  and  the  nerve  fibres  which  have  entered  lower  down,  the  fibres  from 
each  root  are  successively  pushed  more  and  more  toward  the  median  line,  and 
so  in  the  cervical  cord  the  fasciculi  of  Goll  are  largely  composed  of  long  fibres 
derived  from  the  sacral  and  lumbar  roots. 

That  it  is  the  coarse  dorsal  root  fibres  which  are  first  affected  in  tabes  is 
generally  admitted,  but  there  is  much  divergence  of  opinion  as  to  the  char- 
acter and  location  of  the  initial  process. 

Nageotte  calls  attention  to  the  frequency  of  a  transverse,  interstitial  neu- 
ritis of  the  dorsal  roots  just  after  they  have  left  the  ganglia  and  are  still  sur- 
rounded by  the  dura,  and  he  believes  that  it  is  this  neuritis  which  is  the  pri- 
mary lesion.  Obersteiner  and  Eedlich  laid  stress  on  the  presence  of  inflam- 
mation of  the  pia  mater  over  the  dorsal  aspect  of  the  cord,  which  involves  the 
root  fibres  as  they  pass  through.  They  point  out  that  it  is  just  here  that  the 
dorsal  roots  are  most  vulnerable,  for  at  this  point — that  is,  while  surrounded  by 
the  pia — they  are  almost  completely  devoid  of  their  myelin  sheaths.  Changes 
in  the  blood-vessels  of  the  cord,  of  the  pia,  and  of  the  nerve  roots  have  been 
described  in  early  tabes,  and  Marie  and  Guillain  advanced  the  belief  that 
the.  changes  in  the  cord  are  due  to  syphilis  of  the  posterior  lymphatic  system 
which  is  confined  to  the  dorsal  columns  of  the  cord,  the  pia  mater  over  them, 
and  the  dorsal  roots.  For  them  the  changes  in  the  nervous  system  are  only 
apparently  radicular  or  systemic. 

With  the  Marchi  stain,  degeneration  of  the  root  fibres  in  the  root-entry 
zone  is  a  constant  finding  in  early  cases.  This  change  is  radicular  in  the  sense 
that  it  varies  in  intensity  with  the  different  roots  and  is  most  marked  in  the 
sacral  and  lumbar  regions.  The  degeneration  is  not  found  in  the  dorsal  roots, 
but  begins  within  the  cord  just  beyond  where  the  root  fibres  lose  their  neuro- 
lemma and  their  myelin  sheaths.  Degenerated  fibres  may  be  traced  into  the 
dorsal  gray  matter  and  among  the  ganglion  cells  of  the  columns  of  Clarke. 
The  long  columns  which  ascend  the  cord  also  degenerate. 

In  more  advanced  cases,  there  are  degeneration  of  the  dorsal  roots  and 
some  alteration  of  the  cells  in  the  spinal  ganglia.  The  fibres  distal  to  the 
ganglia  are  practically  normal,  although  at  times  the  sensory  fibres,  at  the 
periphery  of  a  limb,  show  degeneration.  Within  the  cord,  the  exogenous 
fibres  are  diseased  as  already  described;  there  is  also  degeneration  in  the  en- 
dogenous system  of  fibres.  Optic  atrophy  is  frequently  found.  The  other 
cranial  nerves,  especially  the  fifth  with  its  ganglion,  have  been  found  de- 
generated. 


908  DISEASES  OF  THE  NEEVOUS  SYSTEM 

The  disease  occasionally  spreads  beyond  the  sensory  system  in  the  cord, 
and  in  advanced  cases  the  cells  in  the  ventral  horns  may  be  degenerated  in 
association  with  muscular  atrophy.  Mott  very  generally  found  more  or  less 
marked  changes  in  the  pyramidal  fibres;  these  he  believed  to  be  evidence  of 
changes  in  the  cerebral  cortex.  Degeneration  of  the  cortex  may  exist,  but 
even  when  mental  symptoms  are  absent,  or  very  mild,  similar  though  slight 
changes  have  been  described,  just  as  in  general  paresis,  without  marked 
tabetic  symptoms,  there  may  be  degeneration  of  the  dorsal  columns.  The 
close  association  of  tabes  and  general  paresis  will  be  considered  later. 

Sjrmptoms. — For  convenience,  these  are  considered  under  three  stages — 
the  incipient  or  preataxic,  the  ataxic  and  the  paralytic. 

Incipient  Stage. — The  onset  differs  very  widely  in  the  different  cases, 
and  mistakes  in  diagnosis  are  often  made  early  in  the  disease.  The  following 
are  the  most  characteristic  initial  symptoms : 

Pains,  usually  of  a  sharp  stabbing  character;  hence,  the  term  lightning 
pains.  They  last  for  only  a  second  or  two  and  are  most  common  in  the  legs 
or  about  the  trunk,  and  tend  to  follow  dorsal  root  areas.  They  dart  from 
place  to  place.  At  times  they  are  associated  with  a  hot  burning  feeling  and 
often  leave  the  affected  area  painful  to  pressure,  and  occasionally  herpes  may 
follow.  The  intensity  of  the  pain  varies  from  a  sore,  burning  feeling  of  the 
skin  to  a  pain  so  intense  that,  were  it  not  for  momentary  duration,  it  would 
exceed  human  endurance.  They  occur  at  irregular  intervals,  and  are  prone 
to  follow  excesses  or  to  come  on  when  health,  is  impaired.  When  typical,  these 
pains  are  practically  pathognomonic.  Gastric  and  other  crises  may  occur. 
Parsesthesia  may  be  among  the  first  symptoms — numbness  of  the  feet,  tin- 
gling, -etc — and  at  times  a  sense  of  constriction  about  the  body. 

Ocular  Symptoms. —  (a)  Optic  atrophy.  This  occurs  in  about  10  per  cent, 
of  the  cases,  and  is  often  an  early  and  even  the  first  symptom.  There  is  a 
gradual  loss  of  vision,  which  in  a  large  majority  of  cases  leads  to  total  blind- 
ness. This  appears  to  be  secondary  to  a  syphilitic  meningitis,  (h)  Ptosis, 
which  may  be  double  or  single,  (c)  Paralysis  of  the  external  muscles  of  the 
eye.  This  may  be  of  a  single  muscle  or  occasionally  of  all  the  muscles  of 
the  eye.  The  paralysis  is  often  transient,  the  patient  merely  complaining  that 
he  saw  double  for  a  certain  period,  (d)  Argyll-Robertson  pupil,  in  which  there 
is  loss  of  the  iris  reflex  to  light  but  contraction  during  accommodation.  The 
pupils  are  often  very  small — spiigal  myosis. 

Bladder  Symptoms. — The  first  warning  which  the  patient  has  may  be  a 
difficulty  in  emptying  the  bladder.  Incontinence  of  urine  occurs  only  at  a 
later  stage.    Decrease  in  sexual  desire  and  power  may  be  an  early  symptom. 

Tropliic  Disturbances. — These  usually  occur  later,  but  at  times  they  are 
early  symptoms,  and  it  is  not  very  infrequent  to  have  one's  attention  called  to 
the  trouble  by  a  perforating  ulcer  or  a  characteristic  Charcot's  joint. 

Loss  of  the  Deep  Reflexes. — This  early  and  most  important  symptom  may 
occur  years  before  the  development  of  ataxia.  Even  alone  it  is  of  great  mo- 
ment, since  it  is  very  rare  to  meet  with  individuals  in  whom  the  knee  and 
ankle  jerks  are  normally  absent.  The  combination  of  loss  of  either  of  these 
with  one  or  more  of  the  symptoms  mentioned  above,  especially  with  the  light- 
ning pains  and  ptosis  or  Argyll-Eobertson  pupil,  is  practically  diagnostic. 


DISEASES  OF  THE  AFFEREXT  OE  SEXSORY  SYSTEM     909 

These  reflexes  gradually  decrease,  and  one  may  be  lost  before  the  other,  or 
disappear  first  in  one  leg. 

These  initial  symptoms  may  persist  for  years  without  the  development  of 
incoordination.  The  patient  may  look  well  and  feel  well,  and  be  troubled  only 
by  occasional  attacks  of  lightning  pains  or  of  one  of  the  other  subjective 
symptoms.  Progressive  nerve  deafness  and  paralysis  of  the  vocal  cords,  with 
the  laryngeal  muscles  paralyzed  or  paretic,  may  occur.  The  disease  may  never 
progress  beyond  this  stage,  and  when  optic  atrophy  develops  early  and  leads 
to  blindness,  ataxia  rarely,  if  ever,  supervenes,  an  antagonism  noted  by  many 
authors. 

Ataxic  Stage. — Motor  Symptoms. — The  ataxia,  which  comes  on  gradu- 
ally, is  believed  to  be  due  to  a  disturbance  or  loss  of  the  afferent  impulses 
from  the  muscles,  joints,  and  deep  tissues.  A  disturbance  of  the  muscle  sense 
itself  can  usually  be  demonstrated.  One  of  the  first  indications  is  inability 
to  get  about  readily  in  the  dark  or  to  maintain  equilibrium  when  washing  the 
face  with  the  eyes  shut.  When  the  patient  stands  with  the  feet  together  and 
the  eyes  closed,  he  sways  and  has  difficulty  in  maintaining  his  position  (Rom- 
berg's symptom),  and  he  may  be  quite  unable  to  stand  on  one  leg.  He  does 
not  start  off  promptly  at  the  word  of  command.  On  turning  quickly  he  is 
apt  to  fall.  He  has  more  difficulty  in  descending  than  ascending  stairs.  Grad- 
ually the  characteristic  ataxic  gait  develops.  The  normal  man  walks  by  faith, 
the  tabetic  by  sight.  The  patient,  as  a  rule,  walks  with  a  stick,  the  eyes  are 
directed  to  the  ground,  the  body  is  thrown  forward,  and  the  legs  are  wide  apart. 
In  walking,  the  leg  is  thrown  out  violently,  the  foot  is  raised  too  high  and  is 
brought  down  in  a  stamping  manner  with  the  heel  first,  or  the  whole  sole  comes 
in  contact  with  the  ground.  Ultimately  the  patient  may  be  unable  to  walk  with- 
out the  assistance  of  two  canes.  This  gait  is  very  characteristic,  and  unlike  that 
seen  in  any  other  disease.  The  incoordination  is  not  only  in  walking,  but  in 
the  performance  of  other  movements.  If  the  patient  is  asked,  when  in  the  re- 
cumbent posture,  to  touch  one  "knee  with  the  other  foot,  the  irregularity  of  the 
movement  is  very  evident.  Incoordination  of  the  arms  is  less  common,  but 
usually  develops  in  some  grade.  It  may  in  rare  instances  exist  before  the 
incoordination  of  the  legs.  It  may  be  tested  by  asking  the  patient  to  close 
his  eyes  and  to  touch  the  tip  of  the  nose  or  the  tip  of  the  ear  with  the  finger, 
or  with  the  arms  thrust  out  to  bring  the  tips  of  the  fingers  together.  The 
incoordination  may  be  noticed  early  by  a  difficulty  in  buttoning  the  collar 
or  performing  one  of  the  routine  acts  of  dressing. 

One  of  the  most  striking  features  is  that  with  marked  incoordination  there 
is  but  little  loss  of  muscular  power.  The  grip  of  the  hands  may  be  strong 
and  firm,  the  power  of  the  legs  may  be  unimpaired,  and  their  nutrition, 
except  toward  the  close,  may  be  unaffected. 

There  is  a  remarkable  muscular  relaxation  (hypotonia)  which  enables  the 
joints  to  be  placed  in  positions  of  hyperextension  and  hyperflexion.  It  gives 
sometimes  a  marked  backward  curve  to  the  legs. 

Sensory  Symptoms. — The  lightning  pains  may  persist.  They  vary  greatly 
in  different  cases.  Some  patients  are  rendered  miserable  by  the  frequent  oc- 
currence of  the  attacks ;  others  escape  altogether.  In  addition,  common  symp- 
toms are  tingling,  pins  and  needles,  particularly  in  the  feet,  and  areas  of 


910  DISEASES  OF  THE  XEETOCS  SYSTEM 

hyperesthesia  or  of  antesthesia.  The  patient  may  complain  of  a  change  in 
the  sensation  in  the  soles  of  the  feet,  as  if  cotton  was  interposed  betTveen  the 
floor  and  the  skin.  Sensory  disturbances  occur  less  frequently  in  the  hands. 
Objective  sensory  disturbances  can  usually  be  demonstrated,  and,  indeed,  al- 
most every  variety  of  sensory  disturbance  of  tactile,  pain  and  temperature 
sense  has  been  described.  Bands  of  a  moderate  grade  of  anesthesia  about  the 
chest  are  not  uncommon;  they  are  apt  to  follow  the  distribution  of  spinal 
segments.  The  most  marked  disturbances  are  usually  found  on  the  legs. 
Eetardation  of  the  sense  of  pain  is  common,  and  a  pin  prick  on  the  foot  is  first 
felt  as  a  simple  tactile  impression,  and  the  sense  of  pain  is  not  perceived 
for  a  second  or  two  or  may  be  delayed  for  as  much  as  ten  seconds.  The  pain 
felt  may  persist.  A  curious  phenomenon  is  the  loss  of  the  power  of  localizing 
the  pain.  Eor  instance,  if  the  patient  is  pricked  on  one  limb  he  may  say  that 
he  feels  it  on  the  other  (allocheiria),  or  a  pin  prick  on  one  foot  may  be  felt 
on  both  feet.  Pruritus  may  occur  over  the  areas  affected  by  the  pains.  The 
muscular  sense,  which  is  usually  affected  early,  becomes  much  impaired  and 
the  patient  no  longer  recognizes  the  position  in  which  his  limbs  are  placed. 
This  may  be  present  in  the  preataxic  stage. 

Eeflexes. — The  loss  of  the  knee  and  ankle  jerks  is  one  of  the  earliest  symp- 
toms but  occasionally  they  are  retained,  and  anatomically  it  has  been  shown 
that  in  these  cases  the  lumbar  segments  were  little  if  at  all  involved.  The 
skin  reflexes  may  at  first  be  increased,  but  later  are  usually  involved  with 
the  deep  reflexes.    The  oculo-cardiac  reflex  is  often  absent. 

Special  Senses. — The  eye  symptoms  noted  above  may  be  present,  but,  as 
mentioned,  ataxia  is  rare  with  optic  atrophy.  Deafness  may  occur,  due  to 
lesion  of  the  auditory  nerve.  There  may  also  be  attacks  of  vertigo.  Olfactory 
symptoms  are  rare. 

W.  B.  Swift  has  drawn  attention  to  a  voice  sign  which  consists  in  ataxic 
speech  with  "a  slovenly  indistinct  enunciation  that  shows  partially  in  the 
vowels  but  predominantly  in  the  consonants.'"'  Suggested  tests  are  "e"  (as  in 
ell),  "t,"  "journals"  and  "Time  and  tide  wait  for  no  man." 

Visceral  Symptoms. — Among  the  most  remarkable  sensory  disturbances  are 
the  tabetic  crises,  severe  paroxysms  of  pain  referred  to  various  viscera;  thus, 
ocular,  laryngeal,  gastric,  nephritic,  rectal,  urethral,  and  clitoral  crises  have 
been  described.  The  most  common  are  the  gastric  and  larjmgeal.  Gastric 
crises  may  occur  early  and  persist  as  the  most  prominent  feature.  Starr  found 
them  as  the  first  symptom  18  times  in  450  cases.  The  onset  is  usuall}'  sudden, 
with  severe  pain  in  the  epigastrium,  radiating  to  the  back  and  behind  the 
sternum.  Vomiting  follows  the  pain,  and  may  be  quite  independent  of  food. 
Hematemesis  may  occur,  not  necessarily  due  to  ulcer.  Pallor,  sweating,  cold 
extremities,  and  a  small  pulse  are  associated,  and  in  rare  instances  death  occurs 
in  collapse.  The  blood  pressure  may  be  very  high,  as  reported  by  Barker,  and 
it  seems  not  improbable  that  the  condition  is  associated  with  angiospasm  in 
the  territory  of  the  gastric  and  mesenteric  vessels.  The  X-ray  examination 
shows  spasmodic  contractions  of  the  stomach.  Xo  special  change  may  be  found 
at  autopsy.  In  the  laryngeal  crises  there  may  be  true  spasm  with  dyspnoea 
and  noisy  inspiration.  A  patient  may  die  in  the  attack.  There  are  also  nasal 
crises,  associated  with  sneezing  fits. 


DISEASES  OF  THE  AFFERENT  OE  SENSORY  SYSTEM     911 

The  contrary  condition  may  occur,  that  is  absence  of  pain  from  visceral 
lesions,  as  rupture  of  a  gastric  ulcer,  and  render  diagnosis  very  difficult. 

The  sphincters  are  frequently  involved.  Early  in  the  disease  there  may 
be  a  retardation  or  hesitancy  in  making  water.  Later  there  is  retention,  and 
cystitis  may  occur.  Unless  great  care  is  taken  the  inflammation  may  extend 
to  the  kidneys.  Constipation  is  extremely  common.  Later  the  sphincter  ani 
is  weakened.     The  sexual  power  is  usually  lost  in  the  ataxic  stage. 

Trophic  Changes. — Skin  rashes,  such  as  herpes,  oedema,  or  local  sweating, 
may  occur  in  the  course  of  the  lightning  pains.  Alteration  in  the  nails  may 
occur.  A  perforating  ulcer  may  develop  on  the  foot,  usually  beneath  the  great 
toe.  A  perforating  buccal  ulcer  has  also  been  described.  Onychia  may  prove 
very  troublesome. 

Arthropathies  (Charcot's  Joints). — Anatomically  there  are:  (1)  enlarge- 
ment of  the  capsule  with  thickening  of  the  synovial  membranes  and  increase 
in  the  fluids;  (2)  slight  enlargement  of  the  ends  of  the  bones,  with  slight 
exostoses;  (3)  a  dull  velvety  appearance  of  the  cartilages,  with  atrophy  in 
places.  The  knees  are  most  frequently  involved.  The  spine  is  affected  in 
rare  instances.  Recurring  trauma  is  an  important  element  in  the  causation, 
but  trophic  disturbances  have  a  strong  influence.  A  striking  feature  is  the 
absence  of  pain.  Suppuration  may  occur,  also  spontaneous  fractures.  Atrophy 
of  the  muscles,  usually  a  late  manifestation,  may  be  localized  and  associated 
with  neuritis  or  due  to  involvement  of  the  ventral  horns. 

Aneurism  is  found  in  as  high  as  20  per  cent,  of  some  series,  and  aortic 
insufficiency  is  common.    Both  are  associated  syphilitic  manifestations. 

Cerebral  Symptoms. — Hemiplegia  may  develop  at  any  stage  of  the  disease, 
more  commonly  when  it  is  well  advanced.  It  may  be  due  to  hgemorrhagic 
softening  from  disease  of  the  vessels,  to  progressive  cortical  changes  or  rarely 
to  coarse  syphilitic  disease.  The  lost  knee  jerk  may  return  on  the  affected  side. 
Hemianaesthesia  is  sometimes  present. 

Cerebro-Spinal  Fluid. — The  examination  of  this  is  of  great  value ;  the  find- 
ings are : 

(1)  Cell  Content. — Lymphocytosis  is  found  in  about  90  per  cent.,  the 
number  of  cells  usually  being  between  40  and  60,  and  rarely  over  100.  The 
higher  counts  are  found  when  irritative  symptoms  are  marked.  With  an 
arrest  of  the  process  the  counts  are  lower.  (2)  Glohulin.  This  is  positive  in 
90-95  per  cent.  In  old  quiescent  cases  there  may  be  no  increase.  (3)  Wa.sser- 
mann  reaction.  This  is  nearly  always  positive  but  may  be  negative  in  quies- 
cent cases.  The  blood  Wassermann  test  is  positive  in  about  70  per  cent.  (4) 
Colloidal  Gold  reaction.  This  is  present  in  85-90  per  cent,  and  is  useful  in 
diagnosing  tabes  from  paresis.  If  a  paretic  curve  is  given  in  a  patient  with 
signs  of  tabes  it  points  to  the  possible  development  of  paresis  subsequently. 

Paralytic  Stage. — After  persisting  for  an  indefinite  number  of  years 
the  patient  gradually  becomes  bedridden  and  paralyzed.  In  this  condition  he 
is  likely  to  be  carried  off  by  some  intercurrent  affection,  such  as  pyelo-nephritis, 
pneumonia,  or  tuberculosis. 

CouESE. — A  patient  may  remain  in  the  preataxic  stage  for  an  indefinite 
period;  and  the  loss  of  knee-jerk  and  the  atrophy  of  the  optic  nerves  may  be 
the  sole  indications  of  the  disease.  In  such  cases  incoordination  rarely  de- 
velops.   In  a  majority  of  cases  the  progress  is  slow,  and  after  six  or  eight  years, 


912  DISEASES  OF  THE  NERVOUS  SYSTEM 

sometimes  less,  the  ataxia  is  well  marked.  The  symptoms  may  vary  a  good 
deal;  thus,  the  pains,  which  may  have  been  excessive  at  first,  often  lessen. 
The  disease  may  remain  stationary  for  years;  then  exacerbations  occur  and 
it  makes  rapid  progress.  Occasionally  the  process  seems  to  be  arrested. 
There  are  instances  of  what  may  be  called  acute  ataxia,  in  which,  within  a 
year  or  even  less,  the  incoordination  is  marked,  and  the  paralytic  stage  may 
develop  within  a  few  months.  The  disease  itself  rarely  causes  death,  and  after 
becoming  bedridden  the  patient  may  live  for  fifteen  or  twenty  years. 

Diagnosis. — In  the  initial  stage  the  lightning  pains  are  distinctive.  The 
association  of  progressive  atrophy  of  the  optic  nerves  with  loss  of  knee-jerk  is 
characteristic.  The  early  ocular  palsies  are  of  the  greatest  importance.  A 
squint,  ptosis,  or  the  Argyll-Robertson  pupil  may  be  the  first  symptom,  and 
may  exist  with  the  loss  only  of  the  knee-jerk.  Loss  of  the  knee-jerk  alone, 
however,  does  occasionally  occur  in  healthy  individuals.  The  Wassermann  re- 
action and  a  study  of  the  spinal  fluid  are  of  help  in  doubtful  cases. 

The  diseases  most  likely  to  be  confounded  with  tabes  dorsalis  are:  (a) 
Peripheral  Neuritis. — The  steppage  gait  of  arsenical,  alcoholic,  or  diabetic 
paralysis  is  quite  unlike  that  of  tabes.  There  is  a  paralysis  of  the  feet,  and  the 
leg  is  lifted  high  in  order  that  the  toes  may  clear  the  floor.  The  use  of  the 
word  ataxia  in  this  connection  should  not  be  continued.  In  the  rare  cases  in 
which  the  muscle  sense  nerves  are  particularly  afl^ected  and  in  which  there  is 
true  ataxia,  the  absence  of  the  lightning  pains  and  eye  symptoms  and  the 
history  will  suffice  to  make  the  diagnosis  clear.  In  diphtheritic  paralysis  the 
early  loss  of  the  knee-jerk  and  the  associated  eye  symptoms  may  suggest  tabes, 
but  the  history,  the  existence  of  paralysis  of  the  throat,  and  the  absence  of 
pains  render  a  diagnosis  easy. 

(by  Combined  Sclerosis. — Marked  incoordination  with  spastic  paralysis 
is  characteristic  of  the  condition  which  Gowers  termed  ataxic  paraplegia.  In 
a  majority  of  the  cases  this  is  distinguished  also  by  the  absence  of  pains  and 
eye  symptoms,  but  it  may  be  a  manifestation  of  the  cord  lesions  in  tabo- 
paralysis. 

(c)  Cerebral  Disease. — In  diseases  of  the  brain  involving  the  afferent 
tracts  ataxia  is  at  times  a  prominent  symptom.  It  is  usually  unilateral  or 
limited  to  one  limb;  this,  with  the  history  and  the  associated  symptoms,  ex- 
cludes tabes: 

(d)  Cerebellar  Disease. — The  cerebellar  incoordination  has  only  a 
superficiar  resemblance  to  that  of  tabes,  and  is  more  a  disturbance  of  equili- 
brium than  a  true  ataxia;  the  knee-jerk  is  usually  present,  there  are  no  light- 
ning pains,  no  sensory  disturbances;  while,  on  the  other  hand,  there  are 
headache,  optic  neuritis,  and  vomiting. 

(e)  Acute  syphilitic  affections  involving  the  dorsal  columns  of  the 
cord  may  be  associated  with  incoordination  and  resemble  tabes  very  closely. 

(/)  General  Paresis. — Though  of  identical  origin  and  often  associated, 
it  is  of  great  practical  importance  to  determine,  if  possible,  whether  the  type 
is  to  be  spinal  or  cerebral,  for  when  this  is  established,  it  does  not  often  change. 
The  difficulty  arises  in  the  premonitory  stage,  when  ocular  changes  and 
abnormalities  of  sensation  and  the  deep  reflexes  may  be  the  only  symptoms. 
Any   alteration   in   the  mental    characteristics  is  of   the   utmost  significance. 


DISEASES  OF  THE  AFFERENT  OR  SENSORY  SYSTEM     913 

Loss  of  the  deep  reflexes  and  lightning  pains  speak  for  tabes;  active  reflexes, 
with  ocular  changes,  especially  optic  atrophy,  are  suggestive  of  paresis. 

(g)  Visceral  crises  and  neuralgic  symptoms  may  lead  to  error,  and  in 
middle-aged  men  vidth  severe,  recurring  attacks  of  gastralgia  it  is  always  well 
to  bear  in  mind  the  possibility  of  tabes,  and  to  make  a  careful  examination  of 
the  eyes  and  of  the  knee-jerk. 

Prog-nosis. — Complete  recovery  can  not  be  expected,  but  arrest  of  the 
process  is  not  uncommon  and  a  marked  amelioration  is  frequent.  Optic-nerve 
atrophy,  one  of  the  most  serious  events  in  the  disease,  has  this  hopeful  aspect — 
that  incoordination  rarely  follows  and  the  progress  of  the  spinal  symptoms  may 
be  arrested.  On  the  other  hand,  mental  symptoms  are  more  likely  to  follow. 
The  optic  atrophy  itself  is  occasionally  checked.  On  the  whole,  the  prognosis 
in  tabes  is  bad.  There  is  more  hope  that  in  very  early  cases  coming  on  soon 
after  infection  the  course  may  be  arrested.  Death  is  usually  from  some  cardio- 
vascular  complication ;  next  in  frequency  from  tuberculosis  and  pneumonia. 

Treatment. — To  arrest  the  progress  and  to  relieve,  if  possible,  the  symp- 
toms are  the  objects  which  the  practitioner  should  have  in  view.  A  quiet,  well- 
regulated  method  of  life  is  essential.  It  is  not  well,  as  a  rule,  for  a  patient  to 
give  up  his  occupation  so  long  as  he  is  able  to  keep  about  and  perform  ordi- 
nary work,  provided  there  is  no  evident  mental  change.  Tabetics  have  for 
years  conducted  large  businesses,  and  there  have  been  several  notable  instances 
in  our  profession  of  men  who  have  risen  to  distinction  in  spite  of  the  existence 
of  this  disease.  Care  should  be  taken  in  the  diet,  particularly  if  gastric  crises 
have  occurred.  Excesses  of  all  sorts,  more  particularly  in  bacclio  et  venere, 
should  be  carefully  avoided.    A  man  in  the  pre-ataxic  stage  should  not  marry. 

To  secure  arrest  of  the  disease  many  remedies  have  been  employed. 

In  the  specific  treatment  the  object  should  be  to  secure  a  normal  spinal  fluid 
if  possible.  It  is  well  to  begin  with  small  doses  of  arsphenamine  intravenously 
(0.2-0.3  gm.)  once  a  week  for  six  weeks.  Then  a  course  of  mercury  should 
be  given  by  inunction  or  injection,  followed  by  arsphenamine  again.  If  this 
results  in  improvement  in  the  spinal  fluid  it  may  be  kept  up  at  intervals  with 
periods  of  rest  in  between.  If  there  is  no  change  or  only  slight  gain  the 
intraspinal  treatment  with  auto-arsphenaminized  serum  may  be  used.  The 
number  of  injections  can  be  decided  by  the  findings  in  the  spinal  fluid.  This 
treatment  should  be  carried  out  persistently.  In  some  cases  the  giving  of 
mercury  in  full  doses  by  inunction  followed  by  a  spinal  puncture  in  which  as 
much  serum  is  withdrawn  as  possible  has  proved  of  benefit.  The  use  of 
mercurial  serum  has  been  helpful  in  some  cases.  Iodide  of  potassium  can 
be  given  in  addition  in  full  dosage. 

For  the  pains,  complete  rest  in  bed  and  counter-irritation  to  the  spine 
(either  blisters  or  the  thermo-cautery)  may  be  employed.  The  severe  spells 
which  come  on  particularly  after  excesses  of  any  kind  are  often  promptly  re- 
lieved by  a  hot  bath  or  by  a  Turkish  bath.  For  the  severe  recurring  attacks 
of  lightning  pains  spinal  cocainization  may  be  tried.  Cannabis  indica  is 
sometimes  useful.  Suppositories  of  codein  (gr.  1,  0.06  gm.)  and  extract  of 
belladonna  (gr.  %,  0.03  gm.)  may  give  relief.  In  the  severe  paroxysms  of 
pain  hypodermics  of  morphia  or  of  cocaine  must  be  used.  The  use  of  morphia 
should  be  postponed  as  long  as  possible.  Electricity  is  of  very  little  benefit. 
For   the   severe   attacks   of   gastralgia   morphia   is    also   required.      Gastro- 


914  DISEASES  OF  THE  XEEVOUS  SYSTEM 

enterostomy  has  been  performed,  the  solar  plexus  has  been  stretched,  and  the 
dorsal  spinal  nerve  roots  of  the  seventh,  eighth,  ninth,  and  tenth  have  been 
divided  with  good  results.  The  laryngeal  crises  are  rarely  dangerous.  An 
application  of  cocaine  may  be  made  during  the  spasm,  or  a  few  whifEs  of 
chloroform  or  nitrite  of  amyl  may  be  given.  In  all  cases  of  tabes  with  in- 
creased arterial  tension  the  prolonged  use  of  nitroglycerin,  given  until  the 
physiological  effect  is  produced,  is  of  great  service  in  allaying  the  neuralgic 
pains  and  diminishing  the  frequency  of  the  crises.  Its  use  must  be  guarded 
when  there  is  aortic  insufficiency.  The  special  indication  is  increased  tension. 
The  bladder  symptoms  demand  constant  care.  When  the  organ  can  not  be 
perfectly  emptied  the  catheter  should  be  used,  and  the  patient  may  be  taught 
its  use  and  how  to  keep  it  thoroughly  sterilized. 

Frenkel's  method  of  re-education  often  helps  the  patient  to  regain  to  a 
considerable  extent  the  control  of  the  voluntary  movements  which  he  has  lost. 
By  this  method  the  patient  is  first  taught,  by  repeated  systematic  efforts,  to 
perform  simple  movements ;  from  this  he  goes  to  more  and  more  complex  move- 
ments. The  treatment  should  be  directed  and  supervised  by  a  trained  teacher, 
as  the  result  depends  upon  the  skill  of  the  teacher  quite  as  much  as  upon  the 
perseverance  of  the  patient. 


II.     GENEEAL  PARESIS  AND   TABO-PAEALYSIS 

It  is  undoubted  that  most  cases  of  tabes  run  their  course  with  practically 
no  mental  symptoms,  and  that  cases  of  general  paresis  may  never  present 
symptoms  that  suggest  tabes.  For  practical  purposes  we  are  forced  to  keep 
the  distinction  clearly  in  mind,  and  for  this  reason  it  seems  best  to  consider 
them  separately.  There  is,  however,  a  group  of  cases  in  which  the  symptoms  of 
the  two  diseases  are  associated  in  every  combination  for  which  the  name  "tabo- 
paralysis"  is  used. 

General  Paresis 

Definition. — A  chronic  meningo-encephalitis  caused  by  the  spirochaete 
of  syphilis,  often  associated  with  other  local  changes  leading  to  mental  dis- 
turbances and  finally  to  dementia  and  paralysis. 

Etiology. — The  average  interval  from  the  syphilitic  infection  is  twelve 
years.  Males  are  affected  much  more  frequently  than  females.  It  occurs 
chiefly  between  the  ages  of  thirty  and  fifty-five,  although  it  may  begin  in 
childhood  as  the  result  of  congenital  syphilis.  An  overwhelming  majority  of 
the  cases  are  in  married  people,  and  not  infrequently  both  husband  and  wife 
are  affected,  or  one  has  paresis  and  the  other  tabes.  Statistics  show  that  it  is 
more  common  in  the  lower  classes  of  society,  but  in  America  in  general  medical 
practice  the  disease  is  certainly  more  common  in  the  well-to-do  classes. 

Morbid  Anatomy. — The  dura  is  often  thickened,  and  its  inner  surface 
may  show  the  various  forms  of  hypertrophic  pachymeningitis.  The  pia  is 
cloudy,  thickened,  and  adherent  to  the  cortex.  The  cerebro-spinal  fluid  is 
increased  in  the  meningeal  spaces,  especially  in  the  meshes  of  the  pia,  and  at 
times  to  such  an  extent  as  to  resemble  cysts.  The  brain  is  small,  and  weighs 
less  than  normal.     The  convolutions  are  atrophied,  especially  in  the  anterior 


DISEASES  OF  THE  AFFERENT  OR  SENSORY  SYSTEM      915 

and  middle  lobes.  In  acute  cases  the  brain  may  be  swollen,  hypera^mic,  and 
oedematous.  The  brain  cortex  is  usually  red,  and,  except  in  advanced  cases, 
it  may  not  be  atrophied,  the  atrophy  of  the  hemispheres  being  at  the  expense 
of  the  white  matter.  The  lateral  ventricles  are  dilated  to  compensate  for 
the  atrophy  of  the  brain,  and  the  ependyma  may  be  granular.  The  fourth 
ventricle  is  more  constantly  dilated,  with  granulations  of  its  floor  covering 
the  calamus  scriptorius,  a  condition  seldom  seen  in  any  other  affection. 

In  many  cases  changes  are  present  in  the  spinal  cord  and  peripheral  nerves. 
There  are  the  typical  tabetic  changes.  There  may  be  degeneration  of  the 
pyramidal  systems  of  fibres  secondary  to  the  cortical  changes.  Most  com- 
monly there  is  a  combination  of  these,  two  processes.  Foci  of  haemorrhages, 
and  softening  dependent  upon  coarse  vascular  changes,  are  not  infrequently 
found,  but  are  not  typical  of  the  disease. 

There  are  various  views  as  to  the  nature  of  the  changes.  The  vascular  the- 
ory is  that  from  an  inflammatory  process  starting  in  the  sheaths  of  the  arte- 
rioles there  is  a  diffuse  parenchymatous  degeneration  with  atrophic  changes 
in  the  nerve  cells  and  neuroglia.  The  syphilitic  toxin  causes  degeneration  in 
the  nervous  tissues  with  secondary  changes  in  the  neuroglia  and  vascular  sys- 
tems.   The  spirochgetes  are  found  in  the  brain  tissue  and  rarely  in  the  cord. 

Symptoms. — Peodeomal  Stage. — Irritability,  inattention  to  business 
amounting  sometimes  to  indifference  or  apathy,  and  sometimes  a  change  m 
character,  marked  by  acts  which  may  astonish  the  friends  and  relatives,  are 
usually  the  first  indications.  There  may  be  unaccountable  fatigue  after 
moderate  physical  or  mental  exertion.  Instead  of  apathy  or  indifference  there 
may  be  an  extraordinary  degree  of  physical  and  mental  restlessness.  The 
patient  is  continually  planning,  and  scheming,  or  may  launch  into  extrava- 
gances and  speculation  of  the  wildest  character,  A  common  feature  at  this 
period  is  the  display  of  an  unbounded  egoism.  He  boasts  of  his  personal  at- 
tainments, his  property,  his  position  in  life,  or  of  his  wife  and  children.  Fol- 
lowing these  features  are  imiportant  indications  of  moral  perversion,  mani- 
fested in  offences  against  decency  or  the  law,  many  of  which  acts  have  about 
them  a  suspicious  effrontery,  Forgetfulness  is  common,  and  may  be 
shown  in  inattention  to  business  details  and  in  the  minor  courtesies  of  life. 
At  this  period  there  may  be  no  motor  phenomena.  The  onset  is  usually 
insidious,  although  cases  are  reported  in  which  epileptiform  or  apoplectiform 
seizures  were  the  first  symptoms.  Attacks  of  hemicrania,  like  ophthalmic 
migraine,  may  occur.  Among  the  early  motor  features  are  tremor  of  the 
tongue  and  lips  in  speaking,  slowness  of  speech  and  hesitancy  with  mixing  of 
syllables  or  letters.  Inequality  of  the  pupils,  temporary  paresis  of  the  eye 
muscles  with  diplopia,  the  Argyll-Robertson  pupil,  optic  atrophy,  and  changes 
in  the  deep  reflexes,  may  precede  the  occurrence  of  mental   symptoms  for 

years. 

Second  Stage. — This  is  characterized  in  brief  by  mental  exaltation  or 
excitement  and  a  progress  in  the  motor  symptoms.  "The  intensity  of  the 
excitement  is  often  extreme,  acute  maniacal  stales  are  frequent;  incessant 
restlessness,  obstinate  sleeplessness,  noisy,  boisterous  excitement,  and  blind,  un- 
calculating  violence  especially  characterize  such  states"  (Lewis).  It  is  at  this 
stage  that  the  delusion  of  grandeur  becomes  marked  and  the  patient  believes 
himself  to  be  possessed  of  countless  millions  or  to  have  reached  the  most 


916  DISEASES  OF  THE  NEEVOUS  SYSTEM 

exalted  sphere  possible  in  profession  or  occupation.  This  expansive  delirium 
is,  however,  not  characteristic  of  general  paresis.  Besides,  it  does  not  always 
occur,  but  in  its  stead  there  may  be  marked  melancholia  or  hypochondriasis, 
or,  in  other  instances,  alternate  attacks  of  delirium  and  depression. 

The  fades  has  a  peculiar  stolidity,  and  in  speaking  there  is  marked  tremu- 
lousness  of  the  lips  and  facial  muscles.  The  tongue  is  also  tremulous,  and  may 
be  protruded  with  difficulty.  The  speech  is  slow,  interrupted,  and  blurred. 
Writing  becomes  difficult  on  account  of  unsteadiness  of  the  hand.  Letters, 
syllables,  and  words  may  be  omitted.  The  subject  matter  of  the  patient's  let- 
ters gives  valuable  indications  of  the  mental  condition.  In  many  instances  the 
pupils  are  unequal,  irregular,  sluggish,  sometimes  large.  Important  symptoms 
in  this  stage  are  apoplectiform  seizures  and  paralysis.  There  may  be  slight 
syncopal  attacks  in  which  the  patient  turns  pale  and  may  fall.  Some  of  these 
are  petit  mat.  In  the  apoplectiform  seizure  the  patient  falls  suddenly, 
becomes  unconscious,  the  limbs  are  relaxed,  the  face  is  flushed,  the  breathing 
stertorous,  the  temperature  increased,  and  death  may  occur.  Epileptic  seizures 
are  more  common  than  the  apoplectiform.  There  may  be  a  definite  aura.  The 
attack  usually  begins  on  one  side  and  may  not  spread.  There  may  be  twitch- 
ings  either  in  the  facial  or  brachial  muscles.  Typical  Jacksonian  epilepsy 
may  occur.  Eecurring  attacks  of  aphasia  are  not  uncommon,  and  paralysis, 
either  monoplegic  or  hemiplegic,  may  follow  these  epileptic  seizures,  or  may 
come  on  with  great  suddenness  and  be  transient.  In  this  stage  the  gait  be- 
comes impaired,  the  patient  trips  readily,  has  difficulty  in  going  up  or  down 
stairs,  and  the  walk  may  be  spastic  or  occasionally  tabetic.  This  paresis  may 
be  progressive.  The  deep  reflexes  are  usually  increased,  but  may  be  lost. 
Bladder  or  rectal  symptoms  gradually  develop.  The  patient  becomes  helpless, 
bedridden,  and  completely  demented,  and  unless  care  is  taken  may  suffer  from 
bedsores.  Death  occurs  from  exhaustion  or  some  intercurrent  affection.  The 
spinal  cord  features  may  come  on  with  or  precede  the  mental  troubles.  There 
are  cases  in  which  one  is  in  doubt  for  a  time  whether  the  symptoms  indicate 
tabes  or  general  paresis,  and  it  is  well  to  bear  in  mind  that  every  feature  of 
pre-ataxic  tabes  may  exist  in  the  early  stage  of  general  paresis. 

Cerebrospinal  Fluid. — The  findings  are  as  follows:  (1)  Cell  content. 
A  lymphocytosis  is  present  in  98-100  per  cent,  and  the  average  content  is 
30-60  cells.  (2)  Glohulin.  This  is  practically  always  positive.  (3)  ^Yasser- 
mann  reaction.  This  is  positive  in  nearly  every  case  and  usually  there  is  a 
strong  reaction  with  small  amounts.  The  blood  reaction  is  positive  in  98-100- 
per  cent.  (4)  Colloidal  Gold  reaction..  This  is  nearly  always  positive  in  98- 
100  per  cent.,  with  a  typical  paretic  curve, 

Tabo-paralysis 
Emphasis  has  been  laid  on  the  identity  of  the  processes  underlying  tabes 
and  general  paresis,  the  spinal  cord  in  the  first  case  receiving  the  full  force 
of  the  attack,  and  the  brain  in  the  second.  It  is  suggested  that  stress  deter- 
mines the  location  of  the  process ;  men  whose  occupations  require  much  bodily 
exercise  are  apt  to  have  tabes,  while  those  whose  activities  are  largely  mental 
would  suffer  from  paresis.  Usually  when  the  cord  symptoms  are  pronounced 
the  symptoms  from  the  brain  remain  in  abeyance,  and  the  reverse  is  also 
true.     There  are  exceptions,  and  cases  of  well  marked  tabes  may  later  show 


DISEASES  OF  THE  AFFEBENT  OR  SENSORY  SYSTEM     917 

the  typical  symptoms  of  paresis,  but  even  then  the  ataxia,  if  it  is  not  of  too 
high  a  grade,  may  improve. 

Optic  atrophy,  when  it  occurs  in  the  pre-ataxic  stage  of  tabes,  usually  indi- 
cates that  the  ataxia  will  never  be  pronounced,  but  unfortunately  it  is  fre- 
quently followed  by  the  occurrence  of  mental  symptoms.  Mott  states  that 
about  50  per  cent,  of  his  asylum  cases  of  tabo-paralysis  had  preceding  optic 
atrophy.  Its  occurrence  is  therefore  of  grave  significance.  The  mental  symp- 
toms may  be  delayed  for  many  years. 

Made  up  of  a  combination  of  features  of  the  two  conditions,  the  symptom 
complex  of  tabo-paralysis  varies  greatly.  It  may  begin  as  tabes  with  lightning 
pains,  bladder  symptoms,  Argyll-Robertson  pupil,  loss  of  the  deep  reflexes,  etc., 
to  have  the  mental  symptoms  added  later;  or,  on  the  other  hand,  cord  symp- 
toms may  come  on  after  the  patient  has  shown  marked  mental  changes.  The 
symptoms  from  the  first  may  be  so  combined  that  the  name  tabo-paralysis  is 
at  once  applicable.  Absent  knee-jerks,  ocular  palsies,  or  pupillary  symptoms 
may  precede  the  breakdown  for  many  years,  but  none  of  them  have  so  grave 
a  significance  in  regard  to  the  mental  state  as  has  optic  atrophy.  Other  types 
of  alienation  may  interrupt  the  course  of  tabes,  and  the  mistake  must  not  be 
made  of  regarding  them  all  as  general  paresis. 

Diagnosis. — The  recognition  of  general  paresis  in  the  earliest  stage  is 
extremely  difficult,  as  it  is  often  impossible  to  decide  that  the  slight  alteration 
in  conduct  is  anything  more  than  one  of  the  moods  or  phases  to  which  most 
men  are  at  times  subject.  The  following  description  by  Folsom  is  an  admira- 
ble presentation  of  the  diagnostic  characters  of  the  early  stage  of  the  disease : 
"It  should  arouse  suspicion  if,  for  instance,  a  strong,  healthy  man,  in  or  near 
the  prime  of  life,  distinctly  not  of  the  ^nervous,'  neurotic,  or  neurasthenic 
type,  shows  some  loss  of  interest  in  his  aflPairs  or  impaired  faculty  of  attending 
to  them;  if  he  becomes  varyingly  absent-minded,  heedless,  indifl^erent,  negli- 
gent, apathetic,  inconsiderate,  and,  although  able  to  follow  his  routine  duties, 
his  ability  to  take  up  new  work  is,  no  matter  how  little,  diminished ;  if  he  can 
less  well  command  mental  attention  and  concentration,  conception,  perception, 
reflection,  judgment ;  if  there  is  an  unwonted  lack  of  initiative,  and  if  exertion 
causes  unwonted  mental  and  physical  fatigue;  if  the  emotions  are  intensified 
and  easily  change,  or  are  excited  readily  from  trifling  causes;  if  the  sexual 
instinct  is  not  reasonably  controlled;  if  the  finer  feelings  are  even  slightly 
blunted;  if  the  person  in  question  regards  with  a  placid  apathy  his  own  acts 
of  indifl'erence  and  irritability  and  their  consequences,  and  especially  if  at 
times  he  sees  himself  in  his  true  light  and  suddenly  fails  again  to  do  so;  if 
any  symptoms  of  cerebral  vaso-motor  disturbances  are  noticed,  however  vague 
or  variable." 

There  are  cases  of  cerehral  syphilis  which  closely  simulate  general  paresis. 
The  mode  of  onset  is  important,  particularly  since  paralytic  symptoms  are 
usually  early  in  syphilis.  The  affection  of  the  speech  and  tongue  is  not  present. 
Epileptic  seizures  are  more  common  and  more  liable  to  be  cortical  or  Jack- 
sonian  in  character.  The  expansive  delirium  is  rare.  While  symptoms  of 
general  paresis  are  not  common  in  connection  with  the  development  of 
gummata  or  definite  gummatous  meningitis,  there  are,  on  the  other  hand, 
instances  of  paresis  following  closely  upon  the  sypbilitir  infection.  Post 
mortem  in  such  cases  there  may  be  nothing  more  than  a  general  arterio- 


918  DISEASES  OF  THE  NERVOUS  SYSTEM 

sclerosis  and  diffuse  meningo-encephalitis,  whicli  may  present  notliing  dis- 
tinctive, but  the  lesions  may  be  caused  by  the  spirochaete.  Cases  also  occur  in 
which  typical  syphilitic  lesions  are  combined  with  the  ordinary  lesions  of 
general  paresis.  There  are  certain  forms  of  lead  encephalopathy  which 
resemble  general  jDaresis,  and,  considering  the  association  of  plumbism  with 
arterio-sclerosis,  it  is  not  unlikety  that  the  anatomical  substratum  of  the 
disease  may  result  from  this  poison.  Tumor  may  sometimes  simulate  pro- 
gressive paresis,  but  in  the  former  the  signs  of  general  increase  of  the  intra- 
cranial pressure  are  usually  present.  The  findings  in  the  spinal  fluid  are 
important  aids. 

Cyto  did  gnosis. — The  study  of  the  cerebro-spinal  fluid  is  an  important 
diagnostic  measure,  particularly  in  tabes  and  paresis.  Spinal  lymphocytosis 
is  the  rule  and  is  usually  associated  with  a  marked  globulin  reaction — the  nor- 
mal fluid  containing  at  most  minute  traces,  and  a  negligible  number  of 
formed  elements.  It  is  the  expression  of  a  subacute  or  chronic  inflammatory 
process,  just  as  polymorphonuclear  leukocytosis  is  characteristic  of  an  acute 
process.  It  is  the  syphilitic  triad — tabes,  paresis,  and  cerebro-spinal  lues — 
which  is  suggested  by  lymphocytosis  in  the  spinal  fluid.  Positive  reactions, 
cytological  and  chemical,  are  among  the  earliest  somatic  signs,  and  may  clear 
up  obscure  cases  of  tabes  and  paresis,  just  at  the  time  when  diagnosis  is  most 
difficult. 

Prognosis.— The  disease  rarely  ends  in  recovery.  As  a  rule  the  progress 
is  slowly  downward  and  the  case  terminates  in  a  few  years,  although  it  is 
occasionally  prolonged  ten  or  fifteen  years. 

Treatment  .--Specific  treatment  has  been  disappointing  on  the  whole,  par- 
ticularly by  the  intra-spinal  method,  and  some  authorities  regard  it  as  contra- 
indicated.  Certainly  some  patients  are  harmed  by  it  but  in  such  a  hopeless 
condition  there  is  some  justification  for  taking  the  risk.  The  treatment  is 
practically  the  same  as  in  tabes  dorsalis.  Careful  nursing  and  the  orderly 
life  of  an  asylum  are  necessary  in  a  great  majority  of  the  cases.  For  sleep- 
lessness and  the  epileptic  seizures  bromides  may  be  used.  Prolonged  re- 
missions, which  are  not  uncommon,  are  often  erroneously  attributed  to  the 
action  of  remedies.  Active  treatment  in  the  early  stage  by  wet-packs,  cold 
to  the  "head,  and  systematic  massage  has  been  followed  by  temporary  improve- 
ment. 


III.    DISEASES  OF  THE  EFFERENT  OR  MOTOR  TRACT 

I.     PEOGEESSIVE   (CENTEAL)  MUSCULAE  ATEOPHY 

{Poliomyelitis  Anterior  Chronica;  Amyotrophic  Lateral  Sclerosis;  Progressive 

Bulbar  Paralysis) 

Definition. — A  disease  characterized  by  a  chronic  degeneration  of  the 
motor  tract,  usually  of  the  whole,  but  at  times  limited  to  the  lower  segment. 
Associated  with  it  is  a  progressive  atrophy  of  the  muscles,  with  more  or  less 
spastic  rigidity. 


DISEASES  OF  THE  EFFERENT  OE  MOTOR  TRACT  919 

Three  affections,  as  a  rule  described  apart,  belong  together  in  this  category : 
(a)  Progressive  muscular  atrophy  of  spinal  origin;  (6)  amyotrophic  lateral 
sclerosis;  and  (c)  progressive  bulbar  paralysis.  A  slow  atrophic  change  in  the 
motor  neurones  is  the  anatomical  basis,  and  the  disease  involves,  in  many 
cases,  the  cortical,  bulbar,  and  spinal  centres.  There  may  be  simple  muscular 
atrophy  with  little  or  no  spasm,  or  progressive  wasting  with  marked  spasm 
and  great  increase  in  the  reflexes.  In  others,  there  are  added  symptoms  of 
involvement  of  the  motor  nuclei  in  the  medulla — a  glosso-labio-laryngeal 
paralysis;  while  in  others,  again,  with  atrophy  (especially  of  the  arms),  a 
spastic  condition  of  the  legs  and  bulbar  phenomena,  tremors  develop  and 
signs  of  cortical  lesion.    These  various  stages  may  be  traced  in  the  same  case. 

For  convenience,  bulbar  paralysis  is  considered  separately,  and  progressive 
muscular  atrophy  and  amyotrophic  lateral  sclerosis  are  taken  together. 

History. — The  disease  is  known  as  the  Aran-Duchenne  type  of  progressive 
muscular  atrophy  and  as  Cruveilhier's  palsy,  after  the  French  physicians  who 
early  described  it.  Luys  and  Lockhart  Clarke  first  demonstrated  that  the 
cells  of  the  ventral  horns  of  the  spinal  cord  were  diseased.  Charcot  separated 
two  types — one  with  simple  wasting  of  the  muscles,  .due,  he  believed,  to 
degeneration  confined  to  the  ventral  horns  (and  to  this  he  restricted  the  name 
progressive  muscular  atrophy — type,  Aran-Duchenne)  ;  the  other,  in  which 
there  was  spastic  paralysis  of  the  muscles  followed  by  atrophy.  As  the 
anatomical  basis  for  this  he  assumed  a  primary  degeneration  of  the  pyramidal 
tracts  and  a  secondary  atrophy  of  the  ventral  horns.  To  this  he  gave  the 
name  of  amyotrophic  lateral  sclero-sis.  There  is  but  little  evidence,  however, 
to  show  that  any  such  sharp  distinction  can  be  made  between  these  two  diseases, 
and  Leyden  and  Cowers  regard  them  as  identical. 

Etiology. — The  cause  is  unknown.  It  is  more  frequent  in  males  than  in 
females  and  affects  adults,  usually  after  the  thirtieth  year,  though  occasionally 
youngei  persons  are  attacked.  Cases  of  progressive  muscular  atrophy  under 
twenty  five  years  of  age  belong  as  a  rule  to  the  dystrophies.  Cold,  wet,  ex- 
posure, fright,  and  mental  worries  are  mentioned  as  possible  causes.  Certain 
cases  follow  injury.  The  Werdnig-Hoffman  type  is  a  familial  affection  and 
does  not  belong  here.  The  spastic  form  may  develop  late  in  life — after  seventy 
— as  a  senile  change. 

Morbid  Anatomy. — The  essential  anatomical  change  is  a  slow  degenera- 
tion of  the  motor  path,  involving  particularly  the  lower  motor  neurones.  The 
upper  neurones  are  also  involved,  either  first,  simultaneously,  or  at  a  later 
period.  Associated  with  the  degeneration  in  the  cells  of  the  ventral  horns  there 
is  a  degenerative  atrophy  of  the  muscles.  The  following  are  the  important 
anatomical  changes :  (a)  The  gray  matter  of  the  cord  shows  the  most  marked 
alteration.  The  large  ganglion  cells  of  the  ventral  horns  are  atrophied,  or, 
in  places,  have  entirely  disappeared,  the  neuroglia  is  increased,  and  the  medul- 
lated  fibres  are  much  decreased.  The  fibres  of  the  ventral  nerve-roots  passing 
through  the  white  matter  are  wasted.  (&)  The  ventral  roots  outside  of  the 
cord  are  also  atrophied,  (c)  The  muscles  affected  sliow  degenerative  atrophy, 
and  the  inter-muscular  branches  of  the  motor  nerves  are  degenerated,  (d) 
The  degeneration  of  the  gray  matter  is  rarely  confined  to  the  cord,  but  extends 
to  the  medulla,  where  the  nuclei  of  the  motor  cerebral  nerves  are  found  exten- 
sively wasted,    (e)  In  a  majority  of  all  the  cases  there  is  sclerosis  in  the  ventro- 


920  DISEASES  OF  THE  XERVOUS  SYSTEM 

lateral  white  tracts,  the  lateral  pyramidal  tracts  particularly  are  diseased,  but 
the  degeneration  is  not  confined  to  them,  but  extends  into  the  ventro-lateral 
ground  bundles.  The  direct  cerebellar  and  the  rentro-lateral  ascending  tracts 
are  spared.  The  degeneration  in  the  pyramidal  tracts  extends  toward  the 
brain  to  different  levels,  and  in  several  cases  has  been  traced  to  the  motor  cor- 
tex, the  cells  of  which  have  been  found  degenerated.  In  the  medulla  the 
medial  longitudinal  fasciculus  has  been  found  diseased.  (/)  In  those  cases  in 
which  no  sclerosis  has  been  found  in  the  pyramidal  tracts  there  has  been  a 
sclerosis  of  the  ventro-lateral  ground  bundle  (short  tracts). 

Symptoms. — Irregular  pains  may  precede  the  onset  of  the  wasting.  The 
hands  are  usually  first  affected,  and  there  is  difficulty  in  performing  delicate 
manipulations.  The  muscles  of  the  ball  of  the  thumb  waste  early,  then  the 
interossei  and  lumbricales,  leaving  marked  depressions  between  the  metacarpal 
bones.  Ultimately  the  contraction  of  the  flexor  and  extensor  muscles  and  the 
extreme  atrophy  of  the  thumb  muscles,  the  interossei,  and  lumbricales  produce 
the  claw-hand — main  en  griffe  of  Duchenne.  The  flexors  of  the  forearm  are 
usually  involved  before  the  extensors.  In  the  shoulder-girdle  the  deltoid  is 
first  affected;  it  may  waste  even  before  the  other  muscles  of  the  upper 
extremity.  The  trunk  muscles  are  gradually  attacked;  the  upper  part  of  the 
trapezius  long  remains  unaffected.  Owing  to  the  feebleness  of  the  muscles 
which  support  it,  the  head  tends  to  fall  forward.  The  platysma  myoides  is 
unaffected  and  often  hypertrophies.  The  arms  and  the  trunk  muscles  may 
be  much  atrophied  before  the  legs  are  attacked.  The  face  muscles  are  at- 
tacked late.  Ultimately  the  intercostal  and  abdominal  muscles  may  be  in- 
volved, the  wasting  proceeds  to  an  extreme  grade,  and  the  patient  may  be 
actually  '^skin  and  bone,'^  and,  as  "living  skeletons,"  the  cases  are  not  nn- 
commoii  in  "museums"  and  "side-shows."  Deformities  and  contractures  re- 
sult, and  lordosis  is  almost  always  present.  A  curious  twitching  of  the 
muscles  (fibrillation)  is  common  and  may  occur  in  muscles  which  are  not  at- 
tacked. It  is  a  most  important  symptom,  but  is  not  a  characteristic  feature. 
The  irritability  of  the  muscles  is  increased.  Sensation  is  unimpaired,  but  the 
patient  may  complain  of  numbness  and  coldness  of  the  affected  limbs.  The 
galvanic  and  faradic  irritability  of  the  muscles  progressively  diminishes  and 
may  become  extinct,  the  galvanic  persisting  for  the  longer  time.  In  cases  of 
rapid  wasting  and  paralysis  the  reaction  of  degeneration  may  be  obtained. 
The  excitability  of  the  nerve  trunks  may  persist  after  the  muscles  have  ceased 
to  respond.    The  loss  of  power  is  usually  proportionate  to  the  wasting. 

Amyotrophic  Spastic  Form. — The  foregoing  description  applies  to  the 
group  of  cases  in  which  the  atrophy  and  paralysis  are  flaccid — atonic,  as 
Gcwers  called  it.  In  other  cases,  those  which  Charcot  described  as  amyo- 
trophic lateral  sclerosis,  spastic  paralysis  precedes  the  wasting.  The  reflexes 
are  greatly  increased.  It  is  one  of  the  rare  conditions  in  which  a  jaw  clonus 
may  be  okained.  The  most  typical  condition  of  spastic  paraplegia  may  be 
produced.  On  starting  to  walk,  the  patient  seems  glued  to  the  ground  and 
makes  ineffectual  attempts  to  lift  the  toes ;  then  four  or  five  short,  quick  steps 
are  taken  on  the  toes  with  the  body  thrown  forward ;  and  finally  he  starts  off, 
sometimes  with  great  rapidity.  Some  of  the  patients  can  walk  up  and  down 
stairs  better  than  on  the  level.  The  wasting  is  never  so  extreme  as  in  the 
atonic  form,  and  the  loss  of  power  may  be  out  of  proportion  to  it.     The 


DISEASES  OF  THE  EFFERENT  OE  MOTOR  TRACT  921 

sphincters  are  unaffected.  Sexual  power  may  be  lost  early.  A  flaccid  atrophic 
paralysis  with  increased  reflexes  is  the  common  finding.  The  differences 
depend  upon  the  relative  extent  of  the  involvement  of  the  upper  and  lower 
motor  segments  and  the  time  of  the  involvement  of  each.  The  condition  may 
be  unilateral. 

As  the  degeneration  extends  upward  an  important  change  takes  place  from 
the  occurrence  of  bulbar  symptoms,  which  may,  however,  precede  the  spinal 
manifestations.  The  lips,  tongue,  face,  pharynx,  and  larynx  may  be  involved. 
The  lips  may  be  affected  and  articulation  impaired  for  years  before  serious 
symptoms  occur.  In  the  final  stage  there  may  be  tremor,  the  memory  fails, 
and  a  condition  of  dementia  supervenes. 

Diagfnosis. — -Progressive  (central)  muscular  atrophy  begins,  as  a  rule,  in 
adult  life,  without  hereditary  or  family  influences  (the  early  infantile  form 
being  an, exception),  and  usually  affects  first  the  muscles  of  the  thumb,  and 
gradually  involves  the  interossei  and  lumbricales.  Fibrillary  contractions  are 
common,  electrical  changes  occur,  and  the  deep  reflexes  are  usually  increased. 
These  characteristics  are  usually  sufficient  to  distinguish  it  from  the  other 
forms  of  muscular  wasting.  It  is  well  to  remember  that  the  earliest  and  most 
marked  indication  of  cervical  rih  may  be  atrophy  of  the  small  muscles  of  the 
hand. 

In  syringomyelia  the  symptoms  may  be  similar  to  those  in  the  spastic 
form  of  muscular  atrophy.  The  sensory  disturbances  in  the  former  disease, 
as  a  rule,  make  the  diagnosis  clear,  but  when  these  are  absent  or  but  little  de- 
veloped it  may  be  very  difficult  or  impossible  to  distinguish  the  diseases. 

Treatment. — The  disease  is  incurable.  The  downward  progress  is  slow 
but  certain,  though  in  a  few  cases  a  temporary  arrest  may  take  place.  Arsenic 
and  hypodermic  injections  of  strychnine  may  be  tried.  Systematic  massage  is 
useful  in  the  spastic  cases. 

Bulbar  Paralysis  {Glosso-labio-laryngeal  Paralysis) 

When  the  disease  affects  the  motor  nuclei  of  the  medulla  first  or  early,  it 
is  called  bulbar  paralysis,  but  it  has  practically  no  independent  existence,  as 
the  spinal  cord  is  sooner  or  later  involved. 

Symptoms. — The  disease  begins  with  slight  defect  in  the  speech,  and 
difficulty  in  pronouncing  the  dentals  and  Unguals.  The  paralysis  starts  in 
the  tongue,  and  the  superior  lingual  muscle  gradually  becomes  atrophied,  and 
finally  the  mucous  membrane  is  thrown  into  transverse  folds.  In  the  process 
of  wasting  the  fibrillary  tremors  are  seen.  Owing  to  the  loss  of  power  in  the 
tongue,  the  food  is  with  difficulty  pushed  back  into  the  pharynx.  The  saliva 
also  may  be  increased,  and  is  apt  to  accumulate  in  the  mouth.  When  the  lips 
become  involved  the  patient  can  neither  whistle  nor  pronounce  the  labial  con- 
sonants. The  mouth  looks  large,  the  lips  are  prominent,  and  there  is  constant 
drooling.  The  food  is  masticated  with  difficulty.  Swallowing  becomes  difficult, 
owing  partly  to  the  regurgitation  into  the  nostrils,  partly  to  the  involvement 
of  the  pharyngeal  muscles.  The  muscles  of  the  vocal  cords  waste  and  the 
voice  becomes  feeble,  but  the  laryngeal  paralysis  is  rarely  so  extreme  as  that 
of  the  lips  and  tongue. 

The  course  is  slow  but  progressive.  Death  may  result  from  an  aspiration 
pneumonia,  sometimes  from  choking,  more  rarely  from  involvement  of  the 


922  DISEASES  OF  THE  NERVOUS  SYSTEM 

respiratory  centres.  The  mind  usually  remains  clear.  The  patient  may  be- 
come emotional.  In  a  majority  of  the  cases  the  disease  is  only  part  of  a 
progressive  atrophy,  either  simple  or  associated  with  a  spastic  condition. 
In  the  later  stage  of  amyotrophic  lateral  sclerosis  the  bulbar  lesions  may 
paralyze  the  lips  long  before  the  pharynx  or  larynx  becomes  affected. 

The  diagnosis  is  readily  made,  either  in  the  acute  or  chronic  form.  The 
involvement  of  the  lips  and  tongue  is  usually  well  marked,  while  that  of  the 
palate  may  be  long  deferred.  In  pseudo-hulbar  paralysis  bilateral  disease  of 
the  motor  cortex  in  the  lower  part  of  the  ascending  frontal  convolution,  or 
about  the  knee  of  the  internal  capsule  may  interfere  with  the  supranuclear 
paths,  causing  paralysis  of  the  lips  and  tongue  and  pharynx,  which  closely 
simulates  a  lesion  of  the  medulla.  Sometimes  the  symptoms  appear  on  one 
side,  but  they  may  develop  suddenly  on  both  sides.  Bilateral  lesions  have 
usually  been  found,  but  the  disease  may  be  unilateral.  There  is  arterio- 
sclerosis and  the  bulbar  features  are  usually  sequels  of  hemiplegic  attacks. 

Acute  bulbar  paralysis  may  be  due  to  (a)  hsemorrhagic  or  embolic  soften- 
ing in  the  pons  and  medulla ;  (b)  acute  inflammatory  softening,  analogous  to 
polio-myelitis,  occurring  occasionally  as  a  post-febrile  affection.  It  has  oc- 
casionally followed  diphtheria,  and  occurred  after  severe  electric  shocks  of 
high  voltage.  It  usually  comes  on  very  suddenly,  hence  the  term  apoplectiform. 
The  symptoms  may  correspond  closely  to  those  of  an  advanced  case  of  chronic 
bulbar  paralysis.  The  sudden  onset  and  the  associated  symptoms  make  the 
diagnosis  easy.  In  these  acute  cases  there  may  be  loss  of  power  in  one  arm,  or 
hemiplegia,  sometimes  alternate  hemiplegia,  with  paralysis  on  one  side  of  the 
face  and  loss  of  power  on  the  other  side  of  the  body,  (c)  In  polio-myelitis 
there  are  cases  with  acute  bulbar  symptoms. 

■  II.     SPASTIC  PAEALYSIS  OF  ADULTS 

(Primary  Lateral  Sclerosis)  ' 

Definition. — A  gradual  loss  of  power  with  spasm  of  the  muscles  of  the 
body,  the  lower  extremities  being  first  and  most  affected,  unaccompanied  by 
muscular  atrophy,  sensory  disturbance,  or  other  symptoms.  A  systemic  de- 
generation of  the  pyramidal  tracts  is  assumed. 

Symptoms. — -The  general  symptoms  of  spastic  paraplegia  in  adults  are 
very  distinctive.  The  patient  complains  of  feeling  tired,  of  stiffness  in  the 
legs,  and  perhaps  of  pains  of  a  dull  aching  character  in  the  back  or  in  the 
calves.  There  may  be  no  definite  loss  of  power,  even  when  the  spastic  condi- 
tion is  well  established.  In  other  instances  there  is  definite  weakness.  The 
stiffness  is  felt  most  in  the  morning.  In  a  well  developed  case  the  gait  is  most 
characteristic.  The  legs  are  moved  stiffly  and  with  hesitation,  the  toes  drag 
and  catch  against  the  ground,  and,  in  extreme  cases,  when  the  ball  of  the 
foot  rests  upon  the  ground  a  distinct  clonus  develops.  The  legs  are  kept 
close  together,  the  knees  touch,  and  in  .certain  cases  the  adductor  spasm  may 
cause  cross-legged  progression.  On  examination,  the  legs  may  at  first  appear 
tolerably  supple,  perhaps  flexed  and  extended  readily.  In  other  cases  the 
rigidity  is  marked,  particularly  when  the  limbs  are  extended.  The  snasm  of 
the  adductors  of  the  thigh  may  be  so  extreme  that  Jie  legs  are  separated  with 
the  greatest  difficulty.     In  cases  of  this  extreme  rigidity  the  patient  usually 


DISEASES  OE  THE  EFFERENT  OR  MOTOR  TRACT         923 

loses  the  power  of  walking.  The  nutrition  is  well  maintained,  the  muscles  • 
may  be  hypertrophied.  The  reflexes  are  greatly  increased.  The  slightest 
touch  upon  the  patellar  tendon  produces  an  active  knee-jerk.  The  rectus 
clonus  and  the  ankle  clonus  are  easily  obtained.  In  some  instances  the  slight- 
est touch  may  throw  the  legs  into  violent  clonic  spasm,  the  condition  to  which 
Brown-Sequard  gave  the  name  of  spinal  epilepsy.  The  superficial  reflexes 
are  also  increased.  The  arms  may  be  unaffected  for  years,  but  occasionally 
they  become  weak  and  stiff  at  the  same  time  as  the  legs. 

The  course  of  the  disease  is  progressively  downward.  Years  may  elapse 
before  the  patient  is  bedridden.  Involvement  of  the  sphincters,  as  a  rule, 
is  late;  occasionally  it  is  early.  The  sensory  symptoms  rarely  progress,  and 
the  patients  may  retain  their  general  nutrition  and  enjoy  excellent  health. 
Ocular  symptoms  are  rare. 

Diagnosis. — The  diagnosis,  so  far  as  the  clinical  picture  is  concerned,  is 
readily  made,  but  it  is  often  very  difficult  to  determine  accurately  the  nature 
of  the  underlying  pathological  condition.  A  history  of  syphilis  is  present  in 
many  of  the  cases.  Cases  which  have  run  a  fairly  typical  clinical  course  upon 
coming  to  autopsy  have  been  found  to  have  been  due  to  very  different  condi- 
tions— transverse  myelitis,  multiple  sclerosis,  cerebral  tumor,  etc.  General 
paresis  may  begin  with  symptoms  of  spastic  paraplegia,  and  Westphal  be- 
lieved that  it  was  only  in  relation  to  this  disease  that  a  primary  sclerosis  of 
the  pyramidal  tracts  ever  occurred.  In  any  case  the  diagnosis  of  primary 
systemic  degeneration  of  the  pyramidal  tract  is,  to  say  the  least,  doubtful. 

Treatment. — Not  much  can  be  done  to  check  the  progress.  Division  of 
the  posterior  nerve  roots  is  permissible  when  the  motor  weakness  is  due  chiefly 
to  spasticity.  A  number  of  cases  have  been  operated  upon  successfully.  The 
same  practice  has  been  followed  in  the  spasticity  with  bilateral  athetosis. 

III.     SECONDAEY  SPASTIC  PAEALYSIS 

Following  any  lesion  of  the  pyramidal  tract  there  may  be  a  spastic  paraly- 
sis; thus,  in  a  transverse  lesion  of  the  cord,  whether  the  result  of  slow  com- 
pression (as  in  caries),  chronic  myelitis,  the  pressure  of  tumor,  chronic  men- 
ingo-myelitis,  or  multiple  sclerosis,  degeneration  takes  place  in  the  pyramidal 
tracts^  below  the  point  of  disease.  The  legs  soon  become  stiff  and  rigid,  and« 
the  reflexes  increase.  Bastian  has  shown  that  in  compression  paraplegia  if  the 
transverse  lesion  is  complete,  the  limbs  may  be  flaccid,  without  increase  in  the 
reflexes — parapUgie  flasque  of  the  French.  The  condition  of  the  patient 
in  these  secondary  forms  varies  very  much.  In  chronic  myelitis  or  in  mul- 
tiple sclerosis  he  may  be  able  to  walk  about,  but  with  a  characteristic  spastic 
gait.  In  the  compression  myelitis,  in  fracture,  or  in  caries,  there  may  be 
complete  loss  of  power  with  rigidity. 

It  may  be  difficult  or  even  impossible  to  distinguish  these  cases  from  those 
of  primary  spastic  paralysis.  Reliance  is  to  be  placed  upon  the  associated 
symptoms;  when  these  are  absent  no  definite  diagnosis  as  to  the  cause  of  the 
spastic  paralysis  can  be  given. 

Syphilitic  Spinal  Paralysis. — Erb  described  a  symptom  group  under  the 
term  syphilitic  spinal  paralysis.  The  points  upon  which  he  laid  stress  are 
a  very  gradual  onset  with  a  development  finally  of  the  features  of  a  spastic 
paresis;  the  tendon  reflexes  are  increased,  but  the  muscular  rigidity  is  slight 


924  DISEASES  OF  THE  NERVOUS  SYSTEM 

in  comparison  with  the  exaggerated  deep  reflexes.  There  is  rarely  much  pain, 
and  the  sensory  disturbances  are  trivial,  but  there  may  be  parsesthesia  and  the 
girdle  sensation.  The  bladder  and  rectum  are  usually  involved,  and  there  is 
sexual  failure  or  impotence.  And,  lastly,  improvement  is  not  infrequent.  A 
majority  of  instances  of  spastic  paralysis  of  adults  not  the  result  of  slow  com- 
pression of  the  cord  are  associated  with  syphilis  and  belong  to  this  group. 


C.   HEEEDITAEY  AND  FAMILIAL  DISEASES 

I.     THE    MUSCULAR   DYSTROPHIES 
(Dystrophia  muscularis  progressiva,  Erb.    Primary  Myopathy) 

Definition. — Muscular  wasting,  with  or  without  an  initial  hypertrophy,  be- 
ginning in  various  groups  of  muscles,  usually  progressive  in  character,  and 
dependent  on  primary  changes  in  the  muscles  themselves  or  the  neuro-muscular 
endings. 

Etiolo^. — No  factor  other  than  heredity  is  known,  which  may  show  itself 
by  true  heredity — the  disease  occurring  in  two  or  more  generations — or  several 
members  of  the  same  generation  may  be  affected.  Members  of  the  same  family 
may  be  attacked  through  several  generations :  as  many  as  20  or  30  cases  have 
been  described  in  five  generations.  Males,  as  a  rule,  are  more  frequently 
affected  than  females.  In  families,  persons  of  the  same  sex  are  usually  at- 
tacked, but  unaffected  females  may  transmit  the  disease.  In  Erb's  cases  44 
per  cent,  showed  no  heredity.  The  disease  usually  sets  in  before  puberty,  but 
the  onset  may  be  as  late  as  the  twentieth  or  twenty-fifth  year,  or  in  some 
instances  even  later. 

Pathology. — At  first  the  muscle  fibres  hypertrophy,  and  become  round; 
the  nuclei  increase,  and  the  fibres  may  become  fissured.  At  the  same  time 
there  is  a  slight  increase  in  the  connective  tissue.  Sooner  or  later  the  fibres 
begin  to  atrophy,  and  the  nuclei  become  greatly  increased.  Vacuoles  and 
fissures  appear,  and  the  fibres  become  completely  atrophic,  the  connective  tissue 
increasing  with  deposition  of  fat  to  such  an  extent  as  to  cause  hypertrophic 
lipomatosis — pseudo-hypertrophy.  The  different  stages  of  these  changes  may 
be  found  in  a  single  muscle  at  the  same  time. 

The  nervous  system  has  very  generally  been  found  to  be  without  demon- 
strable lesions,  but  in  certain  cases  changes  in  the  cells  of  the  ventral  horns 
have  been  described. 

Changes  in  the  pineal  gland,  producing  shadows,  have  been  demonstrated 
by  the  X-rays,  from  which  very  naturally  it  is  suggested  that  the  disease  is 
due  to  a  disturbance  in  the  internal  secretions. 

Symptoms. — Clumsiness  in  the  movements  of  the  child  is  tlie  first  symptom 
noticed  and  on  examination  certain  muscles  or  groups  of  muscles  seem  to  be 
enlarged,  particularly  those  of  the  calves.  The  extensors  of  the  leg,  the  glutei, 
the  lumbar  muscles,  the  deltoid,  triceps  and  infraspinatus,  are  the  next  most 
frequently  involved,  and  may  stand  out  with  great  prominence.  The  muscles 
of  the  neck,  face,  and  forearm  rarely  suffer.  Sometimes  only  a  portion  of  a 
muscle  is  involved.    With  this  hypertrophy  of  some  muscles  there  is  wasting  of 


THE  MUSCULAR  DYSTROPHIES  935 

others,  particularly  the  lower  portion  of  the  pectorals  and  the  latissimus  dorsi. 
The  attitude  when  standing  is  very  characteristic.  The  legs  are  far  apart, 
the  shoulders  thrown  back,  the  spine  is  greatly  curved,  and  the  abdomen 
protrudes.  The  gait  is  waddling  and  awkward.  In  getting  up  from  the  floor 
the  position  assumed,  so  w^ell  known  now  through  Gowers'  figures,  is  pathogno- 
monic. The  patient  first  turns  over  in  the  all-fours  position  and  raises  the 
trunk  with  his  arms;  the  hands  are  then  moved  along  the  ground  until  the 
knees  are  reached;  then  with  one  hand  upon  a  knee  he  lifts  himself  up,  grasps 
the  other  knee,  and  gradually  pushes  himself  in  the  erect  posture,  as  it  has 
been  expressed,  by  climbing  up  his  legs.  The  striking  contrast  between  the 
feebleness  of  the  child  and  the  powerful  looking  pseudo-hypertrophic  muscles 
is  very  characteristic.  The  enlarged  muscles  may,  however,  be  relatively  very 
strong. 

The  course  is  slow,  but  progressive.  Wasting  proceeds  and  finally  all  traces 
of  the  enlarged  condition  of  the  muscles  disappear.  At  this  late  period  dis- 
tortions and  contractions  are  common.  The  muscles  of  the  shoulder-girdle  are 
nearly  always  affected  early,  causing  a  symptom  upon  which  Erb  lays  great 
stress.  With  the  hands  under  the  arms,  when  one  endeavors  to  lift  the  patient, 
the  shoulders  are  raised  to  the  level  of  the  ears,  and  one  gets  the  impression 
as  though  the  child  were  slipping  through.  These  "loose  shoulders"  are  very 
characteristic.  The  abnormal  mobility  of  the  shoulder  blades  gives  them  a 
winged  appearance,  and  makes  the  arms  seem  much  longer  than  usual  when 
they  are  stretched  out. 

There  are  no  sensory  symptoms.  The  atrophic  muscles  do  not  show  the 
reaction  of  degeneration  except  in  extremely  rare  instances. 

Clinical  Forms. — A  number  of  types  have  been  described,  depending  upon 
the  age  at  onset,  the  muscles  first  affected,  the  occurrence  of  hypertrophy, 
heredity,  etc.,  but  there  is  no  sharp  division  between  the  forms.  The  following 
are  the  more  important: 

1.  The  pseudo-hypertropMc  of  Duclienne,  most  common  in  childhood  and 
in  family  groups.  The  hypertrophy  of  the  muscles  is  the  striking  feature, 
whether  a  true  hypertrophy  or  a  lipomatosis.  There  is  also  a  juvenile  type 
with  atrophy,  affecting  chiefly  the  shoulder  girdles  and  upper  arms.  Isolated 
cases  occur  in  adults. 

II.  The  facio-scapulo-humeral  type  of  Landouzy-Dejerine.  The  face  is 
first  involved,  causing  the  myopathic  facies,  the  lips  prominent,  the  upper  one 
projecting,  the  eyes  cannot  be  closed,  nor  the  forehead  wrinkled,  the  smile  is 
transverse,  from  inaction  of  the  levators  of  the  lip.  Later  the  shoulder-girdle, 
muscles  are  involved,  the  scapulae  are  winged,  the  upper  arms  wasted,  and 
lastly,  the  thigh  muscles.  With  all  this  there  may  be  no  hypertrophy,  though 
often,  if  carefully  sought,  there  will  be  found  areas  of  enlargement — the  so- 
called  muscle  balls.    This  form  may  begin  in  adults, 

III.  The  thigh-muscle  type  of  Leyden,  Moebius,  and  Zimmerlin,  in  which 
the  disease  starts  in  the  extensors  of  the  thighs  which  are  deeply  involved 
before  other  groups  of  upper  arms  and  trunk  are  attacked. 

In  all  forms,  when  the  muscles  of  the  trunk  become  involved,  there  is 
flattening  of  the  chest  and  the  peculiar  " wasp-ivaist"  described  by  Marie. 

Diagnosis. — The  muscular  dystrojibics  can  usually  be  distinguished  readily 
from  the  other  forms  of  muscular  atrophy. 


926  DISEASES  OF  THE  KEEYOUS  SYSTEM 

(a)   In  the  cerebral  atrophy  loss  of  power  usually  precedes  the  atrophy. 

(6)  Progressive  (central)  muscular  atrophy  begins  in  the  small  muscles 
of  the  hand,  the  reaction  of  degeneration  is  present  and  fibrillary  twitchings 
occur  in  both  the  atrophied  and  non-atrophied  muscles.  The  central  atrophies 
come  late  in  life,  the  dystrophies,  as  a  rule,  early.  In  the  progressive  muscular 
dystrophies  heredity  plays  an  important  role.  In  the  rare  cases  of  early 
infantile  spinal  muscular  atrophy  occurring  in  families  the  symptoms  are  so 
characteristic  of  a  central  disease  that  the  diagnosis  presents  no  difficulty. 

(c)  In  the  neuritic  muscular  atrophies,  due  to  lead  or  to  trauma,  seen 
for  the  first  time  at  a  period  when  the  wasting  is  marked  there  is  often 
difficulty,  but  the  absence  of  family  history  and  the  distribution  are  important 
features.  Moreover,  the  paralysis  is  out  of  proportion  to  the  atrophy.  Sensory 
symptoms  may  be  present. 

(d)  Progressive  neural  muscular  atrophy.  Here  heredity  is  also  a  factor, 
and  the  disease  usually  begins  in  early  life,  but  the  distribution  of  atrophy 
and  paralysis,  which  is  at  first  confined  to  the  periphery  of  the  extremities, 
helps  to  distinguish  it  from  the  dystrophies. 

Prognosis. — The  outlook  in  the  primary  muscular  dystrophies  is  bad.  The 
wasting  progresses  uniformly,  uninfluenced  by  treatment. 

Treatment. — Erb  holds  that  by  electricity  and  massage  the  progress  is 
occasionally  arrested.  The  general  health  should  be  carefully  looked  after, 
moderate  exercise  allowed,  friction  of  the  muscles  with  oil,  and  when  the 
patient  becomes  bedfast,  as  is  inevitable  sooner  or  later,  care  should  be  taken 
to  prevent  contractures  in  awkward  positions. 

II.     FAMILIAL  SPINAL  MUSCULAE  ATEOPHY 

(Werdnig -Hoffman) 

A  rare  disease  which  may  be  hereditary  as  well  as  occurring  in  a  family 
without  disease  in  the  ascendants.  x\natomically  there  is  marked  degeneration 
of  the  anterior  horns  in  the  spinal  cord,  of  the  anterior  roots,  and  less  marked 
changes  in  the  peripheral  nerves,  with  widespread  atrophy  of  the  muscular 
fibres.  Yhile  in  many  cases  the  disease  resembles  muscular  dystrophy, 
anatomically  it  appears  to  be  a  progressive  central  muscular  atrophy.  It 
presents  a  close  similarity  to  Amyotonia  Congenita  (Oppenheim's  Disease). 
The  onset  is  early,  even  before  walking.  The  proximal  muscles  of  the  limbs 
and  the  muscles  of  the  trunk  are  first  involved.  There  is  no  pseudo-hyper- 
trophy. Fibrillary  tremors  may  be  present.  The  disease  is  progressive,  some- 
times with  great  rapidity,  and  death  usually  occurs  before  the  sixth  year. 

III.     PEOGEESSIVE  NEURAL  MUSCULAR  ATEOPHY 

(Peroneal  type  and  hypertrophic  type — Charcot-Marie-Tooth) 

The  peroneal  type,  described  first  by  Charcot,  Marie,  and  Tooth,  is  a 
hereditary  and  familial  disease  beginning  in  childhood,  affecting  first  the 
muscles  of  the  peroneal  group,  leading  to  club-foot,  either  pes  equintts  or  pes 
equino-varus. 

The  pathology  is  not  clear :  the  disease  seems  to  occupy  a  position  inter-' 


HEEEDITARY  ATAXIA  927 

mediate  between  central  muscular  atrophy  and  the  muscular  dystrophies, 
resembling  the  latter  in  the  early  onset  and  familial  character,  and  the  former 
in  the  occurrence  of  fibrillary  twitchings,  the  presence  of  electrical  changes 
and  the  implication  of  the  small  muscles  of  the  hand.  Anatomically  sclerosis 
of  the  posterior  columns,  atrophy  of  the  cells  of  the  anterior  horns  and 
alterations  of  the  peripheral  nerves  have  been  foimd. 

The  disease  may  begin  in  the  hands,  but  as  a  rule  the  upper  limbs  are  not 
affected  until  after  the  legs,  and  then  the  trouble  starts  in  the  small  muscles 
of  the  hand,  so  that  claw-foot  and  claw-hand  are  very  striking  features.  Dis- 
turbances of  sensation  are  common.  Fibrillary  twitchings  also  occur;  the 
deep  reflexes  are  lost  in  the  paralysed  muscles.  The  essential  feature  is 
implication  of  the  distal  with  normal  proximal  portions  of  the  limbs,  which 
gives  a  very  characteristic  picture.  There  is  great  decrease  of  the  electrical 
excitability.  Ocular  symptoms  are  rare;  occasionally  there  is  atrophy  of  the 
optic  nerves.  The  disease  should  be  suspected  in  cases  of  acquired  double 
club-foot. 

IV.     PEOGEESSIYE    INTEESTITIAL    HYPEETEOPHIC    NEUEITIS 

Definition. — A  familial  disease  beginning,  as  a  rule,  in  infancy  with  a 
combination  of  the  symptoms  of  tabes  and  muscular  atrophy.  Anatomically 
there  is  sclerosis  of  the  posterior  columns  of  the  cord  with  interstitial  hyper- 
trophic neuritis. 

It  was  first  described  by  Dejerine  and  Sottas,  and,  though  rare,  a  good 
many  families  have  been  reported,  one  by  Marie  in  which  seven  children  were 
affected. 

Pathology. — The  spinal  cord  lesions  resemble  those  of  tabes,  and  result 
from  degeneration  of  the  posterior  nerve  roots.  The  hypertrophy  of  the 
nerves  is  of  a  type  that  occurs  in  no  other  form  of  disease.  The  connective 
tissue  sheaths  are  greatly  thickened,  and  there  is  widespread  parenchymatous 
degeneration. 

Symptoms. — These  begin  in  early  life  and  are:  (a)  Incoordination  very 
like  that  of  tabes  dorsalis,  only  as  the  disease  progresses  the  gait  is  steppage ; 
(&)  sensory  disturbances,  sometimes  pains  which  are  fulgurant  in  character; 
(c)  muscular  atrophy,  limbs  and  face,  in  the  former  chiefly  distal,  in  the 
latter  resembling  a  myopathy.  The  feet  are  usually  in  the  varus  position, 
kypho-scoliosis  is  also  present,  (d)  Ocular  symptoms  are  marked — myosis 
(Argyll-Eobertson  sign),  (e)  Added  to  this,  the  peripheral  nerves  are  hyper- 
trophied,  sometimes  double  the  normal  size,  smooth  and  not  painful,  those  of 
the  lower  limbs  being  chiefly  involved.    The  optic  and  olfactory  nerves  escape. 

V.     HEEEDITAEY  ATAXIA 

(Friedreich's  Ataxia) 

Definition. — A  familial  disease  occurring  late  in  childhood  characterized 
by  locomotor  and  static  ataxia,  speech  disturbances  and  nystagmus,  and 
anatomically  by  degeneration  of  the  postero-lateral  and  spino-cerebellar 
tracts.     In  18G3  Friedreich  first  reported  six  cases. 

Etiology. — It  is  a  family  disease  affecting  brothers  and  sisters.  The  143 
cases  analysed  by  Griffiths  occurred  in  71  unrelated  families.    Males  are  most 


938  DISEASES  OF  THE  NEEVOUS  SYSTEM 

frequently  attacked,  86  to  57  in  Griffiths'  series.  Direct  inheritance  is  rare, 
noted  only  in  33  cases.  The  onset  is  usually  before  puberty,  but  may  be  as 
late  as  the  25th  year.  The  cause  is  unknown.  Various  influences  in  the 
parents,  such  as  consanguinity,  alcoholism,  and  syphilis  have  been  reported. 
The  disease  belongs  to  Gower's  abiotrophies,  an  inherited  weakness,  lack  of 
vitality  in  certain  sections  of  the  nervous  system,  leading  to  early  de- 
generation. 

Morbid  Anatomy. — Both  cord  and  cerebellum  have  been  reported  smaller 
than  usual.  The  posterior  meninges  may  be  thickened.  The  important 
change  is  a  complete  sclerotic  degeneration  of  the  postero-lateral  tracts  form- 
ing the  most  typical  example  of  combined  degeneration.  The  sclerosis  of 
Burdach's  tract  is  less  complete,  as  a  rule,  than  that  of  Goll's.  Gowers'  tract 
and  the  direct  cerebellar  are  always  involved.  Dejerine  and  Letulle  suggest 
that  the  disease  differs  from  ordinary  spinal  sclerosis  and  is  a  gliosis  due  to 
developmental  errors. 

Symptoms. — The  incoordination  begins  in  the  legs,  and  the  gait  is  swaying, 
irregular,  and  more  like  that  of  a  drunken  man  without  the  characteristic 
stamping  gait  of  the  true  tabes.  Eomberg's  sign  may  or  may  not  be  present. 
The  ataxia  of  the  arms  occurs  early  and  is  very  marked;  the  movements  are 
almost  choreiform,  irregular  and  somewhat  swaying.  In  making  any  voluntary 
movement  the  action  is  overdone,  the  prehension  is  clawlike,  and  the  fingers 
may  be  spread  or  overextended  just  before  grasping  an  object.  The  hand  fre- 
quently moves  about  an  object  for  a  moment,  and  then  suddenly  pounces 
upon  it.  There  are  irregular,  swaying  movements  of  the  head  and  shoulders. 
There  is  present  in  many  cases  what  is  known  as  static  ataxia,  that  is  to  say, 
ataxia  of  quiet  action.  It  occurs  when  the  body  is  held  erect  or  when  a  limb 
is  extended — irregular,  oscillating  movements  of  the  head  and  body  or  of  the 
extended  limb. 

Sensory  symptoms  are  not  usually  present.  The  deep  reflexes  are  lost 
early  in  the  disease,  and,  next  to  the  ataxia,  this  is  the  most  constant  and 
important  symptom.  Babinski's  sign  may  be  present  at  first.  The  skin 
reflexes  are  normal,  and  the  pupil  reflex  is  not  affected. 

Nystagmus  is  a  characteristic  symptom.  Atrophy  of  the  optic  nerve  rarely 
occurs.  Disturbance  of  speech  is  common.  It  is  usually  slow  and  scanning; 
the  expression  is  often  dull;  the  mental  power  is,  as  a  rule,  maintained,  but 
late  in  the  disease  becomes  impaired.  A  striking  feature  is  early  deformity 
of  the  feet,  a  talipes  equinus,  so  that  the  patient  walks  on  the  outer  edge  of 
the  feet.  The  big  toe  is  flexed  dorsally  on  the  first  phalanx.  Scoliosis  is  very 
common. 

Trophic  lesions  are  rare.  As  the  disease  advances,  paralysis  comes  on 
and  may  ultimately  be  complete.     Some  of  the  patients  never  walk. 

Diagnosis. — This  is  not  difficult  when  several  members  of  a  family  are 
affected.  The  onset  in  childhood,  the  curious  form  of  incoordination,  the 
loss  of  knee-jerks,  the  early  talipes  e.quinus,  the  position  of  the  great  toe, 
scoliosis,  the  nystagmus,  and  scanning  speech  make  up  an  unmistakable 
picture.  With  hereditary  chorea  it  has  certain  similarities,  but  usually  this 
disease  does  not  set  in  until  after  the  30th  year. 

The  affection  lasts  for  many  years  and  is  incurable.  Care  should  be  taken 
to  prevent  contractures. 


CHRONIC  HEREDITAEY  CHOREA  929 

VI.  HEEEDITARY  CEREBELLAE  ATAXIA  (Marie) 

Though  resembling  Friedreich's  ataxia,  it  cliiTers  in — (1)  Beginning  late 
in  life  (after  twenty)  ;  (2)  the  ataxia  is  more  purely  cerebellar;  (3)  the  knee- 
jerks  are  retained,  sometimes  increased;  (4)  there  is  no  talipes  or  scoliosis; 
and  (5)  ocular  palsies  are  common.  In  L.  F.  Barker's  study  of  two  cases  in 
the  family  (24  cases  in  all)  recorded  by  Sanger  Brown,  there  was  congenital 
hypoplasia  of  the  cerebellum  and  cord  with  degeneration  of  the  spino-cerebellar 
paths  and  slight  degeneration  of  the  pyramidal  tracts.  He  regards  it  as  the 
cerebellar  type  of  Friedreich's  ataxia. 

VII.     HEREDITARY  SPASTIC  PARAPLEGIA 

Definition. — A  familial,  abiotrophic  disease,  involving  chiefly  the  pyra- 
midal tracts.    It  is  sometimes  hereditary. 

Etiology. — It  begins  in  children  usually  after  the  seventh  year;  the  onset 
may  be  delayed  until  the  twentieth :  three  or  four  members  of  a  family  may 
be  attacked,  boys  more  often  than  girls  in  the  proportion  of  88  to  51  (Delearde 
and  Minet).  In  some  families  in  which  the  disease  has  been  hereditary,  the 
females  have  escaped.  Mild  cases  in  a  family  may  exist  with  increase  of  the 
reflexes  as  the  only  symptom. 

Pathology. — The  spinal  degeneration  is  chiefly  in  thepjTamidal  tracts 
of  the  lumbar  and  lower  thoracic  regions.  In  the  late  stages  the  lesions  may 
be  those  of  a  combined  sclerosis  with  involvement  of  the  direct  cerebellar 
tracts.  JSTewmark's  studies  show  imperfect  development  of  the  cord 
(agenesia)  as  an  important  factor. 

Symptoms. — Early  exaggeration  of  the  knee-jerks  may  precede  any  paral- 
ysis or  weakness:  gradually  there  are  spasticity  and  Babinski's  sign,  with 
contractures  and  paralysis.  It  is  important  to  rule  out  the  cases  with  mental 
features  and  Little's  disease.  The  paralysis  may  extend  to  the  upper  limbs, 
and  eyes  and  speech  are  involved.  In  others  again  there  is  atrophy  of  the 
muscles,  and  the  picture  is  not  unlike  amyotrophic  lateral  sclerosis,  or  a 
disseminated  sclerosis.  Very  different  pictures  may  be  presented  by  affected 
children  in  the  same  family. 

VIII.     CHRONIC  HEREDITARY  CHOREA 

(Huntington's  Chorea) 

Definition. — A  hereditary  disease  characterized  by  irregular  movements, 
disturbance  of  speech  and  progressive  mental  deterioration. 

History. — In  1863  Lyon  described  it  as  chronic  hereditary  chorea.  In 
1872  George  Huntington,  whose  father,  grandfather,  and  great-grandfather 
had  treated  cases,  gave  in  three  brief  paragraphs  its  salient  features — heredity, 
the  late  onset,  and  the  mental  changes.  The  disease  is  more  common  in  the 
United  States  than  in  Europe.  Davenport  has  studied  the  four  great  family 
complexes  of  eastern  Long  Island,  southwestern  Connecticut,  south-central 
Connecticut,  and  eastern  Massachusetts  "which,  show  nearly  1000  cases  of 
Himtington's  chorea,  and  yielding  the  rem.arkable  results  that  practically  all 


930  DISEASES  OF  THE  NEEYOUS  SYSTEM 

can  be  traced  back  to  some  half-dozen  individuals,  including  three  (probable) 
brothers  who  migrated  to  America  in  the  XVIIth  century/' 

Inheritance. — It  never  skips  a  generation.  The  age  of  onset  does  not 
appear  to  vary,  averaging  from  thirty-five  to  thirty-eight.  The  mental  type  is 
usually  hyperkinetic.  Among  3000  persons  related  to  the  962  cases  studied  by 
Davenport,  there  were  many  other  nervous  disorders — epilepsy  in  39,  infantile 
convulsions  in  19,  and  feeble-mindedness  in  73. 

Pathology. — There  is  marked  destruction  of  the  smaller  ganglion  cells 
of  the  globus  pallidus  system  which  have  a  coordinating  and  inhibitory  control 
over  the  larger  motor  cells.  When  this  is  lost  chorea  results  (Hunt).  The 
large  cell  system  of  the  globus  pallidus  stands  in  relation  to  the  paralysis 
agitans  syndrome  and  the  small  cell  system  to  the  chorea  syndrome.  The  other 
findings  are  varied.  Meningeal  thickening  and  atrophy  of  the  cortex,  with  a 
loss  of  cells,  have  been  present  in  some  cases.  Arterio-sclerotic  changes  are 
common  in  older  subjects. 

Symptoms. — Difficulty  in  performing  delicate  actions  with  the  hands,  as 
in  writing,  or  in  buttoning  a  shirt  collar,  may  be  the  earliest  indication,  or 
there  are  slight  involuntary  movements  of  the  head  and  face.  When  well 
established,  the  movements  are  slower  than  in  Sydenham's  chorea,  irregular 
and  incoordinate.  The  face  muscles  are  early  involved,  causing  involuntary 
grimaces.  The  gait  is  irregular  and  swaying,  not  unlike  that  of  a  drunken 
man.  The  speech  is  slow  and  the  syllables  blurred.  The  reflexes,  not  altered 
at  first,  are  later  increased.  Certain  biotypes  have  been  observed  by  Daven- 
port. Thus  the  tremors  may  be  absent  and  the  mental  condition  present,  or 
the  muscular  movements  may  be  present  without  mental  defects.  The  chorea 
may  not  progress  and  the  onset  may  be  early  in  life.  He  found  family  dif- 
ferences in  all  these  points. 

The  mental  changes  may  come  early,  outbreaks  of  temper  and  excitement 
are  common,  alternating  with  periods  of  depression.  Usually  a  progressive 
failure  of  the  mental  powers  leads  to  complete  dementia.  Dreading  a  terrible 
fate,  it  is  not  surprising  to  hear  of  suicide  in  certain  members  of  the  families. 

Little  or  nothing  can  be  done  to  arrest  the  progress  of  the  disease. 

Prevention. — Davenport's  study  shows  how  much  more  serious  the  disease 
is  than  we  had  hitherto  thought.  It  is  transmitted  through  males  and  females, 
and  Davenport  states  that  there  is  no  evidence  of  any  abstention  from  or 
selection  against  marrying  in  the  members  of  the  large  group  of  hereditary 
choreas  studied  by  him.     There  is  no  efficient  treatment. 

IX.     PEOGEESSIVE  LENTICULAE  DEGENEEATION 
{Wilson's  Disease) 

Definition. — A  familial,  not  hereditary,  disease  usually  coming  on  early 
in  life,  characterized  by  tremor  and  spasticity  with  bilateral  changes  in  the 
lenticular  nuclei  and  cirrhosis  of  the  liver. 

Described  by  Wilson  in  1912,  it  is  apparently  the  same  condition  which 
Gowers  designated  tetanoid  chorea  and  resembles  the  pseudo-sclerosis  of 
Westphal  and  Striimpell.  As  to  pathogenesis  Wilson  suggests  the  selective 
action  of  some  toxin  possibly  due  to  the  hepatic  cirrhosis.     The  lenticular 


PERIODIC  PAEALYSIS  931 

nuclei  show  degeneration  with  cavitation  and  atrophy.  The  process  may 
extend  more  widely  to  the  internal  capsule,  motor  cortex  and  pyramidal  tracts. 
The  cirrhosis  of  the  liver  is  marked  and  of  a  mixed  type. 

The  features  are  involuntary  choreiform  movements,  muscular  rigidity, 
spasticity,  and  painful  muscular  contractions.  When  the  patient  grasps  an 
object  he  may  have  difficulty  in  relaxing  his  hold.  There  is  difficulty  in  speech 
and  swallowing,  muscular  weakness,  and  contractures  with  progressive  emacia- 
tion. There  may  be  emotional  disturbances  and  mental  weakness.  The  hepatic 
cirrhosis  does  not  seem  to  have  caused  any  symptoms  or  signs  in  the  reported 
cases.  A  curious  annular  brownish-green  pigmentation  of  the  cornea  has  been 
noted  in  a  few  cases.  The  disease  is  progressive  with  a  course  in  acute  eases 
of  a  few  months  and  in  chronic  forms  of  four  to  seven  years.  There  is  no 
specific  treatment. 

X.    PEEIODIC  PAEALYSIS 

Definition. — A  recurring  paralysis,  lasting  from  a  few  hours  to  a  few 
days,  affecting  members  of  the  same  family,  with  abolition  of  the  faradic  excit- 
ability of  both  muscles  and  nerves.     Death  may  occur  in  an  attack. 

History. — After  a  few  scattered  references  in  literature,  the  disease  was 
accurately  described  in  1885  by  Westphal  and  Oppenheim.  Family  groups 
then  began  to  be  recognized,  and  now  a  large  number  of  cases  have  been 
studied. 

Etiology. — The  majority  have  occurred  in  groups.  Holtzapple  reported 
seventeen  cases  in  four  generations.  Many  members  of  this  family  suffered 
from  migraine.  Transmission  is  either  through  the  male  or  female;  the 
disease  may  skip  a  generation.     Sporadic  cases  occur. 

Patholo^. — ^NTothing  definite  is  known.  Winternitz  could  find  no  organic 
lesions  in  two  fatal  cases  in  the  family  reported  by  Holtzapple.  Naturally  auto- 
intoxication has  been  suggested,  and  extensive  researches  into  metabolism 
have  been  made.  Diminution  of  creatinin  excretion  has  been  determined.  In 
some  respects  the  disease  is  similar  to  Myasthenia  gravis,  in  which  there  are 
attacks  of  transient  paralysis.  Westphal  regarded  the  disease  as  a  vasomotor 
neurosis  associated  with  migraine,  which  was  such  a  striking  feature  in  Holtz- 
apple's  cases.  Temporary  collapse  of  the  vessels  is  met  with  in  this  condition, 
and  Holtzapple  suggests  that  this  may  occur  in  the  anterior  horns. 

Symptoms. — The  clinical  picture  is  similar  in  all  recorded  cases.  The 
paralysis  involves,  as  a  rule,  the  arms  and  legs,  but  may  be  general  below  the 
neck.  It  comes  on  in  healthy  persons  without  apparent  cause,  and  often 
during  sleep.  At  first  there  may  be  weakness  of  the  limbs,  a  feeling  of  weari- 
ness and  sleepiness,  but  rarely  with  sensory  symptoms.  The  paralysis,  begin- 
ning in  the  legs,  to  which  it  may  be  confined,  is  usually  complete  within  the 
first  twenty-four  hours.  The  neck  muscles  are  sometimes  involved,  and  oc- 
casionally those  of  the  tongue  and  pharynx.  The  cerebral  nerves  and  the 
special  senses  are,  as  a  rule,  unaffected.  The  temperature  is  normal  or  sub- 
normal, and  the  pulse  slow.  The  deep  reflexes  are  diminished,  sometimes 
abolished,  and  the  skin  reflexes  may  be  enfeebled.  The  faradic  excitability  of 
both  muscles  and  nerves  is  reduced  or  abolished.  Improvement  begins  within 
a  few  hours  or  a  day  or  two,  the  paralysis  disappearing  completely  and  the 
patient  becoming  perfectly  well.     The  attacks  usually  recur  at  intervals  of  one 


932  DISEASES  OF  THE  XEEVOUS  SYSTEM 

to  two  weeks,  but  the}^  ma}'  return  daily.  They  generally  cease  after  the 
fiftieth  year.  There  may  be  signs  of  acute  dilatation  of  the  heart  during  the 
attack. 

Treatment. — Potassium  citrate  in  full  doses  may  shorten  or  abort  an 
attack. 

XI.     AMAUEOTIC  FAMILY  IDIOCY 

{Tay-Sachs'  Disease) 

Definition. — A  family  disease  of  infancy  characterized  by  lack  of  mental 
development,  progressive  muscular  weakness,  and  macular  changes  in  the 
retina. 

History. — In  1881  Waren  Tay  reported  a  group  of  cases  characterized 
by  muscular  weakness,  macular  lesions,  and  death  before  the  age  of  two  years. 
B.  Sachs  extended  our  knowledge  of  the  disease,  a  comparatively  rare  one, 
about  100  cases  being  reported  to  1917  (Naville). 

Etiology. — Among  familial  diseases  it  is  unique  in  the  limitation  to  one 
race — the  Hebrew,  and  almost  exclusively  to  the  Polish  branch.  No  other 
factor  is  known;  syphilis  is  excluded.  A  dominant  Mendelian  character  is 
present  as  50  per  cent,  of  the  children  are  usually  affected  and  100  per  cent, 
of  the  same  sex.  The  cause  is  unknown.  Sachs  believes  that  the  children 
are  born  with  a  nervous  system  so  inadequate  to  meet  the  demands  that  the 
cells,  after  performing  their  function  for  a  few  years  or  months,  undergo 
complete  degeneration.  The  disease  comes  into  the  category  of  Gowers' 
abiotrophies. 

Pathology.— There  is  marked  agenesia  of  the  brain,  with  degenerative 
changes  in  the  large  pyramidal  cells,  and  swelling  of  the  dendrites.  The  de- 
generative changes  are  widely  spread  throughout  the  gray  matter  of  the  brain, 
the  cord,  and  the  spinal  ganglia  (Schaffer).  The  retinal  changes  are  due  to 
a  similar  degeneration  in  the  ganglion  cells. 

Symptoms. — Healthy  at  birth,  and  to  the  third  or  fourth  month,  the  child 
then  begins  to  be  listless,  moving  the  limbs  very  little,  and  as  time  goes  on, 
is  not  able  to  hold  up  the  head  or  sit  up.  The  muscles  are  flaccid,  rarely 
spastic.  Examination  of  the  fundus  shows  a  cherry-red  spot  in  the  region  of 
the  macula.  Within  a  year  a  hitherto  well-developed  baby  becomes  marantic, 
completely  blind,  and  death  occurs  as  a  rule  before  the  end  of  the  second  year. 
The  disease  must  be  distinguished  from  the  ordinary  diplegias  and  paraplegias. 
It  is  not  always  easy  as  spasticity  may  be  present,  but  the  retinal  changes  are 
distinctive. 

A  juvenile  form  occurring  between  the  eighth  and  the  twelfth  year  asso- 
ciated with  blindness,  but  no  macular  changes,  has  been  reported,  and  not  in 
the  Hebrew  race.  It  is  doubtful  whether  this  is  the  same  disease.  Eelated 
to  the  Tay-Sachs  disease  is  the  remarkable  familial  macular  degeneration 
■without  dementia  in  which  the  disease  starts  about  puberty. 

XII.     MYOCLONIC  EPILEPSY 

Definition. — A  familial  disorder,  beginning  in  childhood  with  epilepsy, 
chiefly  nocturnal,  and  followed  by  myoclonic  attacks  and  progressive 
dementia. 


DISEASES  OF  THE  MENINGES  933 

Etiolo^. — A  majority  of  the  cases  have  occurred  in  family  groups  and 
often  in  degenerate  stock.  Single  cases  may  occur  in  normal  families. 
Nothing  is  known  of  the  causation ;  Lundborg  suggests  a  thyroid  origin. 

Pathology. — The  changes  found  in  the  brain  cortex  have  been  those  of 
chronic  epilepsy  and  dementia. 

Symptoms. — The  onset,  in  childhood,  is  with  nocturnal  epilepsy,  which  in 
a  year  or  two  is  followed  by  myoclonia,  sometimes  preceded  by  tremor.  All 
the  voluntary  muscles  are  involved  in  short,  quick,  clonic  spasms,  which  pro- 
gressively increase  in  intensity.  The  child  may  at  first  have  good  and  bad 
days,  the  latter  following,  as  a  rule,  nights  with  severe  epileptic  seizures.  The 
myoclonia  grows  worse  and  the  patient  falls  into  a  state  of  dementia.  The 
severe  myoclonia  attacks  lead  up  to  genuine  epileptic  seizures.  There  is  a 
strong  psychic  feature  which  is  intensified  if  the  patient  knows  he  is  watched;, 
bright  lights,  sounds,  and  handling  the  muscles  have  the  same  effect  (Lund- 
borg). The  familial  character  and  the  nocturnal  epilepsy  separate  it  from 
the  essential  myoclonia  of  Friedreich. 


D.    DISEASES  OF  THE  MENINGES 

I.     DISEASES   OF   THE  DURA  MATER 
(Pachymeningitis) 

1.  Pachymeningitis  Externa. — Cerebral. — Hsemorrhage  often  occurs  as 
a  result  of  fracture.  Inflammation  of  the  external  layer  of  the  dura  is  rare. 
Caries  of  the  bone,  either  extension  from  middle-ear  disease  or  due  to  syphilis, 
is  the  principal  cause.  In  the  syphilitic  cases  there  may  be  a  great  thickening 
of  the  inner  table  and  a  large  collection  of  pus  betAveen  the  dura  and  the  bone. 

Occasionally  the  pus  is  infiltrated  between  the  two  layers  of  the  dura  mater 
or  may  extend  through  and  cause  a  dura-arachnitis. 

The  symptoms  of  external  pachymeningitis  are  indefinite.  In  the  syph- 
ilitic cases  there  may  be  a  small  sinus  communicating  with  the  exterior.  Com- 
pression symptoms  may  occur  with  or  without  paralysis. 

Spinal. — An  acute  form  may  occur  in  syphilitic  affections  of  the  bones, 
in  tumors,  and  in  aneurism.  The  symptoms  are  those  of  a  compression  of 
the  cord.  A  chronic  form  is  more  common,  and  is  a  constant  accompaniment 
of  tuberculous  caries  of  the  spine.  The  internal  surface  of  the  dura  may 
be  smooth,  while  the  external  is  rough  and  covered  with  caseous  masses.  The 
entire  dura  may  be  surrounded,  or  the  process  may  be  confined  to  the  ventral 
surface. 

2.  Pachymeningitis  Interna. — This  occurs  in  three  forms:  (1)  Pseudo- 
Inembranous,  (3)  purulent,  and  (3)  hemorrhagic.  The  first  two  are  unim- 
portant. Pseudo-membranous  inflammation  of  the  lining  membrane  of  the 
dura  is  not  usually  recognized,  but  a  characteristic  example  of  it  came  under 
observation  as  a  secondary  process  in  pneumonia.  Purulent  pachymeningitis 
may  follow  an  injury,  but  is  more  commonly  the  result  of  extension  from 
inflammation  of  the  pia.  It  is  remarkable  how  rarely  pus  is  found  between 
the  dura  and  arachnoid  membranes. 


934  DISEASES  OF  THE  NERVOUS  SYSTEM 

3.  Haemorrhagic  Interna  Pachymening-itis. — Cerebral  Form. — This  re- 
markable condition^  first  described  by  Yirchow,  is  very  rare  in  general  medical 
practice.  During  ten  years  no  case  came  to  autopsy  at  the  Montreal  General 
Hospital.  On  the  other  hand,  in  the  post-mortem  room  of  the  Philadelphia 
Hospital,  which  received  material  from  a  large  almshouse  and  asylum,  the  cases 
were  not  uncommon,  and  within  three  months  there  were  four  characteristic 
examples,  three  of  which  came  from  the  medical  wards.  The  frequency  in 
asylum  work  may  be  gathered  from  the  fact  that  in  1,185  post  mortems  at 
the  Government  Hospital  for  the  Insane,  Washington,  to  June  30,  1897,  there 
were  197  cases  with  "a  true  neo-membrane  of  internal  pachymeningitis" 
(Blackburn).  Of  these  cases,  45  were  chronic  dementia,  37  were  general 
paresis,  30  senile  dementia,  28  chronic  mania,  28  chronic  melancholia,  22 
chronic  epileptic  insanity,  6  acute  mania,  and  1  case  imbecility.  Forty-two 
of  the  cases  were  in  persons  over  seventy  years  of  age. 

It  has  also  been  found  in  profound  ansemia  and  other  diseases  of  the  blood 
and  of  the  blood  vessels,  and  has  followed  the  acute  fevers — typhoid  fever  in 
a  child  (Barker).  The  lesion  has  been  found  in  badly  nourished  cachectic 
children   ( Herter  ) . 

Patliology. — Virchow's  view  that  the  delicate  vascular  membrane  precedes 
the  haemorrhage  is  undo¥.btedly  correct.  Practically  we  see  one  of  three  con- 
ditions:  (a)  subdural  vascular  membranes,  often  of  extreme  delicacy;  (h) 
simple  subdural  haemorrhage;  (c)  a  combination  of  the  two,  vascular  mem- 
brane and  blood  clot.  Certainly  the  vascular  membrane  may  exist  without  a 
trace  of  hsemorrhage — simply  a  fibrous  sheet  of  varying  thickness,  permeated 
with  large  vessels,  which  may  form  beautiful  arborescent  tufts.  On  the  other 
hand,  there  are  instances  in  which  the  subdural  hgemorrhage  is  found  alone, 
but  it  is  possible  that  in  some  of  these  at  least  the  haemorrhage  may  have 
destroyed  all  trace  of  the  vascular  membrane.  In  some  cases  a  series  of 
laminated  clots  are  found,  forming  a  layer  from  3  to  5  mm.  in  thickness. 
Cysts  may  occur  within  this  membrane.  The  source  of  the  hgemorrhage  is 
probably  the  dural  vessels.  Huguenin  and  others  hold  that  the  bleeding  comes 
from  the  vessels  of  the  pia  mater,  but  certainly  in  the  early  stage  there  is  no 
evidence  of  this;  on  the  other  hand,  the  highly  vascular  subdural  membrane 
may  be  seen  covered  with  the  thinnest  possible  sheeting  of  clot,  which  has 
evidently  come  from  the  dura.  The  subdural  hgemorrhage  is  usually  associated 
with  atrophy  of  the  convolutions,  and  it  is  held  that  this  is  one  reason  why 
it  is  so  common  in  the  insane,  especially  in  dementia  paralytica  and  dementia 
senilis.  We  meet  with  the  condition  also  in  various  cachectic  conditions 
in  which  cerebral  wasting  is  as  common  and  almost  as  marked  as  in  cases  of 
insanity.  Ivonig  found  in  135  cases  of  hsemorrhagic  pachymeningitis  that  23 
per  cent,  accompanied  tuberculosis. 

The  symptoms  are  indefinite,  or  there  may  be  none  at  all,  especially  when 
the  haemorrhages  are  small  or  have  occurred  very  gradually,  and  the  diagnosis 
can  not  be  made  with  certainty.  Headache  has  been  a  prominent  symptom 
in  some  cases,  and  when  the  condition  exists  on  one  side  there  may  be  hemi- 
plegia. The  most  helpful  signs  for  diagnosis,  indicating  that  the  haemor- 
rhage in  an  apoplectic  attack  is  meningeal,  are  (1)  those  referable  to  increased 
intracranial  pressure  (slowing  and  irregularity  of  the  pulse,  vomiting,  coma, 
contracted  pupils,  reacting  to  light  slowly  or  not  at  all)  and  (2)  paresis  and 


DISEASES  OF  THE  MENINGES  935 

paralysis,  gradually  increasing  in  extent,  accompanied  by  symptoms  which 
point  to  a  cortical  origin.  Extensive  bilateral  disease  may,  however,  exist 
without  any  symptoms  whatever. 

The  spinal  fluid  may  be  bloody  but  this  is  not  always  the  case.  It  is  not  a 
little  curious  that  coma  may  come  on  and  be  the  chief  feature  when  anatomi- 
cally the  condition  is  a  laminated  ha^matoma  evidently  of  long  standing. 

Spinal  Form. — The  spinal  pachymeningitis  interna,  described  by  Char- 
cot and  Joffroy,  involves  chiefly  the  cervical  region  (P.  cervicalis  hyper- 
trophica).  The  space  between  the  cord  and  the  dura  is  occupied  by  a  firm, 
concentrically  arranged,  fibrinous  structure,  which  is  seen  to  have  arisen 
within,  not  outside  of,  the  dura  mater.  It  is  a  condition  anatomically 
identical  with  the  haemorrhagic  pachymeningitis  interna  of  the  brain.  The 
etiology  is  unknown ;  syphilis  has  existed  in  a  few  cases.  The  cord  is  usually 
compressed;  the  central  canal  may  be  dilated — hydromyelus — and  there  are 
secondary  degenerations.  The  nerve  roots  are  involved  in  the  growth  and 
are  damaged  and  compressed.  The  extent  is  variable.  It  may  be  limited 
to  one  segment,  but  more  commonly  involves  a  considerable  portion  of  the 
cervical  enlargement.  Some  cases  present  a  characteristic  group  of  symptoms. 
There  are  intense  neuralgic  pains  in  the  course  of  the  nerves  whose  roots  are 
involved.  They  are  chiefly  in  the  arms  and  in  the  cervical  region,  and  vary 
greatly  in  intensity.  There  may  be  hypergesthesia  with  numbness  and  tingling ; 
atrophic  changes  may  develop,  and  there  may  be  areas  of  anesthesia.  Gradually 
motor  disturbances  appear ;  the  arms  become  weak  and  the  muscles  atrophied, 
particularly  in  certain  groups,  as  the  flexors  of  the  hand.  The  extensors,  on 
the  other  hand,  remain  intact,  so  that  the  condition  of  claw-hand  is  gradually 
produced.  The  grade  of  the  atrophy  depends  much  upon  the  extent  of 
involvement  of  the  cervical  nerve  roots,  and  in  many  cases  the  atrophy  of  the 
muscles  of  the  shoulders  and  arms  becomes  extreme.  The  condition  is  one  of 
cervical  paraplegia,  with  contractures,  flexion  of  the  wrist,  and  typical  main 
en  griff e.  Usually  before  the  arms  are  greatly  atrophied  there  are  the  symp- 
toms of  what  the  French  writers  term  the  second  stage— namely,  involvement 
of  the  lower  extremities  and  the  gradual  production  of  a  spastic  paraplegia, 
due  to  secondary  changes  in  the  cord. 

The  disease  runs  a  chronic  course,  lasting,  perhaps,  two  or  more  years. 
In  a  few  instances,  in  which  symptoms  pointed  deflnitely  to  this  condition, 
recovery  has  taken  place.  The  disease  is  to  be  distinguished  from  amyotrophic 
lateral  sclerosis,  syringomyelia,  and  tumors.  From  the  first  it  is  separated  by 
the  marked  severity  of  the  initial  pains  in  the  neck  and  arms ;  from  the  second 
by  the  absence  of  the  sensory  changes  characteristic  of  syringomyelia.  From 
certain  tumors  it  is  very  difficult  to  distinguish;  in  fact,  the  fibrinous  layers 
form  a  tumor  around  the  cord. 

The  condition  known  as  hcematoma  of  the  dura  mater  may  occur  at  any 
part  of  the  cord,  or,  in  its  slow,  progressive  form — pachymeningitis  hasm- 
orrhagica  interna — may  be  limited  to  the  cervical  region  and  produce  the 
symptoms  just  mentioned.  It  is  sometimes  extensive,  and  may  coexist  with 
a  similar  condition  of  the  cerebral  dura.  Cysts  may  occur  filled  with  haem- 
orrhagic contents. 


936 


DISEASES  OF  THE  NERVOUS  SYSTEM 


II.     DISEASES   OF  THE   PIA   MATEE 


(Acute  C erebro-spinal  Leptomeningitis) 


Etiology. — Under  cerebro-spinal  fever  and  tuberculosis  the  two  most  iva- 
portant  forms  of  meningitis  have  been  described.  Other  conditions  with  which 
meningitis  is  associated  are  :  (1)  The  acute  fevers,  more  particularly  pneu- 
monia, erysipelas,  and  septicaemia;  less  frequently  small-pox,  typhoid  fever, 
scarlet  fever,  measles,  influenza,  etc.  (2)  Injury  or  disease  of  the  hones  of  the 
sJculL  In  this  group  by  far  the  most  frequent  cause  is  necrosis  of  the  petrous 
portion  of  the  temporal  bone  in  chronic  otitis.  (3)  Extension  from  disease  of 
the  nose.  Meningitis  has  followed  perforation  of  the  skull  in  sounding  the 
frontal  sinuses,  suppurative  disease  of  these  sinuses,  and  necroses  of  the  cribri- 
form plate.  As  mentioned  under  cerebro-spinal  fever,  the  infection  is  thought 
to  be  possible  through  the  nose.  (4)  As  a  terminal  infection  in  chronic  nephri- 
tis, arterio-sclerosis,  heart  disease,  and  the  wasting  diseases  of  children. 

The  following  etiological  table  of  the  chief  acute  forms  of  meningitis  may 
be  useful  to  the  student : 


Of  cerebro-spinal  \ 
fever.  j 

: 


Meningococcus. 


(a)  Sporadic. 

(b)  Epidemic. 
Pneumococcic.  1  Meninges  involved  alone  or  in  a  general  \  Pneumococcus. 
Streptococcic.  /  pneuinococcus  or  streptococcus  infection.  /  Streptococcus. 
Tuberculous Bacillus  tuberculosis. 

f      (a)   Secondary  to  pneumonia,  en- 
Pneumo-J  docarditis,  etc. 


3.   Pyogenic. 


Miscellane- 
ous acute 
infections. 


I       (b)    Secondary  to  disease  or  injury 
of  cranium  or  its  fossae. 

(a)  Following  local  disease  of  cra- 
nium or  a  local  infection  elsewhere. 

(b)  Terminal  infection  in  various 
chronic  maladies. 

In  typhoid  fever,  influenza,  diph- 
theria, gonorrhoea,  anthrax,  actino- 
[  mycosis,  and  other  acute  diseases. 


Pneumococcus. 


Various  forms  of  staphy- 
lococci and  streptococci. 

Typhoid  bacillus,  influ- 
enza bacillus,  diphtheria 
bacillus,    gonococcus,  etc. 


Morbid  Anatomy. — The  basal  or  cortical  meninges  may  be  chiefly  attacked. 
The  degree  of  involvement  of  the  spinal  meninges  varies.  In  the  form  asso- 
ciated with  pneumonia  and-  ulcerative  endocarditis  the  disease  is  bilateral  and 
usually  limited  to  the  cortex.  In  extension  from  disease  of  the  ear  it  is  often 
unilateral  and  may  be  accompanied  with  abscess  or  with  thrombosis  of  the 
sinuses.  In  the  non-tuberculous  form  in  children,  in  the  meningitis  of  chronic 
nephritis,  and  in  cachectic  conditions  the  base  is  usually  involved.  In  the 
cases  secondary  to  pneumonia  the  effusion  beneath  the  arachnoid  may  be  very 
thick  and  purulent,  completely  hiding  the  convolutions.  The  ventricles  also 
may  be  involved,  though  in  these  simple  forms  they  rarely  present  the 
distention  and  softening  which  are  so  frequent  in  the  tuberculous  meningitis. 
For  a  more  detailed  description  the  student  is  referred  to  the  sections  on 
cerebro-spinal  fever  and  tuberculous  meningitis. 

Symptoins. — Cortical  meningitis  is"  not  to  be  recognized  by  any  symptoms 
or  set  of  symptoms  from  a  condition  which  may  be  produced  by  the  poison  of 
many  of  the  specific  fevers.  In  the  cases  of  so-called  cerebral  pneumonia,  un- 
less the  base  is  involved  and  the  nerves  affected,  the  disease  is  unrecognizable, 
since  identical  symptoms  may  be  produced  by  intense  engorgement  of  the 


DISEASES  OF  THE  MENINGES  937 

meninges.  In  typhoid  fever,  in  which  meningitis  is  ver}'  rare,  the  twitchings, 
spasms,  and  retraction  of  the  neck  are  almost  invariably  associated  with 
cerebro-spinal  congestion,  not  with  meningitis. 

A  knowledge  of  the  etiology  gives  a  very  important  clue.  Thus,  in  middle- 
ear  disease  the  development  of  high  fever,  delirium,  vomiting,  convulsions,  and 
retraction  of  the  head  and  neck  would  be  extremely  suggestive  of  meningitis 
or  abscess.  Headache,  which  may  be  severe  and  continuous,  is  the  most  com- 
mon symptom.  ■\^Tlile  the  patient  remains  conscious  this  is  usually  the  chief 
complaint,  and  even  when  semicomatose  he  may  continue  to  groan  and  place 
his  hand  on  his  head.  In  the  fevers,  particularly  in  pneumonia,  there 
may  be  no  complaint  of  headache.  Delirium  is  frequently  early,  and  is  most 
marked  when  the  fever  is  high.  Photophobia  is  often  present.  Convulsions 
are  less  common  in  simple  than  in  tuberculous  meningitis.  In  the  simple  men- 
ingitis of  children  they  may  occur.  Epileptiform  attacks  which  come  and  go 
are  highly  characteristic  of  direct  irritation  of  the  cortex.  Eigidity  and 
spasm  or  twitchings  of  the  muscles  are  more  common.  Stiffness  and  retrac- 
tion of  the  muscles  of  the  neck  are  important  symptoms;  but  they  are  not 
constant,  and  are  most  frequent  when  the  inflammation  is  extensive  on  the 
meninges  of  the  cervical  cord.  There  may  be  trismus,  gritting  of  the  teeth, 
or  spastic  contraction  of  the  abdominal  muscles.  Vomiting  is  a  common  symp- 
tom in  the  early  stages,  particularly  in  basilar  meningitis.  Constipation  is 
usually  present.  In  the  late  stages  the  urine  and  fseces  may  be  passed  invol- 
untarily. Optic  neuritis  is  rare  in  the  meningitis  of  the  cortex,  but  is  not 
uncommon  when  the  base  is  involved.    Marked  hyperaesthesia  is  common. 

Important  symptoms  are  due  to  lesions  of  the  nerves  at  the  base.  Stra- 
bismus or  ptosis  may  occur.  The  facial  nerve  may  be  involved,  producing 
slight  paralysis,  or  there  may  be  damage  to  the  fifth  nerve,  producing  an- 
aesthesia and,  if  the  Gasserian  ganglion  is  affected,  trophic  changes  in  the 
cornea.  The  pupils  are  at  first  contracted,  subsequently  dilated,  and  perhaps 
unequal.  The  reflexes  in  the  extremities  are  often  accentuated  at  the  begin- 
ning of  the  disease ;  later  they  are  diminished  or  entirely  abolished.  Herpes 
is  common,  particularly  in  the  epidemic  form. 

Fever  is  present,  moderate  in  grade,  rarely  rising  above  103°.  In  the 
non-tuberculous  leptomeningitis  of  debilitated  children  and  in  nephritis 
there  may  be  little  or  no  fever.  The  pulse  may  be  increased  in  frequency 
at  first,  though  this  is  unusual.  One  of  the  striking  features  is  the  slowness 
of  the  pulse  in  relation  to  the  temperature,  even  in  the  early  stages.  Sub- 
sequently it  may  be  irregular  and  still  slower.  The  very  rapid  emaciation 
which  often  occurs  is  doubtless  to  be  referred  to  a  disturbance  of  the  cerebral 
influence  upon  metabolism.  Kernig's  sign  has  been  described  under  cerebro- 
spinal fever.  There  may  be  a  concomitant  reflex  of  one  leg  when  passive 
flexion  is  made  of  the  other  or  when  the  neck  is  bent  forward  there  is  flexion 
of  the  legs  both  at  the  knees  and  hips  or  of  all  four  extremities  (Brudzin- 
ski's  sign).  Lumbar  puncture  is  exceedingly  valuable  for  diagnosis.  The 
sugar  in  the  spinal  fluid  is  reduced  or  absent.  A  turbid  fluid  usually  indi- 
cates an  acute  non-tuberculous  meningitis.  At  first  the  fluid  may  be  only 
opalescent.  A  close  relationship  exists  between  the  severity  of  the  symp- 
toms, the  height  of  the  pyrexia,  and  the  degree  of  turbidity  (Connal).  As  a 
rule  a  preponderance  of  polynuclcar  leucocytes  is  present  with  the  meningo- 


938  DISEASES  OF  THE  NERVOUS  SYSTEM 

coccus  or  the  pyogenic  organisms;  a  mononuclear  exudate  is  characteristic 
of  tuberculosis  or  polio-myelitis.  In  tuberculous  meningitis  the  fluid  is  usually 
clear;  in  only  one  of  69  cases  was  it  opalescent  (Connal). 

Treatment. — There  are  no  remedies  which  in  any  way  control  the  course 
of  acute  meningitis.  An  ice-bag  should  be  applied  to  the  head.  Absolute 
rest  and  quiet  should  be  enjoyed.  When  disease  of  the  ear  is  present, 
a  surgeon  should  be  called  early,  and  if  there  are  symptoms  of  meningo- 
encephalitis which  can  in  any  way  be  localized  trephining  should  be  prac-. 
tised.  An  occasional  saline  purge  will  do  more  to  relieve  the  congestion  than 
blisters  and  local  depletion.  Warm  baths  should  be  given  every  three  hours. 
Recovery  may  follow  in  the  primary  pneumococcus  and  streptococcus  forms 
(Netter).  Large  doses  of  iodide  of  potassium  and  mercury  are  recommended 
by  some  authors.  Hexamine  in  doses  of  60  grains  (4  gm.)  daily  may  be 
tried,  as  Crowe  has  shown  that  it  is  excreted  in  the  cerebro-spinal  fluid  and 
controls  the  growth  of  organisms  in  the  meninges. 

Lumbar  puncture,  as  a  therapeutic  measure,  is  of  great  value,  relieving  the 
headache  and  sometimes  reducing  the  fever. 

The  posterior  basic  meningitis  of  Gee,  Lees,  and  Barlow  is  the  sporadic 
form  of  cerebro-spinal  fever  and  has  been  already  described. 

Meningism. — Sometimes  spoken  of  as  the  syndrome  of  Dupre,  this  is  a 
condition  in  which  there  are  symptoms  of  meningitis,  but  post  mortem  the 
characteristic  pathological  changes  are  not  present.  It  is  practically  the  con- 
dition described  formerly  as  meningeal  irritation,  and  is  seen  most  frequently 
in  the  acute  fevers  of  children,  particularly  in  pneumonia  and  typhoid  fever, 
sometimes  in  alcoholism  and  in  middle-ear  disease.  Lumbar  puncture  usually 
gives  a  large  amount  of  clear  fluid,  sterile,  and  sometimes  showing  a  slight  in- 
crease in  the  number  of  cells. 

Chronic  Leptomeningitis. — This  is  rarely  seen  apart  from  syphilis  or  tu- 
berculosis, in  which  the  meningitis  is  associated  with  the  growth  of  the  granu- 
lomata  in  the  meninges  and  about  the  vessels.  The  symptoms  in  such  cases 
are  extremely  variable,  depending  entirely  upon  the  situation  of  the  growth. 
The  epidemic  meningitis  may  run  a  very  chronic  course,  but  of  all  forms  the 
posterior  basic  may  be  the  most  protracted,  as  cases  have  been  described  with 
a  duration  of  a  year  or  more.  Quincke's  meningitis  serosa  is  considered  with 
hydrocephalus. 


K     MENINGO-MYELO-ENCEPHALITIS 

I.     ACUTE  POLIO-MYELITIS 
(Heine-Medin  Disease) 

Definition. — An  acute  infection  characterized  anatomically  by  widespread 
lesions  of  the  nervous  system,  with  special  localization  in  many  of  the  cases 
in  the  anterior  horns  of  the  gray  matter  in  the  spinal  cord — hence  the  com- 
mon name,  polio-myelitis  anterior. 

History. — In  1840  von  Heine  separated  this  type  from  other  forms  of 
paralysis  and  in  1887  Medin  called  attention  to  its  occurrence  in  widespread 


.     .  ACUTE  POLIO-MYELITIS  939 

epidemics,  which  have  been  specially  studied  in  Sweden  by  Wickham,  Har- 
bitz,  and  others.  Within  the  past  thirteen  years  serious  outbreaks  have  oc- 
curred in  many  parts  of  the  LTnited  States  and  Canada.  The  incidence  of  the 
disease  has  also  increased  in  Great  Britain  and  on  the  Continent  of  Europe, 
while  in  Sweden  and  Xorway  and  parts  of  Austria  the  disease  has  assumed 
epidemic  proportions.  In  ISTew  York  City  in  1907-8  there  were  about  2,000 
cases,  with  a  mortality  of  6  to  7  per  cent.;  in  1916  in  the  U.  S.  registration 
area  there  were  7,130  deaths  and  1,182  in  1917. 

Etiology. — In  its  epidemic  behavior  the  disease  resembles  closely  cere- 
bro-spinal  fever.  Sporadic  cases  occur  in  all  communities  and  under  at 
present  unknown  conditions  increase  at  times  to  epidemic  proportions.  It 
prevails  in  the  late  summer  and  autumn. 

Age  is  an  important  predisposing  element;  a  majority  of  all  cases  occur  in 
children  in  the  first  dentition.  The  more  prevalent  the  epidemic  form  the 
greater  the  proportion  of  young  adults  attacked.  Males  and  females  are  about 
equally  attacked. 

The  degree  of  contagiousness  from  person  to  person  is  slight,  and  in  this 
the  disease  resembles  cerebro-spinal  fever  and  pneumonia. 

The  organism  has  been  isolated  by  Flexner  and  his  co-workers.  The  col- 
onies consist  of  globular  bodies  averaging  0.15  to  0.3  micron  in  size.  Mon- 
keys inoculated  with  the  twentieth  generation  of  the  culture  developed  typical 
experimental  polio-myelitis.  The  infective  agent  is  present  in  the  brain  and 
spinal  cord,  in  the  naso-pharyngeal  secretions  and  in  the  blood.  The  disease 
is  inoculable  into  monkeys  and  may  be  transmitted  from  one  animal  to  another. 
It  has  been  transmitted  also  by  intracerebral  injection  of  an  emulsion  made 
from  flies  which  had  fed  on  the  spinal  cord  of  a  monkey  dead  of  the  disease. 
An  important  point  is  that  the  virus  passes  from  the  central  nervous  system 
in  the  monkey  to  the  nasal  mucosa  and  vice  versa,  and  the  application  of  the 
virus  to  this  part  is  a  ready  means  of  inoculation.  It  has  also  been  found  in 
the  tonsils  and  pharyngeal  mucosa  of  children.  The  path  of  invasion  is  ap- 
parently by  the  upper  respiratory  tract. 

So  far  as  we  know,  the  disease  is  transmitted  either  directly  by  contact 
or  by  the  intervention  of  carriers.  The  distribution  is  more  independent  of 
sanitary  conditions  than  in  the  common  children's  diseases. 

Morbid  Anatomy. — The  lesions  are  widespread  in  the  nervous  system.  We 
can  no  longer  regard  it  as  an  affection  limited  to  the  anterior  horns  of  the 
gray  matter  of  the  spinal  cord,  but  a  widespread  polio-myelo-encephalo-menin- 
gitis. 

Swelling  of  the  spleen  and  a  marked  general  hyperplasia  of  the  lymphoid 
apparatus  have  been  found.  The  cerebro-spinal  fluid  is  usually  increased  but 
clear.  The  pia  mater  is  hypersemic  and  moist,  but  without  exudate.  Cases 
in  which  the  cerebral  symptoms  have  been  pronounced  show  swelling  and 
flattening  of  the  convolutions,  with  hyperaemia  of  the  gray  matter  and  here 
and  there  small  hsemorrhages.  The  changes  in  the  spinal  cord  are  very  char- 
acteristic. The  meninges  are  moist,  the  pia  is  hyperaemic,  sometimes  with 
small  capillary  hemorrhages.  On  section  the  cut  surface  bulges,  the  gray 
matter  is  hypersemic,  appearing  as  a  reddened  H,  or  the  redness  is  limited  to 
the  anterior  horns,  which  may  show  spots  of  haemorrhage.  These  changes  may 
be  localized  to  the  swellings  of  the  cord  or  extend  throughout  its  entire  extent. 


940  DISEASES  OF  THE  NERVOUS  SYSTEM 

Microscopically  there  is  small-celled  infiltration  about  the  vessels  of  the 
meninges,  most  marked  in  the  lumbar  and  cervical  swellings.  The  infiltration 
extends  into  the  fissures  of  the  cord  and  follows  the  blood-vessels.  The  amount 
of  meningeal  implication  is  much  more  intense  than  is  indicated  macrosco- 
pically.  In  the  cord  itself  the  smaller  blood-vessels  are  distended,  hemor- 
rhages occur  in  the  gray  matter,  there  is  marked  perivascular  infiltration, 
chiefly  of  lymphocytes,  which  collect  about  the  vessels,  forming  definite  foci. 
Sometimes  the  majority  of  the  cells  are  polynuclear  leucocytes.  The  ganglion 
cells,  usually  those  of  the  anterior  horns,  degenerate  and  gradually  disappear, 
changes  probably  secondary  to  the  acute  vascular  alterations.  Hypergemia, 
oedema  and  infiltration  are  marked.  In  the  fatal  cases  there  are  changes  in 
the  medulla  and  pons  of  much  the  same  nature,  but  the  ganglion  cells  rarely 
show  such  widespread  destruction. 

Symptoms. — The  incubation  period  is  from  3  to  10  days.  In  the  pre- 
paralytic stage  naso-pharyngeal  symptoms  are  common.  F.  E.  Eraser  notes 
among  the  pre-paralytic  symptoms,  fever,  drowsiness  or  heaviness,  irritability, 
twitchings  and  jerkings,  and  gastro-intestinal  symptoms.  In  72  of  90  cases 
there  was  stiffness  of  the  neck  and  back,  and  general  tenderness  (hypersesthe- 
sia)  on  handling  is  not  at  all  uncommon.  More  commonly  a  child  who  has 
gone  to  bed  well  awakens  in  the  morning  with  the  paralysis  and  slight  fever. 
Prodromal  symptoms  are  more  common  in  the  epidemic  form. 

The  studies  of  recent  years  have  shown  a  number  of  well-characterized 
types,  of  which  the  following  are  the  most  important : 

(a)  Abortive  Form. — In  epidemics,  just  as  in  cerebro-spinal  fever,  there 
are  cases  of  illness  with  the  general  symptoms  of  infection,  and  indications 
of  cerebro-spinal  irritation,  but  without  any  motor  disturbances.  The  symp- 
toms pass  away  and  the  nature  of  the  trouble  remains  doubtful,  nor  would 
suspicion  be  aroused  were  it  not  for  the  existence  of  other  cases.  It  is  inter- 
esting to  note  that  Anderson  and  Frost  have  shown  the  presence  of  specific 
immune  bodies  in  the  blood  of  these  cases. 

(b)  Common  Polio-myletic  or  Spinal  Form. — There  is  paresis  before 
the  paralysis  or  the  paralysis  is  abrupt  in  its  onset,  reaches  its  maximum  in  a 
very  short  time,  showing  the  irregularity  and  lack  of  symmetry  which  is  charac- 
teristic. The  legs  are  involved  much  more  often  than  the  arms.  Paralysis 
of  the  trunk  muscles  occurs  often.  One  or  both  arms  may  be  affected,  or  one 
arm  and  one  leg,  or  both  legs,  or  it  may  be  the  right  leg  and  left  arm,  or  vice 
versa.  In  the  arm  the  paralysis  is  rarely  complete,  the  upper-arm  muscles 
may  be  most  affected  or  the  lower-arm  group;  muscles  acting  functionally 
together,  with  centres  near  each  other  in  the  spinal  cord,  are  paralyzed  to- 
gether. Careful  examination  usually  shows  some  degree  of  weakness  to  be 
more  widespread  than  appears  at  first  sight.  Disturbances  of  sensation  are 
common.    In  this  type  the  bladder  and  rectum  are  rarely  involved. 

(c)  Progressive  Ascending  Form. — A  certain  number  of  cases,  par- 
ticularly in  epidemics,  run  a  course  similar  to  Landry's  paralysis,  with  which, 
no  doubt,  some  of  them  have  been  confounded.  The  disease  begins  in  the 
legs  with  the  usual  initial  symptoms,  the  paralysis  extends  upward,  involving 
the  arms  and  the  trunk,  and  death  may  occur  with  bulbar  symptoms  from 
the  third  to  the  fifth  day.  In  the  Swedish  epidemic  of  1905  of  the  159  cases 
which  died  within  the  first  two  weeks,  45  presented  this  type. 


ACUTE  POI>IO-^[YETJTIS  941 

{d)  Bulbar  Form. — It  has  long  beeu  known  that  occasionally  in  the 
ordinary  spinal  paralysis  of  children  the  cerebral  nerves  are  involved,  but 
in  the  epidemic  form  the  disease  may  begin  with  paralysis  of  the  ocular,  facial, 
lingual,  or  pharyngeal  muscles.  The  patient  has  fever,  and  the  local  picture 
depends  upon  the  extent  and  distribution  of  the  lesions  in  the  medulla  and 
pons.  In  the  1905  Swedish  epidemic  there  were  34  cases  in  which  the  cerebral 
nerves  were  alone  involved,  and  in  the  ISTew  York  epidemic  this  localization  was 
not  very  uncommon.  A  fatal  result  may  follow  extension  of  the  bulbar 
symptoms. 

(e)  Meningitic  Form. — This  is  important,  as  the  cases  simulate  closely 
and  are  apt  to  be  mistaken  for  cerebro-spinal  fever.  The  picture  is  one  of 
an  acute  meningitis — headache,  pain  and  stiffness  in  the  neck,  vomiting,  pain 
and  rigidity  in  the  back,  drowsiness  and  unconsciousness.  The  disease  may 
begin  with  the  paralytic  features  and  subsequently  show  the  meningeal  com- 
plications. Convulsions  and  Kernig's  sign  may  be  present.  A  serious  diffi- 
culty is  that  the  two  diseases  may  prevail  together,  and  only  the  careful  ex- 
amination of  the  cerebro-spinal  fluid  may  give  a  differential  diagnosis. 

(/)  Cerebral  Form. — Here  the  picture  is  that  which  we  have  learned  to 
recognize  as  the  acute  encephalitis  or  polio-encephalitis  of  children,  a  descrip- 
tion of  which  we  owe  to  von  Striimpell.  The  disease  sets  in  suddenly,  with 
fever,  vomiting  and  convulsions,  followed  by  paralysis  of  one  side  of  the  body 
or  one  limb.  Many  of  the  patients  die,  others  recover  and  present  the  usual 
after-picture  of  the  cerebral  hemiplegia  of  children.  A  large  proportion  of 
the  cases  of  this  disease  probably  represent  this  type  of  the  sporadic  form  of 
acute  infectious  poiio-myelo-encephalitis, 

{g)  PoLYXEURiTic  FoRM. — Many  cases  of  the  ordinary  type  and  a  ma- 
jority of  the  sporadic  form  are  painless.  It  is  one  of  the  features  of  the 
epidemic  form  that  the  patients  complain  much  more  of  pain.  This  is  par- 
ticularly the  case  in  a  form  which  simulates  a  polyneuritis.  There  is  loss 
of  the  tendon  reflexes  and  disturbance  of  sensation.  There  is  pain  in  the 
affected  limbs,  particularly  on  movement,  with  tenderness  on  pressure  along 
the  nerves  and  on  pressing  the  muscles;  the  paralysis  may  extend  like  neuritis, 
involving  chiefly  the  peripheral  extensor  muscle  groups,  and  be  followed  by 
rapid  wasting. 

(Ji)  Transverse  Myelitic  Form. — Following  slight  fever  and  indisposi- 
tion, the  features  may  be  those  of  a  transverse  myelitis,  a  complete  flaccid 
paraplegia.  Of  two  cases  of  this  type  in  young  adults,  in  one  recovery  was 
complete,  and  in  the  other  with  a  very  small  araouiit  of  residual  paralysis. 

Anomalous  forms  and  symptoms  are  common  during  an  epidemic.  The 
muscles  of  respiration  may  be  involved  early,  the  diaphragm  alone  may  be 
paralyzed,  or  the  intercostals  or  the  muscles  of  the  palate  and  pharynx.  In- 
volvement of  the  facial  muscles,  usually  a  slight  weakness,  may  be  present, 
but  in  5  out  of  90  cases  studied  by  F.  K.  Fraser  the  facial  muscles  alone  were 
involved.  In  one  instance  ptosis  was  the  only  paralytic  symptom  on  admis- 
sion. Eemarkable  types  may  occur  quite  unlike  the  classical  picture.  In  one 
case  there  was  paralysis  of  one  side  of  the  soft  palate  with  slight  fever;  the 
serum  of  this  patient  protected  a  monkey  from  intra-cerebral  injection  of 
the  polio-myelitic  virus.  There  may  be  slight  fever  with  general  spasticity  of 
the  muscles  and  tremor  or  rigidity  of  the  muscles  with  coma. 


943  DISEASES  OF  THE  NERVOUS  SYSTEM 

Spinal  Fluid. — This  usually  shows  increase  both  in  amount  and  pressure ; 
it  may  be  clear  or  slightly  hazy.  There  is  an  increase  in  the  number  of  cells, 
which  may  be  from  15  or  20  up  to  1200  per  c.  mm.  The  largest  number  are 
usually  mononuclears;  occasionally  there  is  a  larger  number  of  polynuclears 
found  early.  The  albumin  and  globulin  are  usually  slightly  or  moderately  in- 
creased. Fehling's  solution  is  generally  reduced  as  promptly  as  by  the  normal 
fluid.  The  Wassermann  reaction  may  be  the  only  means  of  diagnosing  the  con- 
dition from  syphilis. 

Course. — After  the  acute  features  have  subsided  there  is  little  change  for 
two  or  three  weeks,  after  which  improvement  begins.  This  may  continue  for 
two  or  three  months.  The  residual  paralysis  is  usually  less  than  seemed  prob- 
able at  first.  The  atrophy  becomes  evident  in  a  few  weeks  from  the  onset  of 
the  attack.  The  affected  limbs  show  less  development  as  the  patient  grows 
older,  and  the  deformity  is  usually  most  marked  in  the  leg.  The  reaction  of 
degeneration  is  present  in  the  atrophied  muscles.  Early  in  the  course  the 
muscles  lose  the  faradic  response. 

Dia^osis. — In  the  ordinary  spinal  sporadic  cases  there  is  rarely  any  diffi- 
culty. An  important  point  to  remember  is  that  in  periods  of  epidemic  preva- 
lence the  disease  presents  an  extraordinary  number  of  clinical  types.  Some 
cases  run  a  course  like  an  acute  infection,  others  have  the  picture  of  Landry's 
paralysis,  in  others  again  meningeal  symptoms  predominate,  or  there  may  be 
hypersesthesia  and  pain,  with  the  picture  of  a  polyneuritis. 

It  seems  not  improbable  that  some  obscure  cases  of  meningitis  are  really 
instances  of  sporadic  poliomyelitis.  The  same  may  be  said  of  the  acute  en- 
cephalitis in  children  causing  hemiplegia.  The  extraordinary  complexity  of 
the  symptoms  makes  the  diagnosis  very  difficult,  so  that  the  examination  of 
the  spinal  fluid  is  important. 

The  diagnosis  from  peripheral  neuritis  may  be  very  difficult;  in  both  the 
paralysis  is  of  the  legs,  with  wasting,  loss  of  reflexes,  and  the  bladder  and 
rectum  may  be  involved.  Loss  of  the  vibrating  sensation  tested  with  a  large 
tuning  fork  is  more  common  in  peripheral  neuritis,  and  later  the  electrical 
changes  and  the  action  of  degeneration  may  be  distinctive. 

Prognosis. — The  mortality  varies  greatly  in  different  epidemics.  It  was 
27  per  cent,  in  New  York  City  in  1916.  The  fatal  cases  are  usually  of  the 
ascending,  bulbar  and  meningeal  types.  As  regards  the  muscles,  complete 
loss  of  response  to  faradism  means  severe  atrophy.  If  it  is  never  completely 
lost  the  outlook  is  good  and  even  extensive  paralyses  may  disappear.  The 
prognosis  for  the  paralysis  is  not  easy  to  determine.  Formerly,  we  thought  it 
almost  the  rule  that  residual  paralysis  would  remain  if  any  large  number  of 
muscle  groups  were  involved,  but  cases  of  very  severe  and  widespread  involve- 
ment may  recover  gradually  and  completely. 

Prophylaxis. — The  disease  has  been  made  notifiable.  The  patient  should 
be  isolated,  the  discharges  and  articles  used  by  patients  and  nurses  carefully 
disinfected,  and  special  care  should  be  taken  of  the  nasal  and  pharyngeal  dis- 
charges. It  does  not  seem  necessary  to  enforce  a  quarantine  against  those 
who  come  into  relation  with  the  patients,  but  the  throat  and  nose  of  such 
persons  should  be  disinfected  with  a  menthol  spray.  There  is  some  warrant 
for  the  administration  of  prophylactic  doses  of  hexamine. 

Treatment. — Hexamine  may  be  given  in  doses  of  gr.  v  to  xv  (0.3  to  1  gm.). 


EPIDEMIC  ENCEPHALITIS  943 

When  the  fever  is  high  the  general  treatment  is  that  of  an  acute  infection. 
The  serum  of  those  who  have  recovered  has  been  used,  possibly  with  benefit  if 
given  early.  Sedatives  for  the  pain  may  be  given.  Lumbar  puncture  has  been 
advised,  and  if  the  pressure  is  found  to  be  high  it  should  be  repeated.  The 
intraspinous  injection  of  epinephrine  has  been  tried  but  without  much  effect. 
The  affected  limb  should  be  wrapped  in  cotton  wool,  and  placed  in  the  position 
of  least  strain,  and,  if  there  is  much  pain,  local  sedative  applications  may  be 
used.  In  the  meningeal  type  of  the  disease  warm  baths  and  hot  packs  will 
be  helpful.  In  the  early  stages  it  is  well  not  to  attempt  to  do  much  to  the 
muscles,  but  within  ten  days  careful  massage  may  be  practised,  using  either 
lanolin  or  sweet  oil.  Strychnine  hypodermically  has  been  extensively  used, 
but  how  far  it  has  any  influence  may  be  questioned.  It  should  not  be  given 
early.  Electricity  may  be  used  and  it  has  a  value  in  keeping  up  the  nutrition 
of  the  muscles.  The  faradic  current  should  be  employed  if  there  is  response, 
if  not,  the  galvanic.  The  damage  always  looks  to  be  much  worse  than  it  really 
is,  as  many  of  the  symptoms  depend  on  meningeal  and  vascular  changes  which 
undergo  resolution.  Fatigue  is  harmful  and  should  be  guarded  against  for 
many  months. 

The  muscle  itself  as  a  factor  has  been  emphasized  by  William  MacKenzie 
of  Melbourne  (Brit.  Med.  Jour.  1915,  i)  as  biologically  it  is  all  important  in 
treatment.  The  disease  really  destroys  muscle  adjustments,  and  one  of  the 
first  things  to  do  is  to  place  the  muscle  at  physiological  rest  in  the  zero 
position,  in  which  it  is  itself  relaxed,  and  both  its  own  action,  and  that  of  its 
opponent  prevented.  Massage,  he  urges,  should  not  be  given  too  early,  until, 
for  example,  the  patient  can  elevate  the  upper  limb  when  sitting  up,  and  the 
heel  when  lying  on  the  back.  Persistent  gradual  re-education  of  the  muscles 
yields  remarkable  results.  Passive  movements  may  be  used  and  with  -toys  a 
child  may  be  encouraged  to  use  the  muscles  of  any  group  which  still  act.  The 
treatment  of  residual  deformities  is  a  question  of  orthopaedic  surgery. 

II.     EPIDEMIC  ENCEPHALITIS 

(Encephalitis    letliargica ;    Epidemic    stupor;    Epidemic    polio-encephalitis; 

Infective  encephalitis) 

Definition. — An  infectious  disease,  with  protean  manifestations,  chiefly  in 
the  central  nervous  system,  characterised  by  lethargy,  paralysis  of  the  cranial 
nerves  (usually  the  third),  and  in  some  cases,  spinal  and  neuritic  features* 

History. — There  are  records  of  outbreaks  suggesting  this  disease  in  1713 
in  Germany  and  in  1890  in  parts  of  southern  Europe  (to  which  the  name  Nona 
was  given).  Cases  occurred  in  Austria  in  1917  and  in  England  in  the  spring 
of  1918  with  unusual  cerebral  features,  a  drowsiness  passing  into  lethargy, 
progressive  muscular  weakness,  and  ophthalmoplegia.  At  first  these  were  re- 
garded as  cases  of  botulism.  The  disease  was  widely  spread,  only  a  few  cases 
occurring  in  each  locality,  sometimes  two  or  three  in  the  same  house.  The 
disease  was  recognized  in  the  United  States  about  the  end  of  1918. 

Etiology. — Males  and  females  are  attacked  in  about  equal  numbers.  In 
striking  contrast  to  polio-myelitis,  the  disease  is  more  common  after  the  age 
of  twenty.     Of  100  cases  of  each  disease  analysed  by  James,  39.6  per  cent. 


944  DISEASES  OF  THE  NEEVOUS  SYSTEM 

of  the  encephalitis  patients  were  over  the  age  of  twenty,  while  79.2  per  cent, 
of  the  polio-myelitis  patients  were  under  this  age.  Of  the  encephalitis  patients, 
15  per  cent,  were  above  the  age  of  fifty.  It  is  important  to  note  that  dur- 
ing this  outbreak  there  was  no  increase  of  cases  of  polio-myelitis,  either 
general  or  in  the  neighborhoods  where  the  encephalitis  prevailed.  The  na- 
ture of  the  virus  has  not  been  determined ;  the  disease  apparently  has  been  suc- 
cessfully transmitted  to  monkeys. 

Pathology. — In  40  cases  investigated  by  Macintosh,  the  changes  were 
chiefly  in  the  upper  part  of  the  pons  and  in  the  basal  nuclei,  consisting  of 
peri-vascular  infiltration,  with  large  and.  small  mononuclear  lymphocytes, 
chiefly  those  of  small  and  medium  size.  The  areas  of  extra-vascular  infiltra- 
tion may  form  actual  foci  visible  to  the  naked  eye.  A  striking  feature  was  the 
absence  of  destruction  of  the  ganglion  cells  so  characteristic  of  polio-myelitis. 
The  Noguchi-Flexner  bodies,  found  in  polio-myelitis,  have  not  been  found. 
Cortical  lesions,  such  as  occur  in  Striimpell's  polio-enceflialitis  siMperior,  have 
not  been  found,  nor  were  there  extensive  lesions  of  the  gray  matter,  though 
Marinesco  found  changes  in  the  cells  of  Purkinje.  Altogether  the  anatomical 
lesions  are  like  those  found  in  rabies  and  sleeping  sickness.  The  spinal  cord 
lesions  have  been  very  slight.  Comparing  the  lesions  with  those  in  acute 
polio-myelitis,  there  is  some  similarity. 

The  disease  is  apparently  distinct  from  the  acute  encephalitis  superior  of 
Striimpell.  Whatever  the  etiology  may  be,  the  outbreak  presents  new  features. 
All  agree  that  similar  clinical  features  had  not  been  seen,  at  any  rate,  in  such 
numbers.  The  question  is  complicated  by  the  occurrence  of  many  cases  in 
soldiers  of  an  acute  febrile  disease  with  the  features  of  polyneuritis,  but  occa- 
sionally with  bulbar  and  cerebral  symptoms,  and  anatomical  changes  not  un- 
like those  present  in  endemic  encephalitis  and  in  polio-myelitis.  Some  of 
these  are  only  special  localizations  of  polio-myelitis.  The  lethargy  may  be 
toxic  but  is  possibly  mechanical  due  to  interruption  of  stimuli  in  the  thalamus, 
which  is  frequently  involved. 

Clinical  Features. — The  clinical  picture  is  new,  particularly  the  combina- 
tion of  lethargy  with  third  nerve  and  facial  paralysis,  and  perhaps  weakness 
of  the  extremities.  MacNulty  groups  the  clinical  forms  into:  (1)  Cases  with 
general  features  but  without  localizing  signs.  (2)  Caees  with  third  nerve 
paralysis.  (3)  Cases  with  facial  paralysis.  (4)  Cases  with  spinal  manifes- 
tations. (5)  Cases  with  polyneuritic  manifestations.  In  2,  3,  4  and  5  there 
are  general  disturbances  of  the  central  nervous  system.  (6)  Cases  with  mild 
or  transient  manifestations  (so-called  "abortive"  cases).  To  these  should  be 
added  cases  of  paralysis  of  other  nerves  than  those  mentioned. 

The  incubation  period  is  variable  and  uncertain.  Prodromal  symptoms 
range  from  a  few  hours  to  a  week,  and  are  chiefly  headache,  letliargy,  stiffness 
in  the  back,  diffuse  pains,  and  catarrhal  features.  Among  the  early  symp- 
toms conjunctivitis  is  noted,  and  tonsillitis  with  headache  and  giddiness. 

Lethargy,  present  in  80  per  cent,  of  the  cases,  comes  on  as  a  rule  gradually, 
occasionally  very  suddenly,  and  is  sometimes  not  more  than  a  stupor  and 
heaviness,  from  which  the  patient  can  easily  be  roused,  the  so-called  "anergic 
apathy,''  but  in  others  it  is  a  much  deeper  stupor,  passing  into  coma.  Ocular 
palsies  occur  early,  with  diplopia  and  double  ptosis.  Combined  with  the 
^upor,  this  makes  a  very  characteristic  picture.     The  fever  ranges  from  100° 


EPIDEMIC  ENCEPHALITIS  945 

to  104°,  and  rarel}^  lasts  more  than  four  or  five  days  to  a  week.  It  may  drop 
at  the  end  of  three  or  four  days  and  then  recur.  There  is  nothing  peculiar 
in  the  pulse  rate  or  respiration.  As  the  disease  progresses,  the  patient  presents 
a  dull  apathetic  look.  The  wrinkles  are  smoothed,  the  muscles  of  the  face  may 
be  moved  with  great  difficulty,  or  there  may  be  definite  bilateral  facial  paraly- 
sis. The  pupils  are  diUited,  perhaps  unequal,  with  complete  third  nerve 
paralysis.  The  arms  are  flexed,  and  catalepsy  is  not  uncommon.  When  roused 
the  patient  may  answer  simple  questions  intelligently.  Active  delirium  may 
be  present.  One  patient  in  the  fourth  week  .of  the  disease  had  violent  mania 
and  then  recovered  rapidly.  The  speech  may  be  blurred  and  difficult;  this 
depends  on  the  degree  of  involvement  of  the  facial  muscles.  Tremors,  twitch- 
ings,  and  marked  choreiform  movements  may  occur,  and  persist  long  into 
convalescence. 

Sensory  disturbances  are  rare.  There  may  be  pain,  particularly  on  pres- 
sure of  the  muscles,  and  there  is  sometimes  hypersesthesia.  Paralysis  of  the 
arms  and  legs  may  occur,  either  alone  or  with  bulbar  involvement.  As  a 
rule,  the  reflexes  are  normal,  except  when  there  is  paraplegia;  the  knee-jerks 
may  be  abolished  for  a  time.  Sphincter  features  are  sometimes  present. 
Dysphagia  has  been  recorded  in  a  number  of  cases. 

The  general  features  may  be  present  without  local  paralysis,  which  seems 
more  common  in  children.  Other  cases  present  the  third  nerve  paralysis  alone 
or  with  facial  paralysis,  or  facial  paralysis  on  one  side  or  both  with  general 
weakness  of  the  extremities.  There  are  cases  with  early  ataxia  combined  with 
ocular  paralysis.  Lastly,  a  certain  number  of  cases  (seven  in  MacIsTulty's 
series),  all  in  adults,  showed  signs  of  polyneuritis  in  addition  to  the  bulbar 
features.  Mild  or  abnormal  types,  with  slight  lethargy,  slight  ataxia,  head- 
ache and  transient  facial  paralysis  are  rare.  One  patient  had  unusual  drowsi- 
ness with  an  ataxia  so  marked  that  he  was  thought  to  be  drunk.  He  was  not 
ill  enough  to  be  in  bed,  and  the  symptoms  passed  off  within  ten  days. 

Signs  suggestive  of  meningeal  involvement  are  rare.  The  cerebro-spinal 
fluid  is,  as  a  rule,  clear  with  10  to  20  cells  per  c.  mm.  (rarely  100  cells),  the 
globulin  little,  if  at  all,  increased.  Mononuclear  and  polymorphonuclear  cells 
are  found. 

The  duration  is  variable,  from  two  to  ten  or  twelve  weeks.  Out  of  168  cases 
37  died,  the  majority  with  bulbar  features.  Of  sequels  the  most  serious  are 
residual  palsies  which  resemble  those  of  polio-myelitis.  Muscular  tremors  or 
definite  athetosis  may  persist. 

Diagnosis. — Typical  cases  offer  no  difficulty.  Special  watch  should  be 
kept  for  the  cranial  paralysis  which  in  mild  cases  may  be  of  short  duration. 
The  following  conditions  deserve  mention:  (1)  Polio-myelitis.  The  simi- 
larity may  be  marked  but  the  spinal  fluid  usually  shows  more  marked  changes 
in  this  disease.  (2)  Psychoses  characterized  by  stupor,  lethargy  or  catalepsy. 
(3)  Tuberculous  meningitis  in  which  the  spinal  fluid  findings  are  not  char- 
acteristic. (4)  Acute  syphilitic  meningo-encephalitis  and  endarteritis.  (5) 
Botulism.  (6)  Cerebral  hemorrhage  or  thrombosis  may  be  simulated  by 
some  cases  of  encephalitis.  (7)  Status  epilepticus.  (8)  Uraemia.  (9)  Other 
forms  of  encephalitis. 

Treatment. — The  patient  should  be  isolated  and  carefully  nursed,  care 
being  taken  to  avoid  bed  sores ;  nasal  and  rectal  feeding  may  be  required  and 


946  DISEASES  OF  THE  NERVOUS  SYSTEM 

special  care  should  be  taken  to  keep  the  mouth  and  throat  clean.     Lumbar 
puncture  often  relieves  the  headache.     Drugs  are  not  indicated. 


F.    MYELITIS 
I.     ACUTE  MYELITIS 

Etiology. — Acute  myelitis  affecting  the  cord  in  a  limited  or  extended 
portion — the  gray  matter  chiefly,  or  the  gray  and  white  matter  together,  is  met 
with :  (a)  As  an  independent  affection  following  exposure  to  cold,  or  exertion, 
and  leading  to  rapid  loss  of  power  with  the  symptoms  of  an  acute  ascending 
paralysis.  Some  of  these  cases  are  unusually  widespread  acute  forms  of  polio- 
myelitis. There  is  also  an  acute  hsemorrhagic  form  with  high  fever  (Burley), 
the  relation  of  which  to  other  forms  is  uncertain.  (&)  As  a  sequel  of  the 
infectious  diseases,  such  as  small-pox,  typhus,  measles,  and  gonorrhoea,  (c) 
As  a  result  of  traumatism,  either  fracture  of  the  spine  or  ver}'-  severe  muscular 
effort.  Concussion  without  fracture  may  produce  it,  but  this  is  rare.  Acute 
myelitis,  for  instance,  scarcely  ever  follows  railway  accidents,  (d)  In  dis- 
eases of  the  bones  of  the  spine,  either  caries  or  cancer.  This  is  a  more  common 
cause  of  localized  acute  transverse  myelitis  than  of  the  diffuse  affection,  (e) 
In  disease  of  the  cord  itself,  such  as  tumors  and  syphilis;  in  the  latter,  either 
in  association  with  gummata,  in  which  case  it  is  usually  a  late  manifesta- 
tion; or  it  may  follow  within  a  year  or  eighteen  months  of  the  primary  af- 
fection. 

Morbid  Anatomy,. — In  localized  acute  myelitis  affecting  white  and  gray 
matter,  as  met  with  after  accident  or  an  acute  compression,  the  cord  is 
swollen,  the  pia  injected,  the  consistence  greatly  reduced,  and  on  incising  the 
membrane  an  almost  diffluent  material  may  escape.  In  less  intense  grades,  on 
section  at  the  affected  area,  the  distinction  between  the  gray  and  white  matter 
is  lost,  or  is  extremely  indistinct.  There  are  cases  with  the  appearances  of  an 
acute  hsemorrhagic  myelitis. 

Symptoms. —  (a)  Acute  Diffuse  Myelitis. — This  form  is  in  the  epi- 
demic polio-myelitis,  or  occurs  in  connection  with  syphilis  or  one  of  the  in- 
fectious diseases,  or  is  seen  in  a  typical  manner  in  the  extension  from  injuries 
or  from  tumor.  The  onset,  though  scarcely  so  abrupt  as  in  haemorrhage,  may 
be  sudden;  a  person  may  be  attacked  on  the  street  and  have  difficulty  in 
getting  home.  In  some  instances,  the  onset  is  preceded  by  pains  in  the  legs 
or  back,  or  a  girdle  sensation  is  present.  It  may  be  marked  by  chills,  occa- 
sionally by  convulsions;  fever  is  usually  present  from  the  beginning — at  first 
slight,  but  subsequently  it  may  become  high. 

The  motor  functions  are  rapidly  lost,  sometimes  as  quickly  as  in  Landry's 
ascending  paralysis.  The  paraplegia  may  be  complete,  and,  if  the  myelitis 
extends  to  the  cervical  region,  there  may  be  impairment  of  motion,  and  ulti- 
mately complete  loss  of  power  in  the  upper  extremities  as  well.  The  sensation 
is  lost,  but  there  may  at  first  be  hyperassthesia.  The  re f exes  in  the  initial 
stage  are  increased,  but  in  acute  central  myelitis,  unless  limited  in  extent  to 
the  thoracic  and  cervical  regions,  the  reflexes  are  usually  abolished.  The  rec- 
tum and  bladder  are  paralyzed.     Trophic  disturbances  are  marked;  the  mus- 


ACUTE  MYELITIS  947 

cles  waste  rapidly;  the  skin  is  often  congested,  and  there  may  be  localized 
sweating.  The  temperature  of  the  affected  limbs  may  be  lowered.  Acute 
bed-sores  may  occur  over  the  sacrum  or  on  the  heels,  and  sometimes  a  multiple 
arthritis  is  present.  In  these  acute  cases  the  general  symptoms  become  greatly 
aggravated,  the  pulse  is  rapid,  the  tongue  becomes  dry;  there  is  delirium,  the 
fever  increases,  and  may  reach  107°  or  108°  F. 

The  course  of  the  disease  is  variable.  In  very  acute  cases  death  follows 
in  from  five  to  ten  days.  The  cases  following  the  infectious  diseases,  particu- 
larly the  fevers  and  sometimes  syphilis,  may  run  a  milder  course. 

The  diagnosis  of  this  variety  is  rarely  difficult.  In  common  with  the  acute 
ascending  paralysis  of  Landry,  and  with  certain  cases  of  multiple  neuritis, 
it  presents  a  rapid  and  progressive  motor  paralysis.  From  the  former  it  is 
distinguished  by  more  marked  involvement  of  sensation,  trophic  disturbances, 
paralysis  of  bladder  and  rectum,  rapid  wasting,  electrical  changes,  and  fever. 
From  acute  cases  of  multiple  neuritis  it  may  be  more  difficult  to  distinguish, 
as  the  sensory  features  may  be  marked,  though  there  is  rarely,  if  ever,  in 
multiple  neuritis  complete  anaesthesia ;  the  wasting,  moreover,  is  more  rapid 
in  myelitis.  The  bladder  and  rectum  are  rarely  involved — though  in  excep- 
tional cases  they  may  be — and,  most  important  of  all,  the  trop^hic  changes, 
the  development  of  bullae,  bed-sores,  etc.,  are  not  seen  in  multiple  neuritis. 

(6)  Acute  Teansveese  Myelitis. — The  symptoms  naturally  differ  with 
the  situation  of  the  lesion. 

(1)  Acute  transverse  myelitis  in  the  thoracic  region,  the  most  common 
situation,  produces  a  very  characteristic  picture.  The  symptoms  of  onset  are 
variable.  There  may  be  initial  pains  or  numbness  and  tingling  in  the  legs. 
The  paralysis  may  set  in  quickly  and  become  complete  within  a  few  days ;  but 
more  commonly  it  is  preceded  for  a  day  or  two  by  sensations  of  pain,  heavi- 
ness, and  dragging  in  the  legs.  The  paralysis  of  the  lower  limbs  is  usually 
complete,  and  if  at  the  level,  say,  of  the  sixth  thoracic  vertebra,  the  abdominal 
muscles  are  involved.  Sensation  may  be  partially  or  completely  lost.  At  the 
onset  there  may  be  numbness,  tingling,  or  even  hyperaesthesia  in  the  legs. 
kt  the  level  of  the  lesion  there  is  often  a  zone  of  hyperaesthesia.  A  girdle 
sensation  may  occur  early,  and  when  the  lesion  is  in  this  situation  it  is  usually 
felt  between  the  ensiform  and  umbilical  regions.  The  reflexes  are  variable. 
There  may  at  first  be  abolition ;  subsequently,  those  which  pass  through  the 
segments  lower  than  the  one  affected  may  be  exaggerated  and  the  legs  may 
take  on  a  condition  of  spastic  rigidity.  It  does  not  always  happen,  however, 
that  the  reflexes  are  increased  here,  for  in  a  total  transverse  lesion  of  the 
cord  they  are  usually  entirely  lost,  as  pointed  out  by  Bastian.  That  this  is 
not  due  to  the  preliminary  shock  is  shown  by  the  fact  that  the  abolition  may 
be  permanent.  The  muscles  become  extremely  flabby,  waste,  and  lose  their 
faradic  excitability,  and  the  sphincters  lose  their  tone.  The  temperature  of 
the  paralyzed  limbs  is  variable.  It  may  at  first  rise,  then  fall  and  become  sub- 
normal. Lesions  of  the  skin  are  not  uncommon,  and  bed-sores  are  apt  to 
form. .  There  is  at  first  retention  of  urine  and  subsequently  spastic  incon- 
tinence. If  the  lumbar  centres  are  involved,  there  are  vesical  symptoms  from 
the  outset.  The  urine  is  alkaline  in  reaction  and  may  rapidly  become  am- 
moniacal.     The  bowels  are  constipated  and  there  is  usually  incontinence  of 


948  DISEASES  OF  THE  NERVOUS  SYSTEM 

fgeces.  Some  writers  attribute  the  cystitis  associated  with  transverse  myelitis 
to  disturbed  trophic  influence. 

The  course  of  complete  transverse  myelitis  depends  upon  its  cause.  Death 
may  result  from  extension.  Segments  of  the  cord  may  be  completely  and  per- 
manently destroyed,  in  which  case  there  is  persistent  paraplegia.  The  pyra- 
midal fibres  below  the  lesion  undergo  the  secondary  degeneration,  and  there  is 
an  ascending  degeneration  of  the  dorsal  median  columns.  If  the  lower  seg- 
ments of  the  cord  are  involved  the  legs  may  remain  flaccid.  In  some  instances 
a  transverse  myelitis  of  the  thoracic  region  involves  the  ventral  horns  above 
and  below  the  lesion,  producing  flaccidity  of  the  muscles,  with  wasting,  fibril- 
lary contractions,  and  the  reaction  of  degeneration.  More  commonly,  however, 
in  the  cases  which  last  many  months  there  is  more  or  less  rigidity  of  the 
muscles  with  spasm  or  persistent  contraction  of  the  flexors  of  the  knee. 

(2)  Transverse  Myelitis  of  the  Cervical  Region. — If  the  lesion  is  at  the 
level  of  the  sixth  or  seventh  cervical  nerves,  there  is  paralysis  of  the  upper 
extremities,  more  or  less  complete,  sometimes  sparing  the  muscles  of  the 
shoulder.  Gradually  there  is  loss  of  sensation.  The  paralysis  is  usually  com- 
plete, below  the  point  of  lesion,  but  there  are  rare  instances  in  which  the  arms 
only  are  affected,  the  so-called  cervical  paraplegia.  In  addition  to  the  symp- 
toms already  mentioned  there  are  several  which  are  more  characteristic  of 
transverse  myelitis  in  the  cervical  region,  such  as  the  occurrence  of  vomiting, 
hiccough,  and  slow  pulse,  which  may  sink  to  20  or  30,  pupillary  changes — 
myosis — sometimes  attacks  of  dysphagia,  dyspnoea,  or  syncope. 

Treatment  of  Acute  Myelitis. — In  the  rapidly  advancing  form  due  either 
to  a  diffuse  inflammation  in  the  gray  matter  or  to  transverse  myelitis,  the 
important  measures  are  scrupulous  cleanliness,  care  and  watchfulness  in  guard- 
ing against  bed-sores,  and  the  avoidance  of  cystitis.  In  an  acute  onset  in  a 
healthy  subject  the  spine  may  be  cupped.  Counter-irritation  is  of  doubtful 
advantage.  Chapman's  ice-bag  is  sometimes  useful.  No  drugs  have  the 
slightest  influence  upon  an  acute  myelitis,  except  in  subjects  with  well-marked 
syphilis,  in  which  case  mercury  and  potassium  iodide  should  be  given  ener- 
getically. Tonic  remedies,  such  as  quinine,  arsenic,  and  strychnia,  may  be 
used  in  the  later  stages.  When  the  muscles  have  wasted,  massage  is  beneficial 
in  maintaining. their  nutrition.  The  patient  should  make  every  effort  to  per- 
form muscular  movements  himself  and  thus  aid  improvement.  Electricity 
should  not  be  used  in  the  early  stages.  It  is  of  no  value  in  the  transverse 
myelitis  in  the  thoracic  region  with  retention  of  the  nutrition  in  the  muscles 
of  the  leg. 

II.       ACUTE  ASCENDING  (LANDRY'S)  PARALYSIS 


Definition.^- An  acute  ascending  fiaccid  paralysis  without  the  anatomical 
changes  of  polio-myelitis  or  polyneuritis.  Whether  or  not  there  is  a  disease 
conforming  to  this  definition,  after  excluding  the  neuritic  and  myelitic  cases, 
remains  to  be  determined. 

Etiolo^  and  Pathology. — The  disease  occurs  most  commonly  in  males 
between  the  twentieth  and  thirtieth  years.  It  has  followed  the  specific  fevers 
and  various  organisms  have  been  isolated.     There  is  a  form  of  the  epidemic 


DEGENERATIVE  MYELITIS  949 

polio-myelitis  which  has  an  acute  course  and  a  clinical  picture  similar  to 
Landry's  paralysis.  It  has  been  suggested  that  this  disease  always  represents 
the  sporadic  variety.  Spiller  in  a  rapidly  fatal  case  found  destructive  changes 
in  the  peripheral  nerves  and  corresponding  alterations  in  the  cell  bodies  of 
the  ventral  horns.  He  suggests  that  the  toxic  agent  acts  on  the  lower  motor 
neurones  as  a  whole,  and  that  possibly  the  reason  why  no  lesions  were  found 
in  some  of  the  cases  is  that  the  more  delicate  histological  methods  were  not 
used.  The  view  that  it  is  a  functional  disorder  is  supported  by  the  study  of 
cases  in  which  no  lesion  has  been  found. 

Symptoms. — Weakness  of  the  legs,  gradually  progressing,  often  with  toler- 
able rapidity,  is  the  first  symptom.  In  some  cases  within  a  few  hours  the 
paralysis  of  the  legs  becomes  complete.  The  muscles  of  the  trunk  are  next 
affected,  and  within  a  few  days,  or  even  less  in  more  acute  cases,  the  arms 
are  also  involved.  The  neck  muscles  are  next  attacked,  and  finally  the  muscles 
of  respiration,  deglutition,  and  articulation.  The  reflexes  are  lost,  but  the 
muscles  neither  waste  nor  show  electrical  changes.  The  sensory  symptoms  are 
variable ;  in  some  cases  tingling,  numbness,  and  hyperaesthesia  have  been  pres- 
ent. In  the  more  characteristic  cases  sensation  is  intact  and  the  sphincters 
are  uninvolved.  Enlargement  of  the  spleen  has  been  noted.  Bulbar  symptoms 
may  be  early  and  there  are  cases  in  which  the  picture  has  been  of  acute 
descending  paralysis.  The  course  of  the  disease  is  variable.  It  may  prove 
fatal  in  less  than  two  days.  Other  cases  persist  for  a  week  or  for  two  weeks. 
In  a  large  proportion  of  the  cases  the  disease  is  fatal.  One  patient  was  kept 
alive  for  41  days  by  artificial  respiration  (C.  L.  Greene). 

Diagnosis. — The  diagnosis  is  difficult,  particularly  from  certain  forms  of 
multiple  neuritis,  and  if  we  include  in  Landry's  paralysis  the  cases  in  which 
sensation  is  involved  distinction  between  the  two  affections  is  impossible.  We 
apparently  have  to  recognize  the  existence  of  a  rapidly  advancing  motor  par- 
alysis without  involvement  of  the  sphincters,  without  wasting  or  electrical 
changes  in  the  muscles,  without  trophic  lesions,  and  without  fever — features 
sufficient  to  distinguish  it  from  either  the  acute  central  myelitis  or  the  polio- 
myelitis anterior.  It  is  doubtful,  however,  whether  these  characters  always 
suffice  to  enable  us  to  differentiate  the  cases  of  multiple  neuritis.  The  cases 
of  acute  polio-myelitis  with  the  picture  of  an  acute  ascending  paralysis  should 
not  be  difficult  to  recognize  during  the  progress  of  an  epidemic. 


III.     DEGENERATIVE  MYELITIS 

I.     COMBINED  POSTERO-LATERAL  SCLEROSIS 

(Ataxic  Paraplegia  (Gowers)  ;  Subacute  Ataxic  Paraplegia  (Russell, 
Batten  and  Collier)  ;  Primary  Combined  Sclerosis  (J.  J.  Putnam)  ;  Toxic 
Combined  Sclerosis.) 

Definition. — A  disorder  with  symptoms  referable  to  degeneration  of  the 
posterior  and  lateral  columns  of  the  cord,  occasionally  occurring  without  ob- 
vious cause,  but  most  commonly  an  associated  lesion  of  the  cachexias,  ancemias, 
chronic  toxaemias  and  prolonged  sub-infections. 

Etiology. — Excluding  syphilis,  the  cause  no  doubt  of  many  of  the  cases 


950  DISEASES  OF  THE  NEEVOUS  SYSTEM 

in  male  adults  which  we  formerly  called  ataxic  paraplegia^  and  excluding 
multiple  sclerosis^  the  cause  of  many  of  the  cases  described  in  women,  there 
are  two  groups : 

I.  A  rare  and  doubtful  Primary  Combined  Sclerosis  in  which  in  adult 
males  without  lues  or  obvious  cause  the  symptoms  of  ataxia  and  spastic 
paraplegia  are  present. 

II.  The  Secondary  Combined  Sclerosis  associated  with: 

(a)  Chronic  ill-health  in  women,  as  in  the  form  described  by  J.  J.  Putnam. 

(b)  Ansmia,  as  described  by  Eussell,  Batten  and  Collier. 

(c)  The  toxaemias — ergot,  lead  and  pellagra. 

(d)  The  cachexias — cancer,  tuberculosis,  diabetes,  etc. 

The  anatomiml  features,  a  degenerative  myelitis,  are  a  sclerosis  of  the 
dorsal  columns,  which  is  not  more  marked  in  the  lumbar  region  and  not 
specially  localized  in  the  root  zone  of  the  cuneate  fasciculi.  The  involvement 
of  the  lateral  columns  is  diffuse,  not  always  limited  to  the  pyramidal  tracts, 
and  there  may  be  an  annular  sclerosis. 

Symptoms. — The  patient  complains  of  a  tired  feeling  in  the  legs,  not 
often  of  actual  pain.  The  sensory  symptoms  of  true  tabes  are  absent.  An 
unsteadiness  in  the  gait  gradually  eomes  on  with  progressive  weakness.  The 
reflexes  are  increased  from  the  outset,  and  there  may  be  well  marked  ankle 
clonus.  Eigidity  of  the  legs  comes  on  slowly,  but  it  is  rarely  extreme  as  in 
the  uncomplicated  cases  of  lateral  sclerosis.  From  the  onset  incoordination 
is  a  well  characterized  feature,  and  the  difficulty  of  walking  in  the  dark,  or 
swaying  when  the  eyes  are  closed,  may,  as  in  true  tabes,  be  the  first  symptom 
to  attract  attention.  In  walking  the  patient  uses  a  stick,  keeps  the  eyes  fixed 
on  the  ground,  the  legs  far  apart,  but  the  stamping  gait,  with  elevation  and 
sudden  descent  of  the  feet,  is  not  often  seen.  The  incoordination  may  extend 
to  the  arms.  Sensory  symptoms  are  rare,  but  Gowers  called  attention  to  a 
dull,  aching  pain  in  the  sacral  region.  The  sphincters  usually  become  involved. 
Eye  symptoms  are  rare.  Late  in  the  disease  mental  symptoms  may  occur, 
similar  to  those  of  general  paresis. 

In  the  secondary  variety  there  may  be  few  or  no  symptoms  in  patients  long 
bed-ridden  (Lichtheim,  Bramwell).  In  Putnam's  group,  in  which  30  of  51 
were  women,  paraesthesia  was  an  early  and  permanent  feature,  and  the  same 
occurs  in  the  ansemic  and  cachectic  forms.  When  fully  developed  there  are 
(1)  muscular  hypotony,  (2)  loss  of  the  knee-jerks,  and  (3)  ataxia,  due  to 
involvement  of  the  posterior  columns;  or  (1)  muscular  hypertony,  (2)  ex- 
aggerated deep  reflexes  and  positive  Babinski  sign,  and  (3)  motor  weakness 
due  to  degeneration  of  the  pyramidal  tracts  (L.  F.  Barker).  In  the  late 
stages  the  bladder  and  rectum  may  be  involved.  Pupil  changes  are  rare. 
It  is  a  curious  thing  that  a  severe  anemia  may  follow,  not  precede,  the  signs 
of  cord  disease. 

Diagnosis. — Syphilis  in  middle  aged  adults  must  be  excluded  and  dis- 
seminated sclerosis,  which  may  cause  a  similar  clinical  picture.  The  spastic- 
ataxic  gait  is  a  marked  feature. 

Treatment. — This  offers  little  beyond  general  measures.  Any  primary 
condition  should  receive  the  treatment  indicated. 

"Central  Neuritis." — This  name  has  been  given  by  Scott  to  a  disease  in 
adults  occurring  in  Jamaica,  which  perhaps  belongs  here.     The  early  features 


COMPEESSION  OF  THE  SPINAL  CORD  951 

are  inflarufmation  of  the  eyes,  and  later  changes  in  the  mouth  followed  by 
diarrhoea  or  marked  changes  in  the  nervous  system.  In  the  latter  the  first 
symptoms  are  sensory  disturbances  in  the  feet  and  legs,  followed  by  inco- 
ordination and  loss  of  control  over  the  legs.  The  knee-jerks  are  absent. 
Death  usually  occurred  from  inanition  with  diarrhoea  and  true  paralysis  does 
not  occur.  In  those  who  recovered  there  is  disturbance  of  vision,  deafness  and 
a  peculiar  steppage  gait.  Histologically  the  nervous  system  showed  general 
changes,  perivascular  infiltration,  degeneration  and  fibrosis.  The  disease 
suggests  some  form  of  toxsemia.  The  term  "central  neuritis"  was  given  by 
Adolf  Meyer  to  a  "parenchymatous  systemic  degeneration,  mainly  in  the 
nervous  system,"  found  in  alcoholic,  senile  and  cachectic  states,  and  in  de- 
pressive psychoses  at  the  time  of  involution.  The  features  are  fever,  diarrhoea, 
emaciation,  twitching  and  rigidity  of  the  extremities,  and  changed  reflexes. 
Mentally  there  is  an  anxious  agitation  with  delirium  or  stupor. 

II.     SENILE    SPASTIC   PAEALYSIS 

Unlike  the  Deacon^s  "Wonderful  One-Hoss  Shay,"  the  wear  and  tear  in- 
cident to  daily  use  tells  more  on  one  part  of  the  machine  than  another.  Like 
Dean  Swift  "Some  go  at  the  top  first,  others  in  their  legs,  others  again  in 
both  simultaneously."  ^Yhile  the  whole  nervous  system  may  show  decay — 
"the  golden  bowl  broken  and  the  silver  cord  loosened" — an  early  sign  of  old 
age  is  the  lessening  of  the  control  over  the  muscles,  evidenced  by  tremor  and 
inability  to  perform  the  finer  movements  with  the  same  precision.  The  gait 
becomes  tottering,  the  steps  uncertain,  and  at  last  the  use  of  the  legs  is  lost 
for  purposes  of  walking,  though  every  muscle  group  may  be  put  in  action. 
Or  one  may  watch  the  gradual  onset  of  a  spastic  paraplegia — a  progressive 
weakness  of  legs  with  spasticity  and  greatly  increased  reflexes.  The  steps  are 
short,  the  feet  not  lifted  from  the  ground,  and  the  gait  uncertain;  yet. in  many 
cases  the  strength  of  the  muscles  is  maintained,  and  the  patient  may  "keep 
on  his  legs"  for  years.  The  sphincters  are  not,  as  a  rule,  affected.  Arterio- 
sclerosis is  usually  present  and  in  premature  senility  the  vessels  of  the  legs 
may  be  very  stiff  and  the  dorsal  arteries  of  the  feet  obliterated.  Typical  in- 
termittent claudication  may  precede  the  paraplegia. 


IV.     COMPRESSION  OF  THE  SPINAL  CORD 

(  Co  mpressio  n  My  elitis  ) 

Definition. — Interruption  of  the  functions  of  the  cord  by  slow  compression. 

Etiology. — Caries  of  the  spine,  new  growths,  aneurism,  and  parasites  are 
the  important  causes  of  slow  compression.  Caries,  or  Pott's  disease,  as  it  is 
usually  called,  after  the  surgeon  who  first  described  it,  is  in  a  majority  of 
instances  tuberculous  and  associated  with  angular  curvature.  The  involve- 
ment of  the  cord  is  due  to  pachymeningitis  externa,  to  abscess,  or  in  rare  cases 
to  direct  spicules  of  bone.  There  may  be  a  tuberculous  pachymeningitis  with- 
out caries.  The  paraplegia  in  Pott's  disease  without  any  spinal  deformity  is 
difficult  to  recognize,  and  is  usually  associated  with  pressure  of  tuberculous  ma- 
terial inside  the  dura.    The  paraplegia  may  be  due  to  a  secondary  myelitis.    In 


953  DISEASES  OF  THE  NERVOUS  SYSTEM 

a  few  cases  it  is  due  to  syphilis  and  occasionally  to  extension  of  disease  from 
the  pharynx.  It  is  most  common  in  early  life,  but  may  occur  after  middle  age. 
It  may  follow  trauma.  Compression  may  result  from  aneurism  of  the  thoracic 
aorta  or  the  abdominal  aorta,  in  the  neighborhood  of  the  cceliac  axis.  Ma- 
lignant growths  frequently  cause  a  compression  paraplegia.  A  retroperito- 
neal sarcoma  or  the  growths  of  Hodgkin's  disease  may  invade  the  vertebrae. 
More  commonly  the  involvement  is  secondary  to  scirrhus  of  the  breast.  Of 
parasites,  the  echinococcus  and  the  cysticercus  may  occur  in  the  spinal  canal. 

Symptoms. — These  may  be  considered  as  they  affect  the  bones,  the  nerves, 
and  the  cord. 

Vertebral. — In  malignant  diseases  and  in  aneurism  erosion  of  the  bodies 
may  take  place  without  producing  deformity  of  the  spine.  Fatal  hasmor- 
rhage  may  follow  erosion  of  the  vertebral  artery.  In  caries,  on  the  other 
hand,  it  is  the  rule  to  find  more  or  less  deformity,  amounting  often  to  angular 
curvature.  The  compression  of  the  cord,  however,  is  rarely  if  ever  the  direct 
result  of  this  bony  kyphosis  but  is  due  to  thickening  of  the  dura  and  the 
presence  of  caseous  and  inflammatory  products  between  this  membrane  and 
the  bodies  of  the  diseased  vertebras.  The  spinous  processes  of  the  affected 
vertebrse  are  tender  on  pressure,  and  pain  follows  jarring  movements  or  twist- 
ing of  the  spine.  There  may  be  extensive  tuberculous  disease  without  much 
deformity,  particularly  in  the  cervical  region.  In  the  case  of  aneurism  or 
tumor  pain  is  a  constant  and  agonizing  feature. 

ISTerve-root  Symptoms. — These  result  from  compression  of  the  nerve 
roots  as  they  pass  out  between  the  vertebrae.  In  caries,  even  when  the  disease 
is  extensive  and  the  deformity  great,  radiating  pains  from  compression  involve- 
ment of  the  roots  are  rare.  Pains  are  more  common  in  cancer  of  the  spine 
secondary  to  that  of  the  breast,  and  in  such  cases  may  be  agonizing.  There 
may  be  acutely  painful  areas — the  ancBsthesia  dolorosa — in  regions  of  the  skin 
which  are  anaesthetic  to  tactile  and  painful  impressions.  Trophic  disturb- 
ances may  occur,  particularly  herpes.  Pressure  on  the  ventral  roots  may  give 
rise  to  wasting  of  the  muscles  supplied  by  the  affected  nerves.  This  is  most 
noticeable  in  disease  of  the  cervical  or  lumbar  regions. 

Cord  Symptoms. — (a)  Cervical  Begion. — The  caries  may  be  between 
the  axis  and  the  atlas  or  between  the  latter  and  the  occipital  bone.  In  such 
instances  a  retropharyngeal  abscess  may  be  present,  giving  rise  to  difficulty 
in  swallowing.  There  may  be  spasm  of  the  cervical  muscles,  the  head  may  be 
fixed,  and  movements  may  either  be  impossible  or  cause  great  pain.  In  a  case 
of  this  kind  in  the  Montreal  General  Hospital  movement  was  liable  to  be  fol- 
lowed by  transient,  instantaneous  paralysis  of  all  four  extremities,  owing  to 
compression  of  the  cord.    In  one  of  these  attacks  the  patient  died. 

In  the  lower  cervical  region  there  may  be  signs  of  interference  with  the 
cilio-spinal  centre  and  dilatation  of  the  pupils.  Occasionally  there  is  flushing 
of  the  face  and  ear  of  one  side  of  unilateral  sweating.  Deformity  is  not 
so  common,  but  healing  may  take  place  with  the  production  of  a  callus  of 
enormous  breadth,  with  complete  rigidity  of  the  neck. 

(&)  Thoracic  Begion. — The  deformity  is  here  more  marked  and  pressure 
symptoms  are  more  common.  The  time  of  onset  of  the  paralysis  varies 
very  much.  It  may  be  an  early  symptom,  even  before  the  curvature  is 
manifest,   and  it  is  noteworthy  that  Pott  first  described  the   disease   that 


COMPBESSIOX  OF  THE  SPIXAL  COED  953 

bears  his  name  as  "a  palsy  of  the  lower  limbs  which  is  frequently  found 
to  accompany  a  curvature  of  the  spine."  More  commonly  the  paralysis  is 
late,  occurring  many  months  after  the  curvature.  The  paraplegia  is  slow 
in  its  development;  the  patient  at  first  feels  weak  in  the  legs  or  has  disturb- 
ance of  sensation,  numbness,  tingling,  pins  and  needles.  The  girdle  sensa- 
tion may  be  marked,  or  severe  pains  in  the  course  of  the  intercostal  nerves. 
The  legs  are  frequently  drawn  up,  sometimes  in  spasm,  the  reflex  spinal 
automatism.  Motion  is,  as  a  rule,  more  quickly  lost  than  sensation.  The 
paraplegia  is  usually  of  the  spastic  type,  with  exaggeration  of  the  reflexes. 
Bastian's  symptom — abolition  of  the  reflexes — is  rarely  met  with  in  compres- 
sion from  caries  as  the  transverse  nature  of  the  lesion  is  rarely  complete. 
The  paraplegia  may  persist  for  months,  or  even  for  more  than  a  year,  and  recov- 
ery still  be  possible. 

(c)  Lumhar  Region. — In  the  lower  dorsal  and  lumbar  regions  the  symp- 
toms are  practically  the  same,  but  the  sphincter  centres  are  involved  and 
the  reflexes  are  not  exaggerated. 

(d)  Old  Lesions  of  Cord. — Following  trauma  in  Pott's  disease  the  dura 
may  be  much  thickened,  the  cord  narrowed  and  embedded  in  cicatricial  tissue. 

Diagnosis. — The  X-ray  picture  is  of  first  importance.  Caries  is  by  far  the 
most  frequent  cause  of  slow  compression  of  the  cord,  and  when  there  are  ex- 
ternal signs  the  recognition  is  easy.  There  are  cases  in  which  the  exudation 
in  the  spinal  canal  between  the  dura  and  the  bone  leads  to  compression  before 
there  are  any  signs  of  caries,  and  if  the  root  symptoms  are  absent  it  may  be 
extremely  difficult  to  arrive  at  a  diagnosis.  Persistent  lumbago  is  a  symptom 
of  importance  in  masked  Pott's  disease,  particularly  after  injury.  Brown- 
Sequard\s  paralysis  is  more  common  in  tumor  and  in  injuries  than  in  caries. 
Pressure  on  the  nerve  roots,  too,  is  less  frequent  in  caries  than  in  malignant 
disease.  The  cervical  form  of  pachymeningitis  also  produces  a  pressure  par- 
alysis. Following  removal  of.  the  breast  for  carcinoma,  at  intervals  of  a  year 
to  ten  or  more  years,  recurrence  in  the  vertebrae  may  cause  pressure  on  the 
spinal  nerves  or  on  the  t?ord  itself.  There  may  be  no  local  recurrence.  Neu- 
ralgic pains  in  the  neck  or  back,  or  in  the  course  of  the  sciatic,  often  associated 
with  obscure  nervous  symptoms,  suggesting  hysteria,  may  be  present  for  months 
Ijcfore  any  signs  of  paralysis  or  of  recurrence  elsewhere.  The  persistence  of 
the  pains  and  their  intensity  should  always  arouse  suspicion.  Finally  para- 
plegia may  come  on,  not  often  with  deformity,  and  the  pains  may  be  of  ter- 
rible intensity,  well  deserving  the  name  paraplegia  dolorosa. 

Treatment. — In  compression  by  aneurism  or  metastatic  tumors  the  con- 
dition is  hopeless.  In  the  former  the  pains  are  often  not  very  severe,  but 
in  the  latter  morphia  is  always  necessary.  On  the  other  hand,  compression 
bv  caries  is  often  successfully  relieved  even  after  the  paralysis  has  persisted 
for  a  long  period.  When  caries  is  recognized  early,  rest  and  support  to 
the  spine  by  various  methods  may  do  much  to  prevent  the  onset  of  paraplegia. 
AVhen  paralysis  has  occurred,  rest  with  extension  gives  the  best  hope  of  re- 
covery. It  is  to  be  remembered  that  restoration  may  occur  after  compression 
of  the  cord  has  lasted  for  many  months,  or  even  more  than  a  year.  Cases  have 
been  cured  by  recumbency  alone,  enforced  for  weeks  or  months ;  the  extradural 
and  inflammatory  products  are  absorbed  and  the  caries  heals.  In  earlier  days 
brilliant  results  were  obtained  in  these  cases  bj  suspension,  a  method  intro- 


954  DISEASES  OF  THE  XERA^OUS  SYSTEM 

duced  by  J.  K.  Mitcliell  in  1826,  and  pursued  with  remarkable  success  by 
his  son.  Weir  Mitchell.  In  recent  years  the  suspension  methods  in  the  erect 
posture  have  been  largely  superseded  by  those  of  hyperextension  during  recum- 
bency with  the  application  of  plaster  jackets  to  hold  the  body  and  spine  im- 
movable in  the  improved  position.  Forcible  correction  of  the  deformity  un- 
der anesthesia  as  sometimes  advocated  is  not  to  be  recommended;  but  the 
gentler  partial  corrections,  perhaps  repeated  several  times  with  a  few  weeks' 
interval,  often  lead  to  a  rapid  disappearance  of  paralyses  through  lessening 
of  the  deformity  of  the  vertebrae.  In  protracted  cases,  after  these  methods 
have  been  given  a  fair  trial,  laminectomy  may  be  advisable,  and  has  in  many 
instances  been  successful  in  relieving  paralyses  when  bloodless  methods  have 
failed.  In  old  traumatic  lesions  operation  may  be  indicated  for  severe  nerve- 
root  pains.    The  general  treatment  of  caries  is  that  of  tuberculosis. 


G.   DIFFUSE  SCLEROSES 

General  Remarks. — The  supporting  tissue  of  the  central  nervous  system 
is  the  neuroglia,  derived  from  the  ectoderm,  with  distinct  morphological  and 
chemical  characters.  The  meninges  are  composed  of  true  connective  tissue 
derived  from  the  mesoderm,  a  little  of  which  enters  the  brain  and  cord  with 
the  blood-vessels.  The  neuroglia  plays  the  chief  part  in  pathological  processes 
within  the  central  nervous  system,  but  changes  in  the  connective  tissue  ele- 
ments may  also  be  important.  A  convenient  division  of  the  cerebro-spinal 
scleroses  is  into  degenerative,  inflammatory,  and  developmental  forms. 

The  degenerative  scleroses  comprise  the  largest  and  most  important  sub- 
division, in  which  provisionally  the  following  groups  may  be  made :  (a)  The 
common  secondary  Wallerian  degeneration  which  follows  when  nerve  fibres 
are  cut  off  from  their  trophic  centres;  (&)  toxic  forms,  among  which  may  be 
placed  the  scleroses  from  lead  and  ergot,  and,  most  important  of  all,  the 
scleroses  of  the  dorsal  columns,  due  in  a  large  proportion  of  cases  to  syphilis; 
(c)  the  sclerosis  associated  with  change  in  the  smaller  arteries  and  capillaries, 
met  with  as  a  senile  process  in  the  convolutions. 

The  inflammatory  scleroses  embrace  a  less  important  and  less  extensive 
•group,  comprising  secondary  forms  which  follow  irritative  inflammation 
about  tumors,  foreign  bodies,  hsemorrhages,  and  abscess.  Possibly  a  similar 
change  may  follow  the  primary,  acute  encephalitis,  which  Striimpell  holds  is 
the  initial  lesion  in  the  cortical  sclerosis  so  commonly  found  post  mortem  in 
infantile  hemiplegia. 

The  developmental  scleroses  are  believed  to  be  of  a  purely  neurogliar  char- 
acter, and  embrace  the  new  growth  about  the  central  canal  in  syringomyelia 
and,  according  to  French  writers,  the  sclerosis  of  the  dorsal  columns  in 
Friedreich's  ataxia. 

MULTIPLE     (INSULAE:     DISSEMINATED)     SCLEROSIS 

Defixition", — A  chronic  affection  of  the  brain  and  cord,  characterized  by 
localized  areas  in  which  the  nerve  elements  are  more  or  less  replaced  by 
neuroglia.    This  may  occur  in  the  brain  or  cord  alone,  more  commonly  in  both. 


MULTIPLE  SCLEROSIS  955 

Etiology. — It  is  most  common  in  young  persons  and  in  females.  Several 
members  in  a  family  may  be  attacked.  It  is  much  less  common  in  the  United 
States  than  in  Great  Britain;  only  91  cases  among  12,000  patients  (Collins) 
against  159  among  2568  cases  in  three  years  at  the  National  Hospital,  London. 
The  etiology  is  obscure;  trauma,  fatigue,  cold,  exposure,  intoxications  and 
infections  have  all  been  mentioned.  The  essential  nature  of  the  process  has 
been  much  discussed — the  result  of  the  action  of  a  toxic  agent  on  the  sheaths 
and  axis  cylinders,  with  secondary  proliferation  of  the  glia,  a  primary  inter- 
stitial process,  a  multiple  gliosis  in  which  congenital  influences  play  a  part, 
a  primary  vascular  disorder  with  secondary  changes  in  the  nervous  and  inter- 
stitial tissues,  are  among  the  prevailing  views. 

Morbid  Anatomy. — The  sclerotic  areas  are  widely  distributed  through 
the  white  and  gray  matter.  The  patches  are  most  abundant  in  the  neigh- 
borhood of  the  ventricles,  and  in  the  pons,  cerebellum,  basal  ganglia 
and  the  medulla.  The  cord  may  be  only  slightly  involved  or  there  may  be 
very  many  areas  throughout  its  length.  The  cervical  region  is  apt  to  be 
most  affected.  The  nerve  roots  and  the  branches  of  the  cauda  equina  are 
often  attacked.  There  is  a  degeneration  of  the  medullary  sheaths,  with  the 
persistence  for  some  time  of  the  axis-cylinders  which  are  thought  by  some 
to  be  new  formed  nerve  fibres.  There  is  marked  proliferation  of  the  neu- 
roglia, the  fibres  of  which  are  denser  and  firmer.  Secondary  degeneration, 
although  relatively  slight,  does  occur. 

Symptoms. — The  onset  is  slow  and  the  disease  is  chronic.  The  patients 
are  often  emotional  or  even  hysterical.  Attacks  of  transient  paralysis,  sugges- 
tive of  hysteria,  may  precede  the  onset.  Feebleness  of  the  legs  with  irregu- 
lar pains  and  stiffness  are  among  the  early  symptoms.  Indeed,  a  common 
clinical  picture  is  that  of  spastic  paraplegia.  The  following  are  the  most  im- 
portant features : 

(a)  Volitional  or  Intention  Tremor. — There  is  no  weakness  of  the  arms, 
but  on  attempting  to  pick  up  an  object  there  is  a  trembling  or  rapid  oscillation. 
A  patient  may  be  unable  to  lift  even  a  glass  of  water  to  the  mouth.  The 
tremor  may  be  marked  in  the  legs,  and  in  the  head,  which  shakes  as  he 
walks.  When  the  patient  is  recumbent  the  muscles  may  be  perfectly  quiet. 
On  attempting  to  raise  the  head  from  the  pillow,  trembling  at  once  comes 
on.  (&)  Scanning  Speech. — The  words  are  pronounced  slowly  and  separately, 
or  the  individual  syllables  may  be  accentuated.  This  staccato  or  syllabic  ut- 
terance is  a  common  feature,  (c)  Nystagmus,  a  rapid  oscillatory  movement 
of  both  eyes,  is  more  common  in  multiple  sclerosis  than  any  other  affection 
of  the  nervous  system. 

Sensation  is  unaffected  in  the  majority  of  the  cases.  Optic  atrophy  may 
occur  early,  but  is  usually  partial,  rarely  leading  to  complete  blindness.  The 
sphincters,  as  a  rule,  are  unaffected  until  the  last  stages.  Mental  debility  is 
not  uncommon.  Eemarkable  remissions  occur  in  the  course  of  the  disease,  in 
which  for  a  time  all  the  symptoms  may  improve.  Vertigo  is  common,  and 
there  may  be  sudden  apoplectiform  attacks,  such  as  occur  in  general  paresis. 
The  presence  of  the  extensor  plantar  reflex  (Babinski  sign)  and  the  absence  of 
the  abdominal  reflexes  are  common. 

The  symptoms,  on  the  whole,  are  extraordinarily  variable,  corresponding 
to  the  very  irregular  distribution  of  the  nodules. 


956  DISEASES  OF  THE  NERVOUS  SYSTEM 

Diagnosis. — For  the  early  diagnosis  the  three  important  symptoms  are — 
loss  of  abdominal  reflexes,  weakness  of  the  abdominal  muscles  and  pallor  of  the 
temporal  sides  of  the  optic  disks  (L.  F.  Barker).  Volitional  tremor,  scanning 
speech,  and  nystagmus  form  a  characteristic  symptom-group,  but  this  classi- 
cal triad  is  less  common  than  the  irregular  forms  which  are  very  apt  to  escape 
recognition.  Paralysis  agitans,  certain  cases  of  general  paresis,  and  occa- 
sionally hysteria  may  simulate  the  disease  very  closely.  Of  all  organic  dis- 
eases of  the  nervous  system  disseminated  sclerosis  in  its  early  stages  is  that 
which  is  most  commonly  taken  for  hysteria  (Buzzard,  Sr.).  The  points  to 
be  relied  upon  in  the  differentiation  are,  in  order  of  importance,  optic  atrophy, 
tho  nystagmus,  the  bladder  disturbances,  when  present,  and  the  volitional 
tremor.  The  tremor  in  hysteria  is  not  volitional  but  the  diseases  may  co-exist. 
Unilateral  cases  are  recorded.  If  the  case  is  not  seen  until  near  the  end  the 
diagnosis  may  be  impossible. 

Pseudo-sclerosis — the  Westphall-Striimpell  disease — is  a  rare  condition 
simulating  multiple  sclerosis  and  not  often  distinguished  from  it  during  life. 
Mental  changes  are  more  pronounced,  the  tremor  is  more  exaggerated,  the 
nystagmus  not  always  present,  and  the  gait  more  ataxic.  It  sets  in  earlier, 
sometimes  in  the  first  decade,  and  in  a  majority  of  the  cases  no  lesions  have 
been  found  post  mortem. 

The  PROGNOSIS  is  unfavorable.  Ultimately,  the  patient,  if  not  carried  off 
by  some  intercurrent  affection,  becomes  bedridden.  In  200  cases  the  average 
duration  was  twelve  years;  3  recovered  (Bramwell). 

Treatment. — ^No  known  treatment  has  any  influence  on  the  progress  of 
sclerosis  of  the  brain.  (Neither  the  iodides  nor  mercury  have  the  slightest 
effect,  but  a  prolonged  course  of  arsenic  may  be  tried.  Avoidance  of  fatigue, 
physical  and  mental,  is  Important.  In  acute  stages  there  should  be  absolute 
rest.    Benefit  has  resulted  from  opening  the  spinal  canal  (Elsberg). 

Miliary  sclerosis  is  a  term  which  has  been  applied  to  several  different 
conditions.  GoM^ers  mentions  a  case  in  which  there  were  grayish  red  spots  at 
the  Junction  of  the  white  and  gray  matters,  and  in  which  the  neuroglia  was 
increased.  There  is  also  a  condition  in  which,  on  the  surface  of  the  convolu- 
tions, there  are  small  nodular  projections,  varying  from  a  half  to  five  or  more 
millimetres  in  diameter. 

Diffuse  sclerosis,  which  may  involve  an  entire  hemisphere,  or  a  single 
lobe,  in  which  case  the  term  sclerose  lohaire  has  been  applied  to  it  by  the 
French.  It  is  not  an  important  condition  in  general  practice,  but  occurs 
most  frequently  in  idiots  and  imbeciles.  In  extensive  cortical  sclerosis  of 
one  hemisphere  the  ventricle  is  usually  dilated.  The  symptoms  of  this  con- 
dition depend  upon  the  region  affected.  There  may  be  a  considerable  extent 
of  sclerosis  without  symptoms  or  much  mental  impairment.  In  a  majority 
of  cases  there  is  hemiplegia  or  diplegia  with  imbecility  or  idiocy. 

Tuberose  Sclerosis. — Described  by  Bourneville  in  feeble-minded  children, 
and  regarded  as  a  pathological  curiosity,  the  researches  of  Vogt,  Woiback, 
Fowler  and  Dickson  and  others  have  shown  it  to  be  a  definite  type  of  disease, 
which  may  sometimes  be  recognized  clinically.  Imbecility  and  epilepsy  are 
present,  without,  as  a  rule,  paralysis.  Anatomically  there  are  remarkable 
tuberous  tumors,  embedded  in  the  cortex  cerebri,  ranging  in  size  from  a  pea 
to  a  walnut,  white  in  color,  and  of  a  stony  hardness.     There  is  an  over- 


TOPICAL  DIAGNOSIS  957 

growth  of  the  neuroglia  and  of  large  ganglionic  cells.  A  remarkable  peculiar- 
ity, which  sometimes  enables  the  disease  to  be  recognized,  is  the  occurrence  of 
congenital  tumors  in  other  organs,  heart,  kidneys  and  skin.  Adenoma 
sebaceum  of  the  face,  small,  closely-set  growths  about  the  nose  and  cheeks, 
often  with  a  vascular  matrix,  is  the  most  common.  Eenal  tumors  were  found 
in  19  of  29  cases. 


H.    DIFFUSE  AND  FOCAL  DISEASES  OF  THE 
SPINAL  CORD 

I.    TOPICAL  DIAGNOSIS 

From  the  symptoms  presented  by  a  spinal  cord  lesion  it  is  possible  to 
determine  more  or  less  accurately  not  only  the  level  but  also  the  transverse 
extent  of  the  segmental  involvement.  The  effects  of  an  injury  or  of  dis- 
ease may  be  circumscribed  and  involve  the  gray  matter  of  the  segment  or 
the  tracts  running  through  it ;  it  may  be  more  extensive  and  involve  the  cord 
in  a  given  level  in  its  entire  transverse  extent ;  finally,  there  are  cases  in  which 
only  one  lateral  half  of  the  cord  is  implicated.  It  is  well  for  the  student  to 
have  a  definite  routine  to  follow  in  making  his  examinations,  for  each  factor 
may  be  helpful  in  determining  the  site  and  character  of  the  lesion.  Some  of 
the  more  important  points  to  observe  are  the  following:  (1)  subjective  sensa- 
tions, particularly  the  character  and  seat  of  pain,  if  any  be  present,  such  as  the 
radiating  pains  of  dorsal  root  compression;  (2)  the  patient's  attitude,  as  the 
position  of  the  arms  in  cervical  lesions,  the  character  of  the  respiration,  whether 
diaphragmatic,  etc.;  (3)  motor  symptoms,  the  groups  of  paralyzed  muscles 
and  their  electrical  reaction;  (4)  the  sensory  symptoms,  including  tests  for 
tactual,  thermic,  and  painful  impressions,  for  muscle  sense,  bone  sensation, 
etc.;  (5)  the  condition  of  the  reflexes,  both  the  tendon  and  the  skin  reflexes  as 
well  as  those  of  the  pupil,  the  bladder  and  rectum,  etc.;  (6)  the  surface  tem- 
perature and  condition  of  moisture  or  dryness  of  the  skin,  which  gives  an  indi- 
cation of  vaso-motoT  paralysis.  The  table  on  pages  891-893  and  the  figures  on 
pages  898  and  899  will  be  useful  while  making  an  examination. 

Focal  Lesions. — A  lesion  involving  a  definite  part  of  the  gray  matter  de- 
stroying the  cell  bodies  of  the  lower  motor  neurones  and  leading  to  degenera- 
tion of  their  axis-cylinder  processes,  is  accompanied  by  a  loss  of  power  to  per- 
form certain  definite  movements.  Thus  in  anterior  polio-myelitis  the  only 
symptom  may  be  a  flaccid  paralysis,  and  the  seat  of  the  lesion  is  revealed  by 
the  muscles  involved.  If  from  injury  or  disease  a  lesion  involves  more  than 
the  gray  matter  and,  for  example,  if  the  neighboring  fibres  of  the  pyramidal 
tract  be  affected  there  may  be  in  addition  a  spastic  paralysis  of  the 
muscles  whose  centres  lie  in  the  lower  levels  of  the  cord.  The  degree  of  such 
a  paralysis  depends  upon  the  intensity  of  the  lesion  of  the  pyramidal  tract  and 
may  vary  from  a  slight  weakness  in  dorsal  flexion  of  the  ankle  to  an  absolute 
paralysis  of  all  the  muscles  below  the  lesion.  Again,  if  the  afferent  tracts  are 
affected  sensory  symptoms  may  be  added  to  the  motor  palsy.  There  may  be 
disturbances  of  pain  and  temperature  sense  alone  or  touch  also  may  be  af- 
fected.    This,  however,  is  rare  except  in  serious  lesions.     The  upper  border 


958  DISEASES  OF  THE  NEEVOUS  SYSTEM 

of  disturbed  sensation  often  indicates  most  clearly  the  level  of  the  disease, 
especially  when  this  is  in  the  thoracic  region  where  the  corresponding  level 
of  motor  paralysis  is  not  easily  demonstrated.  It  is  unusual  for  cutaneous 
angesthesia  in  organic  lesions  of  the  cord  to  extend  above  the  level  of  the  second 
rib  and  the  tip  of  the  shoulder,  for  this  represents  the  lower  border  of  the  skin- 
field  of  the  fourth  cervical  (see  sensory  charts),  and  as  the  chief  centre  for  the 
diaphragm  lies  in  this  segment,  a  lesion  at  this  level  sufficiently  serious  to 
cause  sensory  disturbances  would  probably  occasion  motor  paralyses  as  well 
and  would  entirely  shut  off  the  movements  necessary  for  respiration.  The 
demonstrable  upper  border  of  the  ansesthetic  field  may  not  quite  reach  that 
which  represents  the  level  of  the  lesion.  This  is  due  to  the  functional  over- 
lapping of  the  segmental  skin-fields  (Sherrington)  and  applies  more  to 
touch  than  to  pain  and  temperature.  There  is  often  a  narrow  zone  of  hyper- 
Eesthesia  above  the  anaesthetic  region. 

Complete  Transverse  Lesions. — When  the  transverse  lesion  is  total  and  the 
lower  part  of  the  cord  is  cut  off  entirely  from  above,  there  is  complete  sensory 
and  motor  paralysis  to  the  segmental  level  of  the  injury,  and  the  tendon  re- 
flexes, whose  centres  lie  below,  are  lost  instead  of  being  exaggerated,  as  they 
are  apt  to  be  in  case  the  lesion  is  a  focal  one.  The  symptomatology  of  total 
transverse  lesions  is  thus  given  by  Collier.  (1)  Total  flaccid  paralysis  of  mus- 
cles below  the  level  of  the  lesion.  (Spastic  paralysis  indicates  that  the  lesion 
is.  incomplete.)  (2)  Permanent  abolition  of  the  knee-jerk  and  other  deep 
reflexes  supplied  by  the  lower  segments  of  the  cord  (Bastian's  symptom). 
(3)  A  rapid  wasting  of  the  paralyzed  muscles  with  a  loss  of  the  faradic  excit- 
ability. (4)  The  sphincters  lose  their  tone  and  there  is  dribbling  of  urine. 
(5)  There  is  total  anassthesia  to  the  level  of  the  lesion  (the  zone  of  hyper- 
assthesia  is  rarer).  (6)  The  only  sign  of  self-action  remaining  is  in  the  occa- 
sional presence,  though  in  reduced  degree,  of  certain  skin  reflexes  such  as  the 
plantar  reflex  with  its  dorsal  flexor  response  in  the  great  toe. 

Unilateral  Lesions  (Brown-Sequard  Paralysis). — The  motor  symptoms, 
which  follow  lesions  limited  to  one  lateral  half  of  the  cross  section  of  the 
spinal  cord,  are  confined  to  one  side  of  the  body;  they  are  on  the  same  side 
as  the  lesion.  At  the  level  of  the  lesion,  owing  to  destruction  of  cell  bodies 
of  the  lower  system  of  neurones,  there  will  be  found  flaccid  paralysis  and 
atrophy  of  those  muscles  whose  centres  of  innervation  happen  to  lie  at  this 
level.  Owing  to  degeneration  of  the  pyramidal  tract,  the  muscles  whose  cen- 
tres be  at  lower  levels  are  also  paralyzed,  but  they  retain  their  normal  electrical 
reactions,  become  spastic,  and  do  not  atrophy  to  any  great  degree. 

The  sensory  symptoms  are  peculiar.  On  the  side  of  the  lesion  correspond- 
ing to  the  segment  or  segments  of  the  cord  involved  there  is  a  zone  of  an- 
esthesia to  all  forms  of  sensation.  Below  this  there  is  no  loss  in  the  per- 
ception of  pain,  temperature,  or  touch.  Indeed,  hypersesthesia  has  been  de- 
scribed. Muscle  sense  is  disturbed,  and  the  ability  to  appreciate  the  size, 
consistency,  weight,  and  shape  of  an  object.  On  the  side  opposite  to  the  lesion 
and  nearly  up  to  its  level  there  is  complete  loss  of  perception  for  pain  and  tem- 
perature and  there  may  be  some  dulling  of  tactile  sense  as  well. 

The  following  table,  slightly  modified  from  Gowers,  illustrates  the  dis- 
tribution of  these  symptoms  in  a  complete  semi-lesion  of  the  cord : 


TOPICAL  DIAGNOSIS 

Card 


959 


Zone  of  cutaneous  hypersesthesia. 
Zone  of  cutaneous  anaesthesia. 
Lower  segment  type  of  paralysis 
with  atrophy. 


Upper  segment  type  of  paralysis. 

Hypersesthesia  of  skin. 

Muscular  sense  and  allied  sensa- 
tions impaired. 

Reflex  action  first  lessened  and 
then  increased. 

Surface  temperature  raised. 


Muscular  power  normal. 
Loss  of  sensibility  of  skin  to 

pain  and  temperature. 
Muscular  sense  normal. 
Reflex  action  normal. 
Temperature  same  as  that  of 

above  lesion. 


It  is  common  in  syphilitic  diseases  of  the  cord,  tumors  and  stab-wounds, 
and  is  not  infrequently  associated  with  syringomyelia  and  hsemorrhages  into 
the  cord.  It  is  only  in  exceptional  cases,  of  course,  that  the  lesion  is  absolutely 
limited  to  the  hemi-section  of  the  cord  and  the  symptoms  consequently  may 
vary  somewhat  in  degree. 

Lesions  of  the  Conus  Medullaiis  and  Cauda  Equina. — The  chief  lesions 
of  this  region  are  (1)  fractures  and  dislocations,  (2)  myelitis,  (3)  tumors, 
(4)  gunshot  wounds,  and  (5)  neuritis  of  the  nerves  of  the  cauda. 

1.  Conus  Alone. — It  may  be  in  the  seat  of  a  tumor  or  a  focal  myelitis  or 
haemorrhage,  and  it  has  been  damaged  in  a  lumbar  puncture.  The  features 
are  characteristic — paralysis  of  the  rectum  and  bladder,  with  the  "riding- 
breeches  anesthesia"  of  the  perineum,  scrotum,  penis,  and  postero-internal 
aspects  of  the  thighs.  There  is  less  pain  than  in  caudal  lesions  and  the  dis- 
turbance of  sensation  is  bilateral. 

2.  The  Epiconus  may  be  involved  alone,  leading  to  degenerative  atrophy  of 
the  muscles  innervated  by  the  sacral  plexus,  particularly  the  peronei  and  the 
glutei.  "If  the  lesion  be  limited  to  the  grey  matter  of  the  epiconus,  the 
Achilles  reflex  is  abolished,  but  the  knee-jerk  can  be  elicited  and  the  sphincters 
remain  unaffected"  (Barker). 

3.  Cauda  Equina. — An  unusual  number  of  cases  have  followed  bullet  and 
shell  wounds  in  the  late  war.  The  picture  varies  with  the  level  of  the  lesion, 
from  complete  paralysis  of  all  the  muscles  of  the  legs  with  anaesthesia,  includ- 
ing the  genitals,  but  if  below  the  second  sacral  roots,  there  is  no  paralysis  of 
the  lower  limbs,  but  there  is  the  typical  saddle-shaped  angesthesia.  The  caudal 
lesions  are  more  often  unilateral,  and  the  neuralgic  pains  are  more  severe. 

Of  tumors  of  the  cauda  mention  must  be  made  of  the  diffuse  giant  tumors 
described  by  Collins  and  Elsberg,  with  well  marked  caudal  and  conus  symp- 
toms. There  is  also  a  remarkable  neuritis  in  which  the  caudal  roots  are  swollen 
and  the  nerves  degenerated,  in  association  with  a  high  grade  of  local  arterio- 
sclerosis. The  symptoms  in  the  five  cases  reported  by  Kennedy  and  Elsberg 
were  pain,  sphincter  involvement,  and  sensory  changes  in  the  sacral  roots.  A 
similar  neuritis  has  been  described  in  the  horse. 


9G0  DISEASES  OF  THE  NERVOUS  SYSTEM 

n.    AFFECTIONS  OF  THE  BLOOD  VESSELS 

I.     CONGESTION 

Apart  from  actual  myelitis,  we  rarely  see  congestion  of  the  spinal  cord, 
and,  when  we  do,  it  is  "usually  limited  either  to  the  gray  matter  or  to  a  definite 
portion  of  the  organ.  The  white  matter  is  rarely  found  congested,  even  when 
inflamed.  The  gray  matter  often  has  a  reddish  pink  tint,  but  rarely  a  deep 
reddish  hue,  except  when  myelitis  is  present.  If  we  know  little  anatomically 
of  congestion  of  the  cord,  we  know  less  clinically,  for  there  are  no  features  in 
any  way  characteristic  of  it. 

II.     AN^.MIA 

So,  too,  with  this  state.  There  may  be  extreme  grades  without  symptoms. 
In  chlorosis,  for  example,  there  are  rarely  symptoms  pointing  to  the  cord,  and 
there  is  no  reason  to  suppose  that  such  sensations  as  heaviness  in  the  limbs 
and  tingling  are  especially  associated  with  anaemia. 

Profound  anemia  follows  ligature  of  the  aorta.  Within  a  few  moments 
after  the  application  of  the  ligature  paraplegia  came  on  (Herter).  Paralysis 
of  the  sphincters  occurred,  but  less  rapidly.  Observations  made  by  Halsted 
on  occlusion  of  the  abdominal  aorta  in  dogs  have  shown  that  paraplegia  oc- 
curs in  a  large  percentage  of  cases,  many  of  which,  however,  may  recover  as 
the  collateral  circulation  is  established.  In  the  fatal  cases  Oilman  found  ex- 
tensive alterations  in  the  cell  bodies  of  the  lower  part  of  the  cord  with  degen- 
erations. This  is  of  interest  in  connection  with  the  occasional  rapid  develop- 
ment of  a  paraplegia  after  profuse  hgemorrhage,  usually  from  the  stomach 
or  uterus.  It  may  come  on  at  once  or  at  the  end  of  a  week  or  ten  days,  and 
is  probably  due  to  an  anatomical  change  in  the  nerve  elements  similar  to  that 
produced  in  Herter's  experiments.  The  degeneration  of  the  dorsal  columns 
of  the  cord  in  pernicious  anaemia  has  been  described. 

III.     EMBOLISM   AND   THROMBOSIS 

Blocking  of  the  spinal  arteries  by  emboli  rarely  occurs.  Thrombosis  of  the 
smaller  vessels  in  connection  with  endarteritis  plays  an  important  part  in 
many  of  the  acute  and  chronic  changes  in  the  cord. 

IV.     ENDARTERITIS 

It  is  remarkable  how  frequently  in  persons  over  fifty  the  arteries  of  the 
spinal  cord  are  found  sclerotic.  The  following  forms  may  be  met  with  : 
(1)  A  nodular  peri-arteritis  or  endarteritis  associated  with  syphilis  and 
sometimes  with  gummata  of  the  meninges;  (2)  an  arteritis  obliterans,  with 
great  thickening  of  the  intima  and  narrowing  of  the  lumen,  involving  chiefly 
the  medium  and  larger-sized  arteries.  Miliary  aneurisms  or  aneurisms  of  the 
larger  vessels  are  rarely  found  in  the  spinal  cord.  Attacks  of  transient  para- 
plegia may  be  due  to  spasm  or  other  changes  in  the  vessels  of  the  cord.  In  the 
remarkable  neuritis  of  the  cauda  equina  described  by  Kennedy  and  Elsberg 
there  is  marked  sclerosis  of  the  arteries. 


AFFECTIONS  OF  THE  BLOOD  VESSELS        961 

V.     HiEMORRHAGE  INTO  THE  SPINAL  MEMBRANES;   H^MATORACHIS 

In  meningeal  apoplexy,  as  it  is  called,  the  blood  may  lie  between  the 
dura  mater  and  the  spinal  canal — extra-meningeal  hemorrhage — or  within  the 
dura  mater — intra-meningeal  haemorrhage. 

Extra-meningeal  haemorrhage  occurs  usually  as  a  result  of  traumatism. 
The  exudation  may  be  extensive  without  compression  of  the  cord.  The  blood 
comes  from  the  large  plexuses  of  veins  which  may  surround  the  dura.  The 
rupture  of  an  aneurism  into  the  spinal  canal  may  produce  extensive  and  rap- 
idly fatal  hgemorrhage. 

Intra-meningeal  haemorrhage  is  a  less  frequent  result  of  trauma,  but  in 
general  is  perhaps  rather  more  common.  It  is  rarely  extensive  from  causes 
acting  directly  on  the  spinal  meninges  themselves.  Scattered  haemorrhages 
are  not  infrequent  in  the  acute  infectious  fevers,  and  there  may  be  much  ex- 
travasation in  malignant  small-pox.  It  may  be  into  the  theca  alone  and  along 
the  spinal  nerve  roots.  Bleeding  may  occur  also  in  death  from  convulsive 
disorders,  such  as  epilepsy,  tetanus,  and  strychnia  poisoning,  and  has  been  re- 
corded with  difficult  parturition  and  in  purpura.  The  most  extensive  haemor- 
rhages occur  in  cases  in  which  the  blood  comes  from  rupture  of  an  aneurism 
at  the  base  of  the  brain,  either  of  the  laasilar  or  vertebral  artery.  In  ven- 
tricular apoplexy  the  blood  may  pass  from  the  fourth  ventricle  into  the  spinal 
meninges.  In  cranial  fractures,  particularly  those  of  the  base  of  the  skull, 
the  resultant  hgemorrhage  almost  always  finds  its  way  into  the  subarachnoid 
space  about  the  cord  and  may  be  demonstrated  by  the  withdrawal  of  bloody 
fluid  by  a  lumbar  puncture.  The  procedure  is  of  considerable  diagnostic 
value.  On  the  other  hand,  haemorrhage  into  the  spinal  meninges  may  possibly 
ascend  into  the  brain. 

Symptoms. — The  symptoms  in  moderate  grades  may  be  slight  and  in- 
definite. The  spinal  features  suggest  lumbar  puncture  and  the  nature  of  the 
fluid,  flowing  under  pressure,  determines  the  presence  of  haemorrhage.  In  the 
non-traumatic  cases  the  haemorrhage  may  either  come  on  suddenly  or  after 
a  day  or  two  of  uneasy  sensations  along  the  spine.  As  a  rule,  the  onset  is 
abrupt,  with  sharp  pain  in  the  back  and  symptoms  of  irritation  in  the  course 
of  the  nerves.  There  may  be  muscular  spasms,  or  paralysis  may  come  on 
suddenly,  either  in  the  legs  alone  or  both  in  the  legs  and  arms.  In  some  in- 
stances the  paralysis  develops  more  slowly  and  is  not  complete.  There  are  no 
signs  of  cerebral  disturbance.  The  clinical  picture  varies.  If  the  haemorrhage 
is  in  the  lumbar  region,  the  legs  alone  are  involved,  the  reflexes  may  be  abol- 
ished, and  the  action  of  the  bladder  and  rectum  is  impaired.  If  in  the  thoracic 
region,  there  is  more  or  less  complete  paraplegia,  the  reflexes  are  usually  re- 
tained, and  there  are  signs  of  disturbance  in  the  thoracic  nerves,  such  as 
girdle  sensations,  pains,  and  sometimes  eruption  of  herpes.  In  the  cervical 
region  the  arms  as  well  as  the  legs  may  be  involved;  there  may  be  difficulty 
in  breathing,  stiffness  of  the  muscles  of  the  neck,  and  occasionally  pupillary 
symptoms.  In  a  case  of  influenza-pneumonia  in  the  recent  epidemic  there  was 
bilateral  spastic  rigidity  associated  with  extensive  haemorrhage  into  the  theca 
spinalis  and  along  the  nerve  roots.  Tliere  was  no  free  blood  in  the  canal. 
Branson  reports  two  cases,  probably  influenza,  with  bloody  fluid  (40-50  c.  c.) 


963  DISEASES  OF  THE  NERVOUS  SYSTEM 

withdrawn  under  considerable  pressure.     The  spinal  symptoms  were  slight 
and  both  patients  recovered. 

The  prognosis  depends  much  upon  the  cause  of  the  haemorrhage.  Ee- 
covery  may  take  place  in  the  traumatic  cases  and  in  those  associated  with  the 
infectious  diseases. 

Vi.     HiEMOEEHAGE   INTO   THE  SPINAL   CORD;    H^MATOMYELIA 

Most  frequently  a  result  of  traumatism,  intraspinal  hgemorrhage  is  natu- 
rally more  common  in  males  and  during  the  active  period  of  life.  Cases  have 
been  known  to  follow  cold  or  exposure;  it  occurs  also  in  tetanus  and  other 
convulsive  diseases,  and  hsemorrhage  may  be  associated  with  tumors,  with 
syringomyelia  or  myelitis.  A  direct  injury  to  the  spine  from  blows  or  from 
falls  is  by  far  the  most  common  cause.  Acute  flexure  of  the  neck,  often  with- 
out attendant  fracture  or  dislocation  of  the  vertebrae,  is  the  most  common  form 
of  accident.  There  were  many  such  cases  during  the  war.  The  level  of  the 
lesion,  for  this  reason,  is  most  frequently  in  the  lower  cervical  region. 

Anatomical  Condition. — The  extent  of  the  haemorrhage  may  vary  from 
a  small  focal  extravasation  to  one  which  finds  its  way  in  columnar  fashion 
a  considerable  distance  up  and  down  the  cord.  The  bleeding  primarily 
takes  place  into  the  gray  matter,  and  this  as  a  rule  suffers  most,  but  the 
surrounding  medullated  tracts  may  be  thinned  out  and  lacerated. 

Symptoms. — As  one  side  of  the  cord  is  usually  involved  more  than  the 
other,  the  Brown-Sequard  syndrome  is  common.  The  symptoms  are  sud- 
den in  onset,  and  leave  the  patient  with  hyperaesthesia  and  a  paralysis  which 
becomes  spastic  and  is  most  marked  on  one  side,  while  ansesthesia,  chiefly  to 
pain '  and  temperature,  is  most  marked  on  the  opposite  side  of  the  body. 
Often  a  most  distressing  hyperaesthesia,  usually  a  "pins  and  needles"  sensation, 
may  be  present  for  many  days,  but  there  is  rarely  any  acute  pain  of  the  radi- 
ating or  root  type.  As  haematomyelia  is  most  frequent  in  the  lower  cervical 
region,  in  addition  to  the  symptoms  just  mentioned  a  brachial  type  of  palsy  is 
commonly  seen,  with  flaccid  and  atrophic  paralysis  of  the  muscles  innervated 
from  the  lowest  cervical  and  first  thoracic  segments.  The  haemorrhage  may 
occur  in  segments  farther  down  the  cord,  the  lumbar  enlargement  being  af- 
fected next  in  frequency  to  the  lower  cervical.  The  segmental  level  of  the 
paralysis  necessarily  would  vary  accordingly. 

The  condition  may  prove  rapidly  fatal,  particularly  if  the  extravasation 
is  bilateral  and  extends  high  enough  in  the  cord  to  involve  the  centres  for 
the  diaphragm.  More  frequently  there  is  a  more  or  less  complete  recovery 
with  a  residual  palsy  of  the  upper  extremity  and  a  partial  anaesthesia,  corre- 
sponding to  the  level  of  the  lesion,  and  some  spasticity  of  the  leg. 

Dia^osis. — The  diagnosis  of  the  traumatic  cases  is  comparatively  easy, 
and  it  is  important  to  recognize  them,  as  they  are  often  needlessly  subjected 
to  operation  under  the  belief  that  they  are  instances  of  acute  compression. 
The  residual  symptoms  in  old  cases  may  closely  simulate  those  seen  in  syringo- 
myelia. 

Treatment. — Absolute  rest  is  important  and  the  patient  should  be  dis- 
turbed as  little  as  possible.  Special  care  must  be  ^given  the  skin  to  prevent 
bed-sores  and  to  the  bladder  to  prevent  cystitis.     Treatment  of  the  paralyzed 


TUMOES  OF  SPINAL  COED  AND  ITS  MEMBEANES         963 

parts  should  not  be  begun  for  six  weeks  after  the  hemorrhage,  when  electricity., 
gentle  massage,  and  passive  movements  are  indicated. 


m.     TUMORS  OF  THE  SPINAL  CORD  AND  ITS  MEMBRANES 

I.     SYEINGOMYELIA     (GLIOMA,    GLIOMATOSIS) 

Definition. — A  gliosis  about  the  central  canal,  either  forming  a  local 
tumor,  or  more  often  a  diffuse  growth  associated  with  cavity  formations,  ex- 
tending lengthwise,  and  sometimes  communicating  with  the  central  canal. 

Dilatation  of  the  central  canal — hydromyelus — which  must  be  distin- 
guished from  syringomyelia,  is  met  with  as  a  congenital  anomaly;  only  in  a 
few  instances  do  the  cavity  formations  of  syringomyelia  represent  the  dis- 
tended canal  itself. 

Morbid  Anatomy. — The  cervical  and  dorsal  regions  are  the  usual  seat. 
There  are:  (1)  either  a  diffuse  gliosis  or  at  one  level  a  definite  tumor  from 
which  the  growth  extends  for  some  inches,  causing  enlargement  of  the  cordi 
(2)  Tube  like  cavities,  extending  for  a  variable  distance,  usually  in  the  dorsal 
aspect  and  sometimes  involving  only  one  cornu.  The  processes  leading  to  the 
formation  of  the  cavities  are  various,  such  as  haemorrhage  and  thrombotic 
degenerations,  evidences  of  which  may  be  present.  The  wall  of  the  tubes  may 
be  smooth  and  lined  with  ependymal  cells.  (3)  Degenerative  changes  in  other 
parts  of  the  cord  due  to  pressure. 

Symptoms. — Men  are  more  often  affected,  133  of  190  cases  collected  by 
Schlesinger.  A  familiar  type  has  been  described.  The  disease  begins,  as  a 
rule,  before  the  thirtieth  year.  The  symptoms  vary  with  the  seat  and  extent 
of  the  disease.  A  typical  case  beginning  in  the  lower  cervical  region  presents 
the  following  features:  (1)  Lower  motor  neurone  involvement,  with  a  pro- 
gressive atrophy  of  the  muscles  of  the  hands  and  arms,  and  sometimes  fibril- 
lary tremors,  so  that  the  Aran-Duchenne  disease  is  suspected.  The  typical 
claw-hand  may  exist.  As  the  disease  progresses,  there  is  degeneration  of  the 
pyramidal  tracts  with  a  spastic  paraplegia,  so  that  the  picture  suggests  amyo- 
trophic lateral  sclerosis. 

(2)  Sensory  changes;  (a)  pains  of  the  nerve-root  type,  chiefly  in  the  arms; 
(b)  the  syringomyelic  dissociation  of  sensation,  in  which  the  sense  of  touch 
is  retained,  while  those  of  heat  and  of  pain  are  lost.  The  muscular  sense  is 
not  disturbed.  The  loss  of  temperature  sense  may  be  early,  and  a  patient's  fin- 
gers may  be  burnt  by  cigarettes  or  even  charred. 

(3)  Trophic  changes,  as  destructive  whitlows,  with  atrophy  of  the  terminal 
phalanges  (Morvan's  disease),  vaso-motor  swelling  of  the  hands,  sweating,  and 
arthropathies,  which  latter  occur  in  about  10  per  cent,  of  the  cases.  While 
this  is  the  common  and  readily  recognized  form,  there  may  be  no  disturbance 
of  sensation  for  years,  only  the  amyotrophic  type  of  paralysis ;  there  may  be 
general  anesthesia  to  pain  and  temperature,  with  very  little  motor  disturb- 
ance; and  there  is  a  form  with  bilateral  spastic   diplegia. 

Marked  scoliosis  may  be  present,  a  feature  not  easily  explained.  The 
analgesia  and  loss  of  thermic  sense  are  due  to  involvement  of  the  peri- 
ependymal gray  matter  and  the  posterior  horns.  The  tactile  sensations  travel 
in  the  postero-lateral  regions  of  the  cord  which  are  rarely  involved. 


964  DISEASES  OF  THE  NERVOUS  SYSTEM 

The  diagnosis  is  easy  in  well  pronounced  eases,  but  when  the  motor  features 
predominate,  it  may  not  be  possible  to  distinguish  the  disease  from  amyo- 
trophic muscular  paral3^sis.  With  the  widespread  anaesthesia  hysteria  is  simu- 
lated ;  while  the  combination  of  anaesthesia  and  loss  of  the  finger  tips  may  sug- 
gest leprosy.  In  a  few  instances  the  gliosis  extends  to  the  medulla  with  the 
production  of  bulbar  symptoms. 

Treatment. — In  a  few  cases  the  X-rays  have  appeared  to  give  relief  to  the 
pains  and  stiffness. 

II.     TUMOES  OF  THE  MENINGES 

A  majority  of  all  growths  are  extra-medullary,  and  originate  on  the  dura 
or  pia  in  the  blood  vessels  or  on  the  nerve-roots.  Schlesinger's  tabulation  of 
400  cases  shows  that  the  growths  in  order  of  frequency  are  tubercle,  fibroma 
and  syphiloma.  Earer  forms  are  lipoma,  psammoma,  neuroma,  myxoma  and 
angioma.  A  few  cases  of  aneurism  and  echinococcus  cyst  have  been  reported. 
The  nature,  rate  of  growth,  size  and  situation  are  the  important  factors. 

Symptoms. — There  are  two  groups:  (1)  Irritation — sensory  and  motor. 
Pressure  on  the  posterior  roots  causes  pain,  unilateral  or  bilateral,  at  the 
level  of  the  distribution  of  the  nerves.  Hyperaesthesia  with  a  sense  of  burn- 
ing is  common.  In  the  cervical  region  the  sympathetic  fibres  may  l^e  in- 
volved. Only  in  a  few  cases  are  sensory  features  absent.  Motor  irritation  due 
to  pressure  on  the  anterior  roots  and  on  the  antero-lateral  columns  causes  spon- 
taneous spasms  of  the  muscles,  rarely  of  the  arms,  but  very  often  of  the  legs^ 
and  they  constitute  the  most  important  single  symptom  in  tumor  involving 
the  cord.  Suddenly,  without  the  patient's  knowledge,  the  legs  are  drawn  up. 
sometimes  in  pain,  the  thighs  flexed  on  the  abdomen,  the  legs  on  the  thighs 
and  foot,  and  especially  the  big  toe  on  the  ankle.  It  is  a  reflex  of  spinal  autom- 
atism similar  to  that  described  by  Sherrington  in  the  decerebrated  animal. 
It  is  the  "defensive"  reflex  of  Babinski,  but  Sherrington's  term  is  preferable. 
It  may  be  excited  by  stimulating  the  skin  of  the  leg  or  foot,  but  the  important 
point  is  the  automatic  type  of  the  reflex  and  its  significance  as  a  sign  of  pres- 
sure irritation  on  the  cord,  at  any  stage  early  or  late  of  the  process. 

(2)  Compression. — Anaesthesia  may  occur  in  the  region  of  distribution  of 
the  nerve-root  or  roots  involved ;  atrophy  of  the  muscles  may  follow  pressure  on 
the  anterior  roots.  Pressure  on  the  cord  itself  may  produce  the  symptoms  of 
a  hemi-lesion  with  a  typical  Brown- Sequard  syndrome.  Gradually,  after 
months  or  even  years,  the  compression  is  complete  with  a  spastic  paraplegia 
and  all  the  features  of  a  spinal  automatism.  All  stages  from  nerve-root  irri- 
tation to  a  total  transverse  lesion  may  be  followed  through  a  period  of  months 
or  years,  and  this  sequence  of  events  carefully  studied  is  one  of  the  most 
valuable  helps  in  diagnosis. 

The  situation  of  the  growth  is  determined  by  the  root-levels  involved,  and  it 
is  to  be  remembered  that  the  tendency  is  usually  to  locate  it  below  the  actual 
situation.  The  X-rays  are  often  of  great  value  in  determining  the  nature  of 
the  pressure,  particularly  in  excluding  disease  of  the  vertebrae. 

Spinal  Fluid. — From  a  study  of  five  cases  and  a  hundred  collected  from 
the  literature,  Sprunt  and  Walker  describe  two  forms  of  xanthrochromia,  in 
one  of  which  the  color  is  due  to  dissolved  haemoglobin,  the  fluid  does  not  coagu- 
late, and  the  amount  of  globulin  is  small.     This  is  more  common  with  brain 


TOPICAL  DIAGNOSIS  965 

tumor.  In  a  larger  group  the  fluid  is  clear  yellow,  coagulates,  and  has  a  large 
amount  of  globulin  and  no  ha?moglobin — the  so-called  Froin  syndrome;  and 
is  a  compression  sign,  associated  with  the  isolation  of  a  lumber  cul-de-sac, 
in  which  the  fluid  stagnates.  It  suggests  spinal  tumor  or  intra-dural  inflam- 
mation. 

Lumbar  puncture  may  give  a  clear  normal  fluid.  The  leucocytes  may 
be  increased,  and  the  chief  interest  is  the  occurrence  of  xanthrochromia. 

Diagnosis. — When  constant  and  severe  root  pains  are  associated  with  a 
progressive  paralysis,  the  diagnosis  may  be  easily  made.  Caries  may  cause 
identical  symptoms,  but  the  radiating  pains  are  rarely  so  severe.  Cervical 
meningitis  simulates  tumor  very  closely,  and  in  reality  produces  identical 
effects,  but  the  very  slow  progress  and  the  bilateral  character  from  the  outset 
may  be  sufficient  to  distinguish  it.  Syphilitic  meningo-myelitis  may  resem- 
ble tumor  very  closely  and  present  radiating  pains,  a  sense  of  constriction, 
and  progressive  paralysis.  Syringomyelia  may  give  a  similar  picture.  A 
radiogram  rnay  be  of  diagnostic  aid  in  case  the  vertebra  are  infiltrated  by 
the  growth.  The  nature  of  the  tumor  can  rarely  be  indicated  with  precision. 
With  a  marked  syphilitic  history  gumma  may  be  suspected,  or,  with  coexisting 
tuberculous  disease,  a  solitary  tubercle. 

Treatment. — It  is  difficult  to  say  which  rouses  the  greater  admiration — 
the  brilliant  diagnosis  of  the  clinician  or  the  technique  of  the  physiologi'^.al  sur- 
geon, the  combination  of  which  enabled  Gowers  and  Horsley  to  remove,  for 
the  first  time,  and  with  permanent  success,  a  tumor  of  the  spinal  cord.  The 
report  of  this  case  should  be  read  to  his  class  by  every  teacher  of  neurology 
(Medico-Chir.  Soc.  Trans.,  London,  LXXI,  1888).  In  syphiloma  recovery  is 
possible,  even  after  complete  paraplegia.  The  only  hopeful  cases  are  the  iso- 
lated growths  springing  from  the  membranes,  and  the  operation  has  been  fol- 
lov/ed  by  an  ever  increased  percentage  of  recovery. 


I.   DIFFUSE  AND  FOCAL  DISEASES  OF  THE  BRAIN 
I.     TOPICAL  DIAGNOSIS 

In  many  regions  disease  may  exist  without  causing  symptoms — the  so- 
called  silent  areas.  Other  areas  at  once  give  symptoms.  These  are  the  cortical 
motor  centres  and  the  associated  sensory  centres,  the  speech  centres,  the  centres 
for  the  special  senses,  and  the  tracts  which  connect  these  cortical  areas  with 
each  other  and  with  other  parts  of  the  nervous  system. 

The  following  is  a  brief  summary  of  the  effects  of  lesions  from  the  cortex 
to  the  spinal  cord : 

The  Cerebral  Cortex. — (a)  Destructive  lesions  of  the  motor  cortex  cause 
paralysis  in  the  muscles  of  the  opposite  side  of  the  body.  The  paralysis  is  at 
first  flaccid,  later  spastic,  the  extent  depending  upon  that  of  the  lesion.  It  is 
apt  to  be  limited  to  the  muscles  of  the  head  or  of  an  extremity,  giving  rise  to 
the  cerebral  monoplegias.  One  group  of  muscles  may  be  more  affected  than 
others,  especially  in  lesions  of  the  highly  differentiated  area  for  the  upper 
extremity.  It  is  uncommon  to  find  all  the  muscle  groups  of  an  extremity 
equally   involved    in    cortical   monoplegia.      In    small   bilateral    symmetrical 


966  DISEASES  OE  THE  NERVOUS  SYSTEM 

lesions  monoplegia  of  the  tongue  may  result  without  paralysis  of  the  face.  A 
lesion  may  involve  centres  lying  close  together  or  overlapping  one  another,  thus 
producing  associated  monoplegias — e.  g.,  paralysis  of  the  face  and  arm,  or 
of  the  arm  and  leg,  but  not  of  the  face  and  leg  without  involvement  of  the 
arm.  Very  rarely  the  whole  motor  cortex  is  involved,  causing  paralysis  of 
the  opposite  side — cortical  hemiplegia. 

Adjoining  and  posterior  to  the  motor  area  is  the  region  of  the  cortex  in- 
which  the  impulses  concerned  in  general  bodily  sensation  (cutaneous  sensi- 
bility, muscle  sense,  visceral  sensations)  first  arrive  (the  somresthetic  area). 
Combined  with  the  muscular  weakness  there  is  usually  some  disturbance  of 
sensations,  particularly  of  those  of  the  muscular  sense.  In  lesions  of  the 
superior  parietal  lobe  the  stereognostic  sense  is  very  often  affected.  Eor  ex- 
ample, when  a  coin  or  a  knife  is  placed  in  the  hand  of  the  affected  limb,  the 
patient's  eyes  being  closed,  it  is  not  recognized,  owing  to  inappreciation  of 
the  form  and  consistence  of  the  object,  and  this  even  though  the  slightest  tac- 
tile stimulus  applied  to  the  fingers  or  surface  of  the  hand  is  felt'  and  may  be 
correctly  localized.  The  sense  of  touch,  pain,  and  temperature  may  be  low- 
ered, but  not  markedly  unless  the  superior  and  inferior  parietal  lobules  are 
involved  in  subcortical  lesions.  Paraesthesias  and  vaso-motor  disturbances  are 
common  accompaniments  of  paralyses  of  cortical  origin. 

(&)  Irritative  lesions  cause  localized  spasms.  The  most  varied  muscle 
groups  corresponding  to  particular  movement  forms  may  be  picked  out.  If 
the  irritation  be  sudden  and  severe,  typical  attacks  of  Jacksonian  epilepsy  may 
occur.  These  convulsions  are  often  preceded  and  accompanied  by  subjective 
sensory  impressions.  Tingling  or  pain,  or  a  sense  of  motion  in  the  part,  is 
often  the  sig?ial  symptom  (Seguin),  and  is  of  great  importance  in  determining 
the  seat  of  the  lesion. 

When  lesions  are  both  destructive  and  irritative,  there  are  combinations 
of  the  symptoms  produced  by  each.  For  instance,  certain  muscles  may  be 
paralyzed,  and  those  represented  near  them  in  the  cortex  may  be  the  seat 
of  localized  convulsions,  or  the  paralyzed  limb  itself  may  be  at  times  subject 
to  convulsive  spasms,  or  muscles  which  have  been  convulsed  may  become  par- 
alyzed. The  close  observation  of  the  sequence  of  the  symptoms  in  such  cases 
often  makes  it  possible  to  trace  the  progress  of  a  lesion  involving  the  motor 
cortex.  In  these  cases  the  most  frequent  cause  is  a  developing  tumor,  though 
sometimes  local  thickenings  of  the  membranes  of  the  brain,  small  abscesses, 
minute  hasmorrhages,  or  fragments  of  a  fractured  skull  must  be  held  re- 
sponsible. 

Centrum  Semiovale. — Lesions  may  involve  either  projection  fibres  (motor 
or  sensory)  or  association  fibres.  If  the  involvement  of  the  motor  path  causes 
paralysis,  this  has  the  distribution  of  a  cortical  palsy  when  the  lesion  is  near 
the  cortex,  and  of  a  paralysis  due  to  a  lesion  of  the  internal  capsule  when  it 
is  near  that  region.  Other  systems  of  fibres  running  in  the  centrum  semiovale 
may  be  involved  causing  sensory  disturbances — hemi-ana^sthesia  and  hemian- 
opia — and  if  the  lesion  is  in  the  left  hemisphere,  one  of  the  different  forms 
of  aphasia  may  accompany  the  paralysis. 

Two  other  features  may  be  associated  with  a  cortical  or  indeed  with  any 
lesion.  Neighborhood  sijmptoms  are  produced  by  pressure.  A  tumor  may 
cause  disturbance  of  function  in  adjacent  centres,  or  interrupt  motor  or  sen- 


TOPICAL  DIAGXOSTS  967 

sory  paths.  A  hgemorrhage  often  causes  transient  symptoms  which  clear  up 
after  the  clot  shrinks.  Transient  disturbances  of  the  speech  centres  and 
temporary  involvement  of  the  paths  in  the  internal  capsule  are  common 
effects.  Distal  symptoms  are  produced  in  two  ways.  The  pressure  of  a  tumor 
in  the  frontal  lobe  may  influence  the  function  of  the  motor  centres  or  a  pitui- 
tary growth  may  affect  far  distant  parts^  with  localizing  symptoms. 

SliocTc  symptoms  (which  have  been  much  studied  during  the  war)  arise 
from  functional  disturbance  of  parts  distant  from  the  site  of  the  lesion.  A 
blow  in  the  head  may  abolish  the  knee-jerks ;  transient  aphasia  may  be  caused 
by  a  fall  on  the  right  side  of  the  head.  The  loss  of  consciousness  in  apoplexy 
may  be  due  in  part  to  the  shock  of  the  stroke.  In  the  psychic  side  of  war 
this  shock  action  in  causing  local  or  widespread  loss  of  function  has  played 
an  important  role.  The  deleterious  effect  on  neurones  or  centres  far  removed 
from  the  site  of  the  injury  is  called  diaschisis  by  von  Monakow. 

Corpus  Striatum. — Nothing  is  known  of  the  functions  of  the  caudate 
nucleus.  The  progressive  lenticular  degeneration  (Wilson's  disease)  is  de- 
scribed among  the  familial  nervous  affections.  The  globus  pallidus,  part  of 
the  lenticular  nucleus,  is  involved  in  paralysis  agitans  and  in  Huntington's 
chorea  (Eamsay  Hunt). 

Corpus  Callosum. — It  may  be  absent  congenitally.  Though  often  involved 
in  tumors,  characteristic  symptoms  are  rare.  One  of  special  interest  has  been 
noted  b}^  Liepmann  in  connection  with  Apraxia.  The  left  half  of  the  brain  is 
the  dominant  partner  (as  more  than  90  per  cent,  of  persons  are  right-handed) 
in  our  manual  activities,  but  through  the  fibres  of  the  corpus  callosum  it 
has  guiding  influences  on  the  movements  controlled  by  the  right  hemisphere. 
Thus  a  lesion  of  the  left  cerebrum  above  the  capsule  may  cause  apraxia  of  the 
left  arm  by  cutting  the  callosal  fibres  through  which  influences  pass  from 
the  left  to  the  right  arm  centres.  The  anomalous  features  of  right  hemiplegia 
or  monoplegia  with  apraxia  of  the  non-paral3'zed  arm  are  suggestive  of  a 
callosal  lesion. 

The  Thalamus. — Much  knowledge  of  its  functions  has  been  obtained  by 
a  study  of  local  lesions.  It  is  an  important  sub-station  in  the  sensory  path,  and, 
as  iSTothnagel  showed,  it  is  the  loAver  reflex  centre  for  the  emotional  move- 
ments of  laughing  and  crying;  and  lesions  of  this  part  have  long  been  known 
to  be  associated  with  athetoid  and  choreic  movements. 

The  Thalamic  Syndrome,  as  it  is  called,  consists  of:  (1)  Contra-lateral 
hemiangesthesia,  sometimes  with  severe  pains;  (2)  irregular  movements — 
ataxic,  choreic,  or  athetoid;  and,  (3)  as  the  lesion  progresses,  hemi-paresis, 
but  the  plantar  reflex  may  remain  flexor.  Lesions  of  the  posterior  third  may 
involve  the  optic  radiations  causing  bilateral  homonomous  hemianopsia. 
Control  of  the  voluntary  movements  with  loss  of  the  mimic  associated  move- 
ments of  the  lower  half  of  the  face  in  laughing  and  crying  suggests  a  thalamic 
lesion. 

Internal  Capsule  (Fig.  15). — Through  this  pass  within  a  rather  narrow 
area  all,  or  nearly  all,  of  the  projection  fibres  (both  motor  and  sensory) 
which  are  connected  with  the  cerebral  cortex.  It  is  divided  into  an  anterior 
limb,  a  knee,  and  a  posterior  limb,  the  latter  consisting  of  a  thalamo-lenticular 
portion  (its  anterior  two-thirds)  and  a  retro-lenticular  portion  (its  posterior 
Hiird).    The  principal  bundle  passing  through  the  anterior  limb  of  the  capsule 


968  DISEASES  OF  THE  XEEYOUS  SYSTEM 

is  that  which  connects  the  frontal  gyri  and  the  medial  bundle  in  the  base 
of  the  peduncle  (crus)  with  the  nuclei  of  the  pons.  These  fibres  are  centri- 
fugal, and  innervate  chiefly  the  lower  motor  nuclei  governing  bilaterally  in- 
nervated muscles,  especially  those  of  the  eyes,  head,  neck,  and  probably  those 
of  the  mouth,  tongue,  and  larynx.  In  lower  horizontal  planes  these  fibres 
are  situated  near  the  knee  of  the  capsule.  It  is  the  region  of  the  knee  of  the 
capsule  which  transmits  especially  the  fibres  passing  from  the  cerebral  cortex 
to  the  nuclei  of  the  facial,  hypoglossal,  and  third  nerves.  The  path  which 
supplies  the  nuclei  governing  the  muscles  used  in  speech  passes  through  the 
knee. 

The  pyramidal  tract  goes  through  the  thalamo-lenticular  portion  of  the 
capsule.  The  motor  fibres  are  arranged  according  to  definite  muscle  groups, 
or  rather  movement  forms,  those  for  the  movements  of  the  arm  being  anterior 
to  those  for  the  leg.  The  number  of  fibres  for  a  given  muscle  group  corre- 
sponds rather  to  the  degree  of  complexity  of  the  movements  than  to  the  size 
of  the  muscles  concerned.  Thus  the  areas  for  the  fingers  and  toes  are  rela- 
tively large. 

The  fibres  to  the  somaesthetic  area  of  the  cortex — that  is,  those  from  the 
centro-lateral  group  of  nuclei  of  the  thalamus  and  the  tegmental  radiations — - 
carrying  impulses  concerned  in  general  bodily  sensation,  pass  upward  through 
the  posterior  part  of  the  thalamo-lenticular  portion  of  the  capsule.  Some  of 
these  fibres  pass  through  the  anterior  two-thirds  of  the  posterior  limb  along- 
side of  the  fibres  of  the  pyramidal  tract. 

Through  the  retro-lenticular  portion  of  the  posterior  limb,  opposite  the 
posterior  third  of  the  lateral  surface  of  the  thalamus,  pass  (1)  the  fibres  carry- 
ing impulses  concerned  in  the  sensations  of  the  opposite  visual  field  (optic 
radiation  from  the  lateral  geniculate  body  to  the  visual  sense  area  in  the  occipi- 
tal cortex) ;  (2)  the  fibres  carrying  impulses  concerned  in  auditory  sensations 
(radiation  from  the  medial  geniculate  body  to  the  auditory  sense  area  in  the 
cortex  of  the  temporal  lobe)  ;  (3)  the  fibres  (probably  centrifugal)  connecting 
the  cortex  of  the  temporal  lobe  with  the  nuclei  of  the  pons. 

With  this  preliminary^  knowledge  concerning  the  internal  capsule,  it  is  not 
difficult  to  understand  the  symptoms  which  result  when  it  is  diseased. 

Since  here  all  the  fibres  of  the  upper  motor  segment  are  gathered  together 
in  a  compact  bundle,  a  lesion  in  this  region  is  apt  to  cause  complete  hemiplegia 
of  the  opposite  side,  followed  later  by  contractures;  and  if  the  lesion  involves 
the  hinder  portion  of  the  posterior  limb  there  is  also  hemiangesthesia,  including 
even  the  special  senses.  As  a  rule,  however,  lesions  of  the  internal  capsule 
do  not  invoL'e  the  whole  structure.  The  disease  usually  affects  the  anterior 
or  posterior  portions,  and  even  in  instances  in  which  at  first  the  symptoms 
point  to  total  involvement  there  is  a  disappearance  often  of  a  large  part  of 
the  phenomena  after  a  short  time.  Thus,  when  the  pyramidal  tract  is  de- 
stroyed (lesion  of  the  thalamo-lenticular  portion  of  the  capsule)  the  arm 
may  be  affected  more  than  the  leg,  or  vice  versa.  The  facial  paralysis  is 
usually  slight,  though  if  the  lesion  be  well  forward  in  the  capsule  the  paralysis 
of  the  face  and  tongue  may  be  marked. 

The  bilaterally  innervated  muscles  of  the  upper  face,  of  mastication,  of 
deglutition,  phonation,  and  of  the  trunk  muscles  are  very  slightly  involved. 
The  patient  can  wrinkle  the  forehead,  and  close  the  eye  on  the  affected  side. 


TOPICAL  DIAGXOSTS  9G9 

Init  the  muscles  may  be  weak,  as  shcnvu  liy  lessened  respiratory  movement  on 
tlie  paralyzed  side. 

Hemianesthesia  alone  without  involvement  of  the  motor  fibres  is  rare. 
There  is  usually  also  at  least  partial  paralysis  of  the  leg.  When  the  retro- 
lenticular  portion  of  the  capsule  is  destroyed  the  hemiansesthesia  is  accom- 
panied by  hemianopsia,  disturbances  of  hearing,  and  sometimes  of  smell  and 
taste.  The  occurrence  of  hemianesthesia  with  pain,  hemichorea,  marked 
tremor,  or  hemiathetosis — thalamic  syndrome — after  a  capsular  hemiplegia 
points  to  the  involvement  of  the  thalamus  or  of  the  hypothalamic  region. 

Charcot  and  others  have  described  cases  in  which  as  a  result  of  disease  of 
the  internal  capsule  there  has  been  paralysis  of  the  face  and  leg  without  in- 
volvement of  the  arm.  In  such  instances  the  lesion  is  linear,  extending  from 
the  posterior  part  of  the  anterior  limb  of  the  internal  capsule  backward  and 
lateralward  to  the  leg  region  in  the  posterior  limb  of  the  capsule,  the  region 
for  the  arm  escaping. 

Capsular  lesions  when  pure  are  not  usually  accompanied  by  aphasic  symp- 
toms, alexia,  or  agraphia.  A  "subcortical''  motor  aphasia  may  result  if 
the  lesion  is  bilateral,  as  in  pseudo-bulbar  paralysis,  or  if  on  the  left  side  it 
is  so  extensive  as  to  destroy  the  fibres  connecting  Broca's  convolution  with  the 
opposite  hemisphere,  as  well  as  the  pyramidal  fibres  on  the  same  side. 

Crura  (Cerebral  Peduncles). — From  this  level  through  the  pons,  medulla, 
and.  cord  the  upper  and  lov.-er  motor  segments  are  represented,  the  first  by  the 
fibres  of  the  pyramidal  tracts  and  by  the  fibres  which  go  from  the  cortex  to 
the  nuclei  of  the  cerebral  nerves,  the  latter  by  the  motor  nuclei  and  the  nerve 
fibres  arising  from  them.  Lesions  often  affect  both  motor  segments,  and  pro- 
duce paralyses  having  the  characteristics  of  each.  Thus  a  single  lesion  may 
involve  the  pyramidal  tract  and  cause  a  spastic  paralysis  on  the  opposite 
side  of  the  body,  and  also  involve  the  nucleus  or  the  fibres  of  one  of  the 
cerebral  nerves,  and  so  produce  a  lower  segment  paralysis  on  the  same  side 
as  the  lesion — crossed  paralysis.  In  the  crus  the  third  and  fourth  cerebral 
nerves  run  near  the  pyramidal  tract,  and  a  lesion  of  this  region  is  apt  to 
involve  them  or  their  nuclei,  causing  partial  paralysis  of  the  muscles  of  the 
eye  on  the  same  side  as  the  lesions,  combined  with  a  hemiplegia  of  the  opposite 
side  (Weber-Gubler  syndrome)    (Fig.  12,  3). 

The  optic  tract  also  crosses  the  crus  and  may  be  involved,  giving  hemi- 
anopsia in  the  opposite  halves  of  the  visual  fields. 

If  the  tegmentum  be  the  seat  of  a  lesion  which  does  not  involve  the  base 
of  the  peduncle  (or  pes)  there  may  be  disturbances  of  cutaneous  and  muscular 
sensibility,  ataxia,  disturbances  of  hearing,  or  oculo-motor  paralysis.  An  oculo- 
motor paralysis  of  one  side,  accompanied  by  a  hemi-ataxia  of  the  opposite  side, 
appears  to  be  especially  characteristic  of  a  tegmental  lesion  (Benedikt's  syn- 
drome). Or  there  may  be  with  the  crossed  paralysis  the  features  of  cerebellar 
ataxia  (Xothnagel's  syndrome). 

Corpora  duadrigeminau — Anatomical  studies  point  to  the  view  that  the 
superior  colliculus  (anterior  quadrigeminal  body)  represents  the  most  impor- 
tant subcortical  central  organ  for  the  control  of  the  eye-muscle  nuclei.  This 
is  supported  to  a  certain  extent  by  clinical  evidence,  though  as  yet  but  few  cases 
have  been  carefully  studied.  Sight  is  only  slightly,  if  at  all,  disturbed  when 
the  superior  colliculus  is  destroyed.     The  pupil  is  usually  widened,  and  the 


970  DISEASES  OF  THE  NEEVOUS  SYSTEM 

pupillary  reaction,  both  to  light  and  on  accommodation,  interfered  with. 
Apparently  actual  paralysis  of  the  eye  muscles  does  not  occur  unless  the  nucleus 
of  the  third  nerve  ventral  to  the  aqueduct  be  also  injured. 

The  inferior  colliculus  (posterior  quadrigeminal  body)  is  an  important 
way-station  in  the  auditory  conduction-path.  A  large  part  of  the  lateral 
lemniscus  ends  in  its  nucleus,  and  from  it  emerge  meduUated  fibres  which 
pass  through  the  brachium  quadrigeminum  inferius  to  the  medial  geniculate 
body.  Thence  a  large  bundle  runs  through  the  retro-lenticular  portion  of 
the  internal  capsule  to  the  auditory  sense  area  in  the  cortex  of  the  temporal 
lobe. 

In  9  of  19  tumors  of  this  region  collected  by  Weinland  there  were  auditory 
disturbances. 

Since  the  central  auditory  path  of  each  side  receive  impulses  from  both 
ears,  lesion  of  the  colliculus  on  one  side  may  dull  the  hearing  on  both  sides, 
though  the  opposite  ear  is  usually  the  more  defective.  Lesion  of  the  inferior 
colliculus  may  be  accompanied  by  disturbance  of  mastication,  owing  to  paral- 
ysis of  the  descending  (mesencephalic)  root  of  the  trigeminus.  The  fourth 
nerve  may  also  be  involved.  The  ataxia  which  sometimes  accompanies  lesions 
of  the  corpora  quadrigemina  is  probably  to  be  referred  to  disturbance  in  con- 
duction in  the  medial  lemniscus. 

Pons  and  Medulla  Oblongata. — Lesions  involving  the  pyramidal  tract,  to- 
gether with  any  one  of  the  motor  cerebral  nerves  of  this  region,  cause  crossed 
paralysis — Jiemiplegia  alternans.  A  lesion  in  the  lower  part  of  the  pons  causes 
a  lower-segment  paralysis  of  the  face  on  the  same  side  (destruction  of  the 
nucleus  of  the  facial  nerve  or  of  its  root  fibres)  and  a  spastic  paralysis  of  the 
arm  and  leg  en  the  opposite  side  (injury  to  pyramidal  tract)  (Fig.  13,  4). 
This  is  referred  to  as  the  alternate  hemiplegia  or  the  Millard-Gubler  type. 
The  abducens,  the  motor  part  of  the  trigeminus,  and  the  hypoglossus  nerves 
may  also  be  paralyzed  in  the  same  manner.  AVhen  the  central  fibres  to  the 
nucleus  of  the  hypoglossus  are  involved  a  peculiar  form  of  anarthria  results. 
If  the  nucleus  itself  be  diseased,  swallowing  is  interfered  with. 

When  the  sensory  fibres  of  the  fifth  nerve  are  interrupted,  together  with 
the  sensory  tract  (the  medial  lemniscus  or  fillet)  for  the  rest  of  the  body, 
which  has  already  crossed  the  middle  line,  there  is  a  crossed  sensory  paralysis — 
i.  e.,  disturbed  sensation  in  the  distribution  of  the  fifth  on  the  side  of  the 
lesion,  and  of  all  the  rest  of  the  body  on  the  opposite  side — liemiancestliesia 
cruciata. 

A  paralysis  of  the  external  rectus  muscle  of  one  eye  and  of  the  internal 
rectus  of  the  other  eye  (conjugate  paralysis  of  the  muscles  which  turn  the 
eyes  to  one  side),  in  the  absence  of  a  "forced  position"  of  the  eyeballs,  is 
highly  characteristic  of  certain  lesions  of  the  pons.  In  such  cases  the  in- 
ternal rectus  may  still  be  capable  of  functioning  on  convergence,  or  when 
the  eye  to  which  it  belongs  is  tested  independently  of  that  in  which  the  ex- 
ternal rectus  is  paralyzed.  This  form,  known  as  the  Foville  type  of  hemi- 
plegia alternans,  is  found,  as  a  rule,-  only  when  the  lesion  lies  just  in  front 
of  the  abducens  or  involves  the  nucleus  itself,  or  includes,  besides  the  root  fibres. 
of  the  abducens,  that  portion  of  the  formatio  reticularis  that  lies  between  them 
and  the  fasciculus  longitudinalis  medialis  (von  Monakow).  The  facial  nerve 
is  often  involved  in  these  paralyses. 


TOPICAL  DIAGXOSIS  971 

In  lesions  of  the  pons  the  patient  often  has  a  tendency  to  fall  toward  the 
side  on  which  the  lesion  is,  probably  on  account  of  implication  of  the  middle 
peduncle  of  the  cerebellum  (brachium  pontis).  Still  more  frequent  is  the 
simple  motor  hemi-ataxia  consequent  upon  lesion  of  the  medial  lemniscus,  and 
perhaps  of  longitudinal  bundles  in  the  formatio  reticularis.  This  is  often  ac- 
companied by  a  dissociated  sensory  disturbance,  pain  and  temperature  being 
affected,  while  touch  remains  normal.  The  muscular  sense  may  also  be  in- 
volved. Only  when  the  lesion  is  very  extensive  are  there  disturbances  of  hear- 
ing (involvement  of  the  lateral  lemniscus  or  corpus  trapezoideum). 

So  small  is  the  space  in  which  important  paths  and  nuclei  are  crowded 
that  a  lesion  of  the  medulla  may  involve  the  motor  tract  on  both  sides,  caus- 
ing total  bilateral  paralysis — tetraplegia,  usually  due  to  thrombosis  or  to  a 
small  haemorrhage.  Or  the  arm  on  one  side  and  the  leg  on  the  other  may 
be  involved — hemiplegia  cruciata. 

Cerebellum. — As  "the  head  ganglion  of  the  proprio-ceptive  system"  (Sher- 
rington) to  this  lesser  brain  converge  the  impulses  of  deep  sensibility,  and 
from  it  pass  the  impulses  which  control  the  tone  of  the  muscles  and  their  co- 
ordination when  in  action.  The  basis  of  our  recent  knowledge  is  in  the  ex- 
haustive monograph  of  Luciani,  whose  conclusions  have  been  confirmed  and 
extended  by  Horsley  and  his  pupils,  Babinski,  Thomas,  and  by  the  experience 
of  the  late  war  (Gordon  Holmes). 

In  addition  to  its  influence  in  maintaining  equilibrium,  the  cerebellum 
has  an  important  role  in  regulating  and  controlling  voluntary  movements. 
This  is  concerned  with  the  muscular  tone,  the  direction  and  measurement  of 
movements,  the  maintenance  of  attitudes,  and  the  control  of  coordinated  move- 
ments. Hence  disturbance  of  coordination,  hypotonia,  asthenia,  ataxia  (cer- 
ebellar) and  volitional  tremor  result  from  diseased  conditions.  The  disturb- 
ance may  affect  special  functions.  Thus  Eamsay  Hunt  has  described  a  con- 
dition under  the  designation  Dyssenergia  cerehralis  progressiva,  or  chronic 
progressive  cerebellar  tremor,  in  which  there  is  a  generalized  volitional  tremor 
which  begins  locally  and  gradually  progresses.  There  is  a  progressive  degen- 
eration of  the  structures  which  control  and  regulate  the  muscular  movements. 
AYhen  at  rest  and  with  the  muscles  relaxed  the  tremor  ceases.  Other  s3'mptoms 
of  cerebellar  disease,  such  as  vertigo,  disturbance  of  equilibrium,  nystagmus 
and  seizures  are  absent. 

UxiLATERAL  Lesions. — As  the  functions  of  each  lobe  are  homolateral,  the 
symptoms  are  on  the  same  side,  and  are  negative  not  irritative  in  character. 
They  may  be  grouped  as  follows  (Gordon  Holmes)  : — 

1.  Disturhance  of  Muscle  Tone. — The  limbs  flop  about  in  an  unnatural  way, 
and  the  muscles  are  soft  and  flabby.  The  hypotonia  is  so  marked  that  with 
very  little  power  the  thigh  can  be  flexed  on  the  abdomen  and  the  heel  placed 
on  the  buttock.  In  walking  the  arm  swings  inertly,  and  if  the  forearms  are 
held  vertically,  the  wrist  on  the  affected  side  falls  passive  in  extreme  flexion. 

2.  Asthenia,  specially  dwelt  upon  by  Luciani,  was  a  feature  almost  con- 
stant in  the  war  cases.  It  is  noted  when  the  patient  holds  the  arms  out- 
stretched or  raises  a  weight,  and  is  well  shown  by  the  dynamometer.  The 
movements  are  slow,  a  delay  in  initiation  and  in  relaxation.  The  affected 
limbs  tire  easily. 

3.  Ataxia. — In  direction,  force  and  range  the  purposive  movement  errs, 


972  DISEASES  OF  THE  NEPxVOUS  SYSTEM      • 

and  with  the  eyes  dpen.  With  the  arm  outstretched,  asked  to  touch  the  nose 
with  the  index  finger,  he  will  bring  it  to  the  chin,  and  with  undue  force. 
Natural  movements  may  be  decomposed  (Babinski),  e,  g.,  when  asked  to  touch 
the  knee  with  the  heel,  instead  of  flexing  thigh  and  leg  together,  the  hip  is 
first  flexed  and  then  the  knee.  This  asyn&i-gia  is  due  to  a  lack  of  the  proper 
association  of  agonists,  antagonists  and  fixating  muscles.  The  movements  are 
ill  measured  (dysmefria),  particularly  quick  movements,  in  both  force  and 
aim,  and  not  along  the  shortest  possible  line.  Tremor  may  occur  in  the 
moving  limb,  sometimes  "intention"  in  character,  or  static,  as  in  slight  oscil- 
lations of  the  head  when  at  rest;  more  characteristic  is  the  tremor  occurring 
in  maintaining  an  attitude  and  involuntary  movement,  to  which  Luciani  has 
given  the  name  Astasia. 

4.  The  Rebound  Phenomenon. — "With  elbows  supported  the  patient  pulls 
each  hand  towards  his  mouth  against  the  resistance  of  the  observer  who  holds 
the  wrists.  If  let  go  suddenly,  the  hand  on  the  affected  side  flies  to  the  mouth 
often  with  great  force,  while  the  other  is  arrested  almost  immediately  by  the 
antagonists.     This  is  a  striking  and  valuable  test. 

5.  Adiadochokinesis. — In  executing  alternate  movements  as  in  rapid  pro- 
nation and  supination  of  the  elbow,  the  homolateral  limb  moves  more  slowly, 
less  regularly,  and  tires  earlier,  and  there  may  be  adventitious  movements  of 
the  flngers. 

6.  Vertigo,  a  common  feature,  may  not  be  truly  cerebellar  but  labyrinthine. 
The  tendency  is  to  fall  towards  the  affected  side,  but  the  sensation  of  displace- 
ment may  be  of  self  or  of  external  objects.  It  seems  a  more  constant 
symptom  in  tumor  than  in  injury. 

7.  The  Pointing  Test  (Barany). — With  closed  eyes  the  patient  is  asked 
with  his  extended  forefinger  to  touch  the  observer's  finger  held  at  some 
distance  above  the  bed,  and  then  as  he  brings  the  finger  down  to  the  bed  and 
slowly  up  again  the  finger  deviates  outwardly. 

8.  Attitude  and  Gait. — The  head  tends  to  be  flexed  towards  the  side  of 
the  lesion  and  rotated  to  the  opposite  side;  and  the  body  may  be  concave  to 
the  side  of  the  lesion.  On  standing  he  is  shaky  and  unsteady,  and  tends  to 
fall  towards  the  affected  side,  often  with  a  feeling  as  if  he  were  pulled 
over.  The  attitude  may  be  very  striking,  the  head  and  trunk  inclined  to  the 
affected  side,  the  spine  concave  to  it,  with  the  pelvis  tilted,  the  shoulder  lifted, 
the  trunk  rotated  and  held  stiff.  There  is  no  Eomberg  sign.  In  walking  he 
mistrusts  the  affected  leg,  which  is  usually  rotated  outAvards,  the  foot  may  be 
dragged  or  raised  unnaturally  and  brought  to  the  floor  with  a  flop.  Stum- 
bling towards  the  affected  side^  he  makes  efforts  to  control  the  tendency  to 
fall.  When  asked  to  stop,  he  cannot  pull  up  suddenly.  The  arm  on  the 
affected  side  hangs  inertly,  without  the  normal  swing. 

9.  Ocular  Disturbances. — In  wounds  there  is  early  deviation  of  the  eyes  to 
the  opposite  side — or  "skew-deviation,"  the  homolateral  eye  down  and  in, 
the  other  up  and  out.  Fixation  nystagmus  is  the  rule  in  injury,  and  the 
oscillations  are  slower  and  larger  when  the  patient  looks  to  the  affected  side. 
How  far  it  is  due  to  coexisting  labyrinthine  lesion  is  not  determined,  but 
Wilson  and  Pike  claim  that  there  are  differences,  and  it  is  more  enduring. 

Among  minor  features  to  be  mentioned  are  a  slow,  "sing-song"  speech, 
the  words  are  blurred,  and  the  articulation  nasal  and  the  end  syllables  explo- 


APHASIA  973 

sive.  The  homolateral  reflexes  may  for  a  time  be  absent.  As  a  rule  the  knee 
jerk  is  less  brisk,  and  has  a  pendulum  character.  The  superficial  reflexes 
are  not  changed.     Sensation  in  any  form  is  unchanged. 

Bilateral  lesions  show  disturbances  similar  to  those  described  above,  but 
speech  is  more  disturbed,  the  muscles  of  the  trunk  and  neck  are  very  hypo- 
tonic, and  naturally  when  standing  the  maintenance  of  equilibrium  is  much 
more  difficult.  The  features  so  characteristic  of  unilateral  lesion  are  not 
essentially  changed  when  the  ver'mis  is  involved,  unless  perhaps  the  tremor  is 
more  marked.  The  effects  of  cortical  and  nuclear  lesions  do  not  appear  to 
differ.  The  war  experience  does  not  support  the  view  of  special  cortical  local- 
ization, or  of  the  existence  of  focal  centres  for  movement  in  different  direc- 
tions (Barany).  The  numerous  clinical  observations  confirm  Luciani's  con- 
clusions that  aionia,  astJienia,  and  astasia  form  a  characteristic  cerebellar  triad. 


II.     APHASIA 

Under  the  general  term  aphasia — with  agnosia  and  apraxia — is  included 
the  loss  of  the  memories  of  the  vocal,  written,  manual  and  other  signs  and 
symbols  by  which  we  communicate  with  our  fellows  and  indicate  our  knowl- 
edge of  the  nature  and  use  of  things. 

As  in  all  other  voluntary  movements  speech  requires  not  only  a  motor  but 
a  sensory  apparatus,  and  we  have,  as  composing  the  speech  mechanism,  a 
sensory  or  receptive  part  as  well  as  a  motor  or  emissive  part.  These  two  parts 
are  associated  with  the  higher  centres  underlying  the  intellectual  process,  and 
are  controlled  by  them. 

The  muscles  which  are  used  in  the  production  of  articulate  speech  are  many 
and  widely  distributed ;  thus,  the  respiratory  muscles,  the  muscles  of  the  larynx, 
the  pharynx,  the  tongue,  the  lips,  and  those  which  move  the  jaws  are  all 
brought  into  play  during  speech.  These  muscles  are  all  active  in  other  less 
complicated  movements;  for  instance,  respiration,  crying,  sucking,  etc.,  and 
these  comparatively  simple  movements  are  represented  in  the  gray  matter  of 
the  lower  motor  segment  in  the  pons,  medulla,  and  spinal  cord.  The  asso- 
ciation of  neurones  upon  which  these  movements  depend  is  made  during  fetal 
life,  and  is  in  good  working  order  at  the  time  of  birth. 

As  the  child's  brain  grows  and  takes  control  of  the  spinal  centres  through 
the  medium  of  the  pyramidal  tracts,  other  more  complex  movements  are  de- 
veloped and  special  neurones  are  set  apart  for  this  purpose.  There  is,  then, 
a  re-representation  (Hughlings  Jackson)  of  the  finer  movements  of  these  mus- 
cles in  the  upper  motor  segment.  They  are  localized  in  the  central  convolu- 
tions about  the  lower  part  of  the  Eolandic  fissure. 

This  group  of  movements,  which  are  in  part  congenital  and  in  part  ac- 
quired during  the  early  months  of  life,  is  that  from  which  the  delicate  move- 
ments of  articulate  speech  are  developed.  The  structures  upon  which  these 
movements  depend  make  the  primary  or  elementary  speech  mechanism. 

The  cortical  centres  are  in  the  Iowt  third  of  the  central  convolution  on 
both  sides  of  the  brain.  They  are  bilaterally  acting  centres,  and  a  lesion 
limited  to  either  one  should  not  produce  marked  or  permanent  defects  in 
speech.     This  is  true  for  the  right  side,  but  on  the  left  Broca's  convolution 


974  DISEASES  OF  THE  :NrERyOUS  SYSTEM 

is  so  closely  situated  that  it  or  its  connecting  fibres  are  usiially  injured  at  the 
same  time,  and  motor  aphasia  results.  The  path  from  the  cortical  centres  is 
made  up  of  the  motor  fibres  which  go  to  the  nuclei  of  the  pons  and  medulla, 
and  in  the  internal  capsule  is  situated  near  the  knee.  As  in  the  cortex,  a 
unilateral  lesion  here  causes  only  slight  disturbances  of  speech  due  to  difficult 
articulation,  following  weakness  of  the  opposite  side  of  the  face  and  tongue. 
On  the  left  side,  if  the  lesion  is  so  near  the  cortex  as  to  involve  the  fibres 
which  connect  Broca's  convolution  vrlth  the  primary  speech  mechanism,  sub- 
cortical motor  aphasia  is  produced.  Bilateral  lesions  (usually  in  the  internal 
capsule,  but  at  times  in  the  cortex)  cause  speechlessness,  with  paralysis  of  the 
muscles  of  articulation — pseudo-bulbar  paralysis.  To  these  speech  defects 
Bastian  gave  the  name  aphemia  and  Marie,  anarthria. 

The  lower  segment  of  the  primary  speech  mechanism  is  made  up  of  the 
motor  nuclei  in  the  medulla,  etc.,  and  the  peripheral  nerves  arising  from 
them.  Lesions  here,  if  extensive  enough — as,  for  instance,  in  progressive 
bulbar  paralysis — may  cause  speechlessness — anarthria  (Bastian)  ;  but  usually 
they  are  more  limited,  giving  various  disturbances  of  articulation. 

The  Auditory  Speech  Centre. — As  the  child  learns  to  speak  there  is  devel- 
oped in  the  cortex  of  the  brain  an  association  of  centres  which  takes  control 
of  the  primary  speech  mechanism.  The  child  is  constantly  hearing  objects 
called  by  names,  and  he  learns  to  associate  certain  sounds  'vvith  the  look,  feel, 
taste,  etc.,  of  certain  things.  When  he  hears  such  a  sound  he  gets  a  more 
or  less  clear  mental  picture  of  the  object,  or,  in  other  words,  he  has  developed 
certain  auditory  memories.  These  memories  of  the  sounds  of  words  are  stored 
in  what  is  called  the  auditory  speech  centre.  This  centre,  which  in  the 
majority  of  people  is  the  controlling  speech  centre,  is  situated  on  the  left  side 
in  right-handed  people,  and  on  the  right  side  in  those  who  are  left-handed. 
The  afferent  impressions  arising  in  the  ears  reach  the  transverse  gyri  of  the 
temporal  lobes,  those  from  each  ear  going  to  both  sides  of  the  brain.  From 
each  of  these  primary  auditory  centres  impulses  are  sent  to  the  auditory  speech 
centre  in  the  temporal  lobe  of  the  left  hemisphere.  The  exact  location  of  this 
so-called  centre  is  not  accurately  determined,  but  it  is  thought  to  occupy  the 
first  and  perhaps  part  of  the  second  temporal  convolutions.  Marie  denies  all 
speech  centres,  but  places  the  cortical  region,  which  has  to  do  with  the  intel- 
lectual processes  underlying  language,  rather  vaguely  in  the  left  temporo- 
parietal lobe.  This  he  designates  "Wernicke's  zone,'^  a  lesion  of  which  alone 
can  produce  aphasia.  The  child  endeavors,  and  by  repeated  efforts  learns,  to 
make  the  sounds  that  he  hears,  and  he  first  becomes  able  to  repeat  words,  then 
to  speak  voluntarily.  To  do  this,  he  has  to  learn  certain  very  delicate  move- 
ments, and  so  there  is  developed  under  the  control  of  the  auditory  speech 
centres  a  special  motor  centre  for  speech  in  which  these  movements  are 
localized. 

The  Motor  Speech  Centre. — This  was  placed  by  Broca.  and  those  who  im- 
mediately followed  him,  in  the  posterior  part  of  the  left  third  frontal  convolu- 
tion. It  is  around  this — Broca's  centre — that  the  discussion  started  by  Marie 
has  been  most  heated.  Marie  and  his  followers  deny  that  this  portion  of  the 
brain  has  anything  to  do  with  speech,  and  insist  that  the  so-called  motor 
aphasia  is  merely  a  "combination  of  aphasia  (of  which  they  admit  but  one 
type,  that  due  to  lesions  of  Wernicke's  zone)  with  anarthria."     xinarthria  they 


APHASIA  975 

think  of  as  a  speech  disturbance  without  any  intellectual  defect,  due  to  a 
lesion  of  their  lenticular  zone,  an  ill-defined  area  in  the  centre  of  the  brain. 

Marie's  position  has  been  much  discussed,  and  many  excellent  observers 
have  come  to  the  rescue  of  the  old  view  which  accepts  Broca's  convolution  as 
the  motor  speech  centre.  The  studies  of  cases  of  apraxia,  which  seem  ta 
have  determined  a  centre  in  the  left  frontal  lobe  for  certain  purposive  move- 
ments, as  in  the  use  of  objects,  gestures,  etc.,  have  lent  support  to  the  im- 
portance of  Broca's  convolution. 

The  motor  speech  centres  and  the  corresponding  area  in  the  right  brain 
are  connected  either  directly  by  special  motor  fibres  with  the  bulbar  nuclei, 
or,  as  is  more  probable,  indirectly,  through  the  medium  of  the  cortical  cen- 
tres of  the  primary  speech  mechanism  in  the  lower  part  of  the  Rolandic  region 
on  both  sides. 

The  speech  centres  are  in  close  connection  with  the  rest  of  the  brain  cor- 
tex, and  in  this  way  they  take  part  in  the  general  mental  activities,  of  which, 
indeed,  the  speech  processes  form  a  large  part.  Some  authors  have  assumed 
that  the  several  sensory  elements  which  go  to  make  a  concept  are  brought 
together  in  a  special  region  of  the  brain,  and  here,  as  it  were,  united  by  a 
name.  This  is  called  "the  centre  for  concepts,"  or  "naming  centre"  (Broad- 
bent),  but  most  writers  have  followed  Bastian  in  considering  that  the  suppo- 
sition of  such  a  centre  is  unnecessary. 

The  mechanism  which  has  been  described  is  that  which  is  developed  in 
uneducated  people  and  in  children  before  they  have  learned  to  lead  and  write, 
and  is  of  primary  importance  in  all  speech  processes.  As  the  child  learns  to 
read  he  associates  certain  visual  impressions  with  the  speech  memories  he  has 
acquired,  and  then  adds  to  his  concepts  the  visual  memories  of  written  or 
printed  symbols.     These  memories  are  stored  in  the  visual  speech  centre. 

The  Visual  Speech  Centre. — This  is  placed  by  nearly  all  authors  in  the 
angular  and  supramarginal  convolutions  on  the  left  side,  where  it  is  believed 
visual  impressions  from  both  occipital  lobes  are  combined  in  speech  memories. 
Von  Monakow  denies  such  a  special  centre,  but  holds  that  visual  speech  memo- 
ries are  dependent  upon  the  direct  connection  of  the  general  visual  centres 
in  both  occipital  lobes  with  the  speech. sphere.  That  speech  defects  result  from 
injury  to  the  angular  and  supramarginal  convolutions,  he  admits;  but  he 
thinks  these  are  due  to  an  interruption  of  fibre  tracts  which  lie  beneath  and 
not  to  a  destruction  of  a  cortical  centre.  The  distinction  is,  therefore,  of 
more  theoretical  than  practical  importance.  Marie  includes  this  region  in 
his  Wernicke's  zone. 

In  learning  to  write,  the  child  develops  certain  delicate  movements  of  the 
arm  and  hand,  and  thus  acquires  another  method  of  externalizing  his  speech 
activities.  Whether  or  not  this  requires  the  development  of  a  separate  writing 
centre,  apart  from  the  general  Eolandic  arm  centre,  or  is  brought  about  by  an 
evolution  of  the  latter  through  the  medium  of  Broca's  convolution,  is  a  vexed 
question.  Gordinier  recorded  a  case  of  total  agraphia,  with  no  sensory  or 
motor  speech  aphasia,  in  which  a  tumor  occupying  the  foot  of  the  second  left 
frontal  convolution  was  found  at  autopsy.  Agraphia  is  a  special  form  of 
apraxia.  The  movements  of  writing  are  learned  under  the  influence  of  visual 
impressions  in  association  with  other  speech  memories,  although  there  is  a 
more  direct  path,  which  is  used  in  copying  unknown  characters.     Just  as  the 


976  DISEASES  OF  THE  NERVOUS  SYSTEM 

movements  of  articulate  speech  are  constantly  under  the  control  of  auditory 
memories,  so  are  the  movements  of  writing  regulated  by  visual  memories; 
but  in  this  case  the  other  speech  memories  are  of  great  importance. 

With  the  development  of  the  associations  which  underlie  reading  and 
writing,  the  speech  mechanism  may  be  said  to  be  complete,  although  its  activ- 
ities are  capable  of  practically  endless  extension,  as  when  music  or  foreign 
languages  are  learned. 

It  will  be  seen  that  the  cortical  speech  centres — the  speech  sphere  of  the 
French — occupy  the  part  of  the  brain  near  the  Sylvian  fissure,  and  that  they 
all  receive  their  blood  from  the  Sylvian  artery.  Speaking  broadly,  the  pos- 
terior part  of  this  region  is  sensory  and  the  anterior  is  motor.  The  sensory 
areas  are  near  the  optic  radiation  and  the  motor  are  near  the  general  motor 
tracts,  and  so,  with  lesions  of  the  posterior  part,  hemianopia  is  apt  to  be  asso- 
ciated with  the  speech  disturbance  while  hemiplegia  occurs  with  disease  of 
the  anterior  areas.  These  associations  often  help  to  distinguish  a  sensory 
from  a  motor  aphasia,  but  each  type  has  special  characteristics. 

Auditory  Aphasia. — Most  people  in  mentally  recalling  words  do  so  by 
means  of  their  auditory  speech  memories — i.  e.,  they  think  of  the  sound  of 
the  words,  and,  in  voluntary  speech,  it  is  probable  that  the  will  acts  on 
the  motor  centre  indirectly  through  the  auditory  centre.  This  centre  is  also 
necessary  for  reading  in  such  persons.  There  are  persons,  however,  in  whom 
the  mental  processes  are  carried  on  by  visual  memories,  and  in  these  "visuals" 
the  visual  speech  centres  take  the  predominant  place  in  speech  usually  occu- 
pied by  the  auditory  centres. 

Complete  abolition  of  all  the  auditory  speech  memories  by  destruction  of 
the  first  temporal  convolution  causes  the  most  extensive  disturbances  of  speech. 
Such  a  person  is  unable  to  comprehend  speech,  either  spoken  or  printed.  Vol- 
untary speech  is  much  disturbed,  and  although  at  first  he  may  talk,  his  speech 
is  nothing  but  a  jargon  of  misplaced  words,  and  he  soon  becomes  speechless. 
Writing  is  also  lost,  and  he  can  neither  repeat  words  nor  write  at  dictation. 
He  may  be  able  to  copy. 

Lesions  are  often  only  partial,  and  the  resultant  disturbance  may  be  simply 
a  difficulty  in  speech  due  to  the  loss  of  nouns  or  to  the  transposition  of  words 
(paraphasia),  the  v/riting  showing  the  same  defect.  The  patient  usually 
understands  what  he  hears  and  reads,  and  can  repeat  words  and  write  at 
dictation.  Bastian  called  this  condition  "amnesia  verbalis."  It  may  be  so 
pronounced  that  voluntary  speech  and  writing  are  nearly  lost,  even  when  the 
auditory  memories  can  still  be  aroused  by  new  afi^erent  impressions  and  he  is 
able  to  understand  what  is  said  to  him  and  what  he  reads.  He  can  usually 
repeat  and  read  aloud. 

The  afferent  paths,  which  reach  the  auditory  speech  centre  from  the  two 
primary  auditory  centres,  may  be  destroyed.  A  lesion  to  do  this  must  be 
in  the  white  matter  beneath  the  first  temporal  convolution  on  the  left  side. 
Such  a  lesion  blocks  all  auditory  impressions  coming  to  the  centre,  and  the 
patient  is  not  able  to  understand  anything  said  to  him,  can  not  repeat  words  or 
write  from  dictation.  As  the  cortical  centres  are  not  disturbed,  and  the  audi- 
tory speech  memories  are  still  present,  there  is  no  disturbance  of  voluntary 
speech  or  writing,  and  the  patient  can  read  jDerfectly.  This  is  pure  word-deai'- 
ness  or  subcortical  sensory  aphasia. 


APHASIA  977 

Visual  Aphasia. — Destruction  of  the  visual  centre  in  the  angular  and 
supramarginal  convolutions  causes  a  loss  of  the  visual  speech  memories,  and 
the  patient  is  unable  to  read  printed  or  written  characters.  He  is  unable  to 
write — agraphia — and  he  can  not  copy.  His  understanding  of  spoken  words  is 
good,  and  voluntary  speech  is  normal  or  only  slightly  paraphasic. 

A  subcortical  lesion  involving  the  afferent  fibres  going  to  the  visual  speech 
centre  causss  pure  word-blindness  (subcortical  alexia) — i.  e.,  there  is  inability 
to  understand  written  or  printed  words.  Voluntary  speech  and  writing  are 
good.  The  patient  can  not  read  his  own  writing  except  by  aid  of  muscle- 
sense  impression,  in  retracing  the  letters,  either  voluntarily  or  passively.  Asso- 
ciated with  this  is  always  hemianopia. 

Word-deafness  and  word-blindness  are  often  combined,  and  at  times  it  is 
not  only  the  tracts  that  connect  the  primary  auditory  and  visual  centres  with 
the  speech  spheres,  but  also  those  which  associate  them  with  the  other  sensory 
centres  in  the  formation  of  concepts,  that  are  diseased.  In  this  case  the  patient 
has  lost  not  only  his  auditory  and  visual  speech  memories,  but  also  all  of  his 
memories  which  have  to  do  with  hearing  and  sight.  He  has  mind-deafness 
and  mind-blindness — i.  e.,  he  is  unable  to  recognize  objects  when  he  hears 
or  when  he  sees  them.  Further,  there  may  be  a  dissociation  of  all  the  sensory 
centres  from  each  other  or  from  the  higher  psychical  centre,  which  is  prac- 
tically the  same  thing,  in  M-hich  case  the  patient  is  entirely  unable  to  recog- 
nize objects  or  use  them  properly — i.  e.,  he  has  sensory  apraxia  or  agnosia. 

Motor  Aphasia. — Lesions  of  the  motor  speech  zone,  possibly  in  rare  cases 
of  Broca's  convolution  alone,  more  commonly  of  a  wider  area,  cause  loss  of 
the  power  of  speech.  The  patient  may  be  absolutely  dumb,  or  he  may  have 
retained  one  or  two  words  or  phrases,  which  is  believed  to  be  due  to  the  activ- 
ity of  the  corresponding  region  of  the  right  brain.  He  will  make  no  effort  to 
repeat  words.  His  mind  is  comparatively  clear,  and  he  understands  what 
is  said  to  him,  but  reads  poorly.  He  has  not  a  clear  mental  picture  of  words. 
This  is  tested  by  asking  him  to  squeeze  the  observer's  hand  or  to  make  expira- 
tory efforts  as  many  times  as  there  are  syllables  in  a  well-known  name. 

Voluntary  writing  is  usually  lost  in  cortical  motor  aphasia,  and  many 
authors  believe  that  writing  movements  are  controlled  from  this  centre. 
Others,  who  believe  that  there  is  a  special  writing  centre,  contend  that  a  lesion 
strictly  limited  to  the  motor  speech  centre  would  not  cause  agraphia,  and 
cite  cases  which  seem  to  support  their  view.  If  there  is  much  disturbance  of 
internal  speech,  writing  must  be  impaired. 

Subcortical  motor  aphasia  is  described  as  due  to  the  destruction  of  the 
fibres  which  join  Broca's  convolution  to  the  primary  speech  mechanism. 
Lesions'  which  have  produced  this  type  of  aphasia  have  been  in  the  white  mat- 
ter of  the  left  hemisphere  near  Broca's  convolution.  These  would  be  within 
Marie's  lenticular  zone.  There  is  complete  loss  of  the  power  of  speech  without 
any  disturbance  of  internal  speech.  The  patient's  mental  processes  are  not 
disturbed,  and  he  can  write  perfectly  if  the  hand  is  not  paralyzed. 

Cases  of  aphasia  are  rarely  simple,  and  it  is  often  impossible  to  classify 
them  accurately.  The  problems  involved  are,  in  reality,  exceedingly  com- 
plicated, and  the  student  must  not  for  a  moment  suppose  that  cases  are  as 
straightforward  as  the  various  diagrams  at  first  siglit  would  appear  to  indi- 
cate.    A  majority  are  very  complex,  but  with  patience  the  diagnosis  of  the 


978  DISEASES  OF  THE  NEEVOUS  SYSTEM 

dilferent  varieties  can  often  be  worked  out.  The  following  tests  should  be 
applied,  after  the  presence  or  absence  of  paralysis  has  been  determined  and 
M^hether  the  patient  is  right-  or  left-handed:  (1)  The  power  of  recognizing 
the  nature,  uses,  and  relations  of  objects — i.  e.,  whether  agnosia  and  apraxia 
are  present  or  not;  (2)  the  power  to  recall  the  name  of  familiar  objects  seen, 
smelled,  or  tasted,  or  of  a  sound  when  heard,  or  of  an  object  touched;  (3)  the 
power  to  understand  spoken  words;  (4)  the .  capabiiit}^  of  understanding 
printed  or  written  language;  (5)  the  power  of  appreciating  and  understanding 
music;  (6)  the  power  of  voluntary  speech — in  this  it  is  to  be  noted  particu- 
larly whether  he  misplaces  words  or  not;  (7)  the  power  of  reading  aloud  and 
of  understanding  what  he  reads;  (8)  the  power  to  write  voluntarily  and  of 
reading  what  he  has  written;  (9)  the  power  to  copy;  (10)  the  power  to  write 
at  dictation;  and  (11)  the  power  of  repeating  words. 

The  medico-legal  aspects  of  aphasia  are  of  great  importance.  No  general 
principle  can  be  laid  doAvn,  but  each  case  must  be  considered  on  its  merits. 
Langdon,  in  reviewing  the  whole  question,  concludes :  "Sanity  established,  any 
legal  document  ehould  be  recognized  when  it  can  be  proved  that  the  person 
making  it  can  understand  fully  its  nature  by  any  receptive  channel  (viz.,  hear- 
ing, vision,  or  muscular  sense),  and  can,  in  addition,  express  assent  or  dissent 
with  certainty  to  proper  witnesses,  whether  this  expression  be  by  spoken  speech, 
written  speech,  or  pantomime/' 

Prognosis. — In  young  persons  the  outlook  is  good,  and  the  power  of 
speech  is  gradually  restored  apparently  by  the  development  of  other  portions 
of  the  brain.  The  opposite  hemisphere  often  takes  part  in  this.  In  adults 
the  condition  is  less  hopeful,  particularly  in  the  cases  of  complete  motor  aphasia 
with  right  hemiplegia.  The  patient  may  remain  speechless,  though  capable 
of  understanding  everything,  and  attempts  at  re-education  may  be  futile. 
Partial  recovery  may  occur,  and  the  patient  may  he  able  to  talk,  but  misplaces 
words.  In  sensory  aphasia  the  condition  may  be  only  transient,  and  the  dif- 
ferent forms  rarely  persist  alone  without  impairment  of  the  powers  of  ex- 
pression. 

The  education  of  an  aphasic  person  requires  the  greatest  care  and  patience, 
particularly  if,  as  so  often  happens,  he  is  emotional  and  irritable.  It  is  best 
to  begin  by  the  use  of  detached  letters,  and  advance,  not  too  rapidly,  to  words 
of  only  one  syllable.  Children  often  make  rapid  progress,  but  in  adults  failure 
is  only  too  frequent,  even  after  the  most  painstaking  efforts.  In  the  cases  of 
right  sided  hemiplegia  with  aphasia  the  patient  may  be  taught  to  write  with 
the  left  hand. 


III.  AFFECTIONS  OF  THE  BLOOD  VESSELS 

I.     AETEEIO-SCLEEOSIS— CEEEBEAL  FEATUEES 

(1)  Transient  Paralysis. — With  high  blood  pressure  and  sclerotic  vessels 
attacks  of  aphasia,  monoplegia  and  hemiplegia  occur,  with  the  following 
characters: — they  are  transient,  they  leave  no  permanent  damage,  and  they 
recur.  Numbness  and  tingling  may  precede  the  onset.  Some  of  the  purest 
cases  of  motor  aphasia  are  met  with — a  twelve  to  twenty-four  hour  inability 


AFFECTIONS  OF  THE  BLOOD  VESSELS  979 

to  speak,  without  any  mental  disturbance.  Monoplegia  of  the  arm  alone,  or 
with  the  face,  is  more  common  than  hemiplegia.  A  patient  may  have  scores 
of  attacks  over  many  years.  They  are  often  associated  with  increased  blood 
pressure  and  headache.  Twitching  of  the  angle  of  the  mouth  or  of  the 
hand  may  precede  an  attack.  One  patient  had  transient  hemianopia.  Sud- 
den paraplegia  may  come  on  and  last  part  of  a  day.  Coming  down  the  gang- 
way of  a  steamer,  a  friend  who  had  had  many  attacks  of  monoplegia  suddenly 
lost  the  power  in  the  legs,  and  had  to  be  carried.  He  could  walk  next  day. 
Another  dropped  in  the  street,  and  when  seen  twelve  hours  later,  the  paralysis 
was  just  disappearing  and  the  reflexes  obtainable.  These  are  not  attacks  of 
intermittent  claudication. 

(2)  Convulsions,  in  association  with  the  above  attacks  or  independently. 
The  attack  rarely  has  the  graded  features  of  a  true  epileptic  fit,  but  there 
are  widespread  clonic  movements,  with  unconsciousness  lasting  from  a  few 
minutes  to  an  hour.  There  may  be  daily  attacks  for  months  and  transient 
paralysis  may  follow  on  aphasia.  The  general  condition  of  the  patient  may 
remain  good  and  the  mental  state  undamaged. 

(3)  Psychical  Changes. — Following  a  convulsion,  the  patient  may  be  dazed 
and  "not  himself"  for  some  hours.  A  remarkable  feature  in  many  cases 
has  been  the  retention  of  exceptional  mental  vigor.  A  transient  mental  out- 
burst may  replace,  as  it  were,  the  motor  attack.  One  subject  of  innumerable 
monoplegias  would  waken  at  night,  light  the  candle,  stamp  about  the  room, 
tear  up  books  and  papers,  all  the  time  talking  to  himself.  He  would  know 
nothing  about  it  in  the  morning.  Similar  outbursts  occurred  in  the  day. 
Or  a  transient  cloud  may  pass  over  the  mind  before  the  onset  of  hemiplegia. 
Eeturning  from  a  game  of  golf,  a  man  did  not  know  his  house  or  recognize 
his  wife  and  surroundings.  After  a  good  night's  rest  he  woke  with  weakness 
of  the  right  side  and  confusion  of  speech  which  had  gone  by  the  evening. 

As  the  disease  progresses,  the  mental  state  may  fail,  but  in  contradistinc- 
tion to  the  presenile  and  senile  types  of  dementia,  many  of  these  patients  keep 
a  clear  mind  to  the  end,  and  there  are  none  of  the  features  of  Binswanger's 
dementia  presenilis  or  of  Alzheimer's  disease.  An  explanation  of  these  at- 
tacks is  not  easy.  Their  frequency  and  the  rapid  restoration  of  function  rule 
out  destructive  lesions.  Possibly  they  are  due  to  spasm  of  the  arteries  and 
a  temporary  ischaemia,  a  view  strongly  supported  by  the  occurrence  of  similar 
attacks  in  Raynaud's  disease. 

Clinically  there  are  three  groups  of  cases: — (1)  The  arterio-sclerosis  of 
middle-aged  men;  (2)  the  senile  form;  and   (3)   special  presenile  forms. 

1.  Arterio-sclerosis  (see  p.  837  under  diseases  of  the  arteries). 

2.  Senile  Arterio-sclerosis. — Old  age  is  largely  a  question  of  the  blood 
vessels,  but  the  wear  and  tear  of  life  affects  different  parts  in  different  per- 
sons. With  the  progressive  weakening  of  the  mental  powers  as  age  advances, 
widespread  changes  in  the  arteries,  both  basal  and  cortical,  are  found.  Often 
it  is  not  a  question  of  the  petrol-tank — the  blood  supply — but  the  Avhole  ma- 
chine is  worn  out.  A  real  mental  vigor  may  exist  with  advanced  arterio- 
sclerosis. A  man  of  sixty  in  full  practice  at  the  bar  died  suddenly  of  angina 
pectoris.  The  basal  arteries  were  pipe-stems,  and  the  smaller  cortical  vessels 
creaked  under  the  knife ! 


980  DISEASES  OF  THE  XERYOUS  SYSTEM 

In  a  normal  old  age  the  convolutions  waste,  the  pigment  granules  and  the 
lime-salts  increase,  the  meninges  become  cloudy,  the  cortical  arteries  thicken, 
the  glia  in  the  gray  matter  increases  particularly  about  the  smaller  vessels, 
and  there  are  the  areas  of  atrophy,  as  described  by  Marie,  Peck  and  others. 
With  these  organic  changes  the  mental  grip  fails,  the  memory  weakens,  the 
emotions  are  less  under  control,  and  year  by  year  in  a  slow  process  of  devo- 
lution the  last  stage  of  all  is  reached,  second  childhood — babyhood  rather — as 
the  man  ends  as  he  began,  with  only  a  vegetative  system. 

This  happy,  normal  process  with  "mild  gradations  of  decay,"  recognized  by 
all  except  the  senile  himself,  bears  out  Plato's  dictum  that  "old  age  is  an 
easy  death."  But  it  may  be  far  otherwise,  and  "the  evening  of  life  may  be 
a  stormy  and  unhappy  period,"  The  peculiarities  of  the  individual  become 
more  marked  and  to  an  unpleasant  degree;  he  may  become  egotistical,  emo- 
tional and  suspicious,  or  careless  in  minor  proprieties  of  life  and  intensely 
selfish.  The  most  pathetic  of  martyrdoms  are  the  miseries  endured  by  chil- 
dren in  the  unrequited,  unappreciated  devotion  to  an  irritable,  egotistical,  self- 
centred  senile  parent.  But  the  pity  of  it  is  that  the  worst  troubles  may  not 
be  intensification  of  any  personal  peculiarities,  but  terrible  perversions  of 
character  of  a  distressing  nature.  The  man  of  active  useful  life  may  be  de- 
pressed to  distraction  by  the  thoughts  of  the  failure  he  has  been;  the  godly 
man  is  worried  over  his  lost  soul;  the  moral  teacher  and  saintly  soul  may 
become  a  lecher ;  the  loving  affectionate  husband  a  brutal  tyrant ;  the  million- 
aire thinks  himself  a  bankrupt. 

3.  Special  Types. — While  in  normal  old  age  there  is  nothing  local,  on 
the  other  hand;  the  senility  may  be  chiefly  local  and  affect  the  brain  at  a 
comparatively  early  age.  The  changes  are  usually  those  of  normal  old-age, 
and  associated  with  loss  of  judgment,  emotional  perversions,  and  progressive 
mental  impairment.  The  cardio-vascular  and  renal  conditions  play  an  im- 
portant role  in  these  cases  (Southard).  A^arious  forms  have  been  described, — 
the  preshyoplirenia  of  Wernicke — characterized  by  "marked  disturbances  of 
the  recording  faculty,  with  retention  for  a  long  time  of  orderly  thought  and 
judgment  .  .  .  and  tendency  to  confabulation"  (Barker).  Binswanger's 
dementia  presenilis  begins  between  the  ages  of  40  and  50,  with  loss  of  memory, 
apath}^,  etc.,  without  syphilis  or  the  somatic  feature  of  general  paresis. 
Alzheimer's  disease  is  a  slow  dementia  with  focal  symptoms,  aphasia  and 
apraxia,  and  in  addition  to  the  regressive  changes  in  the  vessels  and  glia,  a 
peculiar  condition  of  the  neuro-fibrils.  Southard  and  Alford  called  attention 
to  a  group  of  senile  dementias  (14  of  42  cases  specially  studied)  of  obscure 
etiology,  which  do  not  come  in  these  types  as  the  vessels  are  not  sclerotic,  and 
the  convolutions  are  not  atrophied. 

II.     HYPEE^MIA  AND  ANEMIA 

Less  and  less  stress  is  now  laid  on  these  conditions.  The  symptoms  usually 
referred  to  active  hypergemia  in  the  infectious  diseases,  or  in  association  with 
hypertrophy  of  the  heart  accompanying  disease  of  the  kidney,  are  due  to 
the  action  of  toxic  agents  rather  than  to  changes  in  the  circulation. 

Ancemia. — The  anatomical  condition  of  the  brain  is  very  striking.  The 
membranes  are  pale,  only  the  large  veins  are  full,  the  small  vessels  over  the 


AFFECTIONS  OF  THE  BLOOD  VESSELS  981 

gyri  are  empty,  and  an  unusual  amount  of  cerebro-spiual  fluid  is  present.  On 
section  both  the  gray  and  white  matter  look  extremely  pale  and  the  cut  surface 
is  moist.    Very  few  pnncta  vasculosa  are  seen. 

Symptoms. — The  effects  of  sudden  anemia  of  the  brain  are  well  illustrated 
by  the  ordinary  fainting  fit.  When  the  symptoms  are  the  result  of  haemor- 
rhage, there  are  drowsiness,  giddiness,  inability  to  stand;  flashes  of  light, 
dark  spots  before  the  eyes,  and  noises  in  the  ears;  the  respiration  becomes 
hurried ;  the  skin  is  cool  and  covered  with  sweat ;  the  pupils  are  dilated,  there 
may  be  vomiting,  headache,  or  delirium,  and  gradually,  if  the  bleeding  con- 
tinues, consciousness  is  lost  and  death  may  occur  with  convulsions.  In  the 
more  chronic  forms,  such  as  result  from  impoverishment  of  the  blood,  as  in 
protracted  illness  or  starvation,  a  condition  of  irritable  weakner.s  results. 
Mental  effort  is  difficult,  the  slightest  irritation  is  followed  by  undue  excite- 
ment, the  patient  complains  of  giddiness  and  noises  in  the  ears,  or  there  may 
be  hallucinations  or  delirium.  These  symptoms  are  met  with  in  an  extreme 
grade  as  a  result  of  prolonged  starvation,  and  a  similar  condition  is  seen  in 
certain  cases  of  arterio-sclerosis  when  the  brain  is  poorly  nourished. 

An  interesting  set  of  symptoms,  to  which  the  term  hydrencephaloid  was 
applied  by  Marshall  Hall,  occurs  in  the  angemia  and  debility  produced  by 
prolonged  diarrhoea  in  children.  The  child  is  in  a  semi-comatose  condition- 
with  the  eyes  open,  the  pupils  contracted,  and  the  fontanelle  depressed.  In 
the  earlier  period  there  may  be  convulsions.  The  coma  may  gradually  deepen, 
the  pupils  become  dilated,  and  there  may  be  strabismus  and  even  retraction 
of  the  head,  symptoms  which  closely  simulate  those  of  basilar  meningitis. 

III.     (EDEMA   OF  THE  BEAIN 

Whether  it  occurs  as  a  clinical  entity  is  doubtful.  The  cases  reported  as 
such  resemble  the  serous  meningitis  or  anomalous  forms  of  acute  polio-myelitis, 
particularly  as  skin  rashes  have  been  described.  As  a  secondary  process  it 
occurs  under  the  following  conditions :  In  general  atrophy  of  the  convolu- 
tions, in  which  case  the  oedema  is  represented  by  an  increase  in  the  cerebro- 
spinal fluid  and  in  that  of  the  meshes  of  the  pia.  In  extreme  venous  dilatation 
from  obstruction,  as  in  mitral  stenosis  or  in  tumors,  there  may  be  a  condition 
of  congestive  oedema,  in  which,  in  addition  to  great  filling  of  the  blood  vessels, 
the  substance  of  the  brain  itself  is  unusually  moist.  The  most  acute  oedema 
is  a  local  process  found  around  tumors  and  abscesses.  The  symptoms  of  com- 
pression following  concussion  or  contusion,  as  shown  by  Cannon,  are  fre- 
quently attributable  to  cerebral  oedema  due  to  change  in  osmotic  pressure.  An 
intense  ijifiltration,  local  or  general,  may  occur  in  nephritis,  and  to  it  certain 
of  the  uraemic  symptoms  may  be  due. 

Anatomical  Changes. — These  are  not  unlike  those  of  anaemia.  When  the 
oedema  follows  progressive  atrophy,  the  fluid  is  chiefly  within  and  beneath 
the  membranes.  The  brain  substance  is  anaemic  and  moist  and  has  a  wet, 
glistening  appearance,  which  is  very  char?!cteristic.  In  some  instances  the 
oedema  is  more  intense  and  local,  and  tli"  brain  substance  may  look  infiltrated 
M'ith  fluid.     The  amount  of  fluid  in  the  ventricles  is  usually  increased. 

Symptoms. — The  symptoms  are  in  great  ])art  those  of  lessened  lilood  flow, 
and  are  not  well   defined.      Some   of   the   cerel)ral   features   of   uraemia   may 


982  DISEASES  OF  THE  NERVOUS  SYSTEM 

depend  upon  it.  Cases  have  been  reported  in  which  unilateral  convulsions 
or  paralysis  have  occurred  in  connection  with  chronic  nephritis,  and  in  which 
the  condition  appeared  to  be  associated  with  oedema  of  the  brain.  The  older 
writers  laid  great  stress  upon  an  apoplexia  serosa,  which  may  really  have 
been  a  general  oedema  of  the  brain.  Some  of  the  cases  of  transient  paralysis 
or  aphasia  may  be  caused  by  oedema. 

IV.     CEEBBRAL  H^MOEEHAGE 

The  bleeding  may  come  from  branches  of  either  of  the  two  great  groups 
of  cerebral  vessels — the  hasal,  comprising  the  circle  of  Willis  and  the  central 
arteries  passing  from  it  and  from  the  first  portion  of  the  cerebral  arteries,  or 
the  cortical  group,  the  anterior,  middle,  and  the  posterior  cerebral  vessels.  In 
a  majority  of  the  cases  the  haemorrhage  is  from  the  central  branches,  more 
particularly  from  those  which  are  given  off  by  the  middle  cerebral  arteries  in 
the  anterior  perforated  spaces,  and  which  supply  the  corpora  striata  and  in- 
ternal capsules.  One  of  the  largest  of  these  branches  which  passes  to  the 
third  division  of  the  lenticular  nucleus  and  to  the  anterior  part  of  the  internal 
capsule,  the  lenticulo-striate  artery,  is  so  frequently  involved  in  haemorrhage 
that  it  was  called  by  Charcot  the  artery  of  cerebral  hcemorrhage.  Hemor- 
rhages from  this  and  from  the  lenticulo-thalamic  artery  include  more  than 
60  per  cent,  of  all  cerebral  haemorrhages.  The  bleeding  may  be  into  the 
substance  of  the  brain,  to  which  alone  the  term  cerebral  apoplexy  is  applied,  or 
into  the  membranes,  in  which  case  it  is  termed  meningeal  hsemorrhage;  both 
are  usually  included  under  the  terms  intracranial  or  cerebral  haemorrhage. 

Etiolo^. — High  blood  pressure  and  arterial  disease  in  persons  over  forty 
years  of  age  are  the  main  factors. 

Age. — After  thirty  the  liability  increases  with  each  decade.  It  may  be 
congenital  as  in  the  child  of  a  Avoman  dead  of  typhoid  fever  at  the  Johns 
Hopkins  Hospital.  It  occasionally  occurs  in  children  from  rupture  of  a  small 
aneurism,  but  before  the  age  of  thirty  it  is  very  uncommon.  In  an  analysis 
of  the  United  States  Census  Eeport,  H.  M.  Thomas  found  the  increase  com- 
mon in  the  7th  and  8th  decades.  Of  154  cases  at  St.  Bartholomew's  Hospital 
traceable  to  arterial  changes  there  was  no  case  under  thirty ;  the  maximum  for 
both  sexes  was  at  the  fifty-sixth  year.  After  sixty  the  numbers  appear  to 
decline,  but  if  "due  correction  is  made  for  the  age-distribution  of  a  popula- 
tion, the  liability  of  the  individual  to  this  form  of  death  increases  steadily  up 
to  old  age"  (F.  W.  Andrewes).  Before  the  fifth  decade  haemorrhage  is  rare; 
then  in  the  fifth  and  sixth  decades  cases  progressively  increase  in  number. 

Sex. — There  is  a  marked  preponderance  of  males. 

Eace. — In  the  United  States  the  death  rate  from  apoplexy  in  the  Eeport 
of  1917  was  829  per  million  population.  In  England  and  Wales  in  1916  the 
deaths  from  apoplexy  were  693  per  million  living.  Both  apoplexy  and  paral- 
ysis seem  to  be  much  more  prevalent  among  the  negroes. 

Heredity. — Formerly  thought  to  be  a  very  important  factor,  heredity 
influences  the  incidence  in  rendering  members  of  families  in  which  the  blood 
vessels  degenerate  early  more  liable  to  cerebral  haemorrhage.  What  was  known 
as  the  apoplectic  habitus,  or  build,  is  still  spoken  of,  by  which  we  mean  a 
stout,  plethoric  person  of  medium  size  with  a  short  neck. 


AFFECTIONS  OF  THE  BLOOD  VESSELS  983 

Special  Factors. — Individuals  with  progressive  renal  disease  and  consecu- 
tive arterio-sclerosis  and  hypertrophy  of  the  heart  are  particularly  liable  to 
cerebral  hemorrhage.  Alcohol,  immoderate  eating,  prolonged  muscular  exer- 
tion, syphilis,  chronic  lead  poisoning,  and  gout  are  antecedents  in  many  cases. 
Endocarditis  may  lead  indirectly  to  apoplexy  by  causing  embolism  and  aneur- 
ism of  the  vessels  of  the  brain.  Cerebral  hfemorrhage  occurs  occasionally  in 
the  specific  fevers  and  in  such  profound  alterations  of  the  blood  as  are  met 
with  in  leukaemia. 

The  actual  exciting  cause  is  not  always  evident.  The  attacks  may  be  sud- 
den without  any  preliminary  symptoms.  In  other  instances  straining  efforts 
or  overaction  of  the  heart  in  emotion  may  cause  a  rupture.  Many  cases  occur 
during  sleep.  Some  instances  follow  slight  trauma.  The  records  of  Univer- 
sity College  Hospital  analyzed  by  Ernest  Jones  indicate  that  in  none  of  123 
cases  did  the  attack  come  on  through  excessive  bodily  effort. 

Morbid  Anatomy. — Direct  Changes. — The  lesions  are  almost  invariably 
in  the  cerebral  arteries,  in  which  the  following  changes  may  lead  to  it : 

(a)  The  production  of  miliary  aneurisms,  rupture  of  which  is  the  most 
common  cause  of  cerebral  hemorrhage.  They  occur  most  frequently  on  the 
central  arteries,  but  also  on  the  smaller  branches  of  the  cortical  vessels.  On 
section  of  the  brain  substance  they  may  be  seen  as  localized,  small  dark  bodies, 
about  the  size  of  a  pin's  head.  Sometimes  they  are  seen  in  numbers  upon 
the  arteries  when  carefully  withdrawn  from  the  anterior  perforated  spaces.  In 
apoplexy  after  the  fortieth  year  if  sought  for  they  are  rarely  missed. 

(&)  Aneurism  of  the  branches  of  the  circle  of  Willis.  These  are  by  no 
means  uncommon,  and  will  be  considered  subsequently. 

(c)  Endarteritis  and  periarteritis  in  the  cerebral  vessels  most  commonly 
lead  to  apoplexy  by  the  production  of  aneurisms,  either  miliary  or  coarse. 
There  are  instances  in  which  the  most  careful  search  fails  to  reveal  anything 
but  diffuse  degeneration  of  the  cerebral  vessels. 

(d)  Whether  hsemorrhage"  ever  occurs  by  diapedesis  without  actual  rupture 
is  doubtful.    Possibly  it  does  in  purpura. 

(e)  In  persons  over  sixty  the  hemiplegia  may  depend  upon  small  areas  of 
softening  in  the  gray  matter — the  lacunce  of  Marie — varying  in  size  from  a 
pin's  head  to  a  pea  or  a  small  bean,  grayish  red  in  tint.  The  lenticular  nucleus 
is  particularly  apt  to  be  involved.     The  blood  vessels  are  always  diseased. 

The  haemorrhage  may  be  meningeal,  cerebral,  or  intraventricular. 

Meningeal  hcemorrhage  may  be  outside  the  dura,  between  dura  and  arach- 
noid, or  between  the  arachnoid  and  the  pia  mater.  The  following  are  the 
chief  causes :  Fracture  of  the  skull,  in  which  case  the  blood  usually  comes 
from  the  lacerated  meningeal  vessels,  sometimes  from  the  torn  sinuses.  In 
these  cases  the  blood  is  usually  outside  the  dura  or  between  it  and  the  arach- 
noid. The  next  most  frequent  cause  is  rupture  of  aneuricms  on  the  larger 
cerebral  vessels.  The  blood  is  usually  subarachnoid.  An  intracerebral  haamor- 
rhage  may  burst  into  the  meninges.  A  special  form  of  meningeal  haemorrhage 
is  found  in  the  new-born,  associated  with  injury  during  birth.  And  lastly, 
meningeal  ha?morrhage  may  occur  in  the  constitutional  diseases  and  fevers. 
The  blood  may  be  in  a  large  quantity  at  the  base ;  in  cases  of  ruptured 
aneurism,  particularly,  it  may  extend  into  the  cord  or  upon  the  cortex.     Owing 


984  DISEASES  OF  THE  XERVOUS  SYSTEM 

to  the  greater  frequency  of  the  aneurisms  in  the  middle  cerebral  vessels,  the 
Sylvian  fissures  are  often  distended  with  l3lood. 

Intracerebral  liamorrhage  is  most  frequent  in  the  neighborhood  of  the  cor- 
pus striatum,  particularly  toward  the  outer  section  of  the  lenticular  nucleus. 
The  hemorrhage  may  be  small  and  limited  to  the  lenticular  body,  the  thala- 
mus, and  the  internal  capsule,  or  it  may  extend  to  the  insula.  Haemorrhages 
confined  to  the  white  matter — the  centrum  semiovale — are  rare.  Localized 
bleeding  may  occur  in  the  crura  or  in  the  pons.  Hgemorrhage  into  the  cerebel- 
lum is  not  uncommon,  and  usually  comes  from  the  superior  cerebellar  artery. 
The  extravasation  may  be  limited  to  the  substance  or  may  rupture  into  the 
fourth  ventricle. 

Ventricular  Hcemorrhage. — This  is  rarely  primary,  coming  from  the  vessels 
of  the  plexuses  or  of  the  walls.  More  often  it  is  secondary,  following  haemor- 
rhage into  the  cerebral  substance.  It  is  not  infrequent  in  early  life  and  may 
occur  during  birth.  Of  94  cases  collected  by  Edward  Sanders,  7  occurred 
during  the  first  year,  and  14  under  the  twentieth  year.  In  adults  it  is  almost 
always  caused  by  rupture  of  a  vessel  in  the  neighborhood  of  the  caudate 
nucleus.  The  blood  may  be  found  in  one  ventricle  only,  but  more  com- 
monly it  is  in  both  lateral  ventricles,  and  may  pass  into  the  third  ventricle 
and  through  the  aqueduct  of  Sylvius  into  the  fourth  ventricle,  forming  a 
complete  mould  in  blood  of  the  ventricular  system.  In  these  cases  the 
clinical  jDicture  may  be  that  of  '^apoplexie  foudroyante." 

Multiple  Hcemorrhages. — Of  128  non-traumatic  cases  at  the  Cook  County 
Hospital  there  were  28  with  discrete  multiple  haemorrhages.  The  most  com- 
mon form  is  haemorrhage  into  the  basal  ganglia  and  into  the  pons;  the  next, 
bilateral  basal  haemorrhage.  In  the  brain  compression  following  haemorrhage, 
the  blood  pressure  rises;  this  increased  intracranial  tension  is  doubtless  the 
cause  of  rupture  in  other  vessels  weakened  by  disease.  The  pontine  arteries 
seem  specially  susceptible,  as  the  small  terminal  vessels  come  off  at  right 
angles  to  a  very  large  trunk  (Phyllis  Greenacre). 

Subsequent  Changes. — The  blood  gradually  changes  in  color,  and  ulti- 
mately the  haemoglobin  is  converted  into  haematoidin.  Inflammation  occurs 
about  the  apoplectic  area,  limiting  and  confining  it,  and  ultimately  a  definite 
wall  may  be  produced,  inclosing  a  cyst  with  fluid  contents.  In  other  instances 
a  cyst  is  not  formed,  but  the  connective  tissue  proliferates  and  leaves  a  pig- 
mented scar.  In  meningeal  haemorrhage  the  effused  blood  may  be  gradually 
absorbed  and  leave  only  a  staining  of  the  membranes.  In  other  cases,  particu- 
larly in  infants,  when  the  effusion  is  cortical  and  abundant,  there  may  be 
localized  wasting  of  the  convolutions  and  the  production  of  a  cyst  in  the 
meninges.  Possibly  porencephaly  may  arise  in  this  way.  Secondary  degen- 
eration follows,  varying  in  character  according  to  the  location  of  the  haemor- 
rhage and  the  actual  damage  done  by  it  to  nerve  cells  or  their  medullated 
axones.  Thus,  in  persons  dying  some  years  after  a  cerebral  apoplexy  which 
has  produced  hemiplegia  (lesion  of  the  motor  area  in  the  cortex  or  of  the 
pyramidal  tract  leading  from  it),  the  degeneration  may  be  traced  through  the 
cerebral  peduncle,  the  ventral  part  of  the  pons,  the  pyramids  of  the  medulla, 
the  fibres  of  the  direct  pyramidal  tract  of  the  cord  of  the  same  side,  and 
the  fibres  of  the  crossed  pyramidal  tract  on  the  opposite  side.  After  haemor- 
rhages in  the  middle  and  inferior  frontal  gyri  degeneration  of  the  frontal 


AFFECTIONS  OF  THE  BLOOD  VESSELS  985 

cerebro-cortico-pontal  path  follows,  going  through  the  anterior  limb  of  the 
internal  capsule  and  the  medial  portion  of  the  basis  pedunculi  to  the  nuclei 
pontis ;  also  degeneration  of  the  fibres  connecting  the  nucleus  medialis  thalami 
and  the  anterior  part  of  the  nucleus  lateralis  thalami  with  the  cortex. 

When  the  temporal  gyri  or  their  white  matter  are  destroyed  by  a  hgemor- 
rhage  the  lateral  segment  of  the  basis  pedunculi  degenerates.  Cerebellar 
haemorrhage,  especially  if  it  injure  the  nucleus  dentatus,  may  lead  to  degen- 
eration of  the  brachium  conjunctivum. 

There  may  be  slow  degeneration  in  the  lemniscus  medialis,  extending  as 
far  as  the  nuclei  on  the  opposite  side  of  the  medulla  oblongata,  after  hgemor- 
rhages  in  the  central  gyri,  hypothalamic  region,  or  dorsal  part  of  the  pons. 
Haemorrhages  destroying  the  occipital  cortex,  or  subcortical  haemorrhages  in- 
juring the  optic  radiations,  occasion  slow  degeneration  (cellulipetal)  of  the 
radiations  from  the  lateral  geniculate  body,  and  after  a  time  cause  marked 
atrophy  or  even  disappearance  of  its  ganglion  cells. 

Symptoms. — Primary. — Premonitory  indications  are  rare.  As  a  rule,  the 
patient  is  seized  while  in  full  health  or  about  the  performance  of  some  every 
day  action,  occasionally  an  action  requiring  strain  or  extra  exertion.  There 
may  be  headache,  sensations  of  numbness  or  tingling  or  pains  in  the  limbs, 
or  even  choreiform  movements  in  the  muscles  of  the  opposite  side,  the  so- 
called  prehemiplegic  chorea.  In  other  cases  temporary  disturbances  of  vision 
and  of  associated  movements  of  the  eye-muscles  have  been  noted,  but  none  of 
the  prodromata  of  apoplexy  (the  so-called  "warnings")  are  characteristic. 
Transient  aphasia  or  monoplegia  may  precede  the  attack.  The  onset  may  be 
with  sudden  loss  of  consciousness  and  complete  relaxation  of  the  extremities. 
In  such  instances  the  name  apoplectic  stroke  is  particularly  appropriate.  In 
other  cases  it  is  more  gradual  and  the  loss  of  consciousness  may  not  occur  for  a 
few  minutes  after  the  patient  has  fallen,  or  after  the  paralysis  of  the  limbs 
is  manifest.  In  the  typical  apoplectic  attack  the  condition  is  as  follows: 
There  is  deep  unconsciousness;  the  patient  can  not  be  roused.  The  face  is 
injected,  sometimes  cyanotic,  or  of  an  ashen  gray  hue.  The  pupils  vary;  usu- 
ally they  are  dilated,  sometimes  unequal,  and  always,  in  deep  coma,  inactive. 
If  the  haemorrhage  be  so  located  that  it  can  irritate  the  nucleus  of  the  third 
nerve  the  pupils  are  contracted  (haemorrhages  into  the  pons  or  ventricles). 
The  respirations  are  slow,  noisy,  and  accompanied  with  stertor.  Sometimes 
Cheyne-Stokes  rhythm  may  be  present.  The  chest  movements  on  the  para- 
lyzed side  may  be  restricted,  in  rare  instances  on  the  opposite  side.  The 
cheeks  are  often  blown  out  during  expiration,  with  spluttering  of  the  lips. 
The  pulse  is  usually  full,  slow,  and  of  increased  tension.  The  temperature 
may  be  normal,  but  is  often  found  subnormal,  and,  as  in  a  case  reported  by 
Bastian,  may  sink  below  95°.  In  cases  of  basal  haemorrhage  the. temperature, 
on  the  other  hand,  may  be  high.  The  urine  and  faeces  are  usually  passed  in- 
voluntarily. Convulsions  are  not  common.  It  may  be  difficult  to  decide 
whether  the  condition  is  apoplexy  associated  with  hemiplegia  or  sudden  coma 
from  other  causes.  An  indication  of  hemiplegia  may  be  discovered  in  the 
difference  in  the  tonus  of  the  muscles  on  the  two  sides.  If  the  arm  or  the 
leg  is  lifted,  it  drops  "dead"  on  the  affected  side,  while  on  the  other  it  falls 
more  slowly.  The  lack  of  muscular  tone  of  the  paralyzed  limb  may  be 
determined  by  inspection.     In  this  condition  the  muscle  mass  of  the  thigh  acts 


986  DISEASES  OF  THE  :N"ERY0US  SYSTEM 

like  a  semi-fluid  sac  and  takes  the  shape  determined  by  gravity.  In  a  patient 
lying  or  sitting  on  a  firm  support,  the  thigh  of  the  paralyzed  limb  is  broadened 
or  flattened,  while  that  on  the  normal  side  has  a  more  rounded  contour. 
Eigidity  also  may  be  present.  In  watching  the  movements  of  the  facial 
muscles  in  the  stertorous  respiration  it  will  be  seen  that  on  the  paralyzed 
side  the  relaxation  permits  the  cheek  to  be  blown  out  in  a  more  marked 
manner.  The  head  and  eyes  may  be  turned  to  one  side — ^conjugate  deviation. 
In  such  an  event  the  turning  is  toivard  the  side  of  the  haemorrhage. 

In  other  cases,  in  which  the  onset  is  not  so  abrupt,  the  patient  may  not 
lose  consciousness,  but  in  the  course  of  a  few  hours  there  is  loss  of  power, 
unconsciousness  comes  on  gradually,  and  deepens  into  profound  coma — in- 
gravescent apoplexy.  The  attack  may  occur  during  sleep.  The  patient  may 
be  found  unconscious,  or  wakes  to  find  that  the  power  is  lost  on  one  side. 
Small  haemorrhages  in  the  territory  of  the  central  arteries  may  cause  hemi- 
plegia without  loss  of  consciousness.  In  old  persons  the  hemiplegia  may  be 
slight  and  follow  a  transient  loss  of  consciousness,  and  is  usually  most  marked 
in  the  leg.  It  may  be  quite  slight  and  difficult  to  make  out.  It  is  associated 
with  other  senile  changes.  This  is  the  form  often  due  to  the  presence  of 
lacunar  softening. 

Usually  within  forty-eight  hours  after  the  onset  of  an  attack,  sometimes 
within  from  two  to  six  hours,  there  are  febrile  reaction  and  more  or  less  con- 
stitutional disturbance  associated  with  inflammatory  changes  about  the  hsem- 
orrhage  and  absorption  of  the  blood.  The  period  of  inflammatory  reaction 
may  continue  for  from  one  week  to  two  months.  The  patient  may  die  in  this 
reaction,  or,  if  consciousness  has  been  regained,  there  may  be  delirium  or 
recurr-ence  of  the  coma.  At  this  period  the  so-called  early  rigidity  may  develop 
in  the  paralyzed  limbs  and  trophic  changes  occur,  such  as  sloughing  or  the 
formation  of  vesicles.  The  most  serious  of  these  is  the  sloughing  eschar  of 
the  lower  part  of  the  back,  or  on  the  paralyzed  side,  which  may  appear  within 
forty-eight  hours  of  the  onset  and  is  usually  of  grave  significance.  The  con- 
gestion at  the  bases  of  the  lungs  so  common  in  apoplexy  is  regarded  by  some 
as  a  trophic  change. 

Conjugate  Deviation. — In  a  right  hemiplegia  the  eyes  and  head  may  be 
turned  to  the  left  side ;  that  is  to  say,  the  eyes  look  toward  the  cerebral  lesion. 
This  is  almost  the  rule  in  hemiplegia.  When,  however,  convulsions  or  spasm 
occur  or  the  state  of  so-called  early  rigidity,  the  conjugate  deviation  of  the 
head  and  eyes  may  be  in  the  opposite  direction;  that  is  to  say,  the  eyes  look 
away  from  the  lesion  and  the  head  is  rotated  toward  the  convulsed  side. 
This  symptom  may  be  associated  with  cortical  lesions,  particularly,  according 
to  some  authors,  when  in  the  neighborhood  of  the  sujoramarginal  and  angular 
gyri.  It  may  also  occur  in  a  lesion  of  the  internal  capsule  or  in  the  pons,  but 
in  the  latter  situation  the  conjugate  deviation  is  the  reverse  of  that  which 
occurs  in  other  cases,  as  the  patient  looks  away  from  the  lesion,  and  in  spasm 
or  convulsion  looks  toward  the  lesion. 

Hemiplegia. — In  cases  in  which  consciousness  is  restored  and  the  patient 
improves,  a  unilateral  paralysis  may  persist  due  to  the  destruction  of  the 
motor  area  or  the  pyramidal  tract  in  any  part  of  its  course.  Hemiplegia  is 
complete  when  it  involves  face,  arm,  and  leg,  or  partial  when  it  involves  only 
one  or  other  of  these  parts.     This  may  be  the  result  of  a  lesion   {a)  of  the 


AFFECTIOXS  OF  THE  BLOOD  VESSELS 

V.BG 


987 


Fig.  20. — Diagram  of  Motor  Path  from  Left  Brain. 
The  ujjper  segment  is  black,  the  lo^'er  red.  The  nuclei  of  the  motor  cerebral  nerves 
are  shown  on  the  right  side;  on  the  left  side  the  cerebral  nerves  of  that  side  are  indi- 
cated. A  lesion  at  1  would  cause  upper  segment  paralysis  in  the  arm  of  the  opposite 
side — cerebral  monoplegia;  at  2,  upper  segment  paralysis  of  the  whole  opposite  side 
of  the  body— hemiplegia ;  at  3  (in  the  crus),  upper  segment  paralysis  of  the  opposite 
face,  arm,  and  leg,  and  lower  segment  paralysis  of  the  eye-muscles  on  the  same 
side — crossed  paralysis;  at  4  (in  the  lower  part  of  the  pons),  upper  segment  paralysis 
of  the  opposite  arm  and  leg,  and  lower  segment  paralysis  of  the  face  and  external  rectus 
on  the  same  side — crossed  paralysis;  at  5,  upper  segment  paralysis  of  all  muscles  rep- 
resented below  lesion,  and  lower  segment  paralysis  of  muscles  represented  at  level  of 
lesion — spinal  paraplegia;  at  6,  lower  segment  paralysis  of  muscles  localized  at  seat  of 
lesion — anterior   poliomyelitis.      (Van   Gehuchten,   modified.) 


988  DISEASES  OF  THE  NERVOUS  SYSTEM 

motor  cortex;  (h)  of  the  pyramidal  fibres  in  the  corona  radiata  and  in  the 
internal  capsule;  (c)  of  a  lesion  in  the  cerebral  peduncle;  or  (d)  in  the  pons 
Varolii.  The  situation  of  the  lesions  and  their  effects  are  given  in  Fig.  20. 
Hgemorrhage  is  perhaps  the  most  common  cause^  but  tumors  and  spots  of 
softening  ma}^  also  induce  it.  The  special  details  of  the  hemiplegia  ma}^  here 
be  considered.  The  face  (except  in  lesions  in  the  lower  part  of  the  pons) 
is  involved  on  the  same  side  as  the  arm  and  leg.  This  results  from  the  fact 
that  the  facial  muscles  stand  in  precisely  the  same  relation  to  the  cortical 
centres  as  those  of  the  arm  and  leg^  the  fibres  of  the  upper  motor  segment  of 
the  facial  nerve  from  the  cortex  decussating  just  as  do  those  of  the  nerves 
of  the  limbs.  The  signs  of  the  facial  paralysis  are  usually  well  marked. 
There  may  be  a  slight  difficulty  in  elevating  the  eyebrows  or  in  closing  the 
eye  on  the  paralyzed  side,  or  in  rare  cases,  the  facial  paralysis  is  complete, 
but  the  movements  may  be  present  with  emotion,  as  laughing  or  crying. 
The  facial  paralysis  is  joartial,  involving  only  the  lower  portion  of  the  nerve, 
so  that  the  orbicularis  oculi  and  the  frontalis  muscles  are  much  less  involved 
than  the  lower  branch.  The  hypoglossal  nerve  also  is  involved.  In  conse- 
quence, the  patient  can  not  put  out  the  tongue  straight,  but  it  deviates  toward 
the  paralyzed  side,  inasmuch  as  the  genio-hyo-glossus  of  the  sound  side  is 
unopposed.  In  a  few  cases  the  protrusion  is  toward  the  side  of  the  lesion,  a 
fact  not  easily  explained.  With  right  hemiplegia  there  may  be  aphasia.  Even 
without  marked  aphasia  difficulty  in  speaking  and  slowness  are  common. 

The  arm  is,  as  a  rule,  more  completely  paralyzed  than  the  leg.  The  loss 
of  power  may  be  absolute  or  partial.  In  severe  cases  it  is  at  first  complete. 
In  others,  when  the  paralysis  in  the  face  and  arm  is  complete,  that  of  the  leg 
is  only  partial.  The  face  and  arm  may  alone  be  paralyzed,  while  the  leg 
escapes.  Less  commonly  the  leg  is  more  affected  than  the  arm,  and  the  face 
may  be  only  slightly  involved. 

Certain  muscles  escape  in  hemiplegia,  particularly  those  associated  in 
symmetrical  movements,  as  those  of  the  thorax  and  abdomen,  a  fact  which 
Broadbent  explains  by  supposing  that  as  the  spinal  nuclei  controlling  these 
movements  on  both  sides  constantly  act  together  they  may,  by  means  of  this 
intimate  connection,  be  stimulated  by  impulses  coming  from  only  one  side 
of  the  brain.  Hughlings  Jackson  pointed  out  that  in  quiet  respiration  the 
muscles  on  the  paralyzed  side  acted  more  strongly  than  the  corresponding 
muscles,  but  that  in  forced  respiration  the  reverse  condition  was  true.  The 
degree  of  permanent  paralysis  after  a  hemiplegic  attack  varies  much  in  dif- 
ferent cases.  When  the  restitution  is  partial,  it  is  always  certain  groups  of 
muscles  which  recover  rather  than  others.  Thus  in  the  leg  the  residual  par- 
alysis concerns  the  flexors  of  the  leg  and  the  dorsal  flexors  of  the  foot — i.  e., 
the  muscles  which  are  active  in  the  second  period  of  walking,  shortening  the 
leg,  and  bringing  it  forward  while  it  swings.  The  muscles  which  lift  the  body 
when  the  foot  rests  upon  the  ground,  those  used  in  the  first  period  of  walking, 
include  the  extensors  of  the  leg  and  "the  plantar  flexors  of  the  foot.  These 
"lengtheners"  of  the  leg  often  recover  almost  completely  in  cases  in  which 
the  paralysis  is  due  to  lesions  of  the  pyramidal  tract.  In  the  arms  the  residual 
paralysis  usually  affects  the  muscle  groups  which  oppose  the  thumb,  those 
which  rotate  the  arm  outward,  and  the  openers  of  the  hand. 

As  a  rule,  there  is  at  first  no  wasting  of  the  paralyzed  limbs. 


AFFECTION'S  OF  THE  BLOOD  VESSELS  989 

Crossed  Hemiplegia. — A  paralj^sis  in  whieli  there  is  loss  of  function  in  a 
cerebral  nerve  on  one  side  with  loss  of  power  (or  of  sensation)  on  the  opposite 
side  of  the  body  is  called  a  crossed  or  alternate  hemiplegia.  It  is  met  with 
in  lesions,  commonly  hemorrhage,  in  the  crns,  the  pons,  and  the  medulla 
(Figs.  14,  15  and  20). 

(a)  Crus. — The  bleeding  may  extend  from  vessels  supplying  the  corpus 
striatum,  internal  capsule,  and  optic  thalamus,  or  the  hemorrhage  may  be 
primarily  in  the  crus.  In  the  classical  case  of  "Weber,  on  section  of  the  lower 
part  of  the  left  crus,  an  oblong  clot  15  mm.  in  length  lay  just  below  the  medial 
and  inferior  surface.  The  characteristic  features  of  a  lesion  in  this  locality 
are  paralysis  of  arm,  face,  and  leg  of  the  opposite  side,  and  oculo-motor  paral- 
ysis of  the  same  side — the  syndrome  of  Weber  or  Weber-Gubler.  Sensory 
changes  may  also  be  present.  Haemorrhage  into  the  tegmentum  is  not  neces- 
sarily associated  with  hemiplegia,  but  there  may  be  incomplete  paralysis  of 
the  oculo-motor  nerve,  with  disturbance  of  sensation  and  ataxia  on  the  opposite 
side.  The  optic  tract  or  the  lateral  geniculate  body  lying  on  the  lateral  side 
of  the  crus  may  be  compressed,  with  resulting  hemianopia. 

(6)  Pons  and  Medulla. — Lesions  may  involve  the  pyramidal  tract  and  one 
or  more  of  the  cerebral  nerves.  If  at  the  lower  aspect  of  the  pons,  the  facial 
nerve  may  be  involved,  causing  paralysis  of  the  face  on  the  same  side  and 
liemiplegia  on  the  opposite  side.  The  fifth  nerve  may  be  involved,  with  the 
fillet  (the  sensory  tract),  causing  loss  of  sensation  in  the  area  of  distribution 
of  the  fifth  on  the  same  side  as  the  lesion  and  loss  of  sensation  on  the  opposite 
side  of  the  body.  The  sensory  disturbance  here  is  apt  to  be  dissociated,  of  the 
syringomyelic  type,  affecting  particularly  the  sense  of  pain  and  temperature. 

Sensory  Disturbances  Resulting  from  Cerebral  Hcemorrhage. — These  are 
variable.  Hemiansesthesia  may  coexist  with  hemiplegia,  but  in  many  instances 
there  is  only  slight  numbing  of  sensation.  When  marked,  it  is  usually  the 
result  of  a  lesion  in  the  internal  capsule  involving  the  retrolenticular  portion 
of  the  posterior  limb.  In  a  study  of  sensor}^  localization  Dana  found  that 
anesthesia  of  organic  cortical  origin  was  always  limited  or  more  pronounced 
in  certain  parts,  as .  the  face,  arm,  or  leg,  and  was  generally  incomplete. 
Total  anaesthesia  was  either  of  functional  or  subcortical  origin.  Marked 
anaesthesia  was  much  more  common  in  softening  than  in  hemorrhage.  Com- 
plete hemianesthesia  is  rare  in  hemorrhage.  Disturbance  of  the  special  senses 
is  not  common.  Hemianopia  may  exist  on  the  same  side  as  the  paralysis, 
and  there  may  be  diminution  in  the  acuteness  of  the  senses  of  hearing,  taste, 
and  smell.  Homonymous  hemianopia  of  the  halves  of  the  visual  fields  oppo- 
site to  the  lesion  is  very  frequent  shortly  after  the  onset,  though  often  over- 
looked (Gowers). 

Psychic  disturbances,  varialjle  in  nature  and  degree,  may  result  from  cere- 
bral hemorrhage. 

The  Eeflexes  in  Apoplectic  Cases. — During  the  apoplectic  coma  all  the 
reflexes  are  abolished,  but  immediately  on  recovery  of  consciousness  they 
return,  first  on  the  non-hemiplegic  side,  later,  sometimes  only  after  weeks, 
on  the  paralyzed  side.  As  to  the  time  of  return,  especially  of  the  patellar 
reflexes,  marked  differences  are  observable  in  individual  cases.  The  deep 
reflexes  later  are  increased  on  the  paralyzed  side,  and  ankle  clonus  may  be 
present.     Plantar  stimulation  usually  gives  an  extensor  response  in  the  great 


990  DISEASES  OF  THE  ^S^ERYOUS  SYSTEM 

toe  (Babinski's  reflex)  or  dorsal  flexion  of  the  foot  on  irritating  the  skin 
over  the  tibia  (Oppenheim's  sign).  The  other  superficial  reflexes  are  usually 
diminished.     The  sphincters  are  not  affected. 

The  course  of  the  disease  depends  upon  the  situation  and  extent  of  the 
lesion.  If  slight,  the  hemiplegia  may  disappear  completely  within  a  few  days 
or  a  few  weeks.  In  severe  cases  the  rule  is  that  the  leg  gradually  recovers 
before  the  arm,  and  the  muscles  of  the  shoulder  girdle  and  upper  arm  before 
those  of  the  forearm  and  hand.     The  face  may  recover  quickly. 

Except  in  the  very  slight  lesions,  in  which  the  hemiplegia  is  transient, 
changes  take  place  which  may  be  grouped  as 

Secondary  Symptoms. — These  correspond  to  the  chronic  stage.  In  a 
case  in  which  little  or  no  improvement  takes  place  within  eight  or  ten  weeks 
it  will  be  found  that  the  paralyzed  limbs  undergo  certain  changes.  The  leg, 
as  a  rule,  recovers  enough  power  to  enable  the  patient  to  get  about,  although 
the  foot  is  dragged.  Occasionally  a  recurrence  of  severe  symptoms  is  seen, 
even  without  a  new  haemorrhage  having  taken  place.  In  both  arm  and  leg 
the  condition  of  secondary  contraction  or  late  rigidity  comes  on  and  is  always 
most  marked  in  the  arm  which  becomes  permanently  flexed  at  the  elbow  and 
resists  all  attempts  at  extension.  The  wrist  is  flexed  upon  the  forearm  and 
the  fingers  upon  the  hand.  The  position  of  the  arm  and  hand  is  very  char- 
acteristic. There  is  frequentty,  as  the  contractures  develop,  a  great  deal  of 
pain.  In  the  leg  the  contracture  is  rarely  so  extreme.  The  loss  of  power  is 
most  marked  in  the  muscles  of  the  foot  and,  to  prevent  the  toes  from  dragging, 
the  knee  in  walking  is  much  flexed,  or  more  commonly  the  foot  is  swung 
round  in  a  half  circle. 

The  reflexes  are  at  this  stage  greatly  increased.  These  contractures  are 
permanent  and  incurable,  and  are  associated  with  a  secondary  descending 
sclerosis  of  the  motor  path.  There  are  instances,  however,  in  which  rigidity 
and  contracture  do  not  occur,  but  the  arm  remains  flaccid,  the  leg  having 
regained  its  power.  This  hemipJegie  fJasque  of  Bouchard  is  found  most  com- 
monly in  children.  Among  other  secondary  changes  in  late  hemiplegia  may 
be  mentioned  the  folloAving:  Tremor  of  the  affected  limbs,  post-paralytic 
chorea,  the  mobile  spasm  known  as  athetosis,  arthropathies  in  the  joints  of 
the  affected  side,  and  muscular  atrophy.  The  cool  surface  and  thin  glossy 
skin  of  a  hemiplegic  limb  are  familiar  to  all. 

Atrophy  of  the  muscles  may  occur.  It  has  been  thought  to  be  due  in 
some  cases  to  secondary  alterations  in  the  gray  matter  of  the  ventral  horns; 
but  atrophy  may  follow  as  a  direct  result  of  the  cerebral  lesion,  the  ventral 
liorns  remaining  intact.  In  Quincke's  case  atrophy  of  the  arm  followed  the 
development  of  a  glioma  in  the  anterior  central  convolution.  The  gray  mat- 
ter of  the  ventral  horns  was  normal.  These  atrophies  are  most  common  in 
cortical  lesions  involving  the  domain  of  the  third  main  branch  of  the  Sylvian 
artery,  and  in  central  lesions  involving  the  lenticulo-thalamic  region.  Their 
explanation  is  not  clear.  The  wasting  of  cerebral  origin,  which  occurs  most 
frequently  in  children,  and  leads  to  hemiatrophy  of  the  muscles  with  stunted 
growth  of  the  bones  and  joints,  is  to  be  sharply  separated  from  the  hemi- 
atrophy of  the  muscles  of  the  adult  following  within  a  relatively  short  time 
upon  the  hemiplegia. 

Diagnosis. — There  are  three  groups  ol.'  cases  which   otl'er  ditliculty. 


AFFECTIOXS  OF  THE  BLOOD  VESSELS        Wl 

(1)  Cases  in  which  the  onset  is  gradual^  a  day  or  two  elapsing  before 
the  paralysis  is  fully  developed  and  consciousness  completely  lost,  are  readily 
recognized,  though  it  may  be  difficult  to  determine  whether  the  lesion  is  due 
to  thrombosis  or  to  hasmorrhage. 

(2)  In  the  sudden  apoplectic  stroke  in  which  the  patient  rapidly  loses 
consciousness  the  difficulty  in  diagnosis  may  be  still  greater,  particularly  if 
the  patient  is  in  deep  coma  when  first  seen. 

The  first  point  to  be  decided  is  the  existence  of  hemiplegia.  This  may 
be-  difficult,  although,  as  a  rule,  even  in  deep  coma  the  limbs  on  the  para- 
lyzed side  are  more  flaccid  and  drop  instantly  when  lifted;  whereas  on  the 
non-paralyzed  side  the  muscles  retain  some  degree  of  tonus.  One  cheek  may 
puff  or  one  side  of  the  mouth  splutter  in  expiration.  The  reflexes  may  be 
decreased  or  lost  on  the  affected  side  and  there  may  be  conjugate  deviation 
of  the  head  and  eyes.  Rigidity  in  the  limbs  on  one  side  is  in  favor  of  a 
hemiplegic  lesion.  It  is  practically  impossible  in  a  majority  of  these  cases 
to  say  wliether  the  lesion  is  due  to  haemorrhage,  embolism,  or  thrombosis. 

(3)  Large  haemorrhage  into  the  ventricles  or  into  the  pons  may  produce 
sudden  loss  of  consciousness  with  complete  relaxation,  simulating  coma  from 
uraemia,  diabetes,  alcoholism,  opium  poisoning,  or  epilepsy. 

The  previous  history  and  the  mode  of  onset  may  give  valuable  information. 
In  epilepsy  convulsions  have  preceded  the  coma;  in  alcoholism  there  is  a 
history  of  constant  drinking,  while  in  opium  poisoning  the  coma  develops 
more  gradually;  but  in  many  instances  the  difficulty  is  practically  very  great. 
With  diabetic  coma  the  breath  often  smells  of  acetone.  In  ventricular 
licemorrhage  the  coma  is  sudden  and  comes  on  rapidly.  The  hemiplegic  symp- 
toms may  be  transient,  quickly  giving  place  to  complete  relaxation.  Con- 
^•ulsions  occur  in  many  cases,  and  may  be  the  very  symptom  to  lead  astray — 
as  in  a  case  of  ventricular  haemorrhage  which  occurred  in  a  puerperal  patient, 
in  whom,  naturally  enough,  the  condition  was  thought  to  be  urgemic.  Eigidity 
is  often  present.  In  haemorrhage  into  the  pons  convulsions  are  frequent. 
The  pupils  may  be  strongly  contracted,  conjugate  deviation  may  occur,  and 
the  temperature  is  apt  to  rise  rapidly.  The  contraction  of  the  pupils  in 
pontine  hgemorrhage  naturally  suggests  opium  poisoning.  The  difference  in 
temperature  in  the  two  conditions  is  a  valuable  diagnostic  point.  The 
apoplectiform  seizures  of  general  paresis  have  usually  been  preceded  by  ab- 
normal mental  symptoms,  and  the  associated  hemiplegia  is  seldom  permanent. 

The  cerebral  attacks  in  Stokes-Adams  disease  may  resemble  apoplexy  very 
closely.  One  stout  patient,  the  subject  of  many  attacks,  had  been  bled  so 
often  that  he  had  a  label  inside  his  coat — "Do  not  bleed  me  in  an  attack." 

It  may  be  impossible  at  first  to  give  a  definite  diagnosis.  In  admissions 
to  hospitals  or  in  emergency  cases  the  physician  should  be  particularly  careful 
about  the  following  points :  The  examination  of  the  head  for  injury  or  frac- 
ture; the  urine  should  be  tested  for  albumin  and  sugar,  and  studied  micro- 
scopically; a  careful  examinatiot  should  be  made  of  the  limbs  with  reference 
to  the  degree  of  relaxation  or  the  presence  of  rigidity,  and  the  condition  of 
the  reflexes ;  the  state  of  the  pupils  should  be  noted  and  the  temperature 
taken.  The  odor  of  the  breath  (alcohol,  acetone,  chloroform,  etc.)  should  be 
jioted.  The  most  serious  mistakes  are  made  in  the  case  of  patients  who  are 
drunk   at  the  time  of  the  attack,  a  combination  by   no   means  uncommon. 


992  DISEASES  OF  THE  NEEVOUS  SYSTEM 

Under  these  circumstances  the  case  may  erroneously  be  looked  upon  as  one 
of  alcoholic  coma.  It  is  best  to  regard  each  case  as  serious  and  to  bear  in 
mind  that  this  is  a  condition  in  which,  above  all  others,  mistakes  are  common. 

In  meningeal  hcemorrhage,  as  from  ruptured  aneurism,  the  attack  is  sud- 
den, with  pain  in  the  head,  rapid  loss  of  consciousness,  bilateral  flaccidity,  or 
difficulty  in  determining  the  existence  of  hemiplegia,  rapid  rise  in  tempera- 
ture, and  the  presence  of  blood  under  high  pressure  in  the  spinal  fluid.  In 
one  case  (death  on  fourth  day)  on  the  secojid  day  suggillations  and  petechise 
complicated  the  diagnosis. 

Prognosis. — From  cortical  haemorrhage,  unless  very  extensive,  the  recovery 
may  be  complete  without  a  trace  of  contracture.  This  is  more  common  when 
the  haemorrhage  follows  injury  than  when  it  results  from  disease  of  the 
arteries.  Infantile  meningeal  haemorrhage,  on  the  other  hand,  is  a  condition 
which  may  produce  idiocy  or  spastic  diplegia. 

Large  heemorrhages  into  the  corona  radiata,  and  especially  those  which 
rupture  into  the  ventricles,  rapidly  prove  fatal. 

The  hemiplegia  which  follows  lesions  of  the  internal  capsule,  the  result  of 
rupture  of  the  lenticulo-striate  artery,  is  usually  persistent  and  followed 
by  contracture.  When  the  retro-lenticular  fibres  of  the  internal  capsule  are 
involved  there  may  be  hemianaesthesia,  and  later,  especially  if  the  thalamus 
be  implicated,  hemichorea  or  athetosis.  In  any  case  the  following  symptoms 
are  of  grave  omen:  persistence  or  deepening  of  the  coma  during  the  second 
and  third  day;  rapid  rise  in  temperature  within  the  first  forty-eight  hours 
after  the  initial  fall.  In  the  reaction  which  takes  place  on  the  second  or 
third  day  the  temperature  usually  rises,  and  its  gradual  fall  on  the  third  or 
fourth  day  with  return  of  consciousness  is  a  favorable  indication.  The  rapid 
formation  of  bed-sores,  particularly  the  malignant  decubitus  of  Charcot,  is  a 
fatal  indication.  The  occurrence  of  albumin  and  sugar,  if  abundant,  in  the 
urine  is  an  unfavorable  symptom. 

When  consciousness  returns  and  the  patient  is  improving,  the  question  is 
anxiously  asked  as  to  the  paralysis.  The  extent  of  this  can  not  be  determined 
for  some  weeks.  With  slight  lesions  it  may  pass  o£E  entirely.  If  persistent  at 
the  end  of  a  month  some  grade  of  permanent  palsy  is  certain  to  remain,  and 
gradually  the  late  rigidity  supervenes. 

V.     EMBOLISM  AND  THEOMBOSIS 
(Cerebral  Softening) 

Embolism. — The  embolus  usually  enters  the  carotid,  rarely  the  vertebral 
artery.  In  the  great  majority  of  cases  it  comes  from  the  left  heart  and  is 
either  a  vegetation  of  a  fresh  endocarditis  or,  more  commonly,  of  a  recurring 
endocarditis,  or  from  the  segments  involved  in  an  ulcerative  process.  Less 
often  the  embolus  is  a  portion  of  a  -clot  which  has  formed  in  the  auricular 
appendix.  Portions  of  clot  from  an  aneurism,  thrombi  from  atheroma  of  the 
aorta,  or  from  the  territory  of  the  pulmonary  veins,  may  also  cause  blocking 
of  the  branches  of  the  circle  of  Willis.  In  the  puerperal  condition  cerebral 
embolism  is  not  infrequent.  It  may  occur  in  women  with  heart  disease,  but 
in  other  instances  the  heart  is  uninvolved,  and  the  condition  lias  been  thought 


AFFECTIONS  OF  THE  BLOOD  VESSELS  .  993 

to  be  associated  with  the  development  of  heart  clots,  owing  to  increased 
coagulability  of  the  blood.  A  majority  of  cases  of  embolism  occur  in  heart 
disease,  89  per  cent.'  (Saveliew),  Cases  are  rare  in  the  acute  endocarditis  of 
rheumatic  fever,  chorea,  and  febrile  conditions.  It  is  much  more  common  in 
the  secondary  recurring  endocarditis  which  attacks  old  sclerotic  valves.  The 
embolus  most  frequently  passes  to  the  left  middle  cerebral  artery  and  the 
posterior  cerebral  and  the  vertebral  are  less  often  affected.  A  large  plug  may 
lodge  at  the  bifurcation  of  the  basilar.  Embolism  of  the  cerebellar  vessels 
is  rare. 

Embolism  occurs  more  frequently  in  women,  owing,  no  doubt,  to  the 
greater  frequency  of  mitral  stenosis.  Contrary  to  this  general  statement, 
Newton  Pitt's  statistics  of  79  cases  at  Guy's  Hospital  indicate,  however,  that 
males  are  more  frequently  affected;  as  in  this  series  there  were  44  males  and 
35  females.     Saveliew  gives  54  per  cent,  in  women. 

Thrombosis. — Clotting  of  blood  in  the  cerebral  vessels  occurs  (1)  about 
an  embolus,  (2)  as  the  result  of  a  lesion  of  the  arterial  wall  (either  endar- 
teritis with  or  without  atheroma  or,  particularly,  the  syphilitic  arteritis),  (3) 
in  aneurisms,  both  large  and  miliary,  and  (4)  as  a  direct  result  of  abnormal 
conditions  of  the  blood  as  in  the  anagmia  of  hemorrhage,  chlorosis,  septicaemia 
and  the  cachexia  of  cancer.  Thrombosis  occasionally  follows  ligation  of  the 
carotid  artery.  The  thrombosis  is  most  common  in  the  middle  cerebral  and 
in  the  basilar  arteries.  It  is  suggested  that  softening  of  limited  areas,  suffi- 
cient to  induce  hemiplegia,  may  be  caused  by  sudden  collapse  of  certain 
cerebral  arteries  from  cardiac  weakness. 

Anatomical  Changes. — Degeneration  and  softening  of  the  territory  sup- 
plied by  the  vessels  are  the  ultimate  result  in  both  embolism  and  thrombosis. 
Blocking  in  a  terminal  artery  may  be  followed  by  infarction,  in  which  the 
territory  may  either  be  deeply  infiltrated  with  blood  (hsemorrhagic  infarction) 
or  be  simply  pale,  swollen,  and  necrotic  (anaemic  infarction).  Gradually  the 
process  of  softening  proceeds,  the  tissue  is  infiltrated  with  serum  and  is  moist, 
the  nerve  fibres  degenerate  and  become  fatty.  The  neuroglia  is  swollen  and 
oedematous.  The  color  of  the  softened  area  depends  upon  the  amount  of  blood. 
The  haemoglobin  undergoes  gradual  transformation,  and  the  early  red  color 
may  give  place  to  yellow.  Formerly  much  stress  was  laid  upon  the  difference 
between  red,  yellow,  and  white  softening.  The  red  and  yellow  are  seen  chiefly 
on  the  cortex.  Sometimes  the  red  softening  is  particularly  marked  in  cases 
of  embolism  and  in  the  neighborhood  of  tumors.  The  gray  matter  shows  many 
punctiform  haemorrhages — capillary  apoplexy.  There  is  a  variety  of  yellow 
softening — the  plaques  jaunes — common  in  elderly  persons,  occurring  in  the 
gray  matter,  in  spots  from  1  to  2  cm.  in  diameter,  sometimes  angular  in 
shape,  the  edges  cleanly  cut,  and  the  softened  area  represented  by  a  turbid, 
yellow  material  or  in  some  instances  there  is  space  crossed  by  fine  trabeculae, 
in  the  meshes  of  which  there  is  fluid.  White  softening  occurs  most  fre- 
quently in  the  white  matter,  and  is  seen  best  about  tumors  and  abscesses.  In- 
flammatory changes  are  common  in  and  about  the  softened  areas.  When  the 
embolus  is  derived  from  an  infected  focus,  as  in  ulcerative  endocarditis,  sup- 
puration may  follow.  The  final  changes  vary  very  much.  The  degenerated 
and  dead  tissue  elements  are  gradually  Ijut  slowly  removed,  and  if  the  region 


994  DISEASES  OF  THE  NERVOUS  SYSTEM 

is  small  may  be  replaced  by  a  growth  of  comiective  tissue  and  the  formation 
of  a  scar.     If  large,  the  resorption  results  in  the  formation  of  a  cyst. 

The  position  and  extent  of  the  softening  depend  upon  the  obstructed  artery. 
An  embolus  which  blocks  the  middle  cerebral  at  its  origin  involves  not  only 
the  arteries  to  the  anterior  perforated  space,  but  also  the  cortical  branches,  and 
in  such  a  case  there  is  softening  in  the  neighborhood  of  the  corpus  striatum, 
as  well  as  in  part  of  the  region  supplied  by  the  cortical  vessels.  The  freedom 
of  anastomosis  between  these  branches  varies.  Thus,  in  embolism  of  the  mid- 
dle cerebral  artery  in  which  the  softening  has  involved  only  the  territory 
of  the  central  branches,  blood  may  reach  the  cortex  through  the  anterior  and 
posterior  cerebrals.  When  the  middle  cerebral  is  blocked  (as  is  perhaps 
oftenest  the  case)  beyond  the  point  of  origin  of  the  central  arteries,  one  or 
other  of  its  branches  is  usually  most  involved.  The  embolus  may  lodge  in 
the  vessel  passing  to  the  third  frontal  convolution,  or  in  the  artery  of  the 
ascending  frontal  or  ascending  parietal ;  or  it  may  lodge  in  the  branch  passing 
to  the  supramarginal  and  angular  gyri,  or  enter  the  lowest  branch  wdiich  is 
distributed  to  the  upper  convolutions  of  the  temporal  lobe.  These  are  prac- 
tically terminal  arteries,  and  instances  frequently  occur  of  softening  limited 
to  a  part,  at  any  rate,  of  the  territory  supplied  by  them.  Some  of  the  most 
accurate  focalizing  lesions  are  produced  in  this  way. 

There  is- unquestionably  greater  freedom  of  communication  in  the  cortical 
branches  of  the  different  arteries  than  is  usually  admitted,  although  it  is  not 
possible,  for  example,  to  inject  the  posterior  cerebral  through  the  middle  cere- 
bral, or  the  middle  cerebral  from  the  anterior;  but  the  absence  of  softening 
in  some  instances  in  which  smaller  branches  are  blocked  shows  how  complete 
may  be  the  compensation,  probably  by  way  of  the  capillaries.  The  dilatation 
of  the'  collateral  branches  may  take  place  very  rapidly;  thus  a  patient  with 
chronic  nephritis  died  twenty-four  hours  after  the  hemiplegic  attack.  There 
were  recent  vegetations  on  the  mitral  valve  and  an  embolus  in  the  right  middle 
cerebral  artery  just  beyond  the  first  two  branches.  The  central  portion  of 
the  hemisphere  was  swollen  and  oedematous.  The  right  anterior  cerebral  was 
greatly  dilated,  and  its  diameter  was  nearly  three  times  that  of  the  left. 

Symptoms. — Extensive  thrombotic  softening  may  exist  without  any  symp- 
.toms.  It  is  not  uncommon  in  the  examination  of  the  bodies  of  elderly  per- 
sons to  find  the  plaques  jaunes  scattered  over  the  convolutions.  So,  too, 
softening  may  take  place  in  the  "silent"  regions,  without  exciting  any  symp- 
toms. When  the  central  or  cortical  branches  of  the  middle  cerebral  arteries 
are  involved  the  symptoms  are  similar  to  those  of  haemorrhage  from  the  same 
arteries.  Permanent  or  transient  hemiplegia  results.  When  the  central 
arteries  are  involved  the  softening  in  the  internal  capsule  is  commonly  fol- 
lowed by  hemiplegia.  Certain  peculiarities  are  associated  with  embolism 
and  with  thrombosis  respectively. 

In  embolism  the  patient  is  usually  the  subject  of  heart  trouble,  or  there 
exist  some  of  the  conditions  already  mentioned.  The  onset  is  sudden,  without 
premonitory  symptoms  but  sometimes  with  intense  headache.  When  the 
embolus  blocks  the  left  middle  cerebral  artery, the  hemiplegia  is  associated  with 
aphasia.  In  thrombosis,  on  the  other  hand,  the  onset  is  more  gradual;  the 
]:)atient  has  previously  complained  of  headache,  vertigo,  tingling  in  the  fingers ; 
the  speech  may  have  been  embarrassed  for  some  days;  the  patient  has  had  loss 


AFFECTIONS  OF  THE  BLOOD  VESSELS        995 

of  memory  or  is  incoherent,  or  paralysis  begins  at  one  part,  as  the  hand,  and 
extends  slowly,  and  the  hemiplegia  may  be  incomplete  or  variable.  Abrupt 
loss  of  consciousness  is  much  less  common,  and  when  the  lesion  is  small  con- 
sciousness is  retained.  Thus,  in  thrombosis  due  to  syphilitic  disease,  the  hemi- 
plegia may  come  on  gradually  without  an)^  disturbance  of  consciousness. 

The  hemiplegia  following  thrombosis  or  embolism  has  practically  the  char- 
acteristics, both  primary  and  secondary,  described  under  haemorrhage. 

The  following  may  be  the  effects  of  blocking  the  different  vessels :  (a) 
Vertebral. — The  left  branch  is  more  frequently  plugged.  The  effects  are  in- 
volvement of  the  nuclei  in  the  medulla  and  symptoms  of  acute  bulbar  paralysis. 
It  rarely  occurs  alone;  more  commonly  with 

(b)  Blocking  of  the  basilar  artery. — When  this  is  entirely  occluded,  there 
may  be  bilateral  paralysis  from  involvement  of  both  motor  paths.  Bulbar 
symptoms  may  be  present;  rigidity  or  spasm  may  occur.  The  temperature 
may  rise  rajDidly.     The  symptoms,  in  fact,  are  those  of  apoplexy  of  the  pons. 

(c)  The  posterior  cerebral  supplies  the  occipital  lobe  on  its  medial  surface 
and  the  greater  part  of  the  temporo-sphenoidal  lobe.  If  the  main  stem  be 
thrombosed  there  is  hemianopia  with  sensory  aphasia.  Localized  areas  of 
softening  may  exist  without  symptoms.  Blocking  of  the  main  occipital  branch 
(arteria  occipitalis  of  Duret) ,  or  of  the  arteria  calcarina,  passing  to  the  cuneus 
may  be  followed  by  hemianopia.  Hemianassthesia  may  result  from  involve- 
ment of  the  posterior  part  of  the  internal  capsule.  Not  infrequently  sym- 
metrical thrombosis  of  the  occipital  arteries  of  the  two  sides  occurs,  as  in 
Forster's  well-known  case.  Still  more  frequent  is  the  occurrence  of  throm- 
bosis of  a  branch  of  the  posterior  cerebral  of  one  hemisphere  and  a  branch 
of  the  middle  cerebral  of  the  other.  It  is  in  such  cases  that  the  most  pro- 
nounced instances  of  apraxia  are  met  with. 

{d)  Internal  Carotid. — The  symptoms  are  variable.  The  vessel  is  ligated 
without  risk  in  a  majority  of  cases ;  in  other  instances  transient  hemiplegia 
follows;  in  others  again  the  hemiplegia  is  permanent.  These  variations  de- 
pend on  the  anastomoses  in  the  circle  of  Willis.  If  these  are  large  and  free, 
no  paralysis  follows,  but  in  cases  in  which  the  posterior  communicating  and 
the  anterior  communicating  vessels  are  small  or  absent  the  paralysis  may 
persist.  In  No.  7  of  the  Elwyn  series  of  cases  of  infantile  hemiplegia,  the 
woman,  aged  twenty-four,  when  six  years  old,  had  the  right  carotid  ligated 
for  abscess  following  scarlet  fever,  with  the  result  of  permanent  hemiplegia. 
Blocking  of  the  internal  carotid  within  the  skull. by  thrombosis  or  embolism 
is  followed  by  hemiplegia,  coma,  and  usually  death.  The  clot  is  rarely  con- 
fined to  the  carotid  itself,  but  spreads  into  its  branches  and  may  involve  the 
ophthalmic  artery, 

(e)  Middle  Cerebral. — This  is  the  vessel  most  commonly  involved,  and  if 
plugged  before  the  central  arteries  are  given  off,  permanent  hemiplegia  usu- 
ally follows  from  softening  of  the  internal  capsule.  Blocking  of  the  branches 
beyond  this  point  may  be  followed  by  hemiplegia,  whit'li  is  more  likely  to 
be  transient,  involves  chiefly  the  arm  and  face,  and  if  the  lesion  be  on  the 
left  side  is  associated  with  aphasia.  There  may  be  plugging  of  the  individual 
branches  passing  to  the  inferior  frontal  (producing  motor  aphasia  if  the 
disease  be  on  the  left  side),  to  the  anterior  and  posterior  central  g}Ti  (usually 
causing  total  hemiplegia),  to  the  supramarginal  and  angular  gyri  (giving  rise, 


996  DISEASES  OF  THE  NEEYOUS  SYSTEM 

if  the  thrombosis  be  on  the  left  side,  probably  without  exception  to  the  so-called 
visual  aphasia  (alexia),  usually  also  to  right-sided  hemianopsia),  or  to  the 
temporal  gyri  (in  which  event  with  left-sided  thrombosis  word-deafness 
results). 

(/)  Anterior  Cerebral. — No  symptoms  may  follow,  and  even  when  the 
branches  which  supply  the  paracentral  lobule  and  the  top  of  the  ascending 
convolutions  are  plugged  the  branches  from  the  middle  cerebral  are  usually 
able  to  effect  a  collateral  circulation  in  these  parts.  Monoplegia  of  the  leg 
may,  however,  result.  Hebetude  and  dullness  of  intellect  may  occur  with 
obstruction  of  the  vessel. 

Treatment  of  Cerebral  Haemorrhage  and  of  Softening-. — The  chief  diffi- 
culty in  deciding  upon  a  method  of  treatment  is  to  determine  whether  the 
apoplexy  is  due  to  haemorrhage  or  to  thrombosis  or  embolism.  The  patient 
should  be  placed  in  bed,  with  his  head  moderately  elevated  and  the  neck  free. 
He  should  be  kept  absolutely  quiet.  If  there  are  dyspnoea,  stertor,  and  signs  of 
mechanical  obstruction  to  respiration,  he  should  be  turned  on  his  side.  This 
lessens  the  liability  to  congestion  of  the  lungs.  Venesection  seems  to  be  indi- 
cated theoretically  in  cases  of  haemorrhage  with  high  pressure,  but  practically 
is  of  little  or  no  value  and  is  not  advisable.  As  Gushing  has  shown  experi- 
mentally, a  rapid  and  increasing  rise  of  arterial  tension  usually  indicates  an 
endeavor  to  counteract  an  increasing  intracranial  pressure,  in  this  case  due  to 
a  continuing  haemorrhage.  The  indication  under  these  circumstances  is  the 
relief  of  the  intracranial  pressure  by  craniotomy  and  removal  of  the  clot,  if 
this  is  possible.  This  is  particularly  applicable  in  subdural  haemorrhage. 
Horsley  and  Spencer,  on  experimental  grounds,  recommended  the  practice, 
formerly  employed  empirically,  of  compression  of  the  carotid,  particularly  in 
the  ingravescent  form.  An  ice-bag  may  be  placed  on  the  head  and  hot  bottles 
to  the  feet.  The  bowels  should  be  freely  opened,  either  by  calomel  or  elaterin. 
Counter-irritation  to  the  neck  or  to  the  feet  is  not  necessary.  Catheterization 
of  the  bladder  may  be  necessary,  especially  if  the  patient  remains  long  un- 
conscious. 

Special  care  should  be  taken  to  avoid  bed-sores;  and  if  bottles  are  used  to 
the  feet,  they  should  not  be  too  hot,  since  blisters  may  be  readily  caused  by  a 
much  lower  temperature  than  in  health.  Stimulants  are  not  necessary,  unless 
the  pulse  becomes  feeble  and  signs  of  collapse  supervene.  During  recovery 
the  patient  should  be  still  kept  entirely  at  rest,  even  in  the  mildest  attacks 
remaining  in  bed  for  at  least  fourteen  days.  The  ice-bag  should  still  be  kept 
to  the  head.  The  diet  should  be  light.  The  bowels  should  be  kept  freely 
open.  Attention  should  be  paid  to  the  position  occupied  by  the  paralyzed 
limb  or  limbs,  which  if  swollen  may  be  wrapped  in  cotton  batting  or  flannel 
Small  doses  of  iodide  (gr.  v,  0.3  gm.)  may  be  given. 

The  treatment  of  softening  from  thrombosis  or  embolism  is  very  unsat- 
isfactory. Venesection  is  not  indicated,  as  it  rather  promotes  clotting.  If,  as 
is  often  the  case,  the  heart's  action  is  feeble  and  irregular,  small  doses  of 
digitalis  may  be  given.  The  bowels  should  be  kept  open,  but  it  is  not  well 
to  purge  actively,  as  in  hsemorrhage. 

In  the  thrombosis  which  follows  syphilitic  disease  of  the  arteries,  and 
which  is  met  with  most  frequently  in  men  between  twenty  and  forty  (in  whom 
the  hemiplegia  often  sets  in  without  loss  of  consciousness),  active  antisyphilitic 


AFFECTION'S  OF  THE  BLOOD  VESSELS  997 

treatment  is  indicated ;  the  iodide  should  be  given  in  full  dosage.  Practically 
these  are  the  only  cases  of  hemiplegia  in  which  we  see  satisfactory  results  from 
treatment. 

Very  little  can  be  done  for  the  hemiplegia  which  remains.  The  damage  is 
too  often  irreparable  and  permanent,  and  it  is  very  improbable  that  iodide  of 
potassium,  or  any  other  remedy,  hastens  in  the  slightest  degree  Nature's  deal- 
ing with  the  blood  clot. 

The  paralyzed  limbs  may  be  gently  rubbed  once  or  twice  a  day,  and  this 
should  be  systematically  carried  out,  in  order  to  maintain  the  nutrition  of  the 
muscles  and  to  prevent  contractures  if  possible.  The  massage  should  not  be 
begun  uaitil  at  least  ten  days  after  the  attack.  The  rubbing  should  be  toward 
the  body,  and  should  not  be  continued  for  more  than  fifteen  minutes  at  a  time. 
After  the  lapse  of  a  fortnight,  or  in  severe  cases  a  month,  the  muscles  may 
be  stimulated  by  the  faradic  current;  faradic  stimulation  alternating  with 
massage,  especially  if  applied  to  the  antagonists  of  the  muscles  which  ordinarily 
undergo  contracture,  is  of  service,  even  when  there  can  be  but  little  hope  of 
any  return  of  voluntary  movement.  The  patient  should  be  encouraged  to 
perform  simple  movements  and  exercises  himself.  When  contractures  occur, 
electricity  at  intervals  may  be  of  some  benefit  along  with  passive  movement 
and  friction,  and  it  has  been  suggested  that  tendon  transplantation,  or  indeed 
cross  suture  of  nerves,  may  cause  some  improvement. 

In  a  case  of  complete  hemiplegia  the  friends  should  at  the  outset  be 
frankly  told  that  the  chances  of  full  recovery  are  slight.  Power  is  usually  re- 
stored in  the  leg  sufficient  to  enable  the  patient  to  get  about,  but  in  the 
majority  of  instances  the  finer  movements  of  the  hand  are  permanently  lost. 
The  general  health  should  be  looked  after,  the  bowels  regulated,  and  the 
secretions  of  the  skin  and  kidneys  kept  active.  In  permanent  hemiplegia  in 
persons  above  the  middle  period  of  life,  more  or  less  mental  weakness  is  apt 
to  follow  the  attack,  and  the-  patient  may  become  irritable  and  emotional. 

And,  lastly,  when  hemiplegia  has  persisted  for  more  than  three  months  and 
contractures  have  developed,  it  is  the  duty  of  the  physician  to  explain  to  the 
patient,  or  to  his  friends,  that  the  condition  is  past  relief,  that  medicines  and 
electricity  will  do  no  good,  and  that  there  is  no  possible  hope  of  cure. 

VI.     ANEUKISM  OF  THE  CEEEBRAL  AETEEIES 

Miliary  aneurisms  are  not  included,  but  reference  is  made  only  to  aneurism 
of  the  larger  branches.  The  condition  is  not  uncommon.  There  were  12 
instances  in  800  autopsies  in  the  Montreal  General  Hospital.  This  is  a  con- 
siderably larger  proportion  than  in  Newton  Pitt's  collection  from  Guy's  Hos- 
pital, 19  times  in  9,000  inspections. 

Etiology. — Males  are  more  frequently  affected  than  females.  Of  the  12 
cases  7  were  males.  The  disease  is  most  common  at  the  middle  period  of  life. 
One  of  the  cases  was  a  lad  of  six.  Pitt  describes  one  at  the  same  age.  The 
chief  causes  are  (a)  endarteritis,  either  simple  or  syphilitic,  which  leads  to 
weakness  of  the  wall  and  dilatation;  and  (6)  embolism.  These  aneurisms  are 
often  found  with  endocarditis.  Pitt,  in  his  study  of  the  subject,  concludes  that 
it  is  exceptional  to  find  cerebral  aneurism  unassociated  with  fungating  endo- 


998  DISEASES  OF  THE  XERYOUS  SYSTEM 

carditis.  The  embolus  disappears,  and  dilatation  follows  the  secondary  in- 
flammatory changes  in  the  coats  of  the  vessel. 

Morbid  Anatomy. — The  middle  cerebral  branches  are  most  frequently  in- 
volved. In  the  12  cases  the  distribution  was  as  follows :  Internal  carotid,  1 : 
middle  cerebral;,  5 ;  basilar,  3;  anterior  communicating,  3.  Except  in  one  case 
they  were  saccular  and  communicated  with  the  lumen  of  the  vessel  by  an 
orifice  smaller  than  the  circumference  of  the  sac.  In  154  cases  (statistics  of 
Lebert,  Durand,  and  Bartholow)  the  middle  cerebral  was  involved  in  44,  the 
basilar  in  41,  internal  carotid  in  23,  anterior  cerebral  in  14,  posterior  com- 
municating in  8,  anterior  communicating  in  8,  vertebral  in  7,  posterior  cere- 
bral in  6,  inferior  cerebellar  in  3  (Gowers).  The  size  of  the  aneurism  varies 
from  that  of  a  pea  to  that  of  a  walnut.  The  hemorrhage  may  be  entirely 
meningeal  with  very  slight  laceration  of  the  brain  substance,  but  the  bleeding 
may  be,  as  Coats  has  shown,  entirely  within  the  substance. 

Symptoms. — The  aneurism  may  attain  considerable  size  and  cause  no 
symptoms.  In  a  majority  of  the  cases  the  first  intimation  is  the  rupture  and 
the  fatal  apoplexy.  Distinct  symptoms  are  most  frequently  caused  by  aneu- 
rism of  the  internal  carotid,  which  may  compress  the  optic  nerve  or  the  com- 
missure, causing  neuritis  or  paralysis  of  the  third  nerve.  A  murmur  may  be 
audible.  Aneurism  in  this  situation  may  give  rise  to  irritative  and  pressure 
s3Tnptoms  at  the  base  of  the  brain  or  as  in  the  remarkable  case  reported  by 
Weir  Mitchell  and  Dercum  bilateral  temporal  hemianopia.- 

Aneurism  of  the  vertebral  or  of  the  basilar  may  involve  the  nerves  from 
the  fifth  to  the  twelfth.  A  large  sac  at  the  termination  of  the  basilar  may 
compress  the  third  nerves  or  the  crura. 

The  diagnosis  is,  as  a  rule,  impossible.  The  larger  sacs  produce  the  symp- 
toms of  tumor,  and  their  rupture  is  usually  fatal. 

VII.     THEOMBOSIS  OF  THE  CEREBRAL  SINUSES  AND  VEINS 

The  condition  may  be  primary  or  secondary.  Lebert  (1854)  and  Tonnele 
were  among  the  first  to  recognize  the  condition  clinically. 

Primary  thrombosis  of  the  sinuses  and  veins  is  rare.  It  occurs  (a)  in 
children,  particularly  during  the  first  six  months  of  life,  usualty  in  connec- 
tion with  diarrhoea.  Gowers  believed  that  it  is  of  frequent  occurrence,  and 
that  thrombosis  of  the  veins  is  not  an  uncommon  cause  of  infantile  hemiplegia. 

(h)  In  connection  with  chlorosis  and  anemia,  the  so-called  auioclithonous 
sinus-tJiromhosis.  Of  82  cases  of  thrombosis  in  chlorosis,  78  were  in  the  veins 
and  32  in  the  cerebral  sinuses.  The  longitudinal  sinus  is  most  frequently 
involved.  The  thrombosis  is  usually  associated  with  venous  thromboses  in 
other  parts  of  the  body,  and  the  patients  die,  as  a  rule,  in  from  one  to  three 
weeks,  but  both  Bristow  and  Buzzard,  Sen.,  report  recoveries. 

(c)  In  the  terminal  stages  of  cancer,  tuberculosis,  and  other  chronic  dis- 
eases thrombosis  may  occur  in  the  sinuses  and  cortical  veins.  To  the  coagu- 
lum  in  these  conditions  the  term  marantic  thrombus  is  applied. 

Secondary  thrombosis  is  much  more  frequent  and  follows  extension  of 
inflammation  from  contiguous  parts  to  the  sinus  wall.  The  common  causes 
are  disease  of  the  internal  ear,  fracture,  compression  of  the  sinuses  by  tumor, 


AFFECTIONS  OF  THE  BLOOD  VESSELS  999 

or  suppurative  disease  outside  the  skull,  particularl}^  erysipelas,  carbuncles,  and 
parotitis.  Tn  secondary  cases  the  lateral  sinus  is  most  frequently  involved. 
Of  57  fatal  cases  in  which  ear  disease  caused  death  with  cerebral  lesions,  there 
were  32  in  which  thrombosis  existed  in  the  lateral  sinuses  (Pitt.).  Tubercu- 
lous caries  of  the  temporal  bone  is  often  directly  responsible.  The  thrombus 
may  be  small,  or  fill  the  entire  sinus  and  extend  into  the  internal  jugular 
vein.  In  more  than  half  of  these  instances  the  thrombus  was  suppurating. 
The  disease  spreads  directly  from  the  necrosis  on  the  posterior  wall  of  the 
tympanum  by  way  of  the  petroso-mastoid  canal.  It  is  not  so  common  in  dis- 
ease of  the  mastoid  cells. 

Symptoms. — Primary  thronnhosls  of  the  longitudinal  sinus  may  occur  with- 
out exciting  symptoms  and  is  found  accidentally  at  the  post  mortem.  There 
may  be  mental  dullness  with  headache.  Convulsions  and  vomiting  may  occur. 
In  other  instances  there  is  nothing  distinctive.  In  the  chlorosis  cases  the  head 
symptoms  have,  as  a  rule,  been  marked.  Ball's  patient  was  dull  and  stupid, 
had  vomiting,  dilatation  of  the  pupils,  and  double  choked  disks.  Slight  paresis 
of  the  left  side  occurred.  An  interesting  feature  in  this  case  was  the  develop- 
ment of  swelling  of  the  left  leg.  In  the  cases  reported  by  Andrews,  Church, 
Tuckwell,  Isambard  Owen,  and  Wilks  the  patients  had  headache,  vomiting, 
and  delirium.  Paralysis  was  not  present.  In  Douglas  Powell's  case,  with 
similar  symptoms,  there  was  loss  of  power  on  the  left  side.  Bristowe 
reports  a  case  in  an  ansemic  girl  of  nineteen,  who  had  convulsions,  drowsiness, 
and  vomiting.  Tenderness  and  swelling  developed  in  the  position  of  the  right 
internal  jugular  vein,  and  a  few  days  later  on  the  opposite  side.  The  diagnosis 
was  rendered  defi.ni'te  by  the  occurrence  of  phlebitis  in  the  right  leg.  The 
patient  recovered. 

The  onset  of  such  symptoms  as  have  been  mentioned  in  an  ansemic  or 
chlorotic  girl  should  lead  to  the  suspicion  of  cerebral  thrombosis.  In  infants 
the  diagnosis  can  rarely  be  made.  Involvement  of  the  cavernous  sinus  may 
cause  oedema  about  the  eyelids  or  prominence  of  the  eyes. 

In  the  secondm-y  thrombi  the  symptoms  are  commonly  those  of  septi- 
csemia.  For  instance,  in  over  70  per  cent,  of  Pitt's  cases  the  mode  of  death 
was  by  pulmonary  pyaemia.  This  author  draws  the  following  important  con- 
clusions:  (1)  The  disease  spreads  oftener  from  the  posterior  wall  of  the 
middle  ear  than  from  the  mastoid  cells.  (2)  The  otorrhoea  is  generally  of 
some  standing,  but  not  always.  (3)  The  onset  is  sudden,  the  chief  symp- 
toms being  pyrexia,  rigors,  pains  in  the  occipital  region  and  in  the  neck, 
associated  with  a  septicaemic  condition.  (4)  Well-marked  optic  neuritis  may 
be  present.  (5)  The  appearance  of  acute  local  pulmonary  mischief  or  of 
distant  suppuration  is  almost  conclusive  of  thrombosis.  (6)  The  average 
duration  is  about  three  weeks,  and  death  is  generally  from  pulmonary  pyemia. 
The  chief  points  in  the  diagnosis  may  be  gathered  from  these  statements. 

Associated  with  thrombosis  of  the  lateral  sinus  there  may  ])e  venous  stasis 
and  painful  oedema  behind  the  ear  and  in  the  neck.  The  external  jugular 
vein  on  the  diseased  side  may  be  less  distended  than  on  the  opposite  side,  since 
owing  to  the  thrombus  in  the  lateral  sinus  the  internal  jugular  vein  is  less 
full  than  on  the  normal  side,  and  tlie  blood  from  the  external  jugular  can  flow 
more  easily  into  it. 


1000  DISEASES  OF  THE  XEEVOUS  SYSTEM 

Treatment. — In  marantic  individuals  stimulants  are  indicated.  The  posi- 
tion assumed  in  bed  should  favor  both  the  arterial  and  venous  circulation. 
The  clothing  should  not  restrict  the  neck,  and  care  should  be  taken  to  avoid 
tending  of  the  neck.  The  internal  administration  of  potassium  iodide  and 
calomel  has  been  recommended  in  the  autochthonous  forms,  but  no  treatment 
is  likely  to  be  of  any  avail. 

The  secondary  forms,  especially  those  following  upon  disease  of  the  middle 
ear,  are  often  amenable  to  operation,  and  many  lives  have  been  saved  by.  sur- 
gical intervention  after  extensive  sinus  thrombosis. 

YIII.     CEEEBEAL   PALSIES   OF   CHILDEEN 

Introduction. — There  are  three  great  groups :  I.  Those  due  to  pre-natal 
factors,  agenesia  cei'ebri,  microcephalus,  porencephaly,  congenital  cysts,  etc. 
II.  Natal  or  intrapurtum  which  includes  the  large  group  of  birth  palsies  due 
to  meningeal  hsemorrhage,  etc.,  and  III.  The  post-natal  group  of  which  by  far 
the  larger  proportion  is  due  to  acute  encephalitis  occurring  between  the  second 
and  sixth  year,  and  leading  to  hemiplegia.  In  all  these  cerebral  palsies  there 
are  three  important  factors:  (1)  Disturbance  in  some  degree  of  the  normal 
mental  development,  (2)  a  paralysis  disturbing  the  natural  and  normal  move- 
ment of  the  muscles,  and  (3)  spasticity  in  greater  or  less  degree. 

A  number  of  important  conditions  may  be  grouped  together  for  con- 
venience of  description — Aplasia  cerebri,  meningeal  haemorrhage,  spastic 
diplegia.  Little's  disease,  bilateral  athetosis,  etc. 

I.  Aplasia  (Agenesia)  cerebei. — This  is  due  to  failure  of  development 
of  the  cerebral  cortex  due  to  intra-uterine  conditions.  Xothing  abnormal  may 
be  noted  at  birth,  which  has  not  been  delayed  or  assisted  by  instruments.  The 
head  may  be  small  and  the  sutures  may  close  early.  Then  it  is  noticed  that 
the  child  does  not  develop  normally  in  the  use  of  the  muscles ;  the  movements 
are  irregular  but  not  athetoid.  The  head  wobbles,  the  child  does  not  sit  up, 
the  dentition  is  delayed,  and  by  the  time  the  second  year  is  reached,  the  failure 
of  development  is  evident.  The  arms  and  legs  may  become  stiff  and  the  condi- 
tion of  bilateral  spastic  rigidity  supervene.  More  often  the  limbs  remain 
relaxed,  the  child  may  learn  to  walk  in  an  awkward  way,  the  full  power  over 
the  movements  is  never  acquired,  and  the  child  settles  into  a  state  of  idiocy. 
Anatomically  the  brain  is  small,  the  convolutions  ill  developed,  and  there  may 
be  areas  of  lobular  sclerosis,  sometimes  the  remarkable  tuberose  form. 

II.  Meningeal  Hemorrhage — ivith  conservative  paraplegia  spastica 
cerehralis  (Heine);  Little's  disease;  Tetraplegia  spastica. — Heine,  one  of  the 
founders  of  modern  orthopedics,  recognized  the  cerebral  origin  of  many  of  the 
palsies  of  children;  and  Little  subsequently  called  attention  to  the  "influence 
of  abnormal  parturition,  difficult  labors,  premature  birth  and  asphyxia  on  the 
mental  and  physical  condition  of  the  child,  especially  in  relation  to  de- 
formities.'^ In  1885  Sarah  McNutt's  careful  studies  correlated  the  meningeal 
haemorrhage  with  the  subsequent  palsies  as  recognized  by  Heine  and  Little. 

The  causes  are:  (1)  Tearing  of  the  veins  due  to  pressure  on  the  head  in 
a  contracted  pelvis  and  in  forceps  delivery.  (2)  Asphyxia.  The  extreme 
stasis,  particularly  just  after  the  head  is  born,  causes  rupture  of  the  veins  at 


AFFECTION^S  OF  THE  BLOOD  VESSELS  1001 

the  point  of  entrance  to  the  longitudinal  sinus  tCushing).  (3)  The^hsemor- 
rhage  may  be  in  association  Avith  the  haeniorrhagic  condition  of  the  new 
born. 

The  haemorrhage  is  from  the  pia,  usually  over  the  cortex  and  widely  spread. 
It  may  be  more  on  one  side  than  the  other,  and  may  extend  over  the  cere- 
bellum. The  br&in  substance  may  be  softened  or  compressed,  and  present  foci 
of  hemorrhage.  The  hemorrhage  may  be  extradural,  and  even  extend  into 
the  spinal  cord.  First  birth,  premature  birth,  foot  presentation,  but  above  all, 
the  indiscriminate  and  careless  use  of  the  forceps  are  the  causal  factors.  There 
is  much  wisdom  in  the  dread  expressed  by  Shandy  Senior,  of  the  dangers  of 
compression  of  the  delicate  and  fine  web  of  the  brain. 

Symptoms.  (Early). — The  asphyxia  may  be  protracted.  Unusual  torpor, 
absence  of  the  natural  crying,  inability  to  take  the  breast,  flaccidity  of  the 
limbs,  sometimes  with  rigidity  on  one  side  or  convulsions,  unequal  and  dilated 
pupils,  and-  slow  breathing  with  signs  of  atelectasis  are  the  most  suggestive 
features.  There  may  be  haemorrhages  elsewhere  if  the  condition  is  associated 
with  the  hemorrhagic  disease  of  the  i^ewborn,  as  in  cases  reported  by  Green 
and  by  Margaret  Warwick.     Lumbar  puncture  may  show  blood. 

Symptoms  (Late).-^If  the  child  recovers,  nothing  may  be  noticed  for  a 
few  months.  Perhaps  there  are  convulsions.  The  first  thing  to  attract  atten- 
tion is  that  when  the  child  should  begin  to  walk  the  limbs  are  not  used 
readily,  and  on  examination  a  stiffness  of  the  legs  and  arms  is  found.  Even 
at  the  age  of  two  the  child  may  not  be  able  to  sit  up,  and  often  the  head  is 
not  well  supported  by  the  neck  muscles.  The  rigidity,  as  a  rule,  is  more 
marked  in  the  legs,  and  there  is  an  adductor  spasm.  When  supported  on  the 
feet,  the  child  either  rests  on  its  toes  and  the  inner  surface  of  the  feet,  with 
the  knees  close  together,  or  the  legs  ma}^  be  crossed.  The  stiffness  of  the 
upper  limbs  varies.  It  may  be  scarcely  noticeable  or  the  rigidity  may  be  as 
marked  as  in  the  legs.  When  the  spastic  condition  affects  the  arms  as  well  as 
the  legs,  we  speak  of  the  condition  as  diplegia  or  tetraplegia ;  when  the  legs 
alone  are  involved,  as  paraplegia.  There  seems  to  be  no  sufficient  reason  for 
considering  them  separately.  The  spasticity  is  probably  due  to  the  interrup- 
tion of  the  cortico-spinal  fibres  which  exercise  an  inhibitory  influence  on  the 
cells  of  the  anterior  horns.  Constant  irregular  movements  of  the  arms  are  not 
uncommon.  The  child  has  great  difficulty  in  grasping  an  object.  The  spasm 
and  weakness  may  be  more  evident  on  one  side  than  the  other.  The  mental 
condition  is,  as  a  rule,  defective  and  convulsive  seizures  are  common. 

III.  Acute  Sporadic  Excephalitis  of  Childrex  with  Coxsecutivh 
Hemiplegia. — This  is  an  acute  infection  characterized  by  fever,  convulsions, 
coma,  and  a  consecutive  hemiplegia.  It  is  possibly  the  sporadic  form  of,  or 
related  to,  epidemic  encephalitis  or  acute  polio-myelitis. 

History. — Heine  first  recognized  IlemipJegia  spastica  cerebralis,  separating 
it  from  other  forms  of  infantile  paralysis. 

Etiology. — Cases  of  hemiplegia  in  Children's  Homes  and  Institutions  for 
the  Feeble-Minded  fall  into  two  groups — (1)  a  large  one,  95  out  of  135  in 
Osier's  series,  in  which  the  disease  began  at  or  shortly  after  the  second  year, 
suddenly,  in  healthy  children;  and  (2)  a  small  one,  with  a  more  advanced 
age  of  onset,  comprising  cases  of  trauma,  heart  disease,  etc.     A  certain  num- 


1002  DISEASES  OF  THE  NERVOUS  SYSTEM 

ber  in  the  first  group  follow  the  acute  infections,  19  of  the  series.  The  inci- 
dence in  relation  to  acute  polio-myelitis  is  not  knovm.  There  did  not  appear 
to  be  an  increase  of  cases  during  the  recent  outbreaks.  Practically  nothing  is 
known  of  the  cause.  It  may  be  related  to  polio-myelitis,  but  it  is  a  much  less 
variable  malady. 

Patholo^. — The  motor  area  of  one  hemisphere  is  involved  in  an  acute 
hsemorrhagic  lesion,  the  convolutions  swollen  and  deeply  injected,  the  veins 
thrombosed,  and  on  section  the  substance  is  moist,  deep  red,  and  the  limitation 
of  the  gray  matter  ill  defined  or  obliterated.  The  picture  corresponds  with 
Strumpell's  encephalitis.  No  other  changes  of  moment  may  be  present.  Years 
later  the  cerebral  changes  depend  on  the  extent  of  the  original  lesion — sclerosis 
with  atrophy  of  the  motor  area  opposite  the  paralyzed  limb  is  the  most  com- 
mon, or  there  is  a  sub-meningeal  cyst. 

Symptoms. — Clinically  the  disease  is  very  sharply  defined.  A  perfectly 
healthy  child  between  the  second  and  fifth  years  has  a  convulsion,  or  a  series 
of  them,  with  fever,  possibly  vomiting,  and  then  becomes  comatose.  Pre- 
liminary indisposition  is  rare;  headache  may  be  complained  of,  but  without 
warning  the  fit,  as  a  rule,  is  the  first  symptom  of  the  disease.  The  fever 
may  reach  103°-104°.  There  may  be  marked  conjugate  deviation  of  the 
head  and  eyes:  the  pupils  are  usually  dilated,  and  may  be  unequal.  The 
head  may  be  retracted,  and  naturally  meningitis  is  suspected.  In  the  deep 
coma  the  hemiplegia  may  be — often  is — overlooked,  but  on  careful  examina- 
tion the  face  is  seen  to  be  drawn  and  the  arm  and  leg  of  one  side  limp  and 
paralyzed.  One  of  two  things  happens — either  the  coma  persists,  the  con- 
vulsions recur,  and  the  child  dies  from  the  second  to  the  fifth  day,  or  the 
fever  drops,  the  coma  lessens,  and  within  a  couple  of  days  the  child  seems 
quite  well,  but  one  side  is  paralyzed. 

Complete  recovery  is  rare.  The  face  and  arm  improve  rapidly,  the  leg  lags 
and  drags,  as  in  an  ordinary  hemiplegia.  Speech  if  disturbed  returns.  The 
chief  tragedy  is  a  failure  to  develop  mentally,  which  takes  so  many  of  these 
cases  into  the  Feeble-Minded  Homes.  The  arm  of  the  affected  side  may  not 
develop  but  remains  shorter  and  the  hand  smaller.  In  other  cases  recovery  is 
not  so  complete ;  both  leg  and  arm  are  spastic  and  the  latter  may  present  post- 
hemiplegic movements.  Sensation  is  not  disturbed.  A  very  distressing  feature 
is  the  onset  of  epilepsy,  which  may  be  in  the  form  of  pure  Jacksonian  fits, 
2)etit  mal,  or  general  seizures.    Of  the  135  cases  in  the  series,  41  had  epilepsy. 

Post-hemiplegic  Movements. — It  was  in  cases  of  this  sort  that  Weir 
Mitchell  first  described  the  post-hemiplegic  movements.  They  are  extremely 
common,  and  were  present  in  34  of  the  series.  There  may  be  either  slight 
tremor  in  the  affected  muscles,  or  incoordinate  choreiform  movements — the 
so-called  post-hemiplegic  chorea — or,  lastly. 

Athetosis. — This  is  a  remarkable  condition  in  which  there  is  a  combination 
of  spasm  with  the  most  extraordinary  bizarre  movements  of  the  muscles.  The 
patient  may  not  be  able  to  walk.  The  head  is  turned  from  side  to  side ;  there 
are  continual  irregular  movements  of  the  face  muscles,  and  the  mouth  is 
drawn  and  greatly  distorted.  The  extremities  are  more  or  less  rigid,  particu- 
larly in  extension.  On  the  slightest  attempt  to  move,  often  spontaneously, 
there  are  extraordinary  movements  of  the  arms  and  legs.     The  patients  are 


TUMOES,  INFECTIONS,  GEANULOMATA,  CYSTS  OF  BEAIN    1003 

often  unable  to  help  themselves  on  account  of  these  movements.  The  reflexes 
are  increased.    The  mental  condition  is  variable. 

Treatment. — Cases  with  asphyxia  and  convulsions  after  difficult  labors 
have  been  operated  upon  soon  after  birth  by  Cushing  and  others,  and  cortical 
clots  have  been  removed.  In  some  cases  there  has  been  a  complete  restoration 
to  health  and  the  usual  spastic  sequels  have  not  occurred.  As  the  child  grows, 
conditions  have  to  be  met — the  mental,  requiring  the  care  and  training  neces- 
sary for  the  grade  of  feeble-mindedness,  and  the  orthopedic  treatment  of  the 
spasticity,  for  which  much  can  be  done.  The  educational  care  in  institutions 
has  shown  how  much  patient  training  is  able  to  help  the  development  of  these 
defective  children.  In  all  these  patients  the  degree  of  development  depends 
very  much  upon  the  thorough,  painstaking  and  systematic  training  of  their 
minds  and  muscles. 

Surgically  much  may  be  done  by  tenotomy  and  the  use  of  proper  apparatus. 
For  the  relief  of  the  spasticity  operations  on  the  brain  are  rarely  of  any  help. 
Better  results  have  been  obtained  by  injecting  drugs  into  the  motor  nerves  or 
by  their  resection,  and  where  there  is  a  high  grade  of  bilateral  spasticity,  the 
resection  of  the  posterior  nerve  roots  appears  sometimes  to  have  been  helpful. 


IV.    TUMORS,  INFECTIONS,  GRANULOMATA,  AND  CYSTS 

OF  THE  BRAIN 

The  following  are  the  most  common  varieties  of  new  growths  within  the 
cranium : 

Infectious  Granulomata. —  (a)  Tubercle  may  form  large  or  small  growths, 
usually  multiple.  Tuberculosis  of  the  glands  or  bones  may  coexist,  but  the 
tuberculous  disease  of  the  brain  may  occur  in  the  absence  of  other  clinically 
recognizable  tuberculous  lesions.  The  disease  is  most  frequent  early  in  life. 
Three-fourths  of  the  cases  occur  under  twenty,  and  one-half  of  the  patients 
are  under  ten  years  of  age  (Cowers).  Of  300  cases  of  tumor  in  persons 
under  nineteen  collected  from  various  sources  by  Starr,  152  were  tubercle. 
The  nodules  are  most  numerous  in  the  cerebellum  and  about  the  base. 

(&)  Syphiloma  is»most  commonly  found  on  the  cortex  cerebri  or  about  the 
pons.  The  tumors  are  superficial,  attached  to  the  arteries  or  the  meninges, 
and  rarely  grow  to  a  large  size.  They  may  be  multiple.  A  gummatous 
meningitis  of  the  base  is  common  and  in  this  process  the  oculomotor  nerves 
are  often  affected.  The  motor  nerves  of  the  eye  are  particularly  prone  to 
syphilitic  infiltration,  and  ptosis  and  squint  are  common.  The  pituitary  body 
may  be  involved  with  symptoms  suggestive  of  diabetes  insipidus. 

Tumors. —  (c)  Glioma  and  Neuroglioma. — They  may  be  firm  and  hard, 
almost  like  an  area  of  sclerosis,  and  not  sharply  defined  or  soft  and  with 
hsemorrhages.  They  persist  remarkably  for  many  years.  Klebs  called  atten- 
tion to  the  occurrence  of  elements  in  them  not  unlike  ganglion-cells.  Tumors 
of  this  character  may  contain  the  "Spinnen"  or  spider  cells ;  enormous  spindle- 
rhaped  cells  with  single  large  nuclei;  cells  like  the  ganglion-cells  of  nerve- 
centres  with  nuclei  and  one  or  more  processes;  and  translucent,  band-like 
fibres,  tapering  at  each  end,  which  result  from  a  vitreous  or  hyaline  trans- 


1004  DISEASES  OF  THE  NERVOUS  SYSTEM 

formation  of  the  large  spindle-cells.     A  separate  type  is  recognizable,  in  which 
the  cells  resemble  the  ependymal  epithelium. 

(d)  Fibrosarcoma  (endothelioma)  occurs  most  commonly  in  the  mem- 
branes covering  the  hemispheres  or  brain  stem,  and  for  a  long  time  may  cause 
injury  by  its  compression  effects  alone.  Tumors  of  this  kind  are  particularly 
common  in  the  cerebello-pontine  recess.  When  sarcoma  originates  in  the 
brain  substance  it  may  become  one  of  the  largest  and  most  diffusely  infiltrating 
of  intracranial  growths.  When  meningeal  in  origin,  it  is  the  form  of  tumor 
most  amenable  to  surgical  treatment. 

(e)  Carcinoma  may  be  secondary  to  cancer  in  other  parts.  It  is  seldom 
primary.  Occasionally  cancerous  tumors  have  been  found  in  symmetrical 
parts  of  the  brain. 

(/)  Other  varieties  are  fibroma,  usually  developing  from  the  membranes; 
bony  tumors,  which  grow  sometimes  from  the  falx,  psammoma,  cholesteatoma, 
and  angioma.  Eatty  tumors  are  occasionally  found  on  the  corpus  callosum. 
There  is  a  remarkable  condition,  originally  described  by  Eokitansky,  of 
brownish-black  pigmentation  of  the  brain,  partly  diffuse,  partly  focal,  associ- 
ated with  pigmented  nasvi  of  the  skin.  The  nsevi  in  the  brain  are  in  no  sense 
a  metastasis  from  the  skin,  but  are  benign  tumors  arising  primarily  ( Mac- 
La  chlan). 

Cysts. — These  occur  between  the  membranes  and  the  brain,  as  a  result  of 
hgemorrhage  or  of  softening.  Porencephalus  is  a  sequel  of  congenital  atrophy 
or  of  haemorrhage,  or  may  be  due  to  a  developmental  defect.  Hydatid  cysts 
have  been  referred  to  in  the  section  on  parasites.  An  interesting  variety  of 
cyst  is  that  which  follows  severe  injury  to  the  skull  in  early  life.  Gliomata 
often  undergo  cystic  degeneration.     Dermoid  cyst  has  been  described. 

Site.; — A  majority  of  all  tumors  occur  in  the  cerebrum  and  especially  in 
the  centrum  ovale.  The  cerebellum,  pons,  and  membranes  are  next  most  often 
involved.  Glioma  is  more  common  in  the  hemispheres  and  grows  slowly.  It 
is  usually  single.  Tubercles  are  usually  multiple.  Secondary  sarcoma  and 
carcinoma  are  often  multiple. 

Symptoms.^GENERAL. — The  following  are  the  most  important:  Head- 
ache, either  dull,  aching,  and  continuous,  or  sharp,  stabbing,  and  paroxysmal. 
It  may  be  diffuse  or  limited  to  the  back  or  front.  When  in  the  back  of  the 
head  it  may  extend  down  the  neck  (especially  in  tumors  in  the  posterior  fossa), 
and  when  in  the  front  it  may  be  accompanied  with  neura^.gic  pains  in  the  face. 
Occasionally  the  pain  may  be  very  localized  and  associated  with  tenderness  on 
pressure. 

Choked  disk  (optic  neuritis)  should  be  looked  for  in  every  patient  present- 
ing cerebral  symptoms,  for  it  may  be  present  without  impairment  of  vision. 
Loss  of  visual  acuity  usually  indicates  that  optic  atrophy  has  set  in.  It  is 
usually  double,  but  occasionally  is  found  in  only  one  eye.  Growths  may  attain 
considerable  size  without  producing  optic  neuritis.  On  the  other  hand,  it 
may  occur  with  a  very  small  tumor,  when  this  tumor  is  so  situated  as  to 
cause  internal  hydrocephalus.  J.  A.  Martin,  from  an  extensive  analysis  of  the 
literature  with  reference  to  the  localizing  value,  concludes:  When  there  is  a 
difference  in  the  amount  of  the  neuritis  in  each  eye  it  is  more  than  twice  as 
probable  that  the  tumor  is  on  the  side  of  the  most  marked  neuritis.  It  is  con- 
stant in  tumors  of  the  corpora  qnadrigemina,  present  in  89  per  cent,  of  cere- 


TUMORS,  INFECTIONS,  GRANULOMATA,  CYSTS  OF  BRAIN    lOOo 

bellar  tumors,  and  absent  in  nearly  two  thirds  of  the  cases  of  tumor  of  the 
pons,  medulla,  and  of  the  corpus  collosum.  It  is  least  frequent  in  cases  of 
tuberculous  tumor;  most  common  in  cases  of  glioma  and  cystic  tumors. 

Paton  and  Holmes  report  upon  the  eyes  of  700  cases  of  cerebral  tumor, 
concluding  that  the  essential  feature  of  the  associated  optic  neuritis  is  cedema, 
and  in  60  eyes  examined  histologically  the  one  unfailing  change  was  acute 
oedema,  the  origin  of  which  they  attribute  to  the  venous  engorgement. 

Vomiting  is  a  common  feature  and,  with  headache  and  optic  neuritis, 
makes  up  the  characteristic  clinical  picture  of  cerebral  tumor.  An  important 
point  is  the  absence  of  definite  relation  to  the  meals.  A  chemical  examination 
shows  that  the  vomiting  is  independent  of  digestive  disturbances.  It  may 
be  very  obstinate,  particularly  in  growths  of  the  cerebellum  and  the  pons. 

Giddiness  is  often  an  early  symptom,  on  rising  suddenly  or  turning  quickly. 

Mental  Symptoms. — These  are  usually  of  progressive  mental  weakness  lead- 
ing to  dementia.  Mania,  depressive  conditions,  delusions,  hallucinations,  con- 
fusional  states,  paranoia,  and  general  paralysis  have  all  been  described.  The 
patient  may  act  in  an  odd,  unnatural  manner,  or  there  may  be  stupor  and 
heaviness.  The  patient  may  be  emotional  or  silly,  or  there  are  symptoms 
resembling  hysteria. 

Convulsions,  either  general  and  resembling  true  epilepsy  or  localized  (Jack- 
sonian)  in  character.  Seizures  beginning  with  a  gustatory  or  olfactory  aura 
are  common  with  tumors  originating  in  the  infundibular  region.  There  may 
be  slowing  of  the  pulse,  as  in  all  cases  of  increased  intracranial  pressure. 

Localizing  Symptoms. — The  smaller  the  tumor  and  the  less  marked  the 
general  symptoms  of  cerebral  compression  the  more  likely  is  it  that  any  focal 
symptoms  occurring  are  of  direct  origin.  Localizing  features  are  often  mis- 
leading. A  frontal  tumor  may  have  cerebellar  features  due  to  increased  in- 
tercranial  pressure  wdiich  has  compressed  the  cerebellum  against  the  base  of 
the  skull.  The  characteristic  Barany  cerebellar  tests  have  been  present  with 
temporal  lobe  tumors. 

{a)  Central  Motor  Area. — The  symptoms  are  either  irritative  or  destruc- 
tive in  character.  Irritation  in  the  lower  third  may  produce  spasm  in  the 
muscles  of  the  face,  in  the  angle  of  the  mouth,  or  in  the  tongue.  The  spasm 
with  tingling  may  be  strictly  limited  to  one  muscle  group  before  extending  to 
others,  and  this  Seguin  terms  the  signal  symptom.  The  middle  third  of  the 
motor  area  contains  the  centres  controlling  the  arm,  and  here,  too,  the  spasm 
may  begin  in  the  fingers,  in  the  thumb,  in  the  muscles  of  the  wrist,  or  in  the 
shoulder.  In  the  upper  third  of  the  motor  areas  the  irritation  may  produce 
spasrn  beginning  in  the  toes,  in  the  ankles,  or  in  the  muscles  of  the  leg.  In 
many  instances  the  patient  can  determine  accurately  the  point  of  origin  of 
the  spasm,  and  there  are  important  sensory  disturbances,  such  as  numbness 
and  tingling,  which  may  be  felt  first  at  the  region  affected. 

In  all  cases  it  is  important  to  determine,  first,  the  point  of  origin,  the 
signal  symptom;  second,  the  order  or  march  of  the  spasm;  and  third,  the 
subsequent  condition  of  the  parts  first  aifected,  whether  it  is  a  state  of  paresis 
or  anaesthesia. 

Destructive  lesions  in  the  motor  zone  cause  paralysis,  often  preceded  by 
local  convulsive  seizures;  there  may  be  a  monoplegia,  as  of  the  leg,  and  con- 
vulsive seizures  in  the  arm.  often  due  to  irritation.     Tumors  in  the  neigh- 


1006  DISEASES  OF  THE  NERVOUS  SYSTEM 

borhood  of  the  motor  area  may  cause  localized  spasms  and  subsequently,  as 
the  centres  are  invaded  by  the  growth,  paralysis  occurs.  With  tumors  in  the 
left  hemisphere  the  speech  mechanism  is  apt  to  be  involved  if  the  transverse 
temporal  gyrus  or  the  third  frontal  convolution  and  their  connecting  path  are 
implicated. 

(&)  Prefrontal  Region. — Neither  motor  nor  sensory  disturbance  may  be 
present.  The  general  symptoms  are  often  well  marked.  The  most  striking 
feature  of  growths  in  this  region  is  mental  torpor  and  gradual  imbecility. 
Particularly  when  the  left  side  is  involved  mental  characteristics  may  be 
greatly  altered.  In  its  extension  downward  the  tumor  may  involve  on  the  left 
side  the  lower  frontal  convolution  and  produce  aphasia,  or  in  its  progress 
backward  cause  irritative  or  destructive  lesions  of  the  motor  area.  Exophthal- 
mos on  the  side  of  the  tumor  may  occur  and  be  helpful  in  diagnosis. 

(c)  Tumors  in  the  parieto-occipital  lohe,  particularly  on  the  right  side,  may 
grow  to  a  large  size  without  causing  any  symptoms.  There  may  be  word- 
blindness  and  mind-blindness  when  the  left  angular  gyrus  and  its  underlying 
white  matter  are  involved,  and  paraphasia.  Astereognosis  may  accompany 
growths  in  the  superior  parietal  region. 

{d)  Tumors  of  the  occipital  lobe  produce  hemianopia,  and  a  bilateral  lesion 
may  produce  blindness.  Tumors  in  this  region  on  the  left  hemisphere  may 
be  associated  with  word-blindness  and  mind-blindness.  In  all  cases  of  tumor 
a  careful  study  should  be  made  of  the  fields  of  vision.  In  addition  to  the 
lateral  hemianopia  there  may  be  remarkable  visual  hallucinations,  and  in 
tumors  of  the  left  occipital  lobe  dissociation  of  the  color  sense  and  inability 
to  find  the  proper  colors  of  various  objects  presented. 

(e)  Tumors  in  the  temporal  lohe  may  attain  a  large  size  without  produc- 
ing symptoms.  In  their  growth  they  involve  the  lower  motor  centres.  On 
the  left  side  involvement  of  the  transverse  temporal  gyri  (auditory  sense  area) 
may  be  associated  with  word-deafness. 

(/)  Tumors  growing  in  the  neighborhood  of  the  basal  ganglia  produce 
hemiplegia  from  involvement  of  the  internal  capsule.  Limited  growths  in 
either  the  nucleus  caudatus  or  the  nucleus  lentiformis  of  the  corpus  striatum 
do  not  necessarily  cause  paralysis.  Tumors  in  the  thalamus  opticus  may  also, 
when  small,  cause  no  symptoms,  but,  increasing,  they  may  involve  the  fibres 
of  the  sensory  portion  of  the  internal  capsule,  producing  hemianopia  and 
sometimes  hemiangesthesia.  Growths  in  this  situation  are  apt  to  cause  early 
optic  neuritis,  and,  growing  into  the  third  ventricle,  may  cause  a  distention 
of  the  lateral  ventricles.  What  has  been  termed  the  thalamic  syndrome  may 
be  present — hemianesthesia  to  pain,  touch  and  temperature,  with  the  loss  of. 
deep  sensibility.  With  this  there  may  be  a  very  remarkable  type  of  pain, 
involving  the  hand  and  arm  and  the  foot  and  leg,  on  the  affected  side,  a  sense 
of  burning  discomfort  rather  than  sharp  pain.  Ataxic  features  are  usually 
present  and  astereognosis.  Motor  hemiplegia  may  be  present,  and  it  is  unac- 
companied by  contractures  (Dana)." 

Growths  in  the  corpora  quadrig emina  are  rarely  limited,  but  most  com- 
monly involve  the  crura  cerebri  as  well.  Ocular  symptoms  are  marked.  The 
pupil  reflex  is  lost  and  there  is  nystagmus.  In  the  gradual  growth  the  third 
nerve  is  involved  as  it  passes  through  the  crus,  in  which  case  there  will  be 


TUMOES,  INFECTIONS,  GEANULOMATA,  CYSTS  OF  BEAIN    1007 

oculo-motor  paralysis  on  one  side  and  hemiplegia  on  the  other,  a  combination 
almost  characteristic  of  unilateral  disease  of  the  cms. 

(g)  Tumors  of  the  pons  and  medulla.  The  symptoms  are  chiefly  those 
of  pressure  upon  the  nerves  emerging  in  this  region.  In  disease  of  the  pons 
the  nerves  may  be  involved  alone  or  with  the  pyramidal  tract.  Of  52  cases 
analyzed  by  Mary  Putnam  Jacobi,  in  13  the  cerebral  nerves  were  involved 
alone,  in  13  the  limbs  were  affected,  and  in  26  there  were  hemiplegia  and  in- 
volvement of  the  nerves.  In  22  of  the  latter  there  was  alternate  paralysis — 
i.  e.,  involvement  of  the  nerves  on  one  side  and  of  the  limbs  on  the  opposite 
side.  In  4  cases  there  were  no  motor  symptoms.  In  tuberculosis  (or  syphilis) 
a  growth  at  the  inferior  and  inner  aspects  of  the  crus  may  cause  paralysis  of 
the  third  nerve  on  one  side,  and  of  the  face,  tongue,  and  limbs  on  the  opposite 
side  (syndrome  of  Weber).  A  tumor  growing  in  the  lower  part  of  the  pons 
usually  involves  the  sixth  nerve,  producing  internal  strabismus,  the  seventh 
nerve,  producing  facial  paralysis,  and  the  auditory  nerve,  causing  deafness. 
Conjugate  deviation  of  th*  eyes  to  the  side  opposite  that  on  which  there  is 
facial  paralysis  also  occurs.  When  the  motor  cerebral  nerves  are  involved  the 
paralyses  are  of  the  peripheral  type  (lower  segment  paralyses). 

Tumors  of  the  medulla  may  involve  the  cerebral  nerves  alone  or  cause 
in  some  instances  a  combination  of  hemiplegia  with  paralysis  of  the  nerves. 
Paralyses  of  the  nerves  are  helpful  in  topical  diagnosis,  but  the  fact  must  not 
be  overlooked  that  one  or  more  of  the  cerebral  nerves  may  be  paralyzed  as 
'a  result  of  a  much  increased  general  intracranial  pressure.  Signs  of  irritation 
in  the  ninth,  tenth,  and  eleventh  nerves  are  usually  present,  and  produce 
difficulty  in  .swallowing,  irregular  action  of  the  heart,  irregular  respiration, 
vomiting,  and  sometimes  retraction  of  the  head  and  neck.  The  hypoglossal 
nerve  is  least  often  affected.  The  gait  may  be  unsteady  or,  if  there  is  pressure 
on  the  cerebellum,  ataxic.  Occasionally  there  are  sensory  symptoms,  numb- 
ness and  tingling.     Toward  th§  end  convulsions  may  occur. 

(h)  Tumors  of  the  cerebellum  may  be  latent,  but  they  usually  give  rise  to 
very  characteristic  symptoms,  headache  in  the  occipital  region,  giddiness,  inco- 
ordination, but  there  is  nothing  definite  in  the  direction  of  the  swaying,  and 
early  optic  neuritis.     They  may  be  intracerebellar  or  extracerebellar. 

Tumors  or  enlargements  of  the  pituitary  gland  itself,  or  growths  from  a 
congenital  anlage  in  its  neighborhood  which  implicate  the  pituitary  gland 
secondarily,  are  very  common.  The  congenital  tumors  arise  presumably  from 
developmental  faults,  and  show  either  a  teratomatous  character  or  are  solid 
or  cystic  tumors  with  squamous  epithelium,  often  attaining  adamantine  char- 
acteristics. The  most  common  tumor  is  a  so-called  struma  (malignant  ade- 
noma) of  the  gland  proper.  There  are  characteristic  signs  of  pressure  upon 
the  neighborhood  structures,  bitemporal  hemianopia  being  a  frequent  though 
not  invariable  feature.  These  lesions  may  occur  in  patients  who  have  suf- 
fered from  acromegaly,  or  in  those  who  show  signs  of  glandular  deficiency  or 
dyspituitarism,  and  in  whom  there  may  or  may  not  be  suggestive  acrome- 
galic tendencies.    The  X-rays  are  most  useful  in  diagnosis. 

Diagnosis. — From  the  general  symptoms  alone  the  existence  of  tumor  may 
be  determined,  for  the  combination  of  headache,  optic  neuritis,  and  vomiting 
is  distinctive.  As  pointed  out  by  E.  T.  Williamson,  progressive  hemiplegia, 
without  other  symptoms,  a  paralysis,  which  gradually  becomes  more  marked 


1008  DISEASES  OF  THE  NERVOUS  SYSTEM 

day  by  day  and  week  by  week,  is  almost  pathognomonic,  even  in  the  absence  of 
optic  neuritis,  headache,  and  vomiting.  The  two  exceptions  to  this  rule  appear 
to  be  in  cerebral  abscess,  and  in  rare  instances  a  polio-encephalitis.  It  must 
not  be  forgotten  that  severe  headache  and  neuro-retinitis  may  be  caused  by 
nephritis.  The  localization  must  be  gathered  from  the  consideration  of  the 
symptoms  and  from  the  data  given  in  the  section  on  Topical  Diagnosis.  Mis- 
takes are  most  likely  to  occur  in  connection  with  uraemia,  hysteria,  vascular 
lesions,  abscess,  serous  meningitis,  hydrocephalus,  and  general  paresis;  but 
careful  consideration  of  all  the  circumstances  of  the  case  usually  enables  the 
practitioner  to  avoid  error.  Rontgen  ray  shadows  are  noticed  with  calcification 
in  the  tumor  or  when  there  is  atrophy  or  thickening  of  the  bones  of  the  skull 
or  the  characteristic  changes  in  the  sella  turcica  in  pituitary  tumors.  The 
pineal  gland,  which  so  often  shows  gritty  deposits,  may  be  indicated  by  a 
shadow.  In  about  45  of  100  cases  of  brain  tumor  the  X-ray  picture  was  of  help 
in  the  diagnosis  (Dandy). 

Pro^osis. — Syphilitic  tumors  alone  are  amenable  to  medical  treatment. 
Tuberculous  growths  occasionally  cease  to  grow  and  become  calcified.  The 
gliomata  and  fibromata,  particularly  when  the  latter  grow  from  the  mem- 
branes, may  last  for  years.  The  more  rapidly  growing  sarcomata  usually 
prove  fatal  in  from  six  to  eighteen  months.  Death  may  be  sudden,  particularly 
in  growths  near  the  medulla ;  more  commonly  it  is  due  to  coma  in  consequence 
of  gradual  increase  in  the  intracranial  pressure. 

Treatment — (a)  Medical. — A  AVassermann  test  of  the  blood  and  cere- 
brospinal fluid  should  always  be  made  before  antiluetic  measures  are  insti- 
tuted. It  must  not  be  overlooked  that  vigorous  treatment  with  potassium 
iodide  often  causes  a  temporary  amelioration  of  pressure  symptoms  due  to  a 
glioma,  so  that  the  therapeutic  test  is  not  a  dependable  one.  If  syphilis  is 
proved  the  iodide  of  potassium  and  mercury  should  be  given.  Arsphenamine  is 
sometimes  given  in  repeated  small  doses.  Nowhere  do  we  see  more  brilliant 
therapeutical  effects  than  in  certain  cases  of  cerebral  gummata.  The  iodide 
should  be  given  in  increasing  doses.  In  tuberculous  tumors  the  outlook  is  less 
favorable,  though  instances  of  cure  are  reported,  and  there  is  post  mortem 
evidence  to  show  that  the  solitary  tuberculous  tumors  may  undergo  changes 
and  become  obsolete.  A  general  tonic  treatment  .is  indicated  in  these  cases. 
The  headache  usually  demands  prompt  treatment.  Iodide  of  potassium  in  full 
doses  sometimes  gives  marked  relief.  An  ice-cap  for  the  head  or,  in  the  occi- 
pital headache,  the  application  of  the  Paquelin  cautery  may  be  tried.  The 
bromides  are  not  of  much  use  in  the  headache  from  this  cause,  and,  as  the 
last  resort,  morphia  must  be  given.  Eor  the  convulsions  bromide  of  potas- 
sium is  of  little  service. 

(&)  Surgical. — Many  tumors  of  the  brain  have  been  successfully  re- 
moved. Though  the  percentage  of  cases  in  which  total  enucleation  is  possible 
is  doubtless  small,  yet  in  all  cases  marked  amelioration  of  the  pressure  symp- 
toms is  possible  by  surgical  measures.  It  is  important  that  they  should  be 
instituted  early,  even  in  the  absence  of  localizing  symptoms,  for  the  sake  of 
preserving  vision.  The  most  advantageous  cases  are  the  localized  fibromata 
and  sarcomata  growing  from  the  dura  and  only  compressing  the  brain  sub- 
stance. There  have  been  numerous  successful  operations  with  removal  of 
growths  from  the  cerebellum  and  cerebello-pontine  recess.     The  safety  with 


INFLAMMATION  OF  THE  BEAIN  1009 

which  the  exploratory  operation  can  be  made  warrants  it  in  all  doubtful  cases. 
For  two  objects  the  decompression  operation  may  be  performed,  to  relieve  the 
headache,  which  it  sometimes  does  promptly  and  permanently,  and  to  save 
sight.  It  is  now  very  generally  practised  and  the  reduction  of  the  greatly 
increased  intracranial  pressure  may  cause  the  choked  disk  to  subside  and  the 
risk  of  subsequent  atrophy  is  much  diminished. 


V.    INFLAMMATION  OF  THE  BRAIN 

I.     ACUTE    ENCEPHALITIiS 

A  focal  or  diffuse  inflammation  of  the  brain  substance,  usually  of  the  gray 
matter  (polio-encephalitis),  is  met  with  (a)  as  a  result  of  trauma;  (b)  in  cer- 
tain intoxications,  alcohol,  food  poisoning,  and  gas  poisoning;  (c)  follow- 
ing the  acute  infections;  and  (d)  as  one  of  the  varieties  of  polio-myelo-en- 
cephalitis.  The  anatomical  features  are  those  of  an  acute  hasmorrhagic  polio- 
encephalitis, corresponding  in  histological  details  with  acute  polio-myelitis. 
Focal  forms  are  seen  in  ulcerative  endocarditis,  in  which  the  gray  matter  may 
present  deep  ha^morrhagic  areas,  firmer  than  the  surrounding  tissue.  In 
the  fevers  there  may  be  more  extensive  regions,  involving  two  or  three  con- 
volutions. This  acute  jDolio-encephalitis  superior  was  thought  by  Striimpell  to 
be  the  essential  lesion  in  infantile  hemiplegia.  Localizing  symptoms  are  usu- 
ally present,  though  they  may  be  obscured  in  the  severity  of  the  general  in- 
fection. The  most  typical  encephalitis  accompanies  the  meningitis  in  cerebro- 
spinal fever. 

In  acute  mania,  in  delirium  tremens,  in  chorea  insaniens,  in  the  maniacal 
form  of  exophthalmic  goitre,  and  in  the  so-called  cerebral  forms  of  the  malig- 
nant fevers  the  gray  cortex  is  deeply  congested,  moist,  and  swollen,  and  with 
the  finer  methods  of  research  will  probably  show  changes  which  may  be  classed 
as  encephalitis. 

The  symptoms  are  not  very  definite.  In  severe  forms  they  are  those  of 
an  acute  infection;  some  cases  have  been  mistaken  for  typhoid  fever.  The 
onset  may  be  abrupt  in  an  individual  apparently  healthy.  Other  eases  have 
occurred  in  the  convalescence  from  the  fevers,  particularly  influenza.  One  of 
J.  J.  Putnam's  cases  followed  mumps.  The  general  symptoms  are  those  which 
accompany  all  severe  acute  affections  of  the  brain — headache,  somnolence, 
coma,  delirium,  vomiting,  etc.  The  local  symptoms  are  very  varied,  depend- 
ing on  the  extent  of  the  lesions,  and  may  be  irritative  or  paralytic.  Usually 
fatal  within  a  few  weeks,  cases  may  drag  on  for  weeks  or  months  and  recover, 
generally  with  paralysis. 

TI.     ABCESS  OF  THE  BRAIN 

Definition. — Purulent  encephalitis  with  abscess  formation  the  result  of 
infection  by  micro-organisms. 

Etiology. — Suppuration  of  the  brain  substance  is  rarely  primary,  but 
results,  as  a  rule,  from  extension  of  inflammation  from  neighboring  parts 
or  infection  from  a  distance  through  the  blood.  The  question  of  idiopathic 
brain  abscess  need  scarcely  be  considered,  thougli  instances  occur  in  which  it  is 
difficult  to  assign  a  cause.    There  are  three  important  etiological  factors. 


1010  DISEASES  OF  THE  NERVOUS  SYSTEM 

(a)  Trauma.  Falls  upon  the  head  or  blows,  with  or  without  abrasion  of 
the  skin.  More  commonly  it  follows  fracture  or  punctured  wounds.  In  this 
group  meningitis  is  frequently  associated  with  the  abscess.  Simple  trauma 
or  concussion  does  not  produce  abscess  but  organisms  may  enter  through  a 
laceration  of  the  base  opening  one  of  the  many  sinuses. 

(&)  By  far  the  most  important  infective  foci  are  those  which  arise  in 
direct  extension  from  disease  of  the  middle  ear,  of  the  mastoid  cells,  or  of  the 
accessory  nasal  sinuses.  From  the  roof  of  the  mastoid  antrum  the  infection 
readily  passes  to  the  sigmoid  sinus  and  induces  an  infective  thrombosis.  In 
other  instances  the  dura  becomes  involved,  and  a  subdural  abscess  is  formed, 
which  may  readily  involve  the  arachnoid  or  the  pia  mater.  In  another  group 
the  inflammation  extends  along  the  lymph  spaces,  or  the  thrombosed  veins, 
into  the  substance  of  the  brain  and  causes  suppuration.  Macewen  thinks  that 
without  local  areas  of  meningitis  the  infective  agents  may  be  carried  through 
the  lymph  and  blood  channels  into  the  cerebral  substance.  Infection  which  ex- 
tends from  the  roof  of  the  tympanic  cavity  is  most  likely  to  be  followed  by 
abscess  in  the  temporal  lobe,  while  infection  extending  from  the  mastoid  cells 
causes  most  frequently  sinus  thrombosis  and  cerebellar  abscess. 

(c)  In  septic  processes.  Abscess  of  the  brain  is  not  often  found  in  pyse- 
mi^.  In  ulcerative  endocarditis  multiple  foci  of  suppuration  are  common. 
Localized  bone  disease  and  suppuration  in  the  liver  are  occasional  causes.  Cer- 
tain inflammations  in  the  lungs,  particularly  bronchiectasis,  may  be  followed 
by  abscess.  It  is  an  occasional  complication  of  empyema.  Abscess  of  the 
brain  may  follow  the  specific  fevers.  The  largest  number  of  cases  occur  be- 
tween the  twentieth  and  fortieth  years,  and  the  condition  is  more  frequent  in 
men  than  in  women.  In  children  under  five  years  of  age,  the  chief  causes 
are  otitis  media  and  trauma. 

Morbid  Anatomy. — The  abscess  may  be  solitary  or  multiple,  diffuse  or  cir- 
cumscribed. Practically  any  one  of  the  different  varieties  of  pyogenic  bac- 
teria may  be  concerned.  The  bacteriological  examination  often  shows  different 
varieties.  Occasionally  cultures  are  sterile.  In  the  acute,  rapidly  fatal  cases 
following  injury  the  suppuration  is  not  limited;  but  in  long  standing  cases 
the  abscess  is  inclosed  in  a  definite  capsule,  which  may  have  a  thickness  of 
from  2  to  5  mm.  The  pus  varies  much  in  appearance,  depending  upon  the 
age  of  the  abscess.  In  early  cases  it  may  be  mixed  with  reddish  debris  and 
softened  brain  matter,  but  in  the  solitary  encapsulated  abscess  the  pus  is  dis- 
tinctive, having  a  greenish  tint,  an  acid  reaction,  and  a  peculiar  odor,  some- 
times like  that  of  sulphuretted  hydrogen.  The  brain  substance  surrounding 
the  abscess  is  usually  cedematous  and  infiltrated.  The  size  varies  from  that 
of  a  walnut  to  that  of  a  large  orange.  There  are  cases  in  which  the  cavity 
occupies  the  greater  portion  of  a  hemisphere.  Multiple  abscesses  are  usually 
small.  In  four-fifths  of  all  cases  the  abscess  is  solitary.  Suppuration  occurs 
most  frequently  in  the  cerebrum,  and  the  temporal  lobe  is  more  often  involved 
than  other  parts,  and  always  on  the  side  .of  the  ear  disease.  The  cerebellum  is 
the  next  most  common  seat,  particularly  in  connection  with  ear  disease. 

Symptoms. — Following  injury  or  operation  the  disease  may  run  an  acute 
course,  with  fever,  headache,  delirium,  vomiting,  and  rigors.  The  symptoms 
are  those  of  suppurative  meningo-encephalitis,  and  it  may  be  very  difficult  to 
determine,  unless  there  are  localizing  symptoms,  whether  there  is  really  sup- 


INFLAMMATION  OF  THE  BRAIN  1011 

puration  in  the  brain  substance.  In  the  cases  following  ear  disease  the  symp- 
toms may  at  first  be  those  of  meningeal  irritation.  There  may  be  irritability, 
restlessness,  severe  headache,  and  aggravated  earache.  Other  striking  symp- 
toms, particularly  in  the  more  prolonged  cases,  are  drowsiness,  slow  cerebra- 
tion, vomiting,  and  optic  neuritis.  In  the  chronic  form  which  may  follow 
injury,  otorrhoea,  or  local  lung  trouble,  there  may  be  a  latent  period  of 
weeks  to  several  months,  or  even  a  year  or  more.  In  the  "silent"  regions, 
when  the  abscess  becomes  encapsulated  there  may  be  no  symptoms  whatever 
during  the  latent  period.  During  this  time  the  patient  may  be  under  care- 
ful observation  and  no  suspicion  be  aroused  of  suppuration.  Then  severe 
headache,  vomiting,  and  fever  set  in,  perhaps  with  a  chill.  So,  too,  after  a 
blow  upon  the  head  or  a  fracture  the  symptoms  may  be  transient,  and  months 
afterward  cerebral  symptoms  of  the  most  aggravated  character  may  develop. 

The  localization  is  often  difficult.  If  situated  in  or  near  the  motor  region 
there  may  be  convulsions  or  paralysis,  and  an  abscess  in  the  temporal  lobe 
may  compress  the  lower  part  of  the  pre-central  convolution  and  produce  par- 
alysis of  the  arm  and  face,  and  on  the  left  side  cause  aphasia.  A  large  abscess 
may  exist  in  the  frontal  lobe  without  causing  paralysis,  but  in  these  cases  there 
is  almost  always  some  mental  dullness.  In  the  temporal  lobe,  the  common 
seat,  there  may  be  no  focalizing  symptoms.  So  also  in  the  parieto-occipital 
region;  though  early  examination  may  lead  to  the  detection  of  hemianopia. 
In  abscess  of  the  cerebellum  vomiting  is  common.  If  the  middle  lobe  is  af- 
fected there  may  be  staggering — cerebellar  incoordination.  Localizing  symp- 
toms in  the  pons  and  other  parts  are  still  more  uncertain. 

Diagnosis. — In  the  acute  cases  there  is  rarely  any  doubt.  A  consideration 
of  possible  etiological  factors  is  of  the  highest  importance.  The  history  of 
injury  followed  by  fever,  marked  cerebral  symptoms,  the  onset  of  rigors, 
delirium,  and  perhaps  paralysis,  make  the  diagnosis  certain.  In  chronic 
ear  disease,  such  cerebral  symptoms  as  drowsiness  and  torpor,  with  irregular 
fever,  supervening  upon  tKe  cessation  of  a  discharge,  should  excite  the  sus- 
picion of  abscess.  Cases  in  which  suppurative  processes  exist  in  the  orbit, 
nose,  or  naso-pharynx,  or  in  which  there  has  been  subcutaneous  phlegmon  of 
the  head  or  neck,  a  parotitis,  a  facial  erysipelas,  or  tuberculous  or  syphilitic 
disease  of  the  bones  of  the  skull,  should  be  carefully  watched,  and  immediately 
investigated  should  cerebral  symptoms  appear.  It  is  particularly  in  the 
chronic  cases  that  difficulties  arise.  The  symptoms  resemble  those  of  tumor 
of  the  brain;  indeed,  they  are  those  of  tumor  plus  fever.  Choked  disk,  how- 
ever, so  commonly  associated  with  tumor,  may  be  absent.  In  a  patient  with  a 
history  of  trauma  or  with  localized  lung  or  pleural  trouble,  who  for  weeks 
or  months  has  had  slight  headache  or  dizziness,  the  onset  of  a  rapid  fever, 
especially  if  it  be  intermittent  and  associated  with  rigors,  intense  headache, 
and  vomiting,  points  strongly  to  abscess.  The  pulse  rate  in  cases  of  cerebral 
abscess  is  usually  accelerated,  but  cases  are  not  rare  in  which  it  is  slowed. 
Macewen  lays  stress  upon  the  value  of  percussion  of  the  skull  as  an  aid  in 
diagnosis.  The  note,  which  is  uniformly  dull,  becomes  much  more  resonant 
when  the  lateral  ventricles  are  distended  in  cerebellar  abscess  and  in  condi- 
tions in  which  the  venae  Galeni  are  compressed.  Tenderness  of  the  skull 
has  been  noted  over  the  region  of  the  abscess. 

It  is  not  always  easy  to  determine  wliether  the  meninges  are  involved  and 


1012  DISEASES  0"F  THE  XEEVOUS  SYSTEM 

often  in  ear  disease  the  condition  is  a  meningo-encephalitis.  Sometimes  with 
acute  ear  disease  the  symptoms  may  simulate  closely  cerebral  meningitis  or 
abscess.  Indeed,  Gowers  stated  that  not  only  may  these  general  symptoms 
be  produced  by  ear  disease,  but  even  distinct  optic  neuritis. 

Treatment. — In  ear  disease  free  discharge  of  the  inflammatory  products 
should  be  promoted  and  careful  disinfection  practised.  The  treatment  of  in- 
juries and  fractures  comes  within  the  scope  of  the  surgeon.  The  acute  symp- 
toms, such  as  fever,  headache,  and  delirium,  must  be  treated  by  rest,  an  ice^ 
cap,  and,  if  necessary,  local  depletion.  In  all  cases,  when  a  reasonable  sus- 
picion exists  of  the  occurrence  of  abscess,  the  brain  should  be  explored.  The 
cases  following  ear  disease,  in  which  the  suppuration  is  in  the  temporal  lobe 
or  in  the  cerebellum,  offer  the  most  favorable  chances  of  recovery.  The 
localization  can  rarely  be  made  accurately  in  these  cases,  and  the  operator 
must  be  guided  more  by  general  anatomical  and  pathological  knowledge.  In 
cases  of  injury  the  exploration  should  be  over  the  seat  of  the  blow  or  the 
fracture.  In  ear  disease  the  suppuration  is  most  frequent  in  the  temporal 
lobe  or  in  the  cerebellum,  and  the  operation  should  be  performed  at  the  points 
most  accessible  to  these  regions. 


VI.    HYDROCEPHALUS 

Definition. — A  condition,  congenital  or  acquired,  in  which  there  is  a  great 
accumulation  of  fluid  within  the  ventricles  of  the  brain. 

The  cases  may  be  divided  into  three  groups — idiopathic  internal  hydro- 
cephalus (serous  meningitis),  congenital  or  infantile,  and  secondary  or  ac- 
quired. , 

Serous  Meningitis  {Quinclce's  Disease,  Idiopathic  Internal  Hydrocephalus; 
Angio-neurotic  Hydrocephalus). — A  knowledge  of  this  condition  explains 
many  anomalous  and  puzzling  cases.  An  ependymitis  causing  a  serous  ef- 
fusion into  the  ventricles,  with  distention  and  pressure  effects,  it  may  be 
compared  to  the  serous  exudates  in  the  pleura  or  synovial  membranes.  It  is 
not  certain  that  the  process  is  inflammatory,  and  Quincke  likens  it  to  the 
angio-neurotic  oedema  of  the  skin.  In  very  acute  cases  the  ependyma  may  be 
smooth  and  natural  looking ;  in  more  chronic  cases  thickened  and  sodden.  The 
exudate  does  not  differ  from  the  normal,  and  if  on  lumbar  puncture  the  fluid 
has  a  specific  gravity  above  1.009,  with  albumin  above  two  tenths  per  cent., 
the  condition  is  more  likely  to  be  hydrocephalus  from  stasis,  secondary  to 
tumor,  etc. 

Both  children  and  adults  are  affected,  the  latter  more  frequently.  In  the 
acute  form  the  condition  is  mistaken  for  tuberculous  or  purulent  meningitis. 
There  are  headache,  retraction  of  the  neck,  and  signs  of  increased  intracranial 
pressure,  choked  disks,  slow  pulse,  etc.  Fever  is  usually  absent,  but  there  are 
cases  with  recurring  paroxysms  of  fever.  Quincke  reported  cases  of  recovery. 
In  the  chronic  form  the  symptoms  are  those  of  tumor — general,  such  as  head- 
ache, slight  fever,  somnolence,  and  delirium;  and  local,  as  exophthalmos, 
optic  neuritis,  spasms,  and  rigidity  of  muscles  and  paralysis  of  the  cerebral 
nerves.  Exacerbations  occur,  and  the  symptoms  vary  in  intensity  from  day 
to  day.  Eecovery  may  follow  and  some  of  the  reported  cases  of  disappearance 
of  all  symptoms  of  brain  tumor  belong  in  this  category. 


HYDEDCEPHALUS  1013 

A  variety  of  this  is  the  circumscribed  serous  meningitis  confined  to  the 
cerebello-pontile  angle,  due  to  adhesions  of  the  arachnoid  to  the  cerebellum  in 
the  region  of  the  flocculus.  Fluid  accumulates  in  the  cisterna  lateralis,  which 
has  its  own  choroid  plexus.  The  increased  pressure  leads  to  disturbance  in; 
function  of  the  nerves  in  this  region,  causing  the  syndrome  described  by 
Barany — tinnitus  with  deafness,  vertigo,  occipital  headache,  facial  paralysis, 
and  the  '^pointing  error."  Other  lesions  of  this  region,  syphilitic  meningitis 
and  tumors,  may,  of  course,  cause  this  syndrome. 

Congenital  Hydrocephalus. — There  are  two  types,  one  due  to  obstruction 
of  outflow  from  the  ventricles,  the  other  from  decreased  absorption  from  the 
sub-arachnoid  space  (Dandy  and  Blackfan). 

The  lateral  ventricles  are  enormously  distended,  but  the  ependyma  is 
usually  clear,  sometimes  a  little  thickened  and  granular,  and  the  veins  large. 
The  choroid  plexuses  are  vascular,  sometimes  sclerotic,  but  often  natural 
looking.  The  third  ventricle  is  enlarged,  the  aqueduct  of  Sylvius  dilated, 
and  the  fourth  ventricle  may  be  distended.  The  quantity  of  fluid  may  reach 
several  litres.  ~It  is  limpid  and  contains  a  trace  of  albumin  and  salts.  The 
changes  in  consequence  of  the  ventriciilar  distention  are  remarkable.  The 
cerebral  cortex  is  greatly  stretched,  and  over  the  middle  region  the  thickness 
may  amount  to  no  more  than  a  few  millimetres  without  a  trace  of  the  sulci 
or  convolutions.  The  basal  ganglia  are  flattened.  The  skull  enlarges,  and 
the  circumference  of  the  head  of  a  child  of  three  or  four  years  may  reach 
35  or  even  30  inches.  The  sutures  widen,  Wormian  bones  develop  in  them, 
and  the  bones  of  the  cranium  become  exceedingly  thin.  The  veins  are  marked 
beneath  the  skin.  A  fluctuation  wave  may  sometimes  be  obtained,  and 
Fisher's  brain  murmur  may  be  heard.  The  orbital  plates  of  the  frontal  bone 
are  depressed,  causing  exophthalmos,  so  that  the  eyeballs  can  not  be  covered 
by  the  eyelids.  The  small  size  of  the  face,  widening  somewhat  above,  is  strik- 
ing in  comparison  with  the  enormously  expanded  skull. 

The  enlarged  head  may  obstruct  labor;  more  frequently  the  condition  is 
noticed  some  time  after  birth.  The  cause  is  unknown.  It  has  occurred  in 
several  members  of  the  same  family.  Convulsions  may  occur.  The  reflexes 
are  increased,  the  child  learns  to  walk  late,  and  ultimately  in  severe  cases  the 
legs  become  feeble  and  sometimes  spastic.  Sensation  is  much  less  affected 
than  motility.  Choked  disk  is  not  uncommon.  The  mental  condition  is  vari- 
able; the  child  may  be  bright,  but,  as  a  rule,  there  is  some  grade  of  im- 
becility. The  congenital  cases  usually  die  within  the  first  four  or  five  years. 
The  process  may  be  arrested  and  the  patient  may  reach  adult  life.  Even 
when  extreme,  the  mental  faculties  may  be  retained,  as  in  Bright's  celebrated 
patient.  Cardinal,  who  lived  to  the  age  of  twenty-nine,  and  whose  head  was 
translucent  when  the  sun  was  shining  behind  him.  Care  must  be  taken  not 
to  mistake  the  rachitic  head  for  hydrocephalus.  The  condition  may  be  asso- 
ciated with  other  defects,  harelip,  spina  bifida  and  club-foot. 

Dandy  has  introduced  a  method  of  fluoroscopy  after  the  injection  of  air 
into  the  ventricles,  the  outlines  of  wliich  are  then  well  seen  and  the  extent  but 
not  always  the  type  of  hydrocephalus  determined. 

Acquired  Chronic  Hydrocephalus. — This  is  stated  to  be  occasionally  pri- 
mary (idiopathic) — that  is  to  say,  it  comes  on  spontaneously  in  the  adult 
without  observable  lesion.     Dean  Swift  is  said  to  have  died  of  hydrocephalus^ 


1014  DISEASES  OF  THE  NEEVOUS  SYSTEM 

but  this  seems  very  unlikely.  It  is  based  upon  the  statement  that  "he  (Mr. 
Whiteway)  opened  the  skull  and  found  much  water  in  the  brain,"  a  condition 
no  doubt  of  Tiydrocephalus  ex  vacuo,  due  to  the  wasting  associated  with  his 
prolonged  illness  and  paralysis.  In  nearly  all  cases  there  is  either  a  tumor  at 
the  base  of  the  brain  or  in  the  third  ventricle,  which  compresses  the  venae 
Galeni.  The  passage  from  the  third  to  the  fourth  ventrical  may  be  closed, 
either  by  a  tumor  or  by  parasites.  More  rarely  the  foramen  of  Magendie, 
through  which  the  ventricles  communicate  with  the  cerebro-spinal  meninges, 
becomes  closed  by  meningitis.  Chronic  inflammations  of  the  ependyma  may 
block  the  foramina  of  exit  of  the  ventricular  fluid.  There  may  be  unilateral 
hydrocephalus  from  closure  of  one  of  the  foramina  of  Monro.  In  cerebro- 
spinal fever,  particularly  in  the  sporadic  form,  the  foramina  of  exit  of  the 
fluid  may  be  occluded,  with  great  distention  of  the  ventricles.  These  con- 
ditions in  adults  may  produce  the  most  extreme  hydrocephalus  without  any 
enlargement  of  the  head.  Even  when  the  tumor  begins  early  in  life  there  may 
be  no  expansion  of  the  skull.  In  the  case  of  a  girl  aged  sixteen,  blind  from 
her  third  year,  the  head  was  not  unusually  large,  the  ventricles  were  enor- 
mously distended,  and  in  the  Eolandic  region  the  brain  substance  was  only 
5  mm.  in  thickness.  A  tumor  occupied  the  third  ventricle.  In  other  instances 
the  sutures  separate  and  the  head  gradually  enlarges. 

The  symptoms  are  curiously  variable.  In  the  case  mentioned  there  were 
headaches  and  gradual  blindness;  then  a  prolonged  period  in  which  she  was 
able  to  attend  to  her  studies.  Headaches  again  supervened,  the  gait  became 
irregular  and  somewhat  ataxic.  Death  occurred  suddenly.  In  another  case 
there  were  prolonged  attacks  of  coma  with  a  slow  pulse,  and  on  one  occasion 
the  patient  remained  unconscious  for  more  than  three  months.  Gradually 
progressing  optic  neuritis  without  focalizing  symptoms,  headache,  and  at- 
tacks of  somnolence  or  coma  are  suggestive  s5miptoms.  These  cases  of  ac- 
quired chronic  hydrocephalus  can  not  be  certainly  diagnosed  during  life, 
though  the  condition  may  be  suspected.     They  simulate  tumor  very  closely. 

Treatment. — Medicines  are  powerless  to  cause  the  absorption  of  the  fluid. 
In  the  meningitis  serosa  Quincke  advised  the  use  of  mercury.  Various  opera- 
tions have  been  devised  for  conveying  the  fluid  to  the  subtemporal  or  subcu- 
taneous regions,  and  attempts  have  been  made  to  conduct  the  fluid  to  the 
peritoneum  and  the  pleura,  or  even  connecting  the  cisterna  magna  directly  with 
the  longtitudinal  sinus. 


J.    DISEASES  OF  THE  PERIPHEEAL  NERVES 
I.     NEURITIS 

Neuritis  may  be  localized  in  a  single  nerve,  or  general,  involving  a  large 
number  of  nerves — multiple  neuritis  or  polyneuritis. 

Etiolo^,. — Localized  neuritis  arises  from  (a)  cold,  which  is  a  very  fre- 
quent cause,  as,  for  example,  in  the  facial  nerve.  (&)  Trauma — wounds, 
blows,  direct  pressure  on  the  nerves,  the  tearing  and  stretching  which  follow  a 
dislocation  or  a  fracture,  and  the  hypodermic  injection  of  ether.  Under  this 
section  come  the  profeesional  palsies,  due  to  pressure  in  the  exercise  of  cer- 


NEURITIS  1015 

tain  occupations,  (c)  Extension  of  inflammation  from  neighboring  parts, 
as  in  a  neuritis  of  tlie  facial  nerve  due  to  caries  in  the  temporal  bone,  or  in 
that  met  with  in  syphilitic  disease  of  the  bones,  disease  of  the  joints,  and 
occasionally  in  tumors. 

Multiple  neuritis  has  a  very  complex  etiology,  the  causes  of  which  may 
be  classified  as  follows:  (a)  The  poisons  of  infectious  diseases,  as  in  leprosy, 
diphtheria,  typhoid  fever,  small-pox,  and  occasionally  in  other  forms;  (6) 
the  organic  poisons,  comprising  the  diifusible  stimulants,  such  as  alcohol  and 
ether,  bisulphide  of  carbon  and  naphtha,  and  metallic  bodies,  such  as  lead  and 
arsenic;  (c)  cachectic  conditions,  such  as  occur  in  anaemia,  cancer,  tubercu- 
losis, or  marasmus  from  any  cause;  (d)  the  endemic  neuritis  or  beri-beri; 
and  (e)  lastly,  there  are  cases  in  which  none  of  these  factors  prevail,  but  the 
disease  sets  in  suddenly  after  overexertion  or  exposure  to  cold. 

Morbid  Anatomy. — In  neuritis  due  to  the  extension  of  inflammation  the 
nerve  is  usually  swollen,  infiltrated,  and  red  in  color.  The  inflammation  may 
be  chiefly  perineural  or  it  may  pass  into  the  deeper  portion — interstitial  neu- 
ritis— in  which  form  there  is  an  accumulation  of  lymphoid  elements  between 
the  nerve  bundles.  The  nerve  fibres  themselves  may  not  appear  involved,  but 
there  is  an  increase  in  the  nuclei  of  the  sheath  of  Schwann.  The  myelin  is 
fragmented,  the  nuclei  of  the  internodal  cells  are  swollen,  and  the  axis-cylin- 
ders present  varicosities  or  undergo  granular  degeneration.  Ultimately  the 
nerve  fibres  may  be  completely  destroyed  and  replaced  by  a  fibrous  connective 
tissue  in  which  much  fat  is  sometimes  deposited — Upomatous  7ieuritis. 

In  other  instances  the  condition  is  termed  parenchymatous  neuritis,  in 
which  the  changes  are  like  those  met  with  in  the  secondary  or  Wallerian 
degeneration,  which  follows  when  the  nerve  fibre  is  cut  off  from  the  cell  body 
of  the  neurone  to  which  it  belongs.  The  medullary  substance  and  the  axis- 
cylinders  are  chiefly  involved,  the  interstitial  tissue  being  but  little  altered  or 
only  affected  secondarily.  The  muscles  connected  with  the  degenerated  nerves 
usually  show  marked  atrophic  changes,  and  in  some  instances  the  change  in 
the  nerve  sheath  appears  to  extend  directly  to  the  interstitial  tissue  of  the 
muscles — the  neuritis  fascians  of  Eichhorst. 

Symptoms, — Localized  Neuritis.' — As  a  rule,  the  constitutional  disturb- 
ances are  slight.  The  most  important  symptom  is  pain  of  a  boring  or  stabbing 
character,  usually  felt  in  the  course  of  the  nerve  and  in  the  parts  to  which  it  is 
distributed.  The  nerve  itself  is  sensitive  to  pressure,  probably,  as  Weir  Mitchell 
suggested,  owing  to  the  irritation  of  its  nervi  nervorum.  The  skin  may  be 
slightly  reddened  or  even  oedematous  over  the  seat  of  the  inflammation. 
Mitchell  described  increase  in  the  temperature  and  sweating  in  the  affected 
region,  and  such  atrophic  disturbances  as  effusion  into  the  joints  and  herpes. 
The  function  of  the  muscle  to  which  the  nerve  flbres  are  distributed  is  im- 
paired, motion  is  painful,  and  there  may  be  twitchings  or  contractions.  The 
tactile  sensation  of  the  part  may  be  somewhat  deadened,  even  when  the  pain 
is  greatly  increased.  In  the  more  chronic  cases  of  local  neuritis,  such,  for 
instance,  as  follow  the  dislocation  of  the  humerus,  the  localized  pain,  which 
at  first  may  be  severe,  gradually  disappears,  though  some  sensitiveness  of  the 
brachial  plexus  may  persist  for  a  long  time,  and  the  nerve  cords  may  be  firm 
and  swollen.  The  pain  is  variable — sometimes  intense  and  distressing;  at 
others  not  causing  much  inconvenience.     Numbness  and  formication  may  be 


1016  DISEASES  OF  THE  NERVOUS  SYSTEM 

present  and  tactile  sensation  greatly  impaired.  The  motor  disturbances  are 
marked.  Ultimately  there  is  extreme  atrophy  of  the  muscles.  Contractures 
may  occur  in  the  fingers.  The  skin  may  be  reddened  or  glossy,  the  subcutan- 
eous tissue  oedematous,  and  the  nutrition  of  the  nails  may  be  defective.  In 
some  cases  subcutaneous  fibroid  nodules  may  develop. 

A  neuritis  limited  at  first  to  a  peripheral  nerve  may  extend  upward — ■ 
the  so-called  ascending  or  migratory  neuritis — and  involve  the  larger  nerve 
trunks,  or  even  reach  the  spinal  cord,  causing  subacute  myelitis  (Gowers). 
The  condition  is  rarely  seen  in  the  neuritis  from  cold,  or  in  that  which  fol- 
lows fevers ;  but  it  occurs  most  frequently  in  traumatic  neuritis. 

J.  K.  ]\Iitchell,  in  his  monograph  on  injuries  of  nerves,  concluded  that  the 
larger  nerve  trunks  are  most  susceptible,  and  that  the  neuritis  may  spread 
either  up  or  down,  the  former  being  the  most  common.  The  paralysis  second- 
ary to  visceral  disease,  as  of  the  bladder,  may  be  due  to  an  ascending  neuritis. 
The  inflammation  may  extend  to  the  nerves  of  the  other  side,  either  through 
the  spinal  cord  or  its  membranes,  or  without  any  -involvement  of  the  nerve- 
centres,  the  so-called  S3'mpathetic  neuritis.  The  electrical  changes  in  localized 
neuritis  vary  a  great  deal,  depending  upon  the  extent  to  which  the  nerve  is 
injured.  The  lesion  may  be  so  slight  that  the  nerve  and  the  muscles  to  which 
it  is  distributed  may  react  normally  to  both  currents ;  or  it  may  be  so  severe 
that  the  typical  reaction  of  degeneration  develops  within  a  few  days — i.  e., 
the  nerve  does  not  respond  to  stimulation  by  either  current,  while  the  muscle 
reacts  only  to  the  galvanic  current  and  in  a  peculiar  manner.  The  contraction 
caused  is  slow  and  lazy,  instead  of  sharp  and  quick  as  in  the  normal  mus- 
cle, and  the  AC  contraction  is  usually  stronger  than  the  KC  contraction. 
Between  these  extremes  there  are  many  grades,  and  a  careful  electrical  ex- 
amination is  an  important  aid  to  diagnosis  and  prognosis. 

The  duration  varies  from  a  few  days  to  weeks  or  months.  A  slight  trau- 
matic neuritis  may  pass  off  in  a  day  or  two,  while  the  severer  cases,  such  as 
follow  unreduced  dislocation  of  the  humerus,  may  persist  for  months  or  never 
be  completely  relieved. 

Multiple  Xeueitis. — The  following  are  the  most  important  groups: 

(a)  Acute  FehrUe  Polyneuritis. — The  attack  follows  exposure  to  cold  or 
overexertion,  or,  in  some  instances,  comes  on  spontaneously.  The  onset  resem- 
bles that  of  an  acute  infectious  disease.  There  may  be  a  definite  chill,  pains 
in  the  back  and  limbs  or  joints,  so  that  the  case  may  be  thought  to  be  rheu- 
matic fever.  The  temperature  rises  rapidly  and  may  reach  103°  or  101°  F. 
There  are  headache,  loss  of  appetite,  and  the  general  symptoms  of  acute  in- 
fection. The  limbs  and  back  ache.  Intense  pain  in  the  nerves,  however,  is 
by  no  means  constant.  Tingling  and  formication  are  felt  in  the  fingers  and 
toes,  and  there  is  increased  sensitiveness  of  the  nerve  trunks  or  of  the  entire 
limb.  Loss  of  muscular  power,  first  marked,  perhaps,  in  the  legs,  gradually 
comes  on  and  extends  with  the  features  of  an  ascending  paralysis.  In  other 
cases  the  paralysis  begins  in  the  arms.  The  extensors  of  the  wrists  and  the 
flexors  of  the  ankles  are  early  affected;  so  that  there  is  foot  and  wrist  drop. 
In  severe  cases  there  is  general  loss  of  muscular  power,  producing  a  flabby 
paralysis,  which  may  extend  to  the  muscles  of  the  face  and  to  the  intercostals, 
and  respiration  may  be  carried  on  by  the  diaphragm  alone.  The  muscles 
soften  and  waste  rapidly.    There  may  be  only  hyperesthesia  with  soreness  and 


XEUEITIS  1017 

stiffness  of  the  limbs;  in  some  cases,  increased  sensitiveness  with  anaesthesia; 
in  other  instances  the  sensory  disturbances  are  slight.  The  Argyll-Eobertson 
pupil  may  be  present  and  the  pupils  may  be  unequal.  Involvement  of  the 
cranial  nerves  is  rare,  but  the  oculo-motor,  the  facial,  and  the  fifth  have  been 
involved.  The  vagus  may  be  attacked  and  the  quickening  of  the  pulse  is 
usually  attributed  to  this  cause.  Involvement  of  the  bladder  and  rectum  is 
rare,  but  it  does  occur  and  does  not  necessarily  mean  involvement  of  the 
cord.  The  clinical  picture  is  not  to  be  distinguished,  in  many  cases,  from 
Landry's  paralysis;  in  others,  from  the  subacute  myelitis  of  Duchenne. 

The  course  is  variable.  In  the  most  intense  forms  the  patient  may  die  in 
a  week  or  ten  days,  with  involvement  of  the  respiratory  muscles  or  from 
paralysis  of  the  heart.  As  a  rule,  in  cases  of  moderate  severity,  after  persist- 
ing for  five  or  six  weeks,  the  condition  remains  stationary  and  then  slow' 
improvement  begins.  The  paralysis  in  some  muscles  may  persist  for  many' 
months  and  contractures  may  occur  from  shortening  of  the  muscles,  but  even 
when  this  occurs  the  outlook  is,  as  a  rule,  good,  although  the  paralysis  may 
have  lasted  for  a  year  or  more. 

(&)  Recurring  Multiple  Neuritis. — Under  the  term  polyneuritis  recurrens 
Mary  Sherwood  described  from  Eichhorst's  clinic  2  cases  in  adults — in  one' 
case  involving  the  nerves  of  the  right  arm,  in  the  other  both  legs."  In  one 
patient  there  were  three  attacks,  in  the  other  two,  the  distribution  in  the  va- 
rious attacks  being  identical. 

(c)  Alcoholic  Neuritis. — This,  perhaps  the  most  important  form  of  mul- 
tiple neuritis,  was  graphically  described  in  1822  by  James  Jackson,  Sr.,  of-, 
Boston.  Wilks  recognized  it  as  alcoholic  paraplegia,  but  the  starting  point' 
of  the  recent  researches  dates  from  the  observations  of  Dumenil,  of  Eouen. 
It  occurs  most  frequently  in  women,  particularly  in  steady,  quiet  tipplers. ' 
Its  appearance  may  be  the  first  revelation  of  habits  of  secret  drinking.  The-' 
onset  is  usually  gradual,  and  may  be  preceded  for  weeks  or  months  by  neuralgic 
pains  and  tingling  in  the  feet  and  hands.  Convulsions  are  not  uncommon^^ 
Fever  is  rare.  The  paralysis  gradually  sets  in,  at  first  in  the  feet  and  legs,.' 
and  then  in  the  hands  and  forearms.  The  extensors  are  afi^ected  more  than  thfe' 
flexors,  so  that  there  is  wrist-drop  and  foot-drop.  The  paralysis  may  be  thtiS' 
limited  and  not  extend  higher  in  the  limbs.  In  other  instances  thier&'is  para- 
plegia alone,  while  in  some  extreme  cases  all  the  extremities  are  involved.^ 
In  rare  instances  the  facial  muscles  and  the  sphincters  are  also  affected.  The- 
sensory  symptoms  are  very  variable.  There  are  cases  in  which  there^  afe' 
numbness  and  tingling  only,  without  grteat  pain.  In  other  cases  there' are- 
severe  burning  or  boring  pains,  the  nerve  trunks  are  sensitive,  and  the  mus- 
cles are  sore  when  grasped.  The  hands  and  feet  are  frequently  swollen  and'- 
congested,  particularly  when  held  down  for  a  few  moments.  The  cutaneous 
reflexes,  as  a  rule,  are  preserved.    The  deep  reflexes  are  usually  lost. 

The  course  of  these  alcoholic  cases  is,  as  a  rule,  favorable,  and  after  per-" 
sisting  for  weeks  or  months  improvement  gradually  begins,  the  muscles  regain 
their  power,  and  even  in  the  most  desperate  cases  recovery  may  follow.  The 
extensors  of  the  feet  may  remain  paralyzed  for  some  time,  and  give  to  theV 
patient  a  distinctive  walk,  the  so-called  steppage  gait,  characteristic  of  pe^' 
ripheral  neuritis.  It  is  sometimes  known  as  the  pseudo-tabetic  gait,  although' 
in  reality  it  could  not  well  be  mistaken  for  the  gait  of  ataxia.     The  foot  is 


1018  DISEASES  OF  THE  NEEVOUS  SYSTEM 

thrown  forcibly  forward,  the  toe  lifted  high  in  the  air  so  as  not  to  trip  upon  it. 
The  entire  foot  is  slapped  upon  the  ground  as  a  flail.  It  is  an  awkward, 
clumsy  gait,  and  gives  the  patient  the  appearance  of  constantly  stepping  over 
obstacles.  Among  the  most  striking  features  are  the  mental  symptoms.  De- 
lirium is  common,  and  there  may  be  hallucinations  with  extravagant  ideas, 
resembling  somewhat  those  of  general  paresis.  In  some  cases  the  picture  is 
that  of  delirium  tremens,  but  the  most  peculiar  and  almost  characteristic 
mental  disorder  is  that  so  well  described  by  Wilks,  in  which  the  patient  loses 
all  appreciation  of  time  and  place,  and  describes  with  circumstantial  details 
long  journeys  which,  he  says,  he  has  recently  taken,  or  tells  of  persons  whom 
he  has  just  seen.     This  is  the  so-called  Korsakoff's  syndrome. 

(d)  Multiple  Neuritis  in  the  Infectious  Diseases. — This  has  been  already 
referred  to,  particularly  in  diphtheria,  in  which  it  is  most  common.  The 
peripheral  nature  of  the  lesion  in  diphtheria  has  been  shown  by  post  mortem 
examination.  The  outlook  is  usually  favorable  and,  except  in  diphtheria,  fatal 
eases  are  uncommon.  Multiple  neuritis  in  tuberculosis,  diabetes,  and  syphilis 
is  of  the  same  nature,  being  probably  due  to  toxic  materials  absorbed  into  the 
blood.  It  may  follow  suppuration  anywhere,  as  septic  sore  throat,  and  in  the 
recent  war  multiple  neuritis  has  been  seen  not  infrequently  after  superficial 
septic  sores. 

(e)  The  Metallic  Poisons. — iNeuritis  from  arsenic  may  follow:  (1)  The 
medicinal  use  particularly  of  Fowler's  solution.  In  one  case  of  Hodgkin's 
disease  general  neuritis  was  caused  by  §  j  o  ij  of  the  solution.  In  chorea  a 
good  many  cases  have  been  reported.  Changes  in  the  nails  are  not  uncom- 
mon, chiefly  the  transverse  ridging.  In  the  case  of  a  young  woman  who  had 
taken  "rough-on-rats,"  there  were  remarkable  white  lines — the  leuconychia — 
running  across  the  nails,  without  any  special  ridging.  C.  J.  Aldrich  finds 
that  this  is  not  uncommon  in  chronic  arsenical  poisoning.  (3)  The  accidental 
-Contamination  of  food  or  drink.  Chrome  yellow  may  be  used  to  color  cakes, 
as  in  the  cases  recorded  by  D.  D.  Stewart.  A  remarkable  epidemic  of  neuritis 
occurred  in  the  Midland  Counties  of  England,  which  was  traced  to  the  use 
of  beer  containing  small  quantities  of  arsenic,  a  contamination  from  the  sul- 
phuric acid  used  in  making  glucose.  Eeynolds,  who  studied  these  cases,  be- 
lieves that  most  of  the  instances  of  neuritis  in  drinkers  are  arsenical,  but 
admits  that  the  slight  cases  may  be  due  to  the  alcohol  itself.  Pigmentation 
of  the  skin  is  an  important  distinguishing  sign.  Lead  is  a  much  more  fre- 
qnent  cause.  Neuritis  has  followed  the  use  of  mercurial  inunctions.  Zinc 
is  a  rare  cause.  In  a  case  seen  with  Urban  Smith  neuritis  followed  the  use  of 
two  grains  of  the  sulpho-carbolate  taken  daily  for  three  years.  Tea,  coffee, 
a;nd  tobacco  are  mentioned  as  rare  causes. 

(/)  Endemic  neuritis,  beri-beri,  is  considered  elsewhere. 
Anesthesia  Paralysis. — Here  may  most  appropriately  be  considered 
the  forms  of  paralysis  following  the  use  of  anaesthetics,  or  of  too  long-contin- 
ned  compression  during  operations.  There  are  two  groups  of  cases : 
.  (a)  During  an  operation  the  nerves  may  be  compressed,  either  the  brachial 
plexus  by  the  humerus  or  the  musculo-spiral  by  the  table.  The  pressure  most 
frequently  occurs  when  the  arm  is  elevated  alongside  the  head,  as  in  laparot- 
omy done  in  the  Trendelenburg  position,  or  held  out  from  the  body,  as  in 
breast  amputations.    Instances  of  paralysis  of  the  crural  nerves   by  leg-holders 


XEUEITIS  1019 

arc  also  reported.  The  too  firm  application  of  a  tourniquet  may  he  followed 
by  a  severe  paralysis. 

(b)  Paralysis  from  cerebral  lesions  during  etherization.  In  one  of  Gar- 
rigues'  cases  paralysis  followed  the  operation^  and  at  the  autopsy,  seven  weeks 
later,  softening  of  the  brain  was  found.  Apoplexy  or  embolism  may  occur 
during  ansesthesia.  In  Montreal  a  cataract  operation  was  performed  on  an 
old  man.  He  did  not  recover  from  the  anaesthetic  and  post  mortem  a  cerebral 
hamiorrhage  was  found.  Epileptic  convulsions  may  occur  during  anesthesia, 
and  may  even  prove  fatal.  The  possibility  of  paralysis  from  loss  of  blood  in 
prolonged  operations  has  to  be  considered.  And,  lastly,  a  paralysis  might  re- 
sult from  the  toxic  effects  of  the  ether  in  a  very  protracted  administration. 

Angiopathic  Paralysis. — Digital  compression,  the  protracted  application 
of  the  tourniquet  and  ligation  of  the  main  vessel  taught  us  that  normal  action 
of  the  nerves  and  muscles  of  a  limb  was  dependent  upon  a  good  blood  supply. 
In  sudden  blocking  of  the  femoral  artery  with  an  embolus,  the  pain  is  not 
simply  in  the  site  of  the  blockage,  but  is  more  or  less  diffuse  throughout  the 
limb,  which  the  patient  moves  very  slightly  and  with  the  greatest  difficulty.  In 
the  recent  war  in  the  numerous  injuries  to  the  arteries,  these  angiopathic 
paralyses  were  not  uncommon.  In  a  study  of  ten  cases  of  severe  wounds  of 
the  main  vessel  of  a  limb  Burrows  found  the  chief  symptom  to  be:  (a)  sub- 
jective changes,  numbness,  tingling,  etc.;  (h)  anaesthesia,  usually  of  the  glove 
type;  (c)  paralysis,  often  complete;  (d)  hardness  of  the  muscles,  and  (e) 
oedema  of  the  limb.  With  the  re-establishment  of  the  collateral  circulation 
these  may  disappear  in  a  few  days. 

Diag-nosis. — The  electrical  condition  in  multiiDle  neuritis  is  thus  described 
by  Allen  Starr :  "The  excitability  is  very  rapidly  and  markedly  changed ;  but 
the  conditions  which  have  been  observed  are  quite  various.  Sometimes  there 
is  a  simple  diminution  of  excitability,  and  then  a  very  strong  faradic  or  gal- 
vanic current  is  needed  to  produce  contractions.  Frequently  all  faradic  ex- 
citability is  lost  and  then  the  muscles  contract  to  a  galvanic  current  only. 
In  this  condition  it  may  require  a  very  strong  galvanic  current  to  produce 
contraction,  and  tlius  far  it  is  quite  pathognomonic  of  neuritis.  In  polio- 
myelitis, where  the  muscles  respond  to  galvanism  only,  it  does  not  require  a 
strong  current  to  cause  motion  until  some  months  after  the  invasion. 

"The  action  of  the  different  poles  is  not  uniform.  In  many  cases  the  con- 
traction of  the  muscle  when  stimulated  with  the  positive  pole  is  greater  than 
when  stimulated  with  the  negative  pole,  and  the  contractions  may  be  sluggish. 
Then  the  reaction  of  degeneration  is  present.  But  in  some  cases  tlie  normal 
condition  is  found  and  the  negative  pole  produces  stronger  contractions  than 
the  positive  pole.  A  loss  of  faradic  irritability  and  a  marked  decrease  in  the 
galvanic  irritability  of  tlie  muscle  and  nerve  are  therefore  important  symp- 
toms of  multiple  neuritis." 

There  is  rarely  any  difficulty  in  distinguishing  the  alcohol  cases.  The 
combination  of  Avrist-  and  foot-drop  with  congestion  of  the  hands  and  feet, 
and  the  peculiar  delirium  already  referred  to,  are  quite  characteristic.  The 
rapidly  advancing  cases  with  paralysis  of  all  extremities,  often  reaching  to 
the  face  and  involving  the  sphincters,  are  more  commonly  regarded  as  of 
spinal  origin,  but  the  general  opinion  seems  to  point  strongly  to  the  fact  that 
all  such  cases  are  peripheral.     The  less  acute  cases,  in  which  the  paralysis 


1020  DISEASES  OF  THE  NERVOUS  SYSTEM 

gradually  involves  the  legs  and  arms  with  rapid  wasting,  simulate  closely 
and  are  usually  confounded  with  the  subacute  atrophic  spinal  paralysis  of 
Duchenne.  The  diagnosis  from  tabes  is .  rarely  .difficult.  The  steppage  gait 
is  entirely  different.  There  is  rarely  positive  incoordination.  The  patient  can 
usually  stand  well  with  the  eyes  closed.  Foot-drop  is  not  common  in  tabes. 
The  lightning  pains  are  absent  and  there  are  usually  no  pupillary  symptoms. 
The  etiology  is  of  moment.  The  patient  is  recovering  from  a  paralysis  which 
has  been  more  extensive,  or  from  arsenical  poisoning,  or  he  has  diabetes. 

Treatment. — Eest  in  bed  is  essential.  In  the  acute  cases  with  fever  the 
salicylates  and  antipyrin  are  recommended.  To  allay  the  intense  pain  mor- 
phia or  the  hot  applications  of  lead  water  and  laudanum  are  often  required. 
Great  care  must  be  exercised  in  treating  the  alcoholic  form,  and  the  physician 
must  not  allow  himself  to  be  deceived  by  the  statements  of  the  relatives.  It 
is  sometimes  exceeding^  difficult  to  get  a  history  of  drinking.  In  the  alco- 
holic form  it  is  well  to  reduce  the  stimulants  gradually.  If  there  is  any 
tendency  to  bed-sores  an  air-bed  should  be  used  or  the  patient  placed  in  a  con- 
tinuous bath.  Gentle  friction  of  the  muscles  may  be  applied  from  the  outset, 
and  in  the  later  stages,  when  the  atrophy  is  marked  and  the  pains  have  lessened^ 
massage  is  probably  the  most  reliable  means  at  our  command.  Contractures 
may  be  gradually  overcome  by  passive  movements  and  extension.  Often  with 
the  most  extreme  deformity  from  contracture,  recovery  is,  in  time,  still  pos- 
sible.    The  interrupted  current  is  useful  when  the  acute  stage  is  passed. 

Of  internal  remedies,  strychnia  is  of  value  and  may  be  given  in  increasing 
doses.  Arsenic  also  may  be  employed,  and  if  there  is  a  history  of  syphilis  the 
iodide  of  potassium  and  mercury  should  be  given. 


n.     NEUROMATA 

Tumors  situated  on  nerve  fibres  may  consist  of  nerve  substance  proper,  the 
true  neuromata,  or  of  fibrous  tissue,  the  false  neuromata.  The  true  neuroma 
usually  contains  nerve  fibres  only,  or  in  rare  instances  ganglion  cells.  Cases 
of  ganglionic  or  medullary  neuroma  are  extremely  rare;  some  of  them,  as 
Lancereaux  suggests,  are  undoubtedly  instances  of  malformation  of  the  brain 
substance.  In  other  instances  the  tumor  is,  in  all  probability,  a  glioma  with 
cells  closely  resembling  those  of  the  Central  nervous  system.  The  growths  are 
often  intermediate  in  anatomical  structure  between  the  true  and  the  false. 

Plexiform  Neuroma. — In  this  remarkable  condition  the  various  nerve  cords 
may  be  occupied  by  man}^  hundreds  of  tumors.  The  cases  are  often  hereditary 
and  usually  congenital.  The  tumors  may  occur  in  all  the  nerves  of  the  body, 
and,  as  numbers  of  them  may  be  made  out  on  palpation,  the  diagnosis  is  usu- 
ally easy.  One  of  the  most  remarkable  cases  is  that  described  by  Prudden, 
the  specimens  of  which  are  in  the  medical  museum  of  Columbia  College,  New 
York.  There  were  over  1,182  distinct  tumors  distributed  on  the  nerves  of  the 
body.  These  tumors  rarely  are  painful,  but  may  cause  symptoms  through 
pressure  on  neighboring  structures. 

Generalized  Neuro-fibromatosis :  von  Reckling-hausen's  Disease:  Fibroma 
Tyfolluscum. — Special  attention  was  directed  to  this  particidar  form  of  mul- 
tiple neuroma  by  von  Eecklinghausen  in  1882.  The  disease  presents  several 
groups  of  lesions : 


DISEASES  OF  THE  CEREBRAL  NERVES  1021 

1.  Cutaneous. —  (a)  Soft,  fibrous  nodules,  some  sessile,  others  pedun- 
culated, varying  in  size  and  greatly  in  number,  are  scattered  over  the  skin. 
They  may  increase  in  number  as  age  advances.  (&)  Bluish  spots,  indicating 
atrophy  of  the  corium  where  the  fibromata  are  perforating,  (c)  Pigmenta- 
tion, in  the  form  of  freckles,  blotches,  or  diffuse  areas,  (d)  Subcutaneous 
growths,  at  times  of  enormous  size,  causing  the  condition  known  as  "ele- 
phantiasis neuromatosa."     Congenital  naevi  are  frequent. 

2.  Nervous. — Tumors  resembling  plexiform  neuromata  may  be  present 
on  any  of  the  nerve  trunks  from  the  centre  to  the  periphery.  The  variable 
situation  leads  to  a  variety  of  sensory  or  motor  phenomena,  more  especially 
as  they  may  arise  from  the  nerve  roots  within  the  spinal  canal  or  cranium. 
Cases  resembling  tabes,  syringomyelia  and  spastic  paralysis  have  been  re- 
ported. The  patients  often  show  mental  changes  and  the  speech  may  be 
hesitating. 

3.  Bone  Lesions. — Changes  similar  to  those  of  osteomalacia  occur  in 
about  7  per  cent,  of  the  cases. 

Other  features  may  be  mentioned :  Three  generations  have  been  affected, 
or  two  or  three  members  of  a  family,  or  a  mother  and  several  children.  The 
lesions  may  develop  during  pregnancy  and  disappear  after  delivery.  Brick- 
ner,  after  whom  this  syndrome  has  been  named,  collected  16  cases.  The 
tumors  do  not  always  disappear.  Adrian  reported  a  case  with  multiple  myo- 
mata  of  the  stomach.  A  sarcomatous  change  may  occur  in  the  central  tumors, 
but  not  in  the  optic  and  olfactory  nerves  which  have  not  the  sheath  of 
Schwann.     There  may  be  associated  glioma  or  other  brain  tumor. 

The  nature  of  the  disease  is  unknown.  The  occurrence  of  the  pigmenta- 
tion and  the  osteomalacia  suggest  an  endocrine  disturbance;  but  the  familial 
and  hereditary  features  point  rather  to  an  embryonic  origin. 

The  prognosis  depends  on  the  possibility  of  successful  removal  of  such 
tumors  as  are  causing  greatest  inconvenience. 

"Tubercula  Dolorosa." — Multiple  neuromata  may  especially  affect  the  ter- 
minal cutaneous  branches  of  the  sensory  nerves  and  lead  to  small  subcutaneous 
painful  nodules,  often  found  on  the  face,  breast,  or  about  the  Joints.  They 
may  be  associated  with  tumors  of  the  nerve  trunks. 

"Amputation  Neuromata." — These  bulbous  swellings  may  form  on  the 
central  ends  of  nerves  which  have  been  divided  in  injuries  or  operations.  They . 
are  especially  common  after  amputations.  They  are  due  to  the  tangled  coil 
of  axis-cylinder  processes  growing  down  from  the  central  stump  in  an  effort 
to  reach  their  former  end  structures.  They  are  very  painful  and  usually  re- 
quire surgical  removal  but  may  recur. 


III.     DISEASES  OF  THE  CEREBRAL  NERVES 

OLFACTORY   NERVES   AND   TRACTS 

The  functions  of  the  olfactory  nerves  may  bo  disturbed  at  their  origin, 
in  the  nasal  mucous  membrane,  at  tl>e  bulb,  in  tlie  course  of  the  tract,  or 
at  the  centres  in  the  brain.  The  disturbances  may  be  manifested  in  sub- 
jective sensations  of  smell,  complete  loss  of  the  sense,  and  occasionally  in 
hypersesthesia. 


1022  DISEASES  OP  THE  NERVOUS  SYSTEM 

Subjective  Sensations;  Parosmia. — Hallucinatious  of  this  kind  are  found 
in  the  insane  and  in  epilepsy.  The  aura  ma}'  be  represented  by  an  unpleas- 
ant odor^  described  as  resembling  chloride  of  lime^  burning  rags,  or  feathers. 
In  a  few  cases  with  these  subjective  sensations  tumors  have  been  found  in  the 
hippocampi.  In  rare  instances,  after  injury  of  the  head,  the  sense  is  perverted 
— odors  of  the  most  different  character  may  be  alike,  or  the  odor  may  be 
changed,  as  in  a  patient  noted  by  Morell  Mackenzie,  who  for  some  time  could 
not  touch  cooked  meat,  as  it  smelt  to  her  exactly  like  stinking  fish. 

Increased  sensitiveness  (hyperosmia)  occurs  chiefly  in  nervous,  hysterical 
women,  in  whom  it  may  sometimes  be  developed  so  greatly  that,  like  a  dog, 
they  can  recognize  the  difference  between  individuals  by  the  odor  alone. 

Anosmia;  Loss  of  the  Sense  of  Smell. — This  may  be  produced  by:  (a)  Af- 
fections of  the  origin  of  the  nerves  in  the  mucous  membrane,  which  is  perhaps 
the  most  frequent  cause.  It  is  not  uncommon  with  chronic  nasal  catarrh  and 
polypi.  In  paralysis  of  the  fifth  nerve,  the  sense  of  smell  may  be  lost  on  the 
affected  side,  owing  to  interference  with  secretion.  It  is  doubtful  whether 
the  cases  of  loss  of  smell  following  the  inhalations  of  foul  or  strong  odors 
come  under  this  or  under  the  central  division. 

(&)  Lesions  of  the  bulbs  or  of  the  tracts.  In  falls  or  blows,  in  caries 
of  the  bones,  and  in  meningitis  or  tumor,  the  bulbs  or  the  olfactory  tracts 
may  be  involved.  After  an  injury  to  the  head  the  loss  of  smell  may  be  the 
only  symptom.  Mackenzie  noted  a  case  of  a  surgeon  who  was  thrown  from 
his  gig  and  lighted  on  his  head.  The  injury  was  slight,  but  the  anosmia 
which  followed  was  persistent.  In  tabes  the  sense  of  smell  may  be  lost,  pos- 
sibly owing  to  atrophy  of  the  nerves. 

(c)  Lesions  of  the  olfactory  centres.  There  are  congenital  cases  in  which 
the  structures  have  not  developed.  Cases  have  been  reported  in  which  anosmia 
has  been  associated  with  disease  in  the  hemisphere. 

To  test  the  sense  of  smell  the  pungent  bodies,  such  as  ammonia,  which 
act  upon  the  fifth  nerve,  should  not  be  used,  but  such  substances  .as  cloves, 
peppermint,  and  musk.-  This  sense  is  readily  tested  as  a  routine  matter  in 
brain  cases  by  having  two  or  three  bottles  containing  the  essential  oils.  In 
all  instances  a  rhinoscopic  examination  should  be  made,  as  the  condition  may 
be  due  to  local,  not  central  causes.  The  treatment  is  unsatisfactory  even  in 
the  cases  due  to  local  lesions  in  the  nostrils. 

OPTIO  NERVE  AND  TEACT 

"(1)   Lesions  of  the  Retina 

These  are  of  importance  to  the  physician,  and  information  of  the  great- 
est value  may  be  obtained  by  a  systematic  examination  of  the  eye  grounds. 
Only  a  brief  reference  can  be  made  to  the  more  important  appearances. 

Retinitis. — This  occurs  in  certain  general  affections,  more  particularly  in 
nephritis,  syphilis,  leuksemia,  and  anemia.  The  common  feature  in  all  those 
is  the  occurrence  of  hgemorrhage  and  the  development  of  opacities.  There 
may  also  be  a  diffuse  cloudiness  due  to  effusion  of  serum.  The  hsemorrhages 
are  in  the  layer  of  nerve  fibres.  They  vary  greatly  in  size  and  form,  but 
often  follow  the  course  of  vessels.  When  recent  the  color  is  bright  red, 
but  they  gradually  change  and  old  haemorrhages  are  almost  black.     The  white 


DISEASES  OF  THE  CEEEBEAL  NERVES  1033 

spots  are  due  either  to  fibrinous  exudate  or  to  fatty  degeneration  of  the 
retinal  elements,  and  occasionally  to  accumulation  of  leucocytes  or  to  a  local- 
ized sclerosis  of  the  retinal  elements.  The  more  important  forms  of  retinitis 
are: 

Albuminuric  retinitis,  which  occurs  in  chronic  nephritis,  particularly  in 
the  interstitial  or  contracted  form.  The  percentage  of  cases  affected  is  from 
15  to  25.  There  are  instances  in  which  these  retinal  changes  are  associated 
with  the  granular  kidney  at  a  stage  when  the  amount  of  albumin  may  be 
slight  or  transient;  but  in  all  such  instances  it  will  be  found  that  there  is  a 
marked  arterio-sclerosis.  Gowers  recognized  a  degenerative  form  (most  com- 
mon ) ,  in  which,  with  the  retinal  changes,  there  may  be  scarcely  any  alteration 
in  the  disk;  a  hsemorrhagic  form,  with  many  hgemorrhages  and  but  slight 
signs  of  inflammation;  and  an  inflammatory  form,  in  which  there  is  much 
swelling  of  the  retina  and  obscuration  of  the  disk.  It  is  noteworthy  that  in 
some  instances  the  inflammation  of  the  optic  nerve  predominates  over  the 
retinal  changes,  and  one  may  be  in  doubt  for  a  time  whether  the  condition  is 
associated  with  renal  changes  or  dependent  upon  intracranial  disease. 

Syphilitic  Eetinitis. — In  the  acquired  form  this  is  less  common  than 
choroiditis.     In  inherited  syphilis  retinitis  pigmentosa  is  sometimes  found. 

Retinitis  in  Anemia. — A  patient  may  become  blind  after  a  large  hemor- 
rhage, either  suddenly  or  within  two  or  three  days,  and  in  one  or  both  eyes. 
Occasionally  the  loss  may  be  permanent  and  complete.  In  some  of  these 
instances  a  neuro-retinitis  has  been  found,  probably  sufficient  to  account  for 
the  symptoms.  In  the  more  chronic  ansemias,  particularly  the  pernicious  form, 
retinitis  is  common,  as  determined  first  by  Quincke. 

In  MALARIA  retinitis  or  neuro-retinitis  may  be  present,  as  noted  by  Stephen 
Mackenzie.  It  is  seen  only  in  the  chronic  cases  with  anaemia,  and  is  not  nearly 
so  common  proportionately  as  in  pernicious  anaemia. 

Leukemic  Retinitis. — In  this  affection  the  retinal  veins  are  large  and 
distended;  there  is  also  a  peculiar  retinitis,  as  described  by  Liebreich.  It  is 
not  very  common.  There  are  numerous  hgemorrhages  and  white  or  yellow 
areas,  which  may  be  large  and  prominent.  In  one  case  the  retina  post  mortem 
was  dotted  with  many  small,  opaque,  white  spots,  looking  like  little  tumors, 
the  larger  of  which  had  a  diameter  of  nearly  3  mm. 

Retinitis  is  also  found  occasionally  in  diabetes,  in  purpura,  in  chronic 
lead  poisoning,  and  sometimes  as  an  idiopathic  affection. 

Functional  Disturbances  of  Vision. —  (a)  Toxic  Amaurosis. — This  oc- 
curs in  uraemia  and  may  follow  convulsions  or  come  on  independently.  The 
condition,  as  a  rule,  persists  only  for  a  day  or  two.  This  form  of  amaurosis 
occurs  in  poisoning  by  lead,  alcohol,  and  occasionally  by  quinine.  It  seems 
more  probable  that  the  poisons  act  on  the  centres  and  not  on  the  retina. 

(&)  Tobacco  Amblyopia. — Tlie  loss  of  sight  is  usually  gradual,  equal  in 
both  eyes,  and  affects  particularly  the  centre  of  the  field  of  vision.  The  eye- 
grounds  may  be  normal,  but  occasionally  there  is  congestion  of  the  disks. 
On  testing  the  color  fields  a  central  scotoma  for  red  and  green  is  found  in  all 
cases.  Ultimately,  if  the  use  of  tobacco  is  continued,  organic  changes  may 
develop  with  atrophy  of  the  disk. 

(c)   Hystekical  Amauiigsis. — More  frequently  this  is  loss  of  acuteness 


1024  DISEASES  OF  THE  NEEVOUS  SYSTEM 

vision — amblyopia — but  the  loss  of  sight  in  one  or  both  eyes  may  apparently 
■be  complete.    The  condition  will  be  mentioned  under  hysteria. 

(d)  Night-blindness — nyctalopia — the  condition  in  which  objects  are 
clearly  seen  during  the  day  or  by  strong  artificial  light,  but  become  invisible  in 
(the  shade  or  in  twilight,  and  hemeralopia,  in  which  objects  can  not  be  clearly 
seen  without  distress  in  daylight  or  in  a  strong  artificial  light^  but  are  readily 
seen  in  a  deep  shade  or  in  twilight,  are  rare  functional  anomalies  which  may 
occur  in  epidemic  form. 

(e)  Eetinal  hyperesthesia  is  sometimes  seen  in  hysterical  women,  but 
is  not  frequent  in  actual  retinitis.  It  may  occur  with  albuminuric  retinitis, 
and  with  aortic  insufiiciency. 

(2)    Lesions  of  the  Optic  Nerve 

Optic  Neuritis  (Papillitis;  Choked  Disk). — In  the  first  stage  there  is  con- 
gestion of  the  disk  and  the  edges  are  blurred  and  striated.  In  the  second 
stage  the  congestion  is  more  marked;  the  swelling  increases,  the  striation 
also  is  more  visible.  The  physiological  cupping  disappears  and  haemorrhages 
are  not  uncommon.  The  arteries  present  little  change,  the  veins  are  dilated, 
and  the  disk  may  swell  greatly.  In  slight  grades  the  swelling  gradually  sub- 
sides and  occasionally  the  nerve  recovers  completely.  In  instances  in  which 
the  swelling  and  exudate  are  very  great  the  subsidence  is  slow,  and  when  it 
finally  disappears  there  is  complete  atrophy  of  the  nerve.  The  retina  may 
•participate  in  the  inflammation,  which  is  then  a  neuro-retinitis. 

This  condition  is  of  the  greatest  importance  in  diagnosis.  It  may  exist 
in  its  early  stages  without  any  disturbance  of  vision,  and  even  with  exten- 
sive papillitis  the  sight  may  for  a  time  be  good. 

Optic  neuritis  is  seen  occasionally  in  anaemia  and  lead  poisoning,  more 
commonly  in  nephritis  as  neuro-retinitis.  It  occurs  occasionally  as  a  prim- 
ary idiopathic  affection.  The  frequent  connection  with  intracranial  dis- 
ease, particularly  tumor,  makes  its  presence  of  great  value.  The  nature  of 
the  growth  is  without  influence.  In  over  90  per  cent,  of  such  instances  the 
choked  disk  is  bilateral.  It  is  also  found  in  meningitis,  either  the  tuberculous^ 
or  the  simple  form.  In  meningitis  the  inflammation  may  extend  down  the 
nerve  sheath.  In  tumor,  however,  it  is  probable  that  mechanical  conditions,  es- 
pecially venous  stasis,  are  alone  responsible  for  the  oedematous  swelling.  It 
often  subsides  very  rapidly  after  decompression  has  been  performed. 

Optic  Atrophy. — This  may  be:  (a)  A  primary  affection.  There  is  an 
hereditary  form,  in  which  the  disease  has  developed  in  all  the  males  of  a 
family  shortly  after  puberty.  A  large  number  of  the  cases  of  primary  atrophy 
are  associated  with  spinal  disease,  particularly  tabes.  Other  causes  which 
have  been  assigned  for  the  primary  atrophy  are  cold,  sexual  excesses,  diabetes, 
the  specific  fevers,  methyl  alcohol,  and  lead. 

(b)  Secondary  atrophy  results  from  cerebral  diseases,  pressure  on  the 
chiasma  or  on  the  nerves,  or,  most  commonly  of  all,  as  a  sequence  of  papillitis: 

The  ophthalmoscopic  appearances  are  different  in  the  cases  of  primary 
and  secondary  atrophy.  In  the  former  the  disk  has  a  gray  tint,  the  edges 
are  well  defined,  and  the  arteries  look  almost  normal;  whereas  in  the  con- 
secutive atrophy  the  disk  has  a  staring  opaque  white  aspect,  with  irregular 
outlines,  and  the  arteries  are  very  small. 


DISEASES  OF  THE  CEKEBEAL  NEEVES  1025 

The  symptom  of  optic  atrophy  is- loss  of  sight,  proportionate  to  the  dam- 
age in  the  nerve.  The  change  is  in  three  directions:  "(1)  Diminished  acuity 
of  vision;  (2)  alteration  in  the  field  of  vision;  and  (3)  altered  perception  of 
color"  (Gowers).     The  outlook  in  primary  atrophy  is  had. 

(3)  Affections  of  the  Cliiasma  and  Tract 

At  the  chiasma  the  optic  nerves  undergo  partial  decussation.  Each  optic 
tract,  as  it  leaves  the  chiasma,  contains  nerve  fibres  which  originate  in  the 
retinae  of  both  eyes.  Thus,  of  the  fibres  of  the  right  tract,  part  have  come 
through  the  chiasma  without  decussating  from  the  temporal  half  of  the  right 
retina,  the  other  and  larger  portion  of  the  fibres  of  the  tract  have  decussated 
in  the  chiasma,  coming  as  they  do  from  the  left  optic  nerve  and  the  nasal  half 
of  the  retina  on  the  left  side.  The  fibres  which  cross  are  in  the  middle  por- 
tion of  the  chiasma,  while  the  direct  fibres  aje  on  each  side.  The  following 
are  the  most  important  changes  from  lesions  of  the  tract  and  chiasma : 

Unilateral  Affection  of  Tl-act. — If  on  the  right  side,  this  produces  loss 
of  function  in  the  temporal  half  of  the  retina  on  the  right  side,  and  in  the 
nasal  half  of  the  retina  on  the  left  side,  so  that  there  is  only  half  vision, 
and  the  patient  is  blind  to  objects  on  the  left  side.  This  is  termed  homony- 
mous hemianopia  or  lateral  hemianopia.  The  fibres  passing  to  the  right  half 
of  each  retina  being  involved,  the  patient  is  blind  to  objects  in  the  left  half 
of  each  visual  field.  The  hemianopia  may  be  partial  and  only  a  portion  of 
the  half  field  may  be  lost.  The  unaffected  visual  fields  may  have  the  normal 
extent,  but  in  some  instances  there  is  considerable  reduction.  When  the  left 
half  of  one  field  and  the  right  half  of  the  other,  or  vice  versa,  are  blind,  the 
condition  is  known  as  heteronymous  hemianopia. 

Disease  of  the  Chiasma. — (a)  A  lesion  involves,  as  a  rule,  chiefly  the 
central  portion,  in  which  the  decussating  fibres  pass  which  supply  the  inner 
or  nasal  halves  of  the  retinae,  producing  in  consequence  loss  of  vision  in 
the  outer  half  of  each  field,  or  what  is  known  as  temporal  hemianopia. 

(&)  If  the  lesion  is  more  extensive  it  may  involve  not  only  the  central  por- 
tion, but  also  the  direct  fibres  on  one  side  of  the  commissure,  in  which  case 
there  is  total  blindness  in  one  eye  and  temporal  hemianopia  in  the  other. 

(c)  Still  more  extensive  disease  is  not  infrequent  from  pressure  of 
tumors  in  this  region,  the  whole  chiasma  is  involved,  and  total  blindness  re- 
sults. The  different  stages  in  the  process  may  often  be  traced  in  a  single  case 
from  temporal  hemianopia,  then  complete  blindness  in  one  eye  with  temporal 
hemianopia  in  the  other,  and  finally  complete  blindness. 

(d)  A  limited  lesion  of  the  outer  part  of  the  chiasma  involves  only  the 
direct  fibres  passing  to  the  temporal  halves  of  the  retinae  and  inducing  blind- 
ness in  the  nasal  field,  or,  as  it  is  called,  nasal  hemianopia.  This,  of  course,  is 
extremely  rare.  Double  nasal  hemianopia  may  occur  as  a  manifestation  of 
tabes  and  in  tumors  involving  the  outer  fibres  of  each  tract. 

(4)  Affections  of  the  Tract  and  Centres 

The  optic  tract  crosses  the  crus  (cerebral  peduncle)  to  the  hinder  part 
of  the  optic  thalamus  and  divides  into  two  portions,  one  of  which  (the  lateral 
root)  goes  to  the  pulvinar  of  the  thalamus,  the  lateral  geniculate  body,  and 


1026  DISEASES  OF  THE  NEEVOUS  SYSTEM 

to  the  anterior  quadrigeminal  body  (superior  colliculus).  From  these  parts, 
in  which  the  lateral  root  terminates,  fibres  pass  into  the  posterior  part  of  the 
internal  capsule  and  enter  the  occipital  lobe,  forming  the  fibres  of  the  optic 
radiation,  which  terminate  in  and  about  the  cuneus,  the  region  of  the  visual 
perceptive  centre.  The  fibres  of  the  medial  division  of  the  tract  pass  to  the 
medial  geniculate  body  and  to  the  posterior  quadrigeminal  body.  The  medial 
root  contains  the  fibres  of  the  commissura  inferior  of  v.  Gudden,  which  are 
believed  to  have  no  connection  with  the  retina.  It  is  still  held  by  some  physi- 
ologists that  the  cortical  visual  centre  is  not  confined  to  the  occipital  lobe  alone, 
but  embraces  the  occipito-angular  region. 

A  lesion  of  the  fibres  of  the  optic  path  anywhere  between  the  cortical  cen- 
tre and  the  chiasma  will  produce  hemianopia.  The  lesion  may  be  situated: 
(a)  In  the  optic  tract  itself,  (h)  In  the  region  of  the  thalamus,  lateral 
geniculate  body,  and  the  corpora  quadrigemina,  into  which  the  larger  part  of 
each  tract  enters,  (c)  A  lesion  of  the  fibre  passing  from  the  centre  just 
mentioned  to  the  occipital  lobe.  This  may  be  either  in  the  hinder  part  of  the 
internal  capsule  or  the  white  fibres  of  the  optic  radiation.  (cI)  Lesion  of  the 
cuneus.  Bilateral  disease  of  the  cuneus  may  result  in  total  blindness,  (e) 
There  is  clinical  evidence  to  show  that  lesion  of  the  angular  gyrus  may  be 
associated  with  visual  defect,  not  so  often  hemianopia  as  crossed  amblyopia, 
dimness  of  vision  in  the  opposite  eye,  and  great  contraction  in  the  field  of 
vision.  Lesions  in  this  region  are  associated  with  mind-blindness,  a  condition 
in  which  there  is  failure  to  recognize  the  nature  of  objects. 

The  effect  of  lesion  in  the  optic  nerve  in  different  situations  from  the  reti- 
nal expansion  to  the  brain  cortex  are  as  follows:  (1)  Of  the  optic  nerve,  total 
blindness  of  the  corresponding  eye;  (2)  of  the  optic  chiasma,  either  temporal 
hemianopia,  if  the  central  part  alone  is  involved,  or  nasal  hemianopia,  if  the 
lateral  region  of  each  chiasma  is  involved;  (3)  lesion  of  the  optic  tract 
between  the  chiasma  and  the  lateral  geniculate  body  produces  lateral  hemian- 
opia; (4)  lesion  of  the  central  fibres  of  the  nerve  between  the  geniculate 
bodies  and  the  cerebral  cortex  produces  lateral  hemianopia;  (5)  lesion  of  the 
cuneus  causes  lateral  hemianopia;  and  (6)  lesion  of  the  angular  gyrus  may 
be  associated  with  hemianopia,  sometimes  crossed  amblyopia,  and  the  con- 
dition known  as  mind-blindness.     (See  Fig.  21.) 

Diagnosis  of  Lesions  of  the  Optic  Nerve  and  Tract. — Having  determined 
the  presence  of  hemianopia,  the  question  arises  as  to  the  situation  of  the 
lesion,  whether  in  the  tract  between  the  chiasma  and  the  geniculate  bodies 
or  in  the  central  portion  of  the  fibres  between  these  bodies  and  the  visual 
centres.  This  can  be  determined  in  some  cases  by  the  test  known  as  Wer- 
nicke's hemiopic  pupillary  reaction.  The  pupil  refiex  depends  on  the  in- 
tegrity of  the  retina  or  receiving  membrane,  on  the  fibres  of  the  optic  nerve 
and  tract  which  transmit  the  impulse,  and  the  nerve-centre  at  the  termination 
of  the  optic  tract  which  receives  the  impression  and  transmits  it  to  the  third 
nerve  along  which  the  motor  impulses  pass  to  the  iris.  If  a  bright  light  is 
thrown  into  the  eye  and  the  pupil  reacts,  the  integrity  of  this  reflex  arc  is 
demonstrated.  It  is  possible  in  cases  of  lateral  hemianopia  so  to  throw  the 
light  into  the  eye  that  it  falls  upon  the  blind  half  of  the  retina.  If  when  this 
is  done  the  pupil  contracts,  tlie  indication  is  that  the  reflex  arc  above  referred 
to  is  perfect,  by  which  we  mean  that  the  optic  nerve  fibres  from  the  retinal 


DISEASES  OF  THE  CEEEBEAL  NEEVES 


1027 


expansion  to  the  centre,  the  centre  itself,  and  the  third  nerve  are  uninvolved. 
In  such  a  case  the  conclusion  would  be  Justified  that  the  cause  of  the  hemi- 
anopia  was  central ;  that  is,  situated  beyond  the  geniculate  body,  either  in  the 


Fig.  21. — Diagram  of  Visual  Paths.     (From  Vialet,  modified.) 

OP.  N.,  Optic  nerve.  OP.  C,  Optic  chiasm.  OP.  T.,  Optic  tract.  OP.  E.,  Optic 
radiations.  EXT.  GEN.^  External  geniculate  body.  THO.,  Optic  thalamus.  C.  QU., 
Corpora  quadrigemina.  C.  C,  Corpus  callosum.  V.  S.,  Visual  speech  centre.  A.  S., 
Auditory  speech  centre.  H.  S.,  Motor  speech  centre.  A  lesion  at  1  causes  blindness 
of  that  eye;  at  2,  bi-temporal  liemianopia;  at  3,  nasal  hemianopia.  Symmetrical  lesions 
at  3  and  3'  would  cause  bi-nasal  hemianopia;  at  4,  hemianopia  of  both  eyes,  with 
hemianopic  pupillary  inaction;  at  5  and  6,  hemianopia  of  both  eyes,  pupillary  reflexes 
normal;   at  7,  amblyopia,  especially  of  opposite  eye;   at  8,  on  left  side,  word-blindness. 


fibres  of  the  optic  radiation  or  in  the  visual  cortical  centres.  If,  on  the  other 
hand,  when  the  light  is  carefully  thrown  on  the  hemiopic  half  of  the  retina 
the  pupil  remains  inactive,  the  conclusion  is  justifiable  that  there  is  interrup- 
tion in  the  path  between  the  retina  and  nucleus  of  the  third  nerve,  and  that 
the  hemianopia  is  not  central,  but  dependent  upon  a  lesion  situated  in  the 


1028  DISEASES  OF  THE  NEEVOUS  SYSTEM 

optic  tract.  This  test  of  Wernicke's  is  sometimea  difficult  to  obtain.  It  is 
best  performed  as  follows:  "The  patient  being  in  a  dark  or  "nearly  dark  room 
with  the  lamp  or  gas-light  behind  his  head  in  the  usual  position,  I  bid  him 
look  over  to  the  otloer  side  of  the  room,  so  as  to  exclude  accommodative  iris 
movements  (which  are  not  necessarily  associated  with  the  reflex).  Then  I 
throw  a  faint  light  from  a  plane  mirror  or  from'  a  large  concave  mirror,  held 
well  out  of  focus,  upon  the  eye  and  note  the  size  of  the  pupil.  With  my  other 
hand  I  now  throw  a  beam  of  light,  focussed  from  the  lamp  by  an  ophthalmo- 
scopic mirror,  directly  into  the  optical  centre  of  the  eye;  then  laterally  in 
various  positions  and  also  from  above  and  below  the  equator  of  the  eye,  noting 
the  reaction  at  all  angles  of  incidence  of  the  ray  of  light"     (Seguin) . 

The  significance  of  hemianopia  varies.  There  is  a  functional  hemiajiopia 
associated  with  migraine  and  hj^steria.  In  a  considerable  proportion  of  all 
cases  there  are  signs  of  organic  brain  disease.  In  a  certain  number  of  in- 
stances of  slight  lesions  of  the  occipital  lobe  hemichromatopsia  has  been 
observed.  The  homonymous  halves  of  the  retina  as  far  as  the  fixation  point 
are  dulled,  or  blind  for  colors.  Hemiplegia  is  common,  in  which  event  the 
loss  of  power  and  blindness  are  on  the  same  side.  Thus,  a  lesion  in  the  left 
hemisphere  involving  the  motor  tract  produces  right  hemiplegia,  and  when 
the  fibres  of  the  optic  radiation  are  involved  in  the  internal  capsule  there  is 
also  lateral  hemianopia,  so  that  objects  in  the  field  of  vision  to  the  right  axe- 
not  perceived.  Hemiansesthesia  is  not  uncommon  in  such  cases,  owing  to  the 
close  association  of  the  sensory  and  visual  tracts  at  the  posterior  part  of  the 
internal  capsule.     Certain  forms  of  aphasia  also  occur  in  many  of  the  cases. 

The  optic  aphasia  of  Freund  may  be  mentioned  here.  The  patient,  after 
an  apoplectic  attack,  though  able  to  recognize  ordinary  objects  shown  to  him, 
is  unable  to  name  them  correctly.  If  he  be  permitted  to  touch  the  object  he 
may  be  able  to  name  it  quickly  and  correctly.  Freund's  optic  aphasia  differs 
from  mind-blindness,  since  in  the  latter  affection  the  objects  seen  are  not 
recognized.  Optic  aphasia,  like  word-blindness,  never  occurs  alone,  but  is 
always  associated  with  hemianopia,  or  mind-blindness,  and  often  also  with 
"word-deafnese.  In  the  cases  which  have  thus  far  come  to  autopsy  there  has 
always  been  a  lesion  in  the  white  matter  of  the  occipital  lobe  on  the  left  side. 

MOTOR  NERA^ES  OF  THE  EYEBALL 

Third  Nerve  (Nervus  oculomotorius) . — The  nucleus  of  origin  of  this  nerve 
is  situated  in  the  floor  of  the  aqueduct  of  Sylvius;  the  nerve  passes  through 
the  crus  at  the  side  of  which  it  emerges.  Passing  along  the  wall  of  the  cav- 
ernous sinus,  it  enters  the  orbit  through  the  sphenoidal  fissure  and  supplies, 
by  its  superior  branch,  the  levator  palpebrae  superioris  and  the  superior  rectus, 
and  by  its  inferior  branch  the  internal  and  inferior  recti  muscles  and  the  infe- 
rior oblique.  Branches  pass  to  the  ciliary  muscle  and  the  constrictor  of  the 
iris.  Lesions  may  affect  the  nucleus  of  the  nerve  in  its  course  and  cause  either 
paralysis  or  spasm. 

Paralysis. — A  nuclear  lesion  is  usually  associated  with  disease  of  the 
centres  for  the  otlier  eye  muscles,  producing  general  ophthalmoplegia.  More 
commonly  the  nerve  itself  is  involved  in  its  course,  either  by  meningitis,  gum- 
mata,  or  aneurism,  or  is  attacked  by  a  neuritis,  as  in  diphtheria.  Complete 
paralysis  is  accompanied  by  the  following  symptoms : 


DISEASES  OF  THE  CEEEBEAL  NEEVES  1029 

Paralysis  of  all  the  muscles,  except  the  superior  oblique  and  external  rec- 
tus, by  which  the  eye  can  be  moved  outward  and  a  little  downward  and  inward. 
There  is  divergent  strabismus.  There  is  ptosis  or  drooping  of  the  upper  eye- 
lid, owing  to  paralysis  of  the  levator  palpebrse.  The  pupil  is  usually  dilated. 
It  does  not  contract  to  light,  and  the  power  of  accommodation  is  lost.  The 
most  striking  features  of  this  paralysis  are  the  external  strabismus,  with 
diplopia  or  double  vision,  and  the  ptosis.  In  very  many  cases  the  affection 
of  the  third  nerve  is  partial.  Thus  the  levator  palpebrse  and  the  superior 
rectus  may  be  involved  together,  or  the  ciliary  muscles  and  the  iris  may  be 
affected  and  the  external  muscles  may  escape. 

There  is  a  remarkable  form  of  recurring  oculo-motor  paralysis  affecting 
chiefly  women,  and  involving  all  the  branches  of  the  nerve.  In  some  cases 
the  attacks  have  come  on  at  intervals  of  a  month;  in  others  a  much  longer 
period  has  elapsed.  The  attacks  may  persist  throughout  life.  They  are  some- 
times associated  with  pain  in  the  head  and  sometimes  with  migraine.  Mary 
Sherwood  collected  23  cases  from  the  literature. 

Ptosis  is  a  common  and  important  sign  in  nervous  affections.  We  may 
here  briefly  refer  to  the  conditions  under  which  it  may  occur :  (a)  A  con- 
genital, incurable  form;  (h)  the  form  associated  with  definite  lesion  of  the 
third  nerve,  either  in  its  course  or  at  its  nucleus.  This  may  come  on  with 
paralysis  of  the  superior  rectus  alone  or  with  paralysis  of  the  internal  and 
inferior  recti  as  well,  (c)  Tliere  are  instances  of  complete  or  partial  ptosis 
associated  with  cerebral  lesions  without  any  other  branch  of  the  third  nerve 
being  paralyzed.  The  exact  position  of  the  cortical  centre  or  centres  is  as  yet 
unknown.  (d)  Hysterical  ptosis,  which  is  double  and  occurs  with  other 
hysterical  symptoms.  (e)  Pseudo-ptosis,  due  to  affection  of  the  sympa- 
thetic nerve,  is  associated  with  symptoms  of  vaso-motor  palsy,  such  as  eleva- 
tion of  the  temperature  on  the  affected  side  with  redness  and  oedema  of  the 
skin.  Contraction  of  the  pupil  exists  on  the  same  side  and  the  eyeball  ap- 
pears rather  to  have  shrunk  into  the  orbit.  (/)  In  idiopathic  muscular 
atrophy,  when  the  face  muecles  are  involved,  there  may  be  marked  bilateral 
ptosis.  And,  lastly,  in  weak,  delicate  women  there  may  be  a  transient  ptosis, 
particularly  in  the  morning. 

Among  the  most  important  of  tlie  symptoms  of  the  third-nerve  paralysis 
are  those  which  relate  to  the  ciliary  muscle  and  iris. 

Cycloplegia^  paralysis  of  the  ciliary  muscle,  causes  loss  of  the  power  of 
accommodation.  Distant  vision  is  clear,  but  near  objects  cannot  be  prop- 
erly seen.  In  consequence  the  vision  is  indistinct,  but  can  be  restored  by  the 
use  of  convex  glasses.  This  may  occur  in  one  or  in  both  eyes;  in  the  latter 
case  it  is  usually  associated  with  disease  in  the  nuclei.  Cycloplegia  is  an  early 
and  frequent  sign  in  diphtheritic  paralysis  and  occurs  also  in  tabes. 

Iridoplegia,  or  paralysis  of  the  iris,  occurs  in  three  forms  (Gowers)  : 

(a)  Accommodation  iridoplegia,  in  which  the  pupil  does  not  alter  in 
size  during  the  act  of  accommodation.  To  test  this  the  patient  should  look 
first  at  a  distant  and  then. at  a  near  object  in  the  same  line  of  vision. 

(&)  Reflex  Iridoplefiin. — The  path  for  the  iris  reflex  is  along  the  optic 
nerve  and  tract  to  its  termination,  then  to  the  nucleus  of  the  third  nerve, 
and  along  the  trunk  of  this  nerve  to  the  ciliary  ganglion,  and  so  through 
the  ciliary  nerves  to  the  eyes.    Each  eye  should  be  tested  separately,  the  other 


1030  DISEASES  OF  THE  XEEVOITS  SYSTEil 

one  being  covered.  The  patient  should  look  at  a  distant  object  in  a  dark  part 
of  the  room;  then  a  light  is  brought  suddenly  in  front  of  the  eye  at  a  dis- 
tance of  three  or  four  feet,  so  as  to  avoid  the  effect  of  accommodation.  Loss 
of  this  iris  reflex  with  retention  of  the  accommodation  contraction  is  known 
as  the  Argyll-Eobertson  pupil. 

(c)  Loss  of  the  Shin  Reflex. — If  the  skin  of  the  neck  is  pinched  or  pricked 
the  pupil  dilates  reflexly,  the  afferent  impulses  being  conveyed  along  the  cer- 
vical sympathetic.  Erb  pointed  out  that  this  skin  reflex  is  lost  usually  in 
association  with  the  reflex  contraction,  but  the  two  are  not  necessarily  con- 
joined. In  iridoplegia  the  pupils  are  often  small,  particularly  in  spinal  dis- 
ease, as  in  the  characteristic  small  pupils  of  tabes — spinal  myosis.  Irido- 
plegia may  coexist  with  a  pupil  of  medium  size. 

Inequality  of  the  pupils — anisocoria — is  not  infrequent  in  progressive  pare- 
sis and  in  tabes.    It  may  also  occur  in  perfectly  healthy  individuals. 

Spasm. — Occasionally  in  meningitis  and  in  hysteria  there  is  spasm  of  the 
muscles  supplied  by  the  third  nerve,  particularly  the  internal  rectus  and  the 
levator  palpebrge.  Nijstagm'Us  is  a  rhythmical  contraction  of  the  eye  muscles 
met  with  in  many  congenital  and  acquired  lesions  of  the  brain,  particularly  in 
multiple  sclerosis.  It  may  be  hereditary  and  has  been  traced  through  four 
generations  in  association  with  head  nodding  (Yawger).  Lid  nystagmus  may 
also  be  present.  It  is  met  with  in  albinos.  The  nystagmus  of  miners  is  ap- 
parently due  to  poor  light. 

Fourth.  Nerve  (Nervus  trocMearis) . — This  supplies  the  superior  oblique 
muscle.  In  its  course  around  the  outer  surface  of  the  crus  and  in  its  pas- 
sage into  the  orbit  it  is  liable  to  be  compressed  by  tumors,  by  aneurism,  or  in 
the  exudation  of  basilar  meningitis.  Its  nucleus  in  the  upper  part  of  the 
fourth  .ventricle  may  be  involved  by  tumors  or  undergo  degeneration  with  the 
other  ocular  nuclei.  The  superior  oblique  muscle  acts  in  such  a  way  as  to 
direct  the  eyeball  downward  and  rotate  it  slightly.  The  paralysis  causes  de- 
fective downward  and  inward  movement,  often  too  slight  to  be  noticed.  The 
head  is  inclined  somewhat  forward  and  toward  the  sound  side,  and  there  is 
double  vision  when  the  patient  looks  down. 

Sixth.  Nerve. — Emerging  at  the  junction  of  the  pons  and  medulla,  it  passes 
forward  in  a  long  and  exposed  course  to  the  orbit,  and  supplies  the  external 
rectus  muscle.  It  is  often  involved  in  meningeal  exudate,  compressed  by  tu- 
mors and  possibly  involved  in  an  independent  neuritis.  When  paralyzed,  there 
is  internal  squint  with  diplopia  on  attempting  to  look  outwards.  The  true 
and  the  false  images  are  parallel,  and  grow  further  apart  on  looking  to  the 
paralyzed  side.  When  the  nucleus  is  involved,  the  internal  rectus  of  the  op- 
posite eye  may  be  paralyzed  as  the  nucleus  sends  fibres  up  in  the  pons  to  that 
part  of  the  nucleus  of  the  opposite  third  nerve  which  supplies  the  internal 
rectus.  In  one  symptom-complex  there  is  a  combination  of  otitis  media  with 
complete  paralysis  of  the  sixth  nerve.  The  inflammation  travels  to  the  apex 
of  the  petrous  bone,  then  to  the  sixth  nerve.     The  outlook  is  usually  good. 

General  Features  of  Paralysis  of  the  Motor  Nerves  of  the  Eye. — Gowers 
divided  them  into  five  groups : 

(a)  Limitation  of  Moveme7it. — Thus^  in  paralysis  of  the  external  rectus, 
the  eyeball  can  not  be  moved  outward.  When  the  paralysis  is  incomplete 
the  movement  is  deficient  in  proportion  to  the  degree  of  the  palsy. 


DISEASES  OF  THE  CEREBRAL  NERVES  1031 

(b)  Strabisinus. — The  axes  of  the  eyes  do  not  correspond.  Thus,  paralysis 
of  the  internal  rectus  causes  a  divergent  squint ;  of  the  external  rectus,  a  con- 
vergent squint.  At  first  this  is  evident  only  when  the  eyes  are  moved  in  the 
direction  of  the  action  of  the  weak  muscle.  The  deviation  of  the  axis  of  the 
affected  eye  from  parallelism  with  the  other  is  called  the  primary  deviation. 

(c)  Secondary  Deviation. — If,  while  the  patient  is  looking  at  an  ohject, 
the  sound  eye  is  coAered,  so  that  he  fixes  the  object  looked  at  with  the  affected 
eye  only,  the  sound  eye  is  moved  still  further  in  the  same  direction — e.  g., 
outward,  when  there  is  paralysis  of  the  opposite  internal  rectus.  This  is  known 
as  secondary  deviation.  It  depends  upon  the  fact  that,  if  two  muscles  are 
acting  together,  when  one  is  weak  and  an  effort  is  made  to  contract  it,  the 
increased  effort — innervation — acts  powerfully  upon  the  other  muscle,  causing 
an  increased  contraction. 

{d)  Erroneous  Projection. — "We  judge  of  the  relation  of  external  ob- 
jects to  each  other  by  the  relation  of  their  images  on  the  retina;  but  we  judge 
of  their  relation  to  our  own  body  by  the  position  of  the  eyeball  as  indicated 
to  us  by  the  innervation  we  give  to  the  ocular  muscles"  (Gowers).  With 
the  eyes  at  rest  in  the  mid-position,  an  object  at  which  we  are  looking  is 
directly  opposite  our  face.  Turning  the  eyes  to  one  side,  we  recognize  that 
object  in  the  middle  of  the  field  or  to  the  side  of  this  former  position.  We 
estimate  the  degree  by  the  amount  of  movement  of  the  eyes,  and  when  the 
object  moves  and  we  follow  it  we  judge  of  its  position  by  the  amount  of  move- 
ment of  the  eyeballs.  When  one  ocular  muscle  is  weak  the  increased  inner- 
vation gives  the  impression  of  a  greater  movement  of  the  eye  than  has  really 
taken  place.  The  mind,  at  the  same  time,  receives  the  idea  that  the  object  is 
further  on  one  side  than  it  really  is,  and  in  an  attempt  to  touch  it  the  finger 
may  go  beyond  it.  As  the  equilibrium  of  the  body  is  in  a  large  part  main- 
tained by  a  knowledge  of  the  relation  of  external  objects  to  it  obtained  by  the 
action  of  the  eye  muscles,  this  erroneous  projection  disturbs  the  harmony  of 
these  visual  impressions  and  may  lead  to  giddiness — ocular  vertigo. 

{e)  Double  Vision. — This  is  one  of  the  most  disturbing  features  of  paral- 
ysis of  the  eye  muscles.  The  visual  axes  do  not  correspond,  so  that  there  is 
a  double  image — diplopia.  That  seen  by  the  sound  eye  is  termed  the  true 
image;  that  by  the  paralyzed  eye,  the  false.  In  simple  or  homonymous  dip- 
lopia the  false  image  is  "on  the  same  side  of  the  other  as  the  eye  by  which 
it  is  seen."  In  crossed  diplopia  it  is  on  the  other  side.  In  convergent  squint 
the  diplopia  is  simple;  in  divergent  it  is  crossed. 

Ophthalmoplegia. — Under  this  term  is  described  a  chronic  progressive 
paralysis  of  the  ocular  muscles.  Two  forms  are  recognized — ophthalmoplegia 
externa  and  ophthalmoplegia  interna..  The  conditions  may  occur  separately 
or  together  and  are  describexl  by  Gowers  under  nuclear  ocular  palsy. 

Ophthalmoplegia  externa. — The  condition  is  one  of  more  or  less  com- 
plete palsy  of  the  external  muscles  of  the  eyeball,  due  usually  to  a  slow  degen- 
eration in  the  nuclei  of  the  nerves,  but  sometimes  to  pressure  of  tumors  or  to 
basilar  meningitis.  It  is  often,  1)ut  not  necessarily,  associated  with  ophthal- 
moplegia interna.  Of  62  cases  analyzed  by  Siemerling  in  only  11  could 
syphilis  be  positively  determined.  The  levator  muscles  of  the  eyelids  and  the 
superior  recti  are  first  involved,  and  gradually  the  other  muscles,  so  that  the 
eyeballs  are  fixed  and  tlio  eyelids  droop.     Tliere  is  sometimes  slight  protrusion 


1033  DISEASES  OF  THE  NERVOUS  SYSTEM 

of  the  eyeballs.  The  disease  is  essentially  chronic  and  may  last  for  years. 
It  is  found  particularly  in  association  with  general  paresis,  tabes,  and  in 
progressive  muscular  atrophy.  Mental  disorders  were  present  in  11  of  the  63 
cases.  With  it  may  be  associated  optic  atrophy  and -affections  of  other  cere- 
bral nerves.     Oceasionall}^,  as  noted  by  Bristowe,  it  may  be  functional. 

Ophthai^moplegia  interna. — Jonathan  Hutchinson  applied  this  term  to 
a  progressive  paralysis  of  the  internal  ocular  muscles,  causing  loss  of  pupil- 
lary action  and  the  power  of  accommodation.  When  the  internal  and  ex- 
ternal muscles  are  involved  the  affection  is  known  as  total  ophthalmoplegia, 
and  in  a  majority  of  the  cases  the  two  conditions  are  associated.  In  some 
instances  the  internal  form  may  depend  upon  disease  of  the  ciliary  ganglion. 

While,  as  a  rule,  ophthalmoplegia  is  a  chronic  process,  there  is  an  acute 
form  associated  with  hsemorrhagic  softening  of  the  nuclei  of  the  ocular  mus- 
cles. There  is  usually  marked  cerebral  disturbance.  It  was  to  this  form  that 
Wernicke  gave  the  name  poliencephalitis  superior. 

Treatment  of  Ocular  Palsies. — It  is  important  to  ascertain,  if  possible, 
the  cause.  The  forms  associated  with  tabes  are  obstinate,  and  resist  treat- 
ment. Occasionally,  however,  a  palsy,  complete  or  partial,  may  pass  away 
spontaneously.  The  cases  associated  with  chronic  degenerative  changes,  as 
in  progressive  paresis  and  bulbar  paralysis,  are  little  affected  by  treatment. 
On  the  other  hand,  in  syphilitic  cases,  specific  treatment  is  often  beneficial. 
Arsenic  and  strychnia,  the  latter  hypodermically,  may  be  employed.  In  any 
case  in  which  the  onset  is  acute  with  pain,  hot  fomentations  and  counter-irri- 
tation or  leeches  applied  to  the  temple  give  relief.  The  direct  treatment  by 
electricity  has  been  employed,  but  without  any  special  effect.  The  diplopia  may 
be  relieved  by  the  use  of  prisms,  or  it  may  be  necessary  to  cover  the  affected  eye 
with  an  opaque  glass. 

FIFTH   ISTEKVE 

(Nervus  trigeminus) 

Etiology. — Paralysis  may  result  from :  (a)  Disease  of  the  pons,  particu- 
larly haemorrhage  or  patches  of  sclerosis.  (&)  Injury  or  disease  at  the  base  of 
the  brain.  Fracture  rarely  involves  the  nerve ;  on  the  other  hand,  meningitis,, 
acute  or  chronic,  and  caries  of  the  bone  are  not  uncommon  causes,  (c)  The 
branches  may  be  affected  as  they  pass  out — the  first  division  by  tumors  press- 
ing on  the  cavernous  sinus  or  by  aneurism ;  the  second  and  third  divisions  by 
growths  which  invade  the  spheno-maxillary  fossa.  (d)  Primary  neuritis, 
which  is  rare. 

Symptoms. —  (a)  Sensory  Portion. — Disease  of  the  fifth  nerve  may  cause 
loss  of  sensation  in  the  parts  supplied,  including  the  half  of  the  face,  the  cor- 
responding side  of  the  head,  the  conjunctiva,  the  mucosa  of  the  lips,  tongue, 
hard  and  soft  palate,  and  of  the  nose  of  the  same  side.  The  anesthesia  may 
be  preceded  by  tingling  or  pain.  The  muscles  of  the  face  are  also  insensible 
and  the  movements  may  be  slower.  The  sense  of  smell  is  interfered  with, 
owing  to  dryness  of  the  mucous  membrane.  There  may  be  disturbance  of 
the  sense  of  taste.  The  salivary,  lachrymal,  and  buccal  secretions  may  be 
lessened,  and  the  teeth  may  become  loose.  Unless  properly  guarded  from 
injury  an  ulcerative  inflammation  of  the  eye  may  follow.     This  was  supposed 


DISEASES  OF  THE  CEREBEAL  NERVES  1033 

to  be  due  to  nutritional  changes  from  paralysis  of  so-called  trophic  nerve 
fibres.  This  idea  has  been  overthrown  by  the  large  number  of  cases  in  which 
the  Gasserian  ganglion  has  been  removed  for  obstinate  neuralgia  without  con- 
sequent inflammation  of  the  eye.  Herpes  may  occur  in  the  region  supplied  by 
the  nerve,  usually  the  upper  branch,  and  is  associated  with  much  pain,  which 
may  be  persistent,  lasting  for  months  or  years  (Gowers).  In  herpes  zoster 
with  the  neuritis  there  may  be  slight  enlargement  of  the  cervical  glands. 
(See  under  Neuralgia  for  Tic  Douloureux.) 

(&)  j\IoTOR  Portion. — The  inability  to  use  the  muscles  of  mastication  on 
the  affected  side  is  the  distinguishing  feature  of  paralysis  of  this  portion  of 
the  nerve.  It  is  recognized  by  placing  the  finger  on  the  masseter  and  tem- 
poral muscles,  and,  when  the  patient  closes  the  jaw,  the  feebleness  of  their 
contraction  is  noted.  If  paralyzed,  the  external  pterygoid  can  not  move  the 
jaw  toward  the  unaffected  side;  and  when  depressed,  the  jaw  deviates  to  the 
paralyzed  side.  Motor  paralysis  of  the  fifth  nerve  is  almost  invariably  a  result 
of  involvement  after  the  nerve  has  left  the  nucleus  but  cases  have  been  asso- 
ciated with  cortical  lesions.  The  cortical  motor  centre  for  the  trigeminus,  or 
for  movements  effecting  closure  of  the  jaw,  lies  below  that  for  movements  of 
the  face  at  the  lower  part  of  the  anterior  central  convolution. 

Spasm  of  the  Muscles  of  Mastication. — Trismus,  the  masticatory  spasm 
of  Romberg,  may  be  tonic  or  clonic,  and  is  either  an  association  phenomenon 
in  general  convulsions  or,  more  rarely,  an  independent  affection.  In  the  tonic 
form  the  jaws  are  kept  close  together — lock-jaw — or  can  be  separated  only  for 
a  short  space.  The  muscles  of  mastication  can  be  seen  in  contraction  and 
felt  to  be  hard;  the  spasm  is  often  painful.  This  tonic  contraction  is  an 
early  symptom  in  tetanus,  and  is  sometimes  seen  in  tetany.  A  form  of  this 
tonic  spasm  occurs  in  hysteria.  Occasionally  trismus  follows  exposure  to  cold, 
and  is  said  to  be  due  to  reflex  irritation  from  the  teeth,  the  mouth,  or  caries 
of  the  jaw.  It  may  also  be  a  symptom  of  organic  disease  due  to  irritation 
near  the  motor  nucleus  of  the  fifth  nerve. 

Clonic  spasm  of  the  muscles  supplied  by  the  fifth  occurs  in  the  form  of 
rapidly  repeated  contractions,  as  in  "chattering  teeth."  This  is  rare  apart 
from  general  conditions,  though  cases  are  on  record,  usually  in  women  late 
in  life,  in  whom  this  isolated  clonic  spasm  of  the  muscles  of  the  jaw  has  been 
found.  In  another  form  of  clonic  spasm  sometimes  seen  in  chorea  there  are 
forcible  single  contractions.  Gowers  mentioned  an  instance  of  its  occurrence 
as  an  isolated  affection. 

(c)  Gustatory. — There  are  two  views  concerning  the  course  of  the  fibres 
that  carry  gustatory  impulse  from  this  part  of  the  tongue.  According  to  some 
they  take  a  devious  path,  passing  with  the  chorda  tympani  to  the  geniculate 
ganglion,  thence  by  the  great  superficial  petrosal  nerve  to  Meckel's  ganglion, 
and  this  they  leave  to  reach  the  maxillary  nerve,  which  they  follow  through 
the  trigeminal  nerve  to  the  brain.  A  study  of  clinical  cases  of  disease  of  the 
fifth  nerve  has  led  to  this  view.  It  seems  more  probable,  from  the  fact  that 
a  laro-e  number  of  the  trigeminal  neurectomies  are  not  followed  by  loss  of 
taste,  that  the  fibres  pass  with  the  facial  nerve  to  the  brain  directly  from  the 
geniculate  ganglion  by  the  nervus  intermedins  of  Wrisberg.  Possibly  there 
may  be  more  than  one  course  for  these  fibres. 

The  diagnosis  of  disease  of  the  trifacial  nerve  is  rarely  difficult.     It  must 


1034  DISEASES  OE  THE  NEEVOUS  SYSTEM 

be  remembered  that  the  preliminary  pain  and  hyperesthesia  are  sometimes 
mistaken  for  ordinary  neuralgia.  The  loss  of  sensation  and  the  palsy  of  the 
muscles  of  mastication  are  readily  determined. 

Treatment. — When  the  pain  is  severe  morphia  may  be  required  and  local 
applications  are  useful.  If  there  is  a  suspicion  of  syphilis,  appropriate  treat- 
ment should  be  given.     Faradization  is  sometimes  beneficial. 

FACIAL  NERVE 

Paralysis  {BelVs*Palsy) . — Etiology. — The  facial  or  seventh  may  be  para- 
lyzed by  (a)  lesions  of  the  cortex — supranuclear  palsy;  (&)  lesions  of  the 
nucleus  itself ;  or  ( c)  involvement  of  the  nerve  trunk  in.  its  tortuous  course 
vs^ithin  the  pons  and  through  the  wall  of  the  skull. 

(a)  Supranuclear  paralysis,  due  to  lesion  of  the  cortex  or  of  the  facial 
fibres  in  the  corona  radiata  or  internal  capsule,  is,  as  a  rule,  associated  with 
hemiplegia.  It  may  be  caused  by  tumors,  abscess,  chronic  infiammation,  or 
softening  in  the  cortex  or  in  the  region  of  the  internal  capsule.  It  is  distin- 
guished from  the  peripheral  form  by  the  persistence  of  the  normal  electrical 
excitability  of  both  nerves  and  muscles  and  the  frequent  absence  of  involve- 
ment of  the  upper  branches  of  the  nerve,  so  that  the  orbicularis  palpebrarum, 
frontalis,  and  corrugator  muscles  are  spared.  In  rare  instances  these  muscles 
are  paralyzed.  In  this  form  the  voluntary  movements  are  more  impaired  than 
the  emotional.  Isolated  paralysis — monoplegia  facialis — due  to  involvement 
of  the  cortex  or  of  the  fibres  in  their  path  to  the  nucleus,  is  uncommon.  In 
the  great  majority  of  cases  supranuclear  facial  paralysis  is  part  of  a  hemi- 
plegia. Paralysis  is  on  the  same  side  as  that  of  the  arm.  and  leg  because  the 
facial  muscles  bear  the  same  relation  to  the  cortex  as  the  spinal  muscles.  The 
nuclei  of  origin  on  either  side  of  the  middle  line  in  the  medulla  are  united 
by  decussating  fibres  with  the  cortical  centre  on  the  opposite  side  (see  Fig.  20). 
A  few  fibres  reach  the  nucleus  from  the  cerebral  cortex  of  the  same  side,  and 
this  uncrossed  path  may  innervate  the  upper  facial  muscles. 

(&)   The  nuclear  paralysis  caused  by  lesions  of  the  nerve  centres  in  the 
medulla  is  not  common  alone ;  but  is  seen  occasionally  in  tumors,  chronic  soft- 
ening, and  haemorrhage.     It  may  be  involved  in  anterior  polio-myelitis.     In 
diphtheria  this  centre  may  also  be  attacked.     The  symptoms  are  practically  ' 
similar  to  those  of  an  affection  of  the  nerve  fibre  itself — infranuclear  paralysis. 

(c)   Involvement  of  the  Nerve  Trunk. — Paralysis  may  result  from: 

(1)  Involvement  of  the  nerve  as  it  passes  through  the  pons — that  is,  be- 
tween its  nucleus  in  the  floor  of  the  fourth  ventricle  and  the  point  of  emer- 
gence in  the  postero-lateral  aspect  of  the  pons.  The  specially  interesting 
feature  in  connection  with  involvement  of  this  part  is  the  production  of  what 
is  called  alternating  or  crossed  paralysis,  the  face  being  involved  on  the  same 
side  as  the  lesion,  and  the  arm  and  leg  on  the  opposite  side,  since  the  motor 
path  is  involved  above  the  point  of  decussation  in  the  medulla  (Fig.  20).  This 
occurs  only  when  the  lesion  is  in  the  lower  section  of  the  pons.  A  lesion  in 
the  upper  half  of  the  pons  involves  the  fibres  not  of  the  outgoing  nerve  on  the 
same  side,  but  of  the  fibres  from  the  hemispheres  before  they  have  crossed  to 
the  nucleus  of  the  opposite  side.  In  this  case  there  would  be  paralysis  of  the 
face  and  limbs  on  the  side  opposite  to  the  lesion.  The  palsy  would  resemble 
the  cerebral  form,  involving  only  the  lower  fibres  of  the  facial  nerve. 


DISEASES  OF  THE  CEEEBEAL  NEEVES  1035 

(2)  The  nerve  may  be  involved  at  its  point  of  emergence  by  tmnors,  par- 
ticularly by  the  cerebello-pontine  growths,  by  gummata,  meningitis,  or  occa- 
sionally it  may  be  injured  in  fracture  of  the  base. 

(3)  In  passing  through  the  Fallopian  canal  the  nerve  may  be  involved 
in  disease  of  the  ear,  particularly  by  caries  of  the  bone  in  otitis  media.  This 
is  a  common  cause. 

(4)  As  the  nerve  emerges  from  the  styloid  foramen  it  is  exposed  to  in- 
juries and  bloTi-^s  which  not  infrequently  cause  paralysis.  The  fibres  may  be 
cut  in  the  removal  of  tumors  in  this  region,  or  the  paralysis  may  be  caused  by 
pressure  of  the  forceps  in  an  instrumental  delivery. 

(5)  Exposure  to  cold  is  a  common  cause,  inducing  a  neuritis  of  the  nerve 
within  the  Fallopian  canal.  Eeik  believes  that  in  most  of  these  cases  there 
is  an  acute  otitis  media  from  which  the  nerve  is  involved. 

(6)  Syphilis  is  not  an  infrequent  cause,  and  the  paralysis  may  appear 
early  with  the  secondary  symptoms. 

(7)  It  may  occur  in  association  with  herpes. 

Facial  diplegia  is  a  rare  condition  occasionally  found  in  affections  at  the 
base  of  the  brain,  lesions  in  the  pons,  simultaneous  involvement  of  the  nerves 
in  ear-disease,  and  in  diphtheritic  paralysis.  Disease  of  the  nuclei  or  sym- 
metrical involvement  of  the  cortex  might  also  produce  it.  It  may  occur  as 
a  congenital  affection.     H.  M.  Thomas  described  two  cases  in  one  family. 

Symptoms. — In  the  peripheral  facial  paralysis  all  the  branches  of  the 
nerve  are  involved.  The  face  on  the  affected  side  is  immobile  and  can  neither 
be  moved  at  will  nor  participate  in  any  emotional  movements.  The  skin  is 
smooth  and  the  wrinkles  are  effaced,  a  point  particularly  noticeable  on  the 
forehead  of  elderly  persons.  The  eye  can  not  be  closed,  the  lower  lid  droops, 
and  the  eye  waters.  On  the  affected  side  the  angle  of  the  mouth  is  lowered, 
and  in  drinking  the  lips  are  not  kept  in  close  apposition  to  the  glass,  so  that 
the  liquid  is  apt  to  run  out.  In  smiling  or  laughing  the  contrast  is  most 
striking,  as  the  affected  side  does  not  move,  which  gives  a  curious  unequal 
appearance  to  the  two  sides  of  the  face.  The  eye  can  not  be  closed  nor  can 
the  forehead  be  wrinkled.  In  long  standing  cases,  when  the  reaction  of 
degeneration  is  present,  if  the  patient  tries  to  close  the  eyes  while  looking 
fixedly  at  an  object  the  lids  on  the  sound  side  close  firmly,  but  on  the  paralyzed 
side  there  is  only  a  slight  inhibitory  droop  of  the  upper  lid,  and  the  eye  is 
turned  upward  and  outward  by  the  inferior  oblique.  On  asking  the  patient 
to  show  his  upper  teeth,  the  angle  of  the  mouth  is  not  raised.  In  all  these 
movements  the  face  is  drawn  to  the  sound  side  by  the  action  of  the  muscles. 
Speaking  may  be  slightly  interfered  with,  owing  to  the  imperfection  in  the 
formation  of  the  labial  sounds.  Whistling  can  not  be  performed.  In  chew- 
ing the  food,  owing  to  the  paralysis  of  the  buccinator,  particles  collect  on  the 
affected  side.  The  paralysis  of  the  nasal  muscles  is  seen  on  asking  the  patient 
to  suiff.  Owing  to  the  fact  that  the  lips  are  drawn  to  the  sound  side,  the 
tongue,  when  protruded,  looks  as  if  it  were  pushed  to  the  paralyzed  side;  but 
on  taking  its  position  from  the  incisor  teeth,  it  will  be  found  to  be  in  the  mid- 
dle line.  The  reflex  movements  are  lost  in  this  peripheral  form.  It  is  usually 
stated  that  the  palate  is  partially  paralyzed  on  the  same  side  and  that  the 
uvula  deviates.    Both  Cowers  and  Hughlings  Jackson  denied  the  existence  of 


1036  DISEASES  OF  THE  NERVOUS  SYSTEM 

this  involvement  in  the  great  majority  of  cases,  and  Horsley  and  Beevor  have 
shown  that  these  parts  are  innervated  by  the  accessory  nerve  to  the  vagus. 

The  sensory  functions  of  the  facial  nerve,  to  which  much  attention  has 
been  paid  by  Gushing,  Mills  and  others,  are  ministered  to  by  the  geniculate 
ganglion,  the  intermediary  nerve  of  Wrisberg,  and  the  chorda  tympani,  which 
last  has  chiefly  gustatory  functions.  It  seems  likely  that  deep  sensibility  with 
sense  of  pressure,  position  and  passive  movement  runs  in  a  separate  afferent 
system  in  the  motor  nerve  of  the  face.  Cutaneous  sensibility,  both  epicritie, 
by  which  we  localize  light  touch,  and  protopathic,  by  which  we  recognize  de- 
grees of  heat  and  cold,  is  not  ministered  to  by  the  facial  nerve  proper.  There 
are  observations  that  would  indicate,  however,  that  the  anterior  part  of  the 
tongue  and  possibly  a  little  strip  of  the  skin  of  the  auricle  have  a  vestigial  sup- 
ply from  this  nerve. 

When  the  nerve  is  involved  within  the  canal  between  the  genu  and  the 
origin  of  the  chorda  tympani,  the  sense  of  taste  is  lost  in  the  anterior  part  of 
the  tongue  on  the  affected  side,  ^lien  the  nerve  is  damaged  outside  the  skull 
the  sense  of  taste  is  unaffected.  Hearing  is  often  impaired  in  facial  paralysis, 
most  commonly  by  preceding  ear  disease.  The  paralysis  of  the  stapedius  mus- 
cle may  lead  to  increased  sensitiveness  to  musical  notes.  Herpes  is  sometimes 
associated  with  facial  paralysis.  Severe  pain  may  precede  or  accompany  the 
paralysis.  It  is  usually  in  the  ear  and  mastoid  region  but  may  radiate  to  the 
occipital  and  trigeminal  distribution.  The  face  on  the  affected  side  may  be 
swollen. 

The  electrical  reactions,  which  are  those  of  a  peripheral  palsy,  have  con- 
siderable importance  from  a  prognostic  standpoint,  Erb's  rules  are  as  fol- 
lows :  If  there  is  no  change,  either  f aradic  or  galvanic,  the  prognosis  is  good 
and  recovery  takes  place  in  from  fourteen  to  twenty  days.  If  the  faradic 
and  galvanic  excitability  of  the  nerve  is  only  lessened  and  that  of  the  muscle 
increased  to  the  galvanic  current  and  the  contraction  formula  altered  (the 
contraction  sluggish  AC<KC),  the  outlook  is  relatively  good  and  recovery 
will  probably  take  place  in  from  four  to  six  weeks ;  occasionally  in  from  eight 
to  ten.  "When  the  reaction  of  degeneration  is  present  and  the  mechanical  ex- 
citability is  altered,  the  prognosis  is  relatively  unfavorable  and  recovery  may 
not  occur  for  two,  six,  eight,  or  even  fifteen  months. 

Course. — This  is  usually  favorable.  The  onset  in  the  form  following  cold 
is  very  rapid,  developing  perhaps  within  twenty-four  hours,  but  rarely  is  the 
paralysis  permanent.  Hunt  has  drawn  special  attention  to  recurrent  facial  par- 
alysis which  may  be  on  one  or  alternate  sides — "relapsing  alternating."  In 
some  instances  contracture  develops  as  the  voluntary  power  returns,  and  the 
natural  folds  and  the  wrinkles  on  the  affected  side  may  be  deepened,  so  that 
on  looking  at  the  face  one  at  first  may  have  the  impression  that  the  affected 
side  is  the  sound  one.  This  is  corrected  at  once  on  asking  the  patient  to  smile, 
when  it  is  seen  which  side  of  the  face  has  the  more  active  movement.  Aretaeus 
noted  the  difficulty  sometimes  experienced  in  determining  which  side  was  af- 
fected until  the  patient  spoke  or  laughed. 

Peemaxent  Faciae  Paralysis. — One  of  the  distressing  sequels  is  per- 
manent loss  of  power  with  immobility  and  the  disfigurement  resulting  from 
the  overaction  of  the  muscles  on  the  sound  side.  There  are  three  groups  of 
cases:     (1)  Those  due  to  trauma,  especially  the  birth  palsies  from  injury  by 


DISEASES  OF  THE  CEREBRAL  XERVES  103^ 

forceps.  (2)  Due  to  suppurative  middle-ear  disease,  following  scarlet  fever, 
diphtheria,  or  sepsis  of  any  kind,  such  as  puerperal  fever.  (3)  In  a  few  cases 
following  the  ordinary  Bell's  paralysis.  Even  v.hen  paralysis  exists  from 
childhood,  there  may  be  slight  voluntary  control,  and  the  muscles  may  respond 
to  faradic  stimulus.  The  facial  nerve  in  reality  may  have  recovered  or  regen- 
erated, and  the  disfigurement  and  loss  of  function  result  from  the  over-stretch- 
ing of  the  degenerated  muscles  by  the  action  of  their  opponents  on  the  sound 
side  (Turrell). 

Diagnosis. — This  is  usually  easy.  The  distinction  between  the  peripheral 
and  central  form  is  based  on  facts  already  mentioned. 

Treatment. — In  the  cases  which  result  from  cold  and  are  probably  due 
to  neuritis  within  the  bony  canal,  hot  applications  should  be  made;  subse- 
quently the  thermo-cautery  may  be  used  lightly  at  intervals  of  a  day  or  two 
over  the  mastoid  process,  or  small  blisters  applied.  If  the  ear  is  diseased, 
free  discharge  should  be  obtained.  The  galvanic  current  may  be  employed 
to  keep  up  the  nutrition  of  the  muscles.  The  positive  pole  should  be  placed 
behind  the  ear,  the  negative  one  along  the  zygomatic  and  other  muscles. 
The  application  can  be  made  daily  for  a  quarter  of  an  hour  and  the  patient 
can  make  it  himself  before  a  looking  glass.  Massage  in  the  course  of  the 
nerve  and  of  the  muscles  of  the  face  is  also  useful.  A  course  of  iodide  of 
potassium  may  be  given  even  when  there  is  no  indication  of  syphilis. 

In  those  cases  in  which  the  nerve  has  been  destroyed  by  an  injury,  during 
an  operation  or  from  disease,  and  when  there  has  been  no  evidence  of  return- 
ing function  after  electric  treatment  for  a  few  months,  a  nerve  anastomosis 
should  be  performed.  For  this  purpose  either  the  spinal  accessory  or  the 
hypoglossal  nerve  may  be  used.  Though  the  normal  conditions  may  never  be 
completely  regained  after  such  an  operation,  the  motor  power  will  be  largely 
restored  and  the  deformity  lessened.  This  procedure,  based  on  the  results 
of  physiological  experimentation,  makes  one  of  the  most  striking  of  modern 
operations. 

Spasm. — The  spasm  may  be  limited  to  a  few  or  involve  all  the  muscles 
innervated  by  the  facial  nerve,  and  may  be  unilateral  or  bilateral. 

It  is  known  also  as  mimic  spasm  or  convulsive  tic.  Several  different  af- 
fections are  usually  considered  under  the  name  of  facial  or  mimic  spasm,  but 
we  here  speak  only  of  the  simple  spasm  of  the  facial  muscles,  either  primary 
or  following  paralysis,  and  do  not  include  the  cases  of  habit  spasm  in  chil- 
dren, or  the  tic  convulsif  of  the  French. 

Gowers  recognized  two  classes — one  in  which  there  is  an  organic  lesion, 
and  an  idiopathic  form.  It  is  thought  to  be  due  also  to  reflex  causes,  such 
as  the  irritation  from  carious  teeth  or  the  presence  of  intestinal  worms.  The 
disease  usually  occurs  in  adults,  whereas  the  ha1)it  spasm  and  the  iic  convulsif 
of  the  French,  often  confounded  with  it,  are  most  common  in  children.  True 
mimic  spasm  occasionally  comes  on  in  childhood  and  persists.  "When  the  re- 
sult of  organic  disease,  there  has  usually  been  a  lesion  of  the  centre  in  the 
cortex,  as  in  the  case  reported  by  Berkley,  or  pressure  on  the  nerve  at  the  base 
of  the  brain  by  aneurism  or  tumor. 

Symptoms. — The  spasm  may  involve  only  the  muscles  around  the  eye — 
blepharospasm — in  which  case  there  is  constant,  rapid,  quick  action  of  the 
orbicularis  palpebrarum,  which,  in  association  with  photophobia,  may  be  tonic 


1038  DISEASES  OF  THE  NERVOUS  SYSTEM 

in  character.  More  commonly  the  spasm  affects  the  lateral  facial  muscles  with 
those  of  the  eye,  and  there  is  constant  twitching  of  the  side  of  the  face  with 
partial  closure  of  the  eye.  The  frontalis  is  rarely  involved.  In  aggravated 
cases  the  depressors  of  the  angle  of  the  mouth,  the  levator  menti,  and  the 
platysma  myoides  are  affected.  This  spasm  is  confined  to  one  side  of  the  face 
in  a  majority  of  cases,  though  it  may  extend  and  become  bilateral.  It  is 
increased  by  emotional  cavises  and  by  voluntary  movements  of  the  face.  As 
a  rule,  it  is  painless,  but  there  may  be  tender  points  over  the  course  of  the  fifth 
nerve,  particularly  the  supraorbital  branch.  Tonic  spasm  of  the  facial  mus- 
cle may  follow  paralysis,  and  is  said  to  result  occasionally  from  cold. 

The  outlook  in  facial  spasm  is  always  dubious.  A  majority  of  the  cases 
persist  for  years  and  are  incurable. 

Treatment. — Sources  of  irritation  should  be  looked  for  and  removed. 
When  a  painful  spot  is  present  over  the  fifth  nerve,  blistering  or  the  appli- 
cation of  the  cautery  may  relieve  it.  Hypodermic  injections  of  strychnia 
may  be  tried,  but  are  of  doubtful  benefit.  Weir  Mitchell  recommended 
freezing  the  cheek  for  a  few  minutes  daily  or  every  second  day  with  the  spray, 
and  this,  in  some  instances,  is  beneficial.  Often  the  relief  is  transient  and 
at  every  clinic  patients  may  be  seen  who  have  run  the  gamut  of  all  measures 
without  material  improvement.  Severe  cases  may  require  surgical  interfer- 
ence. The  nerve  may  be  divided  near  the  stylomastoid  foramen  and  an  anas- 
tomosis made  between  it  and  the  spinal  accessory. 

AUDITORY  NERVE 

The  eighth,  known  also  as  portio  mollis  of  the  seventh  pair,  passes  from 
the  ear  through  the  internal  auditory  meatus,  and  in  reality  consists  of  two 
separate  nerves — the  cochlear  and  vestibular  roots.  These  two  roots  have  en- 
tirely different  functions,  and  may  therefore  be  best  considered  separately. 
The  cochlear  nerve  is  the  one  connected  with  the  organ  of  Corti,  and  is  con- 
cerned in  hearing.  The  vestibular  nerve  is  connected  with  the  vestibule  and 
semicircular  canals,  and  has  to  do  with  the  maintenance  of  equilibrium. 

The  Cochlear  Nerve 

The  cortical  centre  for  hearing  is  in  the  temporo-sphenoidal  lobe.  Primary 
disease  of  the  auditory  nerve  in  its  centre  or  intracranial  course  is  uncommon. 
More  frequently  the  terminal  branches  are  affected  within  the  labyrinth. 

Affection  of  the  Cortical  Centre. — The  superior  temporal  gyrus  represents 
the  centre  for  hearing.  In  man  destruction  of  this  gyrus  on  the  left  side 
results  in  word-deafness,  which  may  be  defined  as  an  inability  to  understand 
the  meaning  of  words,  though  they  may  still  be  heard  as  sounds.  The  central 
auditory  path  extending  to  the  cortical  centre  from  the  terminal  nuclei  of  the 
cochlear  nerve  may  be  involved  and  produce  deafness.  This  may  result  from 
involvement  of  the  lateral  lemniscus,  from  the  presence  of  a  tumor  in  the 
corpora  quadrigemina,  especially  if  it  involve  the  posterior  quadrigeminal 
bodies,  from  a  lesion  of  the  internal  geniculate  body,  or  it  may  be  associated 
with  a  lesion  of  the  internal  capsule. 

Lesions  of  the  nerve  at  the  base  of  the  brain  may  result  from  the  pressure 


DISEASES  OF  THE  CEREBRAL  NERVES  1039 

of  tumors,  meningitis  (particularly  the  cerebro-spinal  form),  haemorrhage,  or 
traumatism.  A  primary  degeneration  of  the  nerve  may  occur  in  tabes. 
Primary  disease  of  the  terminal  nuclei  of  the  cochlear  nerve  (nucleus  nervi 
cochlearis  dorsalis  and  nucleus  nervi  cochlearis  ventralis)  is  rare.  By  far 
the  most  interesting  form  results  from  epidemic  cerebro-spinal  meningitis, 
in  which  the  nerve  is  frequently  involved,  causiiig  permanent  deafness.  In 
young  children  the  condition  results  in  deaf-mutism. 

Internal  Ear. — In  a  majority  of  cases  with  auditory  nerve  symptoms  the 
lesion  is  in  the  internal  ear,  either  primary  or  the  result  of  extension  of  dis- 
ease of  the  middle  ear.  Two  groups  of  symptoms  may  be  produced — hyper- 
sesthesia  and  irritation,  and  diminished  function  or  nervous  deafness. 

(a)  Htpee^sthesia  and  Irritation.- — This  may  be  due  to  altered  func- 
tion of  the  centre  as  well  as  of  the  nerve  ending.  True  hyperaesthesia— hyper- 
acusis — is  a  condition  in  which  sounds,  sometimes  even  those  inaudible  to 
other  persons,  are  heard  with  great  intensity.  It  occurs  in  hysteria  and  oc- 
casionally in  cerebral  disease.  In  paralysis  of  the  stapedius  low  notes  may  be 
heard  with  intensity.  In  dyssesthesia,  or  dysacusis,  ordinary  sounds  cause  an 
unpleasant  sensation,  as  commonly  happens  in  connection  with  headache,  when 
ordinary  noises  are  badly  borne. 

Tinnitus  aurium  is  a  term  employed  to  designate  certain  subjective  sensa- 
tions of  ringing,  roaring,  tickling,  and  whirring  noises  in  the  ear.  It  is  a 
very  common  and  often  a  distressing  symptom.  It  is  associated  with  many 
forms  of  ear  disease  and  may  result  from  pressure  of  wax  on  the  drum.  It  is 
rare  in  organic  disease  of  the  central  connections  of  the  nerve.  Sudden  in- 
tense stimulation  of  the  nerve  may  cause  it.  A  form  not  uncommonly  met 
with  in  medical  practice  is  that  in  which  the  patient  hears  a  continual  bruit 
in  the  ear,  and  the  noise  has  a  systolic  intensification,  usually  on  one  side.  It 
may  suggest  the  presence  of  an  internal  aneurism.  A  systolic  murmur  may  be 
heard  occasionally  on  auscultation  in  anaemia  and  neurasthenia.  Subjective 
noises  in  the  ear  may  precede  an  epileptic  seizure  and  are  sometimes  present  in 
migraine.  In  whatever  form  tinnitus  exists,  though  slight  and  often  regarded 
as  trivial,  it  occasions  great  annoyance  and  mental  distress,  and  has  even,  driven 
patients  to  suicide. 

The  diagnosis  is  readily  made;  but  it  is  often  extremely  difficult  to  deter- 
mine upon  what  condition  the  tinnitus  depends.  The  relief  of  constitutional 
states,  such  as  anaemia,  neurasthenia,  or  gout,  may  result  in  cure.  A  careful 
local  examination  of  the  ear  should  always  be  made.  One  of  the  most  worry- 
ing forms  is  the  constant  clicking,  sometimes  audible  many  feet  away  from 
the  patient,  and  due  probably  to  clonic  spasm  of  the  muscles,  connected,  with 
the  Eustachian  tube  or  of  the  levator  palati.  The  condition  may  persist  for 
years  unchanged,  and  then  disappear  suddenly.  The  pulsating  forms  of  tinni- 
tus, in  which  the  sound  is  like  that  of  a  systolic  bruit,  are  almost  invariably 
subjective,  and  it  is  very  rare  to  hear  anything  with  the  stethoscope.  It  is 
to  be  remembered  that  in  children  there  is  a  systolic  brain  murmur,  best 
heard  over  the  ear,  and  in  some  instances  appreciable  in  the  adult. 

(b)  Diminished  Function  or  Nervous  Deafness. — In  testing  for  nerv- 
ous deafness,  if  the  tuning  fork  can  not  be  heard  when  placed  near  the*  meatus, 
but  the  vibrations  are  audible  by  placing  the  foot  of  the  tuning  fork  against 
the  temporal  bone,  the  conclusion  may  be  drawn  that  Ihe  deafness  is  not  due 


1040  DISEASES  OF  THE  NEEYOUS  SYSTEM 

to  involvement  of  the  nerve.  The  vibrations  are  conveyed  through  the  tem- 
poral bone  to  the  cochlea  and  vestibule.  The  watch  may  be  used  for  the  same 
purpose,  and  if  the  meatus  is  closed  and  the  watch  is  heard  better  in  contact 
with  the  mastoid  process  than  when  opposite  the  open  meatus,  the  deafness 
is  probably  not  nervous.  Disturbance  of  the  function  of  the  auditory  nerve 
is  not  a  very  frequent  symptom  in  brain  disease,  but  in  all  cases  the  function 
of  the  nerve  should  be  carefully  tested. 

The  Vestibular  Nerve 

Our  sense  of  position  in  space  and  the  control  of  the  balance  of  the  body 
are  functions  of  the  vestibular  nerve,  and  its  central  associations  in  the  cere- 
bellum and  cerebrum.  The  paths  from  the  labyrinth  are  not  accurately  known, 
beyond  the  group  of  Deiters'  Nuclei ;  there  is  uncertainty,  both  as  to  tracts  and 
centres. 

Disturbance  of  the  relation  of  the  body  to  space,  or  of  its  balance,  pro- 
duces in  consciousness  the  impleasant  sensation  which  we  call  dizziness  or 
vertigo.  It  results  from  a  discord  between  the  impressions  arising  in  the 
labyrinth,  the  cerebellum,  the  eye  muscles  and  elsewhere,  and  a  failure  to 
coordinate  these  in  the  centres  (Hughlings  Jackson).  The  controlling  factor 
is  the  vestibular  mechanism.  The  cochlear  nerves  are  often  involved  simul- 
taneously, producing  tinnitus,  and  the  motor-oculi  mechanism,  causing 
nystagmus. 

An  apprehension,  not  a  true  vertigo,  is  common  in  looking  from  a  height, 
and  is  frequent  in  neurotic  individuals.  True  dizziness  is  always  accom- 
panied- by  a  sensation  of  falling  or  turning,  even  when  the  person  is  in 
bed,  and  if  standing,  there  is  incoordination  of  the  muscles,  with  staggering 
or  falling.  The  patient  may  feel  that  he  is  moving  or  the  objects  about  him 
appear  to  rotate.  The  direction  in  which  he  falls  is  variable  and  of  special 
importance.  (Nystagmus  is  often  associated  and  the  direction  and  intensity 
should  be  studied. 

(1)  Auditory  (Labyrinthine)  Vertigo — Meniere's  Syndrome. — In  1861 
Meniere  described  an  affection  characterized  by  noises  in  the  ear,  vertigo 
(which  might  be  associated  with  loss  of  consciousness),  vomiting,  and,  in  many 
cases,  progressive  loss  of  hearing.  Barany  groups  the  conditions  in  which  the 
labyrinth  may  be  affected  and  vertigo  occur  under  the  following  heads :  {a) 
Acute  infectious  diseases,  influenza,  cerebro-spinal  meningitis,  etc.  (&) 
Chronic  infectious  diseases,  syphilis  particularly,  (c)  Constitutional  condi- 
tions and  intoxications.  Hemorrhage  into  the  labyrinth  (in  leuka?mia,  pur- 
pura haemorrhagica,  pernicious  aneemia)  ;  chlorosis,  thyroid  intoxications, 
arterio-sclerosis,  etc.  {d)  Tumors  and  diseases  of  the  central  nervous  sys- 
tem ;  tumors  of  the  acoustic  nerve,  cerebellum,  pons,  and  fourth  ventricle,  men- 
ingitis, cerebellar  abscess,  multiple  sclerosis,  tabes,  etc.  {e)  Trauma,  frac- 
ture of  the  base,  etc.  (/)  Hereditary  degenerative  diseases  and  malformations 
of*  the  internal  ear.  {g)  Intoxications,  alcohol,  nicotine,  quinine,  salicylic 
acid  group,  arsenic.  To  these  may  be  added  gas  emboli  in  caisson  disease  and 
ordinary  emboli. 

Symptoms. — -The  attack  usually  sets  in  suddenly  with  a  buzzing  noise  in 
the  ears  and  the  patient  feels  as  if  he  was  reeling  or  staggering.     He  may  feel 


DISEASES  OF  THE  CEEEBEAL.  NERVES  1041 

himself  to  be  reeling,  or  the  objects  about  him  may  seem  to  be  turning,  or  the 
phenomena  may  be  combined.  The  attack  is  often  so  abrupt  that  the  patient 
falls,  though,  as  a  rule,  he  has  time  to  steady  himself  by  grasping  some  neigh- 
boring object.  Consciousness  is  generally  maintained,  but  may  be  momenta- 
rily lost.  Ocular  symptoms  are  usually  present.  Jerking  of  the  eyeballs,  or 
nystagmus,  occurs.  The  patient  becomes  pale  and  nauseated,  a  clammy  sweat 
breaks  out  on  the  face,  and  vomiting  may  follow.  The  duration  of  the  attack 
varies ;  it  may  be  very  short,  but  usually  the  patient  has  to  lie  quietly  for  some 
time,  as  any  movement  of  the  head  brings  on  another  attack.  Labyrinthine 
vertigo  is  usually  paroxysmal,  coming  on  at  irregular  intervals,  sometimes  of 
weeks  or  months;  or  several  attacks  may  occur  in  a  day. 

Affections  of  the  External  and  Middle  Ears. — Irrigation  of  the  meatus  may 
be  followed  by  giddiness  or  by  a  severe  Meniere  syndrome.  Wax  is  one  of  the 
commonest  causes  and  the  first  to  be  sought  for.  Removal  of  a  dried  frag- 
ment pressing  against  the  drum  may  cure  a  persistent  and  distressing  vertigo. 
All  forms  of  middle  ear  disease  may  cause  vertigo,  the  suppurative  as  well  as 
the  chronic  sclerotic.  Noises  in  the  ear  are  usually  present  as  well.  The  at- 
tacks may  be  of  great  severity,  but  apart  from  gross  brain  lesions,  death  is  rare. 
A  patient  with  chronic  deafness  and  tinnitus  had  severe  vertigo  in  turning  in 
bed  on  the  left  side.  There  was  no  suggestion  of  central  lesion.  Death  oc- 
curred in  one  of  the  attacks. 

(2)  Vertigo  in  Intracranial  Tumors. — The  symptom  is  variable ;  the  larg- 
est growths  may  exist  in  any  region  without  it — a  very  small  one  in  a  special 
locality  may  cause  severe  attacks.  The  vestibular  fibres  may  be  directly  in- 
volved in  any  part  of  their  course  or  indirectly  compressed.  Direct  involve- 
ment is  seen  in  tumors  of  the  cerebello-pontine  angle,  affecting  the  eighth 
and  usually  the  seventh  nerves,  in  tumors  of  the  cerebellum,  and  in  aneurism. 
Vertigo  is  rarely  a  focal  symptom  as  it  may  follow  indirect  pressure  from 
tumors  of  the  cerebrum. 

(3)  Ocular  Vertigo.— The  association  of  giddiness  with  ocular  defects 
has  long  been  recognized,  and  the  newly  studied  ocular  reflexes  of  vestibular 
nerve  origin  now  play  an  important  role  in  diagnosis.  Nystagmus,  double 
vision,  and  paralysis  of  accommodation  may  be  ocular  associations  of  vertigo. 
The  central  connections  of  the  nuclei  of  the  "space  nerve"  with  those  of  the 
ocular  muscles  is  very  close.  Errors  of  refraction  may  cause  an  irritation  and 
instability  of  the  space  iierve  centres  leading  to  severe  vertigo. 

(4)  Cardio-vascular  Vertigo. — Vertigo  is  a  common  feature  in  the  group 
of  symptoms  known  as  "soldier's  heart."  In  cardiac  insufficiency  giddiness  is 
a  frequent  complaint,  particularly  with  aortic  disease.  The  loss  of  conscious- 
ness in  Stokes-Adams'  disease  may  be  preceded  by  distressing  symptoms  of 
vertigo.  One  of  the  commonest  forms  is  seen  in  high  blood  pressure  with  ar- 
terio-sclerosis,  very  often  with  tinnitus.  It  may  be  sligbt  and  noticed  only  in 
the  morning  or  on  getting  up  suddenly.  In  other  instances  it  is  one  of  the 
most  distressing  features  of  progressive  sclerosis  of  the  cerebral  arteries.  Ver- 
tio-o  may  precede  or  accompany  the  attacks  of  transient  hemi-  or  monoplegia 
with  asphasia ;  and  with  a  persistent  headache  and  high  blood  pressure  it  may 
precede  an  apoplexy.    Low  blood  pressure  is  also  a  frequent  cause. 

(5)  Toxic  vertigo  is  described  as  due  to  alcohol,  tobacco  and  quinine,  to 
the  poisons  of  the  specific  fevers,  and  to  focal  infection.    The  essential  process 


1042  DISEASES  OF  THE  NERVOUS  SYSTEM 

is  a  neuritis  of  the  eighth  nerve,  or  a  chronic  degenerative  change,  involving 
cochlea  and  labyrinth.  A  high-pitched  tinnitus,  with  progressive  deafness, 
and  transient  attacks  of  vertigo,  sometimes  of  the  Meniere  type,  are  the  usual 
symptoms.  True  toxic  neuritis  of  the  vestibular  nerve  is  very  rare.  Gastric, 
renal  and  various  types  of  functional  vertigo  have  diminished  progressively  in 
importance  since  the  studies  of  Barany. 

Diagnosis. — The  nervous,  ansemic  and  cardio-vascular  groups  rarely  offer 
any  difficulty  but  the  diagnosis  from  minor  epilepsy  is  not  so  easy,  particu- 
larly in  the  types  without  spasm.  Tinnitus  may  be  present,  but  it  is  rare  to 
have  actual  loss  of  consciousness  in  aural  vertigo,  in  which,  also,  the  actual 
giddiness  is  mote  persistent.  The  simpler  Barany  tests  may  be  applied;  the 
more  complicated  ones  call  for  the  help  of  the  specialist.  A  full  consideration 
will  be  found  in  Barker's  '^'Clinical  Diagnosis,"  vol.  iii.  The  vestibular  re- 
flexes are  as  important  in  some  cases  as  those  of  the  iris. 

Prognosis. — The  outlook  in  Meniere's  disease  is  uncertain.  While  many 
cases  recover  completely,  in  others  deafness  results  and  the  attacks  recur  at 
shorter  intervals.  In  aggravated  cases  the  patient  constantly  suffers  from 
vertigo,  and  may  even  be  confined  to  his  bed. 

Treatment. — Bromide  of  potassium,  in  20  grain  (1.3  gm.)  doses  three 
times  a  day,  is  sometimes  beneficial.  If  there  is  a  history  of  syphilis  the 
iodides  should  be  administered.  The  salicylates  are  recommended,  and  Charcot 
advises  quinine  to  cinchonism.  In  cases  in  which  there  is  increase  in  the 
arterial  tension  nitroglycerin  may  be  given,  at  first  in  very  small  doses,  but 
increasing  gradually.  It  is  not  specially  valuable  in  Meniere's  disease,  but  in 
the  cases  of  giddiness  in  middle  aged  men  and  women  associated  with  arterio- 
sclerosis it  sometimes  acts  very  satisfactorily.  Correction  of  errors  of  refrac- 
tion is  sometimes  followed  by  prompt  relief  of  the  vertigo. 

Endemic  Paralytic  Vertigo. — In  parts  of  Switzerland  and  France  there  i- 
a  remarkable  form  of  vertigo  described  by  Gerlier,  which  is  characterized  by 
attacks  of  paretic  weakness  of  the  extremities,  falling  of  the  eyelids,  remark- 
able depression,  but  with  retention  of  consciousness.  It  occurs  also  in  north- 
ern Japan,  where  Miura  says  it  develops  paroxysmally  among  the  farm  labor- 
ers of  both  sexes  and  all  ages.     It  is  known  there  as  IcubiscCgari. 

GLOSSO-PHARYN^EAL  NERVE 

The  ninth  nerve  contains  both  motor  and  sensory  fibres  and  is  also  a  nerve 
of  the  special  sense  of  taste  to  the  tongue.  It  supplies,  by  its  motor  branches, 
the  stylo-pharyngeus  and  the  middle  constrictor  of  the  pharynx.  The  sensory 
fibres  are  distributed  to  the  upper  part  of  the  pharynx. 

Symptoms. — Of  nuclear  disturbance  we  know  very  little.  The  pharyngeal 
symptoms  of  bulbar  paralysis  are  probably  associated  with  involvement  of  the 
nuclei  of  this  nerve.  Lesion  of  the  nerve  trunk  itself  is  rare,  but  it  may  be 
compressed  by  tumors  or  involved  in  meningitis.  Disturbance  of  the  sense  of 
taste  may  result  from  loss  of  function  of  this  nerve,  in  which  case  it  is  chiefly 
in  the  posterior  part  of  the  tongue  and  soft  palate. 

The  general  disturbances  of  the  sense  of  taste  may  be  briefly  mentioned. 
Loss  of  the  sense  of  taste — ageusia — may  be  caused  by  disturbance  of  the 
peripheral  end  organs,  as  in  affections  of  the  mucosa  of  the  tongue.     This  is 


DISEASES  OF  THE  CEREBRAL  NERVES  1043 

very  common  in  fever  or  dyspepsia,  in  which  conditions,  as  the  saying  is,  every- 
thing tastes  alike.  Strong  irritants,  such  as  pepper,  tobacco,  or  vinegar,  may 
dull  or  diminish  the  sense  of  taste.  Complete  loss  may  be  due  to  involvement 
of  the  nerves  either  in  their  course  or  in  the  centres.  Perversion  of  the  sense 
of  taste — parageusis — is  rarely  found,  except  as  an  hysterical  manifestation 
and  in  the  insane.  Increased  sensitiveness  is  still  more  rare.  There  are  occa- 
sional subjective  sensations  of  taste,  occurring  as  an  aura  in  epilepsy  or  as 
part  of  the  hallucinations  in  the  insane. 

To  test  the  sense  of  taste  the  patient's  eyes  should  be  closed  and  small 
quantities  of  various  su])stances  applied  to  the  protruded  tongue.  The  sensa- 
tion should  be  perceived  before  the  tongue  is  withdrawn.  The  following  are 
the  most  suitable  tests :  For  bitterness,  quinine ;  for  sweetness,  a  strong  solu- 
tion of  sugar  or  saccharin ;  for  acidity,  vinegar ;  and  for  the  saline  test,  com- 
mon salt.  One  of  the  most  important  tests  is  the  feeble  galvanic  current, 
which  gives  the  well-known  metallic  taste. 


PNEUMOGASTRTG    (VAGUS)    NERVE 

The  tenth  nerve  has  an  important  and  extensive  distribution,  supplying 
the  pharynx,  larynx,  lungs,  heart,  oesophagus,  and  stomach.  The  nerve  may 
be  involved  at  its  nucleus  along  with  the  spinal  accessory  and  the  hypoglossal, 
forming  what  is  known  as  bulbar  paralysis.  It  may  be  compressed  by  tumors 
or  aneurism,  or  in  the  exudation  of  meningitis,  simple  or  syphilitic.  In  its 
course  in  the  neck  the  trunk  may  be  involved  by  tumors  or  in  wounds.  It  has 
been  tied  in  ligature  of  the  carotid,  and  has  been  cut  in  the  removal  of  deep- 
seated  tumors.     The  trunk  may  be  attacked  by  neuritis. 

The  affections  of  the  vagus  are  best  considered  in  connection  with  the 
distribution  of  the  separate  nerves. 

Pharyngeal  Branches..: — In  combination  with  the  glosso-pharyngeal  the 
branches  from  the  vagus  form  the  pharyngeal  plexus,  from  which  the  muscles 
and  mucosa  of  the  pharynx  are  supplied.  In  paralysis  due  to  involvement  of 
this  either  in  the  nuclei,  as  in  bulbar  paralysis,  or  in  the  course  of  the  nerve, 
as  in  diphtheritic  neuritis,  there  is  difficulty  in  swallowing  and  the  food  is  not 
passed  on  into  the  oesophagus.  If  the  nerve  on  one  side  only  is  involved  the 
deglutition  is  not  much  impaired.  In  these  cases  the  particles  of  food  fre- 
quently pass  into  the  larynx,  and,  when  the  soft  palate  is  involved,  into  the 
posterior  nares. 

Spasm  of  the  pharynx  is  always  a  functional  disorder,  usually  occurring 
in  hysterical  and  nervous  people.  Cowers  mentioned  a  case  of  a  gentleman 
who  could  no,t  eat  unless  alone,  on  account  of  the  inability  to  swallow  in  the 
presence  of  others  from  spasm  of  the  pharynx.  This  spasm  is  a  well  marked 
feature  in  hydrophobia,  and  occurs  also  in  pseudo-hydrophobia. 

Laryngeal  Branches. — The  superior  laryngeal  nerve  supplies  the  mucous 
membrane  of  the  larynx  above  the  cords  and  the  crico-thyroid  muscle.  The 
inferior  or  recurrent  laryngeal  curves  around  the  arch  of  the  aorta  on 
the  left  side  and  the  subclavian  artery  on  the  right  passes  along  the  trachea 
and  supplies  the  mucosa  below  the  cords  and  all  the  muscles  of  the  larynx 
except  the  crico-thyroid  and  the  epiglottidcan.  P]xperimcnts  have  shown  that 
these  motor   nerves   of  the  pneumogastic   are   all.  derived   from   the   spinal 


1044  DISEASES  OF  THE  NEKVOUS  SYSTEM 

accessory.  The  remarkable  course  of  the  recurrent  laryngeal  nerves  renders 
them  liable  to  pressure  by  tumors  within  the  thorax,  particularly  by  aneurism. 
The  following  are  the  most  important  forms  of  paralysis : 

(a)  Bilateral  Paralysis  op  the  Abductors. — In  this  condition  the 
posterior  crico-arytenoids  are  involved  and  the  glottis  is  not  opened  during 
inspiration.  The  cords  may  be  close  together  in  the  position  of  phonation, 
and  during  inspiration  may  be  brought  even  nearer  together  by  the  pressure 
■of  air,  so  that  there  is  only  a  narrow  chink  through  which  the  air  whistles 
with  a  noisy  stridor.  This  dangerous  form  of  laryngeal  paralysis  occurs  occa- 
sionally as  a  result  of  cold,  or  may  follow  a  laryngeal  catarrh.  The  posterior 
muscles  have  been  found  degenerated  when  the  others  were  healthy.  The  con- 
dition may  be  produced  by  pressure  upon  both  vagi,  or  upon  both  recurrent 
nerves.  As  a  central  affection  it  occurs  in  tabes  and  bulbar  paralysis,  but  may 
be  seen  also  in  hysteria.  The  characteristic  symptoms  are  inspiratory  stridor 
with  unimpaired  phonation.  Possibly,  as  Gowers  suggested,  many  cases  of 
so-called  hysterical  spasm  of  the  glottis  are  in  reality  abductor  paralysis. 

( b )  Unilateral  Abductor  Paralysis. — This  frequently  results  from  the 
pressure  of  tumors  or  involvement  of  one  recurrent  nerve.  Aneurism  is  the 
most  common  cause,  though  on  the  right  side  the  nerve  may  be  involved  in 
thickening  of  the  pleura.  The  symptoms  are  hoarseness  or  roughness  of  the 
voice,  as  is  so  common  in  aneurism.  Dyspnoea  is  not  often  present.  The  cord 
on  the  affected  side  does  not  move  in  inspiration.  Subsequently  the  adductors 
may  become  involved,  in  which  case  phonation  is  still  more  impaired. 

(c)  Adductor  Paralysis. — This  results  from  involvement  of  the  lateral 
crico-arytenoid  and  the  arytenoid  muscle  itself.  It  is  common  in  hysteria, 
particularly  of  women,  and  causes  the  hysterical  aphonia,  which  may  come  on 
suddenly.  It  may  result  from  catarrh  of  the  larynx  or  from  overuse  of  the 
voice.  In  laryngoscopic  examination  it  is  seen,  on  attempting  phonation,  that 
there  is  no  power  to  bring  the  cords  together. 

(d)  Spasm  of  the  Muscles  of  the  Larynx. — In  this  the  adductor  mus- 
cles are  involved.  It  is  not  uncommon  in  children,  and  has  been  referred  to 
as  laryngismus  stridulus.  Paroxysmal  attacks  of  laryngeal  spasm  are  rare 
in  the  adult,  but  cases  are  described  in  which  the  patient,  usually  a  young  girl, 
wakes  at  night  in  an  attack  of  intense  dyspnoea,  which  may  persist  long  enough 
to  produce  cyanosis.  Liveing  states  that  they  may  replace  attacks  of  migraine. 
They  occur  in  a  characteristic  form  in  tabes,  the  so-called  laryngeal  crises. 
There  is  a  spastic  aphonia,  in  which,  when  the  patient  attempts  to  speak,  pho- 
nation is  completely  prevented  by  a  spasm. 

Disturbance  of  the  sensory  nerves  of  the  larynx  is  rare. 

(e)  Anesthesia  may  occur  in  bulbar  paralysis  and  in  diphtheritic  neuritis 
— a  serious  condition,  as  portions  of  food  may  enter  the  windpipe.  It  is  usu- 
ally associated  with  dysphagia  and  is  sometimes  present  in  hysteria.  Hyper- 
sesthesia  of  the  larynx  is  rare. 

Cardiac  Branches. — The  cardiac  plexus  is  formed  by  the  union  of  branches 
of  the  vagi  and  of  the  sympathetic  nerves.  The  vagus  fibres  subserve  motor, 
sensory  and  probably  trophic  functions. 

Motor. — The  fibres  which  inhibit,  control,  and  regulate  the  cardiac  action 
pass  in  the  vagi.  Irritation  may  produce  slowing  of  the  action.  Czermak 
could  slow  or  even  arrest  the  heart's  action  for  a  few  beats  by  pressing  a  small 


DISEASES  OF  THE  CEREBRAL  NERVES  1045 

tumor  in  his  neck  against  one  pneumogastric  nerve,  and  it  is  said  that  the 
same  can  be  produced  by  forcible  bilateral  pressure  on  the  carotid  canal. 
There  are  instances  in  which  persons  appear  to  have  had  voluntary  control 
over  the  action  of  the  heart.  Cheyne  mentions  the  case  of  Colonel  Townshend, 
'Vho  could  die  or  expire  when  he  pleased,  and  yet  by  an  effort  or  somehow 
come  to  life  again,  which  it  seems  he  had  sometimes  tried  before  he  had  sent 
for  us."  Retardation  of  the  heart's  action  has  also  followed  accidental  liga- 
ture of  one  vagus.  Irritation  of  the  nuclei  may  also  be  accompanied  with  a 
neurosis  of  this  nerve.  On  the  other  hand,  when  there  is  complete  paralysis 
of  the  vagi,  the  inhibitory  action  may  be  abolished  and  the  acceleratory  influ- 
ences have  full  sway.  The  heart's  action  is  then  greatly  increased.  This  is 
seen  in  some  instances  of  diphtheritic  neuritis  and  in  involvement  of  the  nerve 
by  tumors,  or  its  accidental  removal  or  ligature.  Complete  loss  of  function 
of  one  vagus,  however,  may  not  be  followed  by  any  symptoms. 

Sensoey  symptoms  on  the  part  of  the  cardiac  branches  are  very  varied. 
Normally,  the  heart's  action  proceeds  regularly  without  the  participation  of 
consciousness,  but  the  unpleasant  feelings  and  sensations  of  palpitation  and 
pain  are  conveyed  to  the  brain  through  this  nerve.  How  far  the  fibres  of  the 
pneumogastric  are  involved  in  angina  it  is  impossible  to  say. 

Pulmonary  Branches. — We  know  very  little  of  the  pulmonary  branches 
of  the  vagi.  The  motor  fibres  are  stated  to  control  the  action  of  the  bronchial 
muscles.  The  various  alterations  in  the  respiratory  rhythm  are  probably  due 
more  to  changes  in  the  centre  than  in  the  nerves  themselves. 

Gastric  and  (Esophageal  Branches. — The  muscular  movements  of  these 
parts  are  presided  over  by  the  vagi  and  vomiting  is  induced  through  them, 
usually  reflexly,  but  also  by  direct  irritation,  as  in  meningitis.  Spasm  of  the 
oesophagus  generally  occurs  with  other  nervous  phenomena.  Gastralgia  may 
be  due  to  cramp  of  the  stomach  or  to  sensory  disturbance  of  this  nerve,  due 
to  irritation  of  the  peripheral  ends,  or  a  neuralgia  of  the  terminal  fibres. 
Some  forms  of  nervous  dyspepsia  probably  depend  upon  disturbed  function  of 
this  nerve.  The  severe  gastric  crises  which  occur  in  tabes  are  due  to  central 
irritation  of  the  nuclei.  Vagotonia  is  an  important  element  in  many  disorders 
of  the  digestive  tract. 

SPINAL  ACCESSORY  NERVE 

Paralysis. — The  smaller  or  internal  part  of  this  nerve  joins  the  vagus  and 
is  distributed  through  it  to  the  laryngeal  muscles.  The  larger  external  part 
is  distributed  to  the  sterno-mastoid  and  trapezius  muscles. 

The  nuclei  of  the  nerve,  particularly  of  the  accessory  part,  may  be  in- 
volved in  bulbar  paralysis.  The  nuclei  of  the  external  portion,  situated  as 
they  are  in  the  cervical  cord,  may  be  attacked  in  progressive  degeneration  of 
the  motor  nuclei  of  the  cord.  The  nerve  may  be  involved  in  the  exudation  of 
meningitis,  or  be  compressed  by  tumors,  or  in  caries.  The  sijmptoms  of  paraly- 
sis of  the  accessory  portion  which  joins  the  vagus  have  already  been  given  in 
the  account  of  the  palsy  of  the  laryngeal  branches  of  the  pneumogastric.  Dis- 
ease or  compression  of  the  external  portion  is  followed  by  paralysis  of  the 
sterno-mastoid  and  of  the  trapezius  on  the  same  side.  In  paralysis  of  one 
sterno-mastoid  the  patient  rotates  the  head  with  difficulty  to  the  opposite 
side,  but  there  is  no  torticollis,  though  in  some  cases  the  head  is  held  obliquely. 


1046  DISEASES  OF  THE  NERA^OUS  SYSTEM 

As  the  trapezius  is  supplied  in  part  from  the  cervical  nerves,  it  is  not  com- 
pletely paralyzed,  but  the  portion  which  passes  from  the  occipital  bone  to  the 
acromion  is  functionless.  The  paralysis  of  the  muscle  is  well  seen  when  the 
patient  draws  a  deep  breath  or  shrugs  the  shoulders.  The  middle  portion  of 
the  trapezius  is  also  weakened,  the  shoulder  droops  a  little,  and  the  angle 
of  the  scapula  is  rotated  inward  by  the  action  of  the  rhomboids  and  the  levator 
anguli  scapulae.  Elevation  of  the  arm  is  impaired,  for  the  trapezius  does  not 
fix  the  scapula  as  a  point  from  which  the  deltoid  can  work. 

In  progressive  muscular  atrophy  we  sometimes  see  bilateral  paralysis  of 
these  muscles.  Thus,  if  the  sterno-mastoids  are  affected,  the  head  tends  to 
fall  back;  when  the  trapezii  are  involved,  it  falls  forward,  a  characteristic 
attitude  of  the  head  in  many  cases  of  progressive  muscular  atrophy.  Gowers 
suggested  that  lesions  of  the  accessory  in  difficult  labor  may  account  for  those 
cases  in  which  during  the  first  year  of  life  the  child  has  great  difficulty  in 
holding  up  the  head.  In  children  this  drooping  of  the  head  is  an  important 
symptom  in  cervical  meningitis,  the  result  of  caries. 

The  TREATMENT  of  the  condition  depends  much  upon  the  cause.  In  the 
central  nuclear  atrophy  but  little  can  be  done.  In  paralysis  from  pressure 
the  symptoms  may  gradually  be  relieved.  The  paralyzed  muscles  should  be 
stimulated  by  electricity  and  massage. 

Accessory  Spasm  (Torticollis;  ^YrynecJc). — The  forms  of  spasm  affecting 
the  cervical  muscles  are  best  considered  here,  as  the  muscles  supplied  by  the 
accessory  are  chiefly,  though  not  solely,  responsible  for  the  condition.  The 
following  forms  may  be  described  in  this  section: 

(a)  Congenital  Torticollis. — This  condition,  also  known  as  fixed  torti- 
collis, depends  upon  the  shortening  and  atrophy  of  the  sterno-mastoid  on 
one  side.  It  occurs  in  children  and  may  not  be  noticed  for  several  years  on- 
account  of  the  shortness  of  the  neck,  the  parents  often  alleging  that  it  has 
only  recently  come  on.  It  affects  the  riglit  side  almost  exclusively.  A  re- 
markable circumstance  in  connection  with  it  is  the  existence  of  facial  asym- 
metry noted  by  Wilks,  which  appears  to  be  an  essential  part  of  this  congenital 
form.  In  congenital  wryneck  the  sterno-mastoid  is  shortened,  hard  and  firm, 
and  in  a  condition  of  more  or  less  advanced  atrophy.  This  must  be  distin- 
guished from  the  local  thickening  in  the  sterno-mastoid  due  to  rupture,  which 
may  occur  at  the  time  of  birth  and  produce  an  induration  or  muscle  callus. 
Although  the  sterno-mastoid  is  almost  always  affected,  there  are  rare  cases 
in  which  the  fibrous  atrophy  affects  the  trapezius.  This  form  of  wryneck  in 
itself  is  unimportant,  since  it  is  readily  relieved  by  tenotomy,  but  Golding- 
Bird  states  that  the  facial  asymmetry  persists,  or  may  become  more  evident. 
With  reference  to  the  pathology  of  the  affection,  Golding-Bird  concludes  that 
the  facial  asymmetry  and  the  torticollis  are  integral  parts  of  one  affection 
which  has  a  central  origin,  and  is  the  counterpart  in  the  head  and  neck  of 
infantile  paralysis  with  talipes  in  the  foot. 

(&)  Spasmodic  Wryneck. — Two  varieties  of  this  spasm  occur,  the  tonic 
and  the  clonic,  which  may  alternate  in  the  same  case ;  or,  as  is  most  common, 
they  are  separate  and  remain  so  from  the  outset.  The  disease  is  most  frequent 
in  adults  and,  according  to  Gowers,  more  common  in  females.  In  America 
it  is  certainly  more  frequent  in  males.     In  females  it  may  be  an  hysterical 


DISEASES  OF  THE  CEEEBEAL  NEEVES  1047 

manifestation.  There  may  be  a  marked  neurotic  family  history,  but  it  is 
usually  impossible  to  fix  upon  any  definite  etiological  factor.  Some  cases 
have  followed  cold;  others  a  blow.  Brissaud  described  what  he  calls  mental 
torticollis.  It  is  usually  met  with  in  neurasthenic  patients  and  in  elderly 
persons,  and  consists  of  a  clonic  spasm  of  the  rotators  of  the  head. 

The  symptoms  are  well  defined.  In  the  tonic  form  the  contracted  sterno- 
mastoid  draws  the  occiput  toward  the  shoulder  of  the  affected  side;  the  chin 
is  raised,  and  the  face  rotated  to  the  other  shoulder.  The  sterno-mastoid  may 
be  affected  alone  or  in  association  with  the  trapezius.  When  the  latter  is 
implicated  the  head  is  depressed  still  more  toward  the  same  side.  In  long- 
standing cases  these  muscles  are  prominent  and  very  rigid.  There  may  be 
some  curvature  of  the  spine,  the  convexity  of  which  is  toward  the  sound  side. 
The  cases  in  which  the  spasm  is  clonic  are  much  more  distressing  and  serious. 
The  spasm  is  rarely  limited  to  a  single  muscle.  The  sterno-mastoid  is  almost 
always  involved  and  rotates  the  head  so  as  to  approximate  the  mastoid  process 
to  the  inner  end  of  the  clavicle,  turning  the  face  to  the  opposite  side  and 
raising  the  chin.  When  with  this  the  trapezius  is  affected,  the  depression  of 
the  head  toward  the  same  side  is  more  marked.  The  head  is  drawn  somewhat 
backward ;  the  shoulder,  too,  is  raised  by  its  action.  According  to  Gowers,  the 
splenius  is  associated  with  the  sterno-mastoid  about  half  as  frequently  as  the 
trapezius.  Its  action  is  to  incline  the  head  and  rotate  it  slightly  toward 
the  same  side.  Other  muscles  may  be  involved,  such  as  the  scalenus  and 
platysma  myoides ;  and  in  rare  cases  the  head  may  be  rotated  by  the  deep  cervi- 
cal muscles,  the  rectus  and  obliquus.  There  are  cases  in  which  the  spasm  is 
bilateral,  causing  a  backward  movement — retro-colic  spasm.  This  may  be 
tonic  or  clonic;  in  extreme  cases  the  face  is  horizontal  and  looks  upward. 

These  clonic  contractions  may  come  on  without  warning,  or  be  preceded 
by  irregular  pains  or  stiffness  of  the  neck.  The  jerking  movements  recur 
every  few  moments,  and  it  is  impossible  to  keep  the  head  still  for  more  than 
a  minute  or  two.  In  time  the  muscles  undergo  hypertrophy  and  may  be  dis- 
tinctly larger  on  one  side  than  the  other.  In  some  cases  the  pain  is  consid- 
erable; in  others  there  is  simply  a  feeling  of  fatigue.  The  spasms  cease  dur- 
ing sleep.  Emotion,  excitement,  and  fatigue  increase  them.  The  spasm  may 
extend  from  the  neck  muscles  and  involve  those  of  the  face  or  arms. 

The  disease  varies  much ;  cases  occasionally  get  well,  but  the  majority  per- 
sist, and,  even  if  temporarily  relieved,  the  disease  frequently  recurs.  The 
affection  is  usually  regarded  as  a  functional  neurosis,  but  it  is  possibly  due  to 
disturbance  of  the  cortical  centres  presiding  over  the  muscles. 

Treafment. — Temporary  relief  is  sometimes  obtained;  a  permanent  cure 
is  exceptional.  Various  drugs  have  been  used,  but  rarely  with  benefit.  Occa- 
sionally, large  doses  of  bromide  lessen  the  intensity  of  the  spasms.  Mor- 
phia, subcutaneously,  has  been  successful  in  some  cases,  but  there  is  great 
danger  of  establishing  the  habit.  Galvanism  may  be  tried.  Counter-irritation 
is  probably  useless.  Fixation  of  the  head  mechanically  can  rarely  be  borne  by 
the  patient.  These  obstinate  cases  come  ultimately  to  the  surgeon,  and  the 
operations  of  stretching,  division,  and  excision  of  the  accessory  nerve  and 
division  of  the  muscles  have  been  tried.     Temporary  relief  may  follow,  but, 


1048  DISEASES  OE  THE  NEEVOUS  SYSTEM 

as  a  rule,  the  condition  returns.     Eisien  Eussell  thinks  that  resection  of  the 
posterior  branches  of  the  upper  cervical  nerves  is  most  likely  to  give  relief. 

(c)  The  NODDING  SPASM  of  children  may  here  be  mentioned  as  involving 
chiefly  the  muscles  innervated  by  the  accessory  nerve.  It  may  be  a  simple  trick, 
a  form  of  habit  sp^sm,  or  a  phenomenon  of  epilepsy  (E.  nutans),  in  which 
case  it  is  associated  with  transient  loss  of  consciousness.  A  similar  nodding 
spasm  may  occur  in  older  children.  In  women  it  sometimes  occurs  as  an  hys- 
terical manifestation,  commonly  as  part  of  the  so-called  salaam  convulsion. 

HYPOGLOSSAL   NERVE 

This  is  the  motor  nerve  of  the  tongue  and  for  most  of  the  muscles  attached 
to  the  hyoid  bone.  Its  cortical  centre  is  probably  the  lower  part  of  the  anterior 
central  gyrus. 

Paralysis. —  (a)  Coktical  Lesion. — The  tongue  is  often  involved  in  hemi- 
plegia, and  the  paralysis  may  result  from  a  lesion  of  the  cortex  itself,  or  of 
the  fibres  as  they  pass  to  the  medulla.  It  does  not  occur  alone  and  is  consid- 
ered with  hemiplegia.  There  is  this  difference,  however,  between  the  cortical 
and  other  forms,  that  the  muscles  on  both  sides  of  the  tongue  may  be  more  or 
less  affected  but  do  not  waste,  nor  are  their  electrical  reactions  disturbed. 

(&)  Nuclear  and  infra-nuclear  lesions  result  from  slow  progressive  de- 
generation, as  in  bulbar  paralysis  or  tabes ;  occasionally  there  is  acute  softening 
from  obstruction  of  the  vessels.  The  nuclei  of  both  nerves  are  usually  affected 
together,  but  may  be  attacked  separately.  Trauma  and  lead  poisoning  have  also 
been  assigned  as  causes.  The  fibres  may  be  damaged  by  a  tumor,  and  at  the 
base  by  meningitis ;  or  the  nerve  is  sometimes  involved  in  the  condylar  foramen 
by  disease  of  the  skull.  It  may  be  involved  in  its  course  in  a  scar,  as  in 
Birkett's  case,  or  compressed  by  a  tumor  in  the  parotid  region.  As  a  result, 
there  is  loss  of  function  in  the  nerve  fibres  and  the  tongue  undergoes  atrophy 
on  the  affected  side.  It  is  protruded  toward  the  paralyzed  side  and  may  show 
fibrillary  twitching. 

The  symptoins  of  involvement  of  one  hypoglossal,  either  at  its  centre  or  in 
its  course,  are  those  of  unilateral  paralysis  and  atrophy  of  the  tongue.  When 
protruded,  it  is  pushed  toward  the  affected  side,  and  there  are  fibrillary  twitch- 
ings.  The  atrophy  is  usually  marked  and  the  mucous  membrane  on  the  af- 
fected side  is  thrown  into  folds.  Articulation  is  not  much  impaired  in  the 
unilateral  affection.  When  the  disease  is  bilateral,  the  tongue  lies  almost 
motionless  in  the  floor  of  the  mouth ;  it  is  atrophied,  and  can  not  be  protruded. 
Speech  and  mastication  are  extremely  difficult  and  deglutition  may  be  im- 
paired. If  the  seat  of  the  disease  is  above  the  nuclei,  there  may  be  little  or 
no  wasting.  The  condition  is  seen  in  progressive  bulbar  paralysis  and  occa- 
sionally in  progressive  muscular  atrophy. 

The  diagnosis  is  readily  made  and  the  situation  of  the  lesion  can  usually 
be  determined,  since  when  supra-nuclear  there  is  associated  hemiplegia  and 
no  wasting  of  the  muscles  of  the  tongue.  Nuclear  disease  is  only  occasionally 
unilateral;  most  commonly  bilateral  and  part  of  a  bulbar  paralysis.  It  should 
be  borne  in  mind  that  the  fibres  of  the  hypoglossal  may  be  involved  within  the 
medulla  after  leaving  their  nuclei.     In  such  a  case  there  may  be  paralysis  of 


DISEASES  OF  THE  SPINAL  NEEVES  1049 

the  tongue  on  one  side  and  paralysis  of  the  limbs  on  the  opposite  side,  and  the 
tongue,  when  protruded,  is  pushed  toward  the  sound  side. 

Spasm. — This  rare  affection  may  be  unilateral  or  bilateral.  It  is  most 
frequently  a  part  of  some  other  convulsive  disorder,  such  as  epilepsy,  chorea, 
or  spasm  of  the  facial  muscles.  In  some  cases  of  stuttering,  spasm  of  the 
tongue  precedes  the  explosive  utterance  of  the  words.  It  may  occur  in  hys- 
teria, and  is  said  to  follow  reflex  irritation  in  the  fifth  nerve.  The  most 
remarkable  cases  are  those  of  paroxysmal  clonic  spasm,  in  which  the  tongue 
is  rapidly  thrust  in  and  out,  as  many  as  forty  or  fifty  times  a  minute.  The 
prognosis  is  usually  good. 

COMBINED  PARALYSIS  OF  THE  LAST  THEEE  AND  FOUR  CRANIAL  NERVES 

The  war  experience  has  widened  our  knowledge  of  these  cases.  There  may 
be ;  (a)  Avelli's  syndrome,  palato-laryngeal  paralysis  from  involvement  of  the 
ninth  and  eleventh.  With  this  there  may  be  involvement  of  the  tenth  with 
paralysis  of  the  superior  constrictor  of  the  pharynx.  When  the  outer  fibres  of 
the  spinal  accessory  are  involved,  the  sterno-cleido-mastoid  may  be  paralyzed  on 
the  same  side  {Schmidt  syndrome),  (b)  Hughlings-Jackson  syndrome.  In- 
volvement of  the  ix,  X,  xi,  and  xii — disturbance  of  taste  and  paralysis  of  the 
superior  constrictor  of  the  pharynx  (ix  and  x)  ;  hemi-ansesthesia  of  the  palate 
and  pharynx,  sometimes  with  cough  and  dyspnoea  and  salivation  which  may  be 
profuse  (x  and  xi)  ;  hemi-paralysis  of  the  larynx  (xi)  with  hemi-paralysis 
of  the  tongue  (xii) .  In  wounds  of  the  retro-parotidean  space  or  after  a  parotid 
bubo,  in  addition  to  the  hypoglossal,  the  sympathetic  nerves  with  fibres  of  the 
ix,  X,  and  xi  may  be  involved,  causing  exophthalmos,  myosis,  and  sweating,  with 
the  combined  paralyses  known  as  Villaret's  syndrome.  These  combined  paral- 
yses may  be  nuclear,  caused  by  gummatous  or  tuberculous  meningitis,  by 
tumor  or  by  injury.  In  the  war  cases  the  lesions  have  often  been  more  ex- 
tensive, and  symptoms  of  involvement  of  the  vagus  have  been  more  common 
than  in  the  ordinary  instances  from  tumor  or  meningitis. 


IV.     DISEASES  OF  THE  SPINAL  NERVES 

CERVICAL  PLEXUS 

OccipitiO-cervical  Neural^a. — This  involves  the  nerve  territory  supplied 
by  the  occipitalis  major  and  minor,  and  the  auricularis  magnus  nerves.  The 
pains  are  chiefly  in  the  back  of  the  head  and  neck  and  in  the  ear.  The  condi- 
tion may  follow  cold  and  is  sometimes  associated  with  stiffness  of  the  neck 
or  torticollis.  Unless  disease  of  the  bones  exists  with  it  or  it  is  due  to  pressure 
of  tumors,  the  outlook  is  usually  good.  There  are  tender  points  midway 
between  the  mastoid  process  and  the  spine  and  just  above  the  parietal  eminence, 
and  between  the  sterno-mastoid  and  the  trapezius.  The  affection  may  be 
due  to  direct  pressure  in  carrying  heavy  weights. 

Affections  of  the  Phrenic  Nerve. — Paralysis  may  follow  a  lesion  in  the 
anterior  horns  at  the  level  of  the  third  and  fourth  cervical  nerves,  or  may  be 
due  to  compression  of  the  nerve  by  tumors  or  aneurism.  More  rarely  paralysis 
results  from  neuritis,  diphtheritic  or  saturnine. 


1050  •    DISEASES  OF  THE  NEEVOUS  SYSTEM 

When  the  diaphragm  is  paralyzed  respiration  is  carried  on  by  the  inter- 
costal and  accessory  muscles.  When  the  patient  is  quiet  and  at  rest  little  may 
be  noticed,  but  the  abdomen  retracts  in  inspiration  and  is  forced  out  in  expira- 
tion. On  exertion  or  even  on  attempting  to  move  there  may  be  dyspnoea.  If 
the  paralysis  sets  in  suddenly  there  may  be  dyspnoea  and  lividity,  which  is 
usually  temporary  (W.  Pasteur).  Intercurrent  attacks  of  bronchitis  seriously 
aggravate  the  condition.  Difficulty  in  coughing,  owing  to  the  impossibility  of 
drawing  a  full  breath,  adds  greatly  to  the  danger  of  this  complication. 

When  the  phrenic  nerve  is  paralyzed  on  one  side  the  paralysis  may  be 
scarcely  noticeable,  but  careful  inspection  shows  that  the  descent  of  the  dia- 
phragm is  much  less  on  the  affected  side. 

The  diagnosis  of  paralysis  is  not  always  easy,  particularly  in  women,  who 
habitually  use  this  muscle  less  than  men,  and  in  whom  the  diaphragmatic 
breathing  is  less  conspicuous.  Immobility  of  the  diaphragm  is  not  uncom- 
mon, particularly  in  diaphragmatic  pleurisy,  in  large  effusions,  and  in  ex- 
tensive emphysema.     The  muscle  itself  may  be  degenerated. 

Owing  to  the  lessened  action  of  the  diaphragm,  there  is  a  tendency  to 
stasis  at  the  bases  of  the  lungs,  and  there  may  be  impaired  resonance  and 
signs  of  oedema.  As  a  rule,  however,  the  paralysis  is  not  confined  to  this 
muscle,  but  is  part  of  a  general  neuritis  or  an  anterior  polio-myelitis,  and  there 
are  other  symptoms  of  value  in  determining  its  presence.  The  outlook  is 
usually  serious.  Pasteur  states  that  of  15  cases  following  diphtheria  only  8 
recovered.    The  treatment  is  that  of  the  neuritis  or  polio-myelitis. 

Hiccough. — Here  may  be. considered  this  remarkable  symptom,  caused  by 
intermittent,  sudden  contraction  of  the  diaphragm.  The  mechanism,  however, 
is  complex,  and  while  the  afferent  impressions  to  the  respiratory  centre  may 
be  peripheral  or  central  the  efferent  are  distributed  through  the  phrenic  nerve 
to  the  diaphragm,  causing  the  intermittent  spasm,  and  through  the  laryngeal 
branches  of  the  vagus  to  the  glottis,  causing  sudden  closure  as  the  air  is  rap- 
idly inspired.     There  are  various  groups: 

(a)  Inflammatory,  seen  particularly  in  affections  of  the  abdominal  vis- 
cera, gastritis,  peritonitis,  hernia,  internal  strangulation,  appendicitis,  suppu- 
rative pancreatitis,  and  in  the  severe  forms  of  typhoid  fever. 

(6)  Ieeitative,  as  in  the  direct  stimulation  of  the  diaphragm  when  very 
hot  substances  are  swallowed,  in  disease  of  the  oesophagus  near  the  diaphragm, 
and  in  many  conditions  of  gastric  and  intestinal  disorder,  more  particularly 
those  associated  with  flatus. 

(c)  Toxic. — In  these  cases  there  is  usually  some  general  disease,  as  gout, 
diabetes,  or  chronic  nephritis.  Hiccough  may  be  very  obstinate  in  the  later 
stages  of  chronic  nephritis. 

(d)  Neurotic,  cases  in  which  the  primary  cause  is  in  the  nervous  system; 
hysteria,  epilepsy,  shock,  or  cerebral  tumors.  Of  these  cases  the  hysterical 
are,  perhaps,  the  most  obstinate. 

The  TREATMENT  is  often  very  uiisatisfactory.  Sometimes  in  the  milder 
forms  a  sudden  reflex  irritation  will  check  it  at  once.  A  pinch  of  snuff  may  be 
effective.  Readers  of  Plato's  Symposium  will  remember  that  the  physician 
Eryximachus  recommended  to  Aristophanes,  who  had  hiccough  from  eating 
too  much,  either  to  hold  his  breath  (which  for  trivial  forms  of  hiccough  is 
yer^  satisfactory)  or  to  gargle  with  a  little  water;  but  if  it  still  continued, 


DISEASES  OF  THE  SPINAL  NERVES  1051 

"tickle  your  nose  with  something  and  sneeze;  and  if  you  sneeze  once  or  twice 
even  the  most  violent  hiccough  is  sure  to  go."  The  attack  must  have  been 
of  some  severity,  as  it  is  stated  subsequently  that  the  hiccough  did  not  dis- 
appear until  Aristophanes  had  resorted  to  the  sneezing. 

Ice,  a  teaspoonful  of  salt  and  lemon  juice,  or  salt  and  vinegar,  or  a  tea- 
spoonful  of.  raw  spirits  may  be  tried.  When  the  hiccough  is  due  to  gastric 
irritation,  lavage  is  sometimes  promptly  curative.  Alkali  should  be  given 
freely.  A  hypodermic  injection  of  gr.  i/g  (0.008  gm.)  of  apomorphia  may 
give  prompt  relief.  In  obstinate  cases  the  various  antispasmodics  have  been 
used  in  succession.  Pilocarpine  has  been  recommended.  The  ether  spray  on 
the  epigastrium  may  be  promptly  curative.  Hypodermics  of  morphia,  inhala- 
tions of  chloroform,  the  use  of  nitrite  of  amyl  and  of  nitroglycerin  have  been 
beneficial  in  some  cases.  Galvanism  over  the  phrenic  nerve,  or  pressure  on  the 
nerves,  applied  between  the  heads  of  the  sterno-cleido-mastoid  muscles  may  be 
used.  Strong  traction  upon  the  tongue  may  give  immediate  relief.  Of  all 
measures  morphia  used  freely  is  the  best. 

BRACHIAL  PLEXUS 

Cervical  Rib. — Frequency. — The  anomaly  is  much  more  common  than 
indicated  in  the  literature.  Sometimes  bilateral,  it  may  be  complete  with 
bony  attachment  to  the  second  rib;  incomplete,  forming  a  short  stump  of 
variable  length,  or — and  this  is  important — there  may  be  a  fibrous  band-like 
attachment  from  a  short  rib  to  the  first.  It  is  more  common  on  the  left  side. 
Symptoms  usually  appear  between  the  fifteenth  and  thirtieth  years. 

The  ribs  may  be  visible,  one  more  plainly  than  the  other,  and  the  subclavian 
artery,  lifted  up,  may  pulsate  high  in  the  supraclavicular  fossa.  This  ab- 
normal pulsation  and  the  fullness  in  the  fossa  may  suggest  the  presence  of 
the  extra  rib.  The  throbbing  may  be  marked  enough  to  suggest  aneurism. 
The  rib  may  be  felt,  often  more  marked  on  one  side;  even  the  bifid  extremity 
may  be  palpable,  and  the  artery  felt  above  the  rib  sometimes  appears  longer 
and  larger  than  normal. 

Symptoms. — In  a  large  proportion  the  patients  are  unaware  of  the 
anomaly;  the  symptoms,  which  may  come  on  suddenly,  may  be  grouped  as 
follows : 

1.  Local,  (a)  Supraclavicular  swelling,  (b)  Pulsation,  (c)  Palpable 
tumor  and  aneurism. 

2.  Neuritic.  (a)  Neuralgic  pains  (supraclavicular,  cervical,  brachial). 
(h)    Parsesthesia.      (c)     Local  anaesthesia,      (d)    Sympathetic  nerve  features. 

3.  Mvscular.  (a)  Atrophy,  in  ulnar  distribution.  (h)  Spasm,  (c) 
Intermittent  claudication.     . 

4.  Vascular,  (a)  Vaso-motor  changes  (ischaemia,  hypersemia,  swelling). 
(b)  Local  gangrene,     (c)  Aneurism,  (i)  spurious,  (ii)  true,     (d)  Thrombosis. 

Neuralgic  pains  occur  in  the  cervical  region,  sometimes  passing  up  the  back 
of  the  head;  more  commonly  the  pain  is  in  the  distribution  of  the  eighth 
cervical  and  first  dorsal  nerve,  sometimes  only  a  dull  pain  and  aching  with 
numbness  and  tingling  or  even  ana'sthesia.  Dissociation  of  cutaneous  sensa- 
tion, loss  of  tactile  and  thermic  with  retention  of  pain  sense,  may  be  present. 
The  cervical  sympathetic  may  be  involved  with  tlie  usual  features.     Muscular 


1052  DISEASES  OF  THE  NEEVOUS  SYSTEM 

atrophy  is  usually  in  the  region  of  distribution  of  the  ulnar  nerve.  The  dif- 
ference between  the  two  arms  may  be  marked  and  the  interossei  wasted,  as 
in  progressive  muscular  atrophy,  for  which,  when  bilateral,  cases  may  be 
mistaken.  With  pressure  on  and  narrowing  of  the  subclavian,  intermittent 
claudication  is  present,  characterised  by  numbness,  tingling  and  swelling, 
sometimes  by  redness  of  the  arm  and  muscular  disability  on  exertion.  At 
rest  the  arm  is  normal  and  comfortable,  but  on  exertion  these  features  occur : 
spasm,  tonic  or  clonic,  in  the  muscles  of  the  hand  is  occasionally  seen. 

Vaso-motor  Changes. — Eedness  with  swelling,  sometimes  cyanosis  and 
mottling,  may  be  present,  with  changes  resembling  Eaynaud's  disease;  in  a 
few  cases  gangrene  of  the  finger  tips  has  followed. 

Aneurism. — The  subclavian  artery  may  be  tilted  by  the  ribs  and  give  a 
wide  area  of  supraclavicular  pulsation.  There  may  be:  (1)  slight  narrowing 
from^  pressure,  with  feeble  pulse  on  the  affected  side;  (2)  manifest  enlarge- 
ment of  the  vessel,  fusiform  or  uniform;  or  (3)  a  definite  cylindrical  aneurism. 
In  27  of  525  clinical  cases  collected  by  Halsted  these  local  changes  were 
present.  The  dilatation  is  distal  to  the  point  of  constriction  made  by  the 
rib  and  the  scalenus  anticus,  which  Halsted  explains  by  the  abnormal  play  of 
the  blood  in  the  relatively  dead  pocket  beyond  the  constriction,  and  the 
absence  of  the  normal  pulse  pret-sure  necessary  to  maintain  the  integrity  of  the 
arterial  wall.     The  nervi  arteriorum  may  be  involved. 

Thrombosis. — This  may  occur  in  the  vessels  beyond  the  point  of  con- 
striction, in  one  case  involving  suddenly  the  brachial  and  gradually  extending 
to  the  axillary  and  subclavian,  with  the  gradual  development  of  an  effective 
collateral  circulation. 

The  relative  distribution  of  the  symptoms  as  given  by  Halsted  from  an  ex- 
haustive review  of  the  literature  was  in  63.3  per  cent,  nerve  symptoms  alone, 
in  29.4  per  cent,  nervous  and  vascular  symptoms,  while  5.3  per  cent,  have 
only  vascular  symptoms. 

Diagnosis. — This  is  easy  as  a  rule  even  without  the  X-rays.  A  serious 
difficulty  arises  when  disease  of  the  cord  occurs  in  the  subjects  of  cervical 
rib,  e.  g.,  syringomyelia  and  progressive  muscular  atrophy.  In  cases  of  pro- 
longed discomfort  or  pain  with  vascular  or  trophic  disturbance  in  the  arm, 
cervical  rib  should  be  considered. 

Treatment. — When  accidentally  discovered,  it  is  best  not  to  tell  the  pa- 
tient. Elevation  of  the  shoulders  may  give  relief.  Massage,  electricity  and 
other  forms  of  local  treatment  may  be  tried.  The  rib  may  be  removed,  but 
only  as  a  last  resort,  as  the  results  are  not  always  satisfactory. 

Combined  Paralysis. — The  plexus  may  be  involved  in  the  supraclavicular 
region  by  compression  of  the  nerve  trunks  as  they  leave  the  spine,  or  by 
tumors  and  other  morbid  processes  in  the  neck.  Below  the  clavicle  lesions  are 
more  common  and  result  from  injuries  following  dislocation  or  fracture,  some- 
times from  neuritis.  A  cervical  rib  may  lead  to  a  pressure  paralysis  of  the 
lower  cord  of  the  plexus.  A  not  infrequent  form  of  injury  in  this  region 
follows  falls  or  blows  on  the  neck,  which  by  lateral  flexion  of  the  head  and 
depression  of  the  shoulder  seriously  stretch  the  plexus.  The  entire  plexus  may 
be  ruptured  and  the  arm  be  totally  paralyzed.  The  rupture  may  occur  any- 
where between  the  vertebrae  and  the  clavicle,  and  involve  all  the  cords  of  the 
plexus,   or  only  the   upper  ones.     The   so-called   "obstetrical  palsy"   usually 


DISEASES  OF  THE  SPINAL  NERVES  1053 

results  from  the  forcible  separation  of  the  head  and  neck  from  the  shoulder 
during  delivery,  with  the  result  of  tearing  the  deep  cervical  fascia  and  the 
nerves,  involving  the  roots  from  above  and  downwards,  so  that  the  injury  may 
vary  from  a  slight  lesion  of  the  upper  root  to  complete  rupture  of  the  plexus 
or  the  tearing  of  the  roots  from  the  cord  itself.  In  the  complete  lesion  the 
arm  is  flaccid  and  immobile,  does  not  grow,  and  there  is  displacement  of  the 
head  of  the  humerus;  sensory  disturbances  are  rare.  The  prognosis  is  bad; 
only  mild  cases  recover  completely.  Suturing  the  broken  cords  and  planting 
them  in  the  neighboring  roots  have  been  followed  by  good  results,  but  com- 
plete recovery  rarely  if  ever  follows.  Another  common  cause  of  lesion  of  the 
brachial  plexus  is  luxation  of  the  head  of  the  humerus,  particularly  the 
subcoracoid  form. 

A  primary  neuritis  of  the  brachial  plexus  is  rare.  More  commonly  the 
process  is  an  ascending  neuritis  from  a  lesion  of  a  peripheral  branch,  involving 
first  the  radial  or  ulnar  nerves,  and  spreading  upward  to  the  plexus,  producing 
gradually  complete  loss  of  power  in  the  arm. 

Lesions  of  Individual  Nerves  of  the  Plexus. —  (a)  Long  Thoracic  Nerve. 
— Serratus  paralysis  follows  injury  to  this  nerve  in  the  neck,  usually  by  direct 
pressure  in  carrying  loads,  and  is  very  common  in  soldiers.  It  may  be  due 
to  a  neuritis  following  an  acute  infection  or  exposure.  Isolated  serratus  pa- 
ralysis is  rare.  It  usually  occurs  in  connection  with  paralysis  of  other  mus- 
cles of  the  shoulder  girdle,  as  in  the  myopathies  and  in  progressive  muscular 
atrophy.  Concomitant  trapezius  paralysis  is  the  most  frequent.  In  the 
isolated  paralysis  there  is  little  or  no  deformity  with  the  hands  hanging  by 
the  sides.  There  are  slight  abnormal  obliquity  of  the  posterior  border  of  the 
scapula  and  prominence  of  the  inferior  angle,  but  when,  as  so  commonly  hap- 
pens, the  middle  part  of  the  trapezius  is  also  paralyzed  the  deformity  is 
marked.  The  shoulder  is  at  a  lower  level,  the  inferior  angle  of  the  scapula 
is  displaced  inward  and  upward,  and  the  superior  angle  projects  upward. 
When  the  arms  are  held  out  in  front  at  right  angles  to  the  body  the  scapula 
becomes  winged  and  stands  out  prominently.  The  arm  can  not,  as  a  rule, 
be  raised  above  the  horizontal.  The  outlook  of  the  cases  due  to  injury  or  to 
neuritis  is  good. 

(h)  Circumflex  Nerve. — This  supplies  the  deltoid  and  teres  minor  and 
may  be  involved  in  injuries,  in  dislocations,  bruising  by  a  crutch,  or  sometimes 
by  extension  of  inflammation  from  the  joint.  Occasionally  the  paralysis  arises 
from  a  pressure  neuritis  during  an  illness.  As  a  consequence  of  loss  of  power 
in  the  deltoid,  the  arm  can  not  be  raised.  The  wasting  is  usually  marked 
and  changes  the  shape  of  the  shoulder.  Sensation  may  be  impaired  in  the 
skin  over  the  muscle.  The  joint  may  be  relaxed  and  there  may  be  a  distinct 
space  between  the  head  of  the  humerus  and  the  acromion. 

(c)  MuscuLO-spiRAL  PARALYSIS;  Eadial  PARALYSIS. — This  is  one  of  the 
most  common  of  peripheral  palsies,  and  results  from  the  exposed  position  of 
the  musculo-spiral  nerve.  It  is  often  bruised  in  the  use  of  the  crutch,  by 
injuries  of  the  arm,  blows,  or  fractures.  It  is  frequently  injured  when  a 
person  falls  asleep  with  the  arm  over  the  back  of  a  chair,  or  by  pressure  of 
the  body  upon  the  arm  when  a  person  is  sleeping  on  a  bench  or  on  the  ground. 
It  may  be  paralyzed  by  sudden  violent  contraction  of  the  triceps.  It  is  some- 
times involved  in  a  neuritis  from  cold,  but  this  is  uncommon  in  comparison 


105-i  DISEASES  OF  THE  ^*EEA^OUS  SYSTEM 

with  other  causes.  The  paralysis  of  lead  poisoning  is  the  result  of  involve- 
ment of  certain  branches  of  this  nerve. 

A  lesion  when  high  up  involves  the  triceps,  the  brachialis  anticus,  and  the 
supinator  longus,  as  well  as  the  extensors  of  the  wrist  and  fingers.  In  lesions 
just  above  the  elbow  the  arm  muscles  and  the  supinator  longus  are  spared. 
The  most  characteristic  feature  is  the  wrist-drop  and  the  inability  to  extend 
the  first  phalanges  of  the  fingers  and  thumb.  In  the  pressure  palsies  the 
supinators  are  usually  involved  and  the  movements  of  supination  can  not  be 
accomplished.  The  sensations  may  be  impaired,  or  there  may  be  marked 
tingling,  but  the  loss  of  sensation  is  rarely  so  pronounced  as  that  of  motion. 

The  affection  is  readily  recognized,  but  it  is  sometimes  dilfieult  to  say  upon 
what  it  depends.  The  sleep  and  pressure  palsies  are,  as  a  rule,  unilateral  and 
involve  the  supinator  longus.  The  paralysis  from  lead  is  bilateral  and  the 
supinators  are  unaffected.  Bilateral  wrist-drop  is  a  very  common  symptom  in 
many  forms  of  multiple  neuritis,  particularly  the  alcoholic;  but  the  mode  of 
onset  and  the  involvement  of  the  legs  and  arms  make  the  diagnosis  easy. 
The  duration  and  course  of  the  musculo-spiral  paralyses  are  very  variable. 
The  pressure  palsies  may  disappear  in  a  few  days.  Eecovery  is  the  rule,  even 
when  the  affection  lasts  for  many  weeks.  The  electrical  examination  is  of 
importance  in  prognosis,  and  the  rules  laid  down  under  paralysis  of  the  facial 
nerve  hold  good  here.     The  treatment  is  that  of  neuritis. 

(d)  TJlxar  Xerve. — The  motor  branches  supply  the  ulnar  half  of  tha 
deep  flexor  of  the  fingers,  the  muscles  of  the  little  finger,  the  interossei,  the 
adductor  and  the  inner  head  of  the  short  flexor  of  the  thumb,  and  the  ulnar 
flexor  of  the  wrist.  The  sensory  branches  supply  the  ulnar  side  of  the  hand — 
two  and  a  half  fingers  on  the  back,  and  one  and  a  half  fingers  on  the  front. 
Paralysis  may  result  from  pressure,  usually  at  the  elbow  joint,  although  the 
nerve  is  here  protected.  Possibly  the  neuritis  in  the  ulnar  nerve  in  some  cases 
of  acute  illness  may  be  due  to  this  cause.  Owing  to  paralysis  of  the  ulnar 
flexor  of  the  wrist,  the  hand  moves  toward  the  radial  side;  adduction  of  the 
thumb  is  impossible;  the  first  phalanges  can  not  be  flexed,  and  the  others 
can  not  be  extended.  In  long  standing  cases  the  first  phalanges  are  over- 
extended and  the  others  strongly  flexed,  producing  the  claw-hand ;  but  this  is 
not  so  marked  as  in  the  progressive  muscular  atrophy.  The  loss  of  sensation 
corresponds  to  the  sensory  distribution  just  mentioned. 

(e)  MEDIA^^  Xerve. — This  supplies  the  flexors  of  the  fingers  except  the 
ulnar  half  of  the  deep  flexors,  the  abductor  and  the  flexors  of  the  thumb,  the 
two  radial  lumbricales,  the  pronators,  and  the  radial  flexor  of  the  wrist.  The 
sensory  fibres  supply  the  radial  side  of  the  palm  and  the  front  of  the  thumb, 
the  first  tw^o  fingers  and  half  the  third  finger,  and  the  dorsal  surfaces  of  the 
same  three  fingers. 

This  nerve  is  seldom  involved  alone.  Paralysis  results  from  injury  and 
occasionally  from  neuritis.  The  signs  are  inability  to  pronate  the  forearm 
beyond  the  mid-position.  The  wrist  can  be  flexed  only  toward  the  ulnar  side ; 
the  thumb  can  not  be  opposed  to  the  tips  of  fingers.  The  second  phalanges 
can  not  be  flexed  on  the  first;  the  distal  phalanges  of  the  first  and  second 
fingers  can  not  be  flexed ;  but  in  the  third  and  fourth  fingers  this  action  can 
be  performed  by  the  ulnar  half  of  the  flexor  profundus.  The  loss  of  sensation 
is  in  the  region  corresponding  to  the  sensory  distribution  already  mentioned. 


DISEASES  OF  THE  SPINAL  NERVES  1055 

The  wasting  of  the  thumb  muscles,  which  is  usually  marked  in  this  paralysis, 
gives  to  it  a  characteristic  appearance. 

Volkmann's  Paralysis. — Ischemic  paralysis,  as  it  is  called,  usually  follows 
the  pressure  of  splints  and  bandages  in  children  with  fracture  in  the  region 
of  the  elbow- joint.  The  changes  are  thought  to  be  due  to  arrest  of  the  circu- 
lation in  the  muscles,  which  are  hardened  and  stiff  and  the  flexors  of  the 
forearm  are  contracted.  The  hand  is  claw-like  with  the  metacarpo-phalangeal 
joints  strongly  extended  and  the  middle  and  terminal  phalanges  strongly 
flexed.  The  condition  may  come  on  with  great  rapidity  and  appears  to  be  a 
muscular  lesion  though  it  is  not  always  possible  to  exclude  pressure  on  the 
nerves.     The  prognosis  is  good  with  judicious  treatment. 

LUMBAR  AND  SACRAL  PLEXUSES 

Lumbar  Plexus. — The  lumbar  plexus  is  sometimes  involved  in  growths  of 
the  lymph  glands,  in  psoas  abscess,  and  in  disease  of  the  bones  of  the  verte- 
brae. The  ohturator  nerve  is  occasionally  injured  during  parturition.  When 
paralyzed  the  power  is  lost  over  the  adductors  of  the  thigh  and  one  leg  can 
not  be  crossed  over  the  other.  Outward  rotation  is  also  disturbed.  The 
anterior  crural  nerve  is  sometimes  involved  in  wounds  or  in  dislocation  of 
the  hip-joint,  less  commonly  during  parturition,  and  sometimes  by  disease 
of  the  bones  and  in  psoas  abscess.  The  special  symptoms  of  affection  of  this 
nerve  are  paralysis  of  the  extensors  of  the  knee  with  wasting  of  the  muscles, 
anaesthesia  of  the  antero-lateral  parts  of  the  thigh  and  of  the  inner  side  of 
the  leg  to  the  big  toe.  This  nerve  is  sometimes  involved  early  in  growths 
about  the  spine,  and  there  may  be  pain  in  its  area  of  distribution.  Loss  of 
the  power  of  abducting  the  thigh  results  from  paralysis  of  the  gluteal  nerve, 
which  is  distributed  to  the  gluteus  medius  and  minimus  muscles. 

External  Cutaneous  Nerve. — A  peculiar  form  of  sensory  disturbance,  con- 
fined to  the  territory  of  this  nerve,  was  first  described  by  Bernhardt  in  1895, 
and  a  few  months  later  by  Eoth,  who  gave  it  the  name  of  meralgia  paraesthet- 
ica. The  disease  is  probably  due  to  a  neuritis  which  seems  to  originate  in  that 
part  of  the  nerve  where  it  passes  under  Poupart's  ligament,  just  internal  to 
the  anterior  superior  iliac  spine.  The  nerve  is  usually  tender  on  pressure  at 
this  point.  The  disease  is  more  common  in  men.  Musser  and  Sailer  in  1900 
collected  99  cases,  of  which  75  were  in  men.  A  large  number  of  the  cases  are 
attributable  to  direct  traumatism  or  to  simple  pressure  on  the  nerve  by  the 
aponeurotic  canal  through  which  it  passes.  Pregnancy  is  among  the  more 
common  causes  in  women.  The  sensory  disturbances  consist  of  various  forms 
of  parsesthesia  located  over  the  outer  side  of  the  thigh,  oftentimes  with  some 
actual  diminution  in  the  acuity  of  sense  perception.  The  symptoms  may  per- 
sist for  years,  and  the  discomfort  in  some  cases  be  so  great,  and  so  exaggerated 
by  the  mere  touch  of  the  clothing,  that  patients  may  be  greatly  incapacitated. 
Excision  of  the  nerve  as  it  passes  under  Poupart's  ligament  has  given  good 
results. 

Sacral  Plexus. — The  sacral  plexus  is  frequently  involved  in  tumors  and 
inflammations  within  the  pelvis  and  may  be  injured  during  parturition. 
Neuritis  is  common,  usually  an  extension  from  the  sciatic  nerve. 

Goldthwaite  calls  attention  to  the  fact  that  the  lumbo-sacral  articulation 


1056  DISEASES  OF  THE  KEEVOUS  SYSTEM 

varies  very  greatly  in  its  stability,  and  actual  displacement  of  the  bones  may 
result  with  separation  of  the  posterior  portion  of  the  intervertebral  disc.  The 
Cauda  equina,  or  the  nerve  roots,  may  be  compressed.  With  displacement  on 
qne  side  the  spine  is  rotated  and  the  articular  process  of  the  fifth  is  drawn 
^to  the  spinal  canal,  with  such  narrowing  that  paraplegia  may  result,  and  he 
reports  a  remarkable  case  in  which  the  paralysis  came  on  during  the  applica- 
'^ion  of  a  plaster  jacket.  Weakness  of  the  joints  or  displacements  may  cause 
irritation  of  the  nerves  inside  and  outside  the  canal  with  resulting  sciatica. 

Of  the  branches,  the  sciatic  nerve,  when  injured  at  or  near  the  notch, 
causes  paralysis  of  the  flexors  of  the  legs  and  the  muscles  below  the  knee,  but 
injury  below  the  middle  of  the  thigh  involves  only  the  latter  muscles.  There 
is  also  anesthesia  of  the  outer  half  of  the  leg,  the  sole,  and  the  greater  portion 
of  the  dorsum  of  the  foot.  Wasting  of  the  muscles  and  trophic  disturbances 
may  follow.  In  paralysis  of  one  sciatic  the  leg  is  fixed  at  the  knee  by  the 
action  of  the  quadriceps  extensor  and  the  patient  is  able  to  walk. 

Paralysis  of  the  small  sciatic  nerve  is  rarely  seen.  The  gluteus  maximus 
is  involved  and  there  may  be  difficulty  in  rising  from  a  seat.  There  is  a  strip 
of  anaesthesia  along  the  back  of  the  middle  third  of  the  thigh. 

External  Popliteal  Nerve. — Paralysis  involves  the  perongei,  the  long  ex- 
tensor of  the  toes,  tibialis  anticus,  and  the  extensor  brevis  digitorum.  The 
^.nkle  can  not  be  flexed,  resulting  in  a  condition  known  as  foot-drop,  and  as 
the  toes  can  not  be  raised  the  whole  leg  must  be  lifted,  producing  the  charac- 
teristic steppage  gait  seen  in  so  many  forms  of  peripheral  neuritis.  In  long- 
standing cases  the  foot  is  permanently  extended  and  there  is  wasting  of  the 
anterior  tibial  and  peroneal  muscles.  The  loss  of  sensation  is  in  the  outer 
half  of  the  front  of  the  leg  and  on  the  dorsum  of  the  foot. 

Internal  Popliteal  Nerve. — When  paralyzed,  plantar  flexion  of  the  foot  and 
flexion  of  the  toes  are  impossible.  The  foot  can  not  be  adducted,  nor  can  the 
patient  rise  on  tiptoe.  In  long  standing  cases  talipes  calcaneus  follows  and 
the  toes  assume  a  claw-like  position  from  secondary  contracture,  due  to  over- 
extension of  the  proximal  and  flexion  of  the  second  and  third  phalanges. 

SCIATICA 

Definition. — The  term  sciatica  is  applied  to  any  painful  condition  referred 
to  the  sciatic  nerve.  It  may  be  defined  as  an  interstitial  inflammation  of 
the  sciatic  nerve,  causing  severe  pain  in  the  branches  of  distribution  and,  if 
long  continued,  atrophy  of  the  muscles. 

Etiology. — Primary  neuritis  of  this  nerve  is  very  rare  and  is  seen  chiefly  in 
men  who  have  diabetes  and  gout.  In  the  vast  majority  the  condition  is 
secondary  to  a  process  elsewhere  which  affects  the  component  cords  or  the 
trunk  itself.  Among  the  causal  factors  are:  (1)  arthritis  which  may  be  of 
the  lower  spine,  lumbo-sacral,  sacro-iliac  or  hip  joints.  In  this  case  the 
arthritic  lesion  is  often  due  to  a  focus  of  infection.  (2)  Anatomical  anom- 
alies, as  an  unusually  long  transverse  process  of  the  fifth  lumbar  vertebra, 
(3)  Disease  of  the  bones  of  the  lower  spine  or  pelvis,  e.  g.,  tuberculosis.  (4) 
Strain,  which  may  be  acute  or  chronic,  especially  of  the  sacro-iliac  joint.  Ex- 
posure to  cold  after  heavy  muscular  exertion  is  said  to  be  a  cause.  In  trench 
warfare  the  men  were  not  as  subject  to  sciatica  as  the  officers.     (5)   Pelvic 


DISEASES  OF  THE  SPINAL  NERVES  1057 

conditions,  such  as  a  solid  ovarian  or  fibroid  tumor  in  women  and  prostatic 
disease  in  men.  Constipation  is  said  to  be  a  cause  and  the  pressure  of  the 
fetal  head  in  labor.  (6)  Syphilis  is  responsible  in  a  few  cases.  (7)  It  may 
be  due  to  a  focus  of  infection.  Sciatica  occurs  most  often  in  adult  males, 
just  as  do  spondylitis  and  sacro-iliac  joint  disease  to  which  it  is  most  often 
secondary. 

Symptoms. — Pain  is  the  most  constant  and  troublesome  symptom.  The 
onset  may  be  severe,  with  slight  pyrexia,  but,  as  a  rule,  it  is  gradual,  and 
for  a  time  there  is  only  slight  pain  in  the  back  of  the  thigh,  particularly  in 
certain  positions  or  after  exertion.  Soon  the  pain  becomes  more  intense  and, 
instead  of  being  limited  to  the  upper  portion  of  the  nerve,  extends  down  the 
thigh,  reaching  the  foot  and  radiating  over  the  entire  distribution  of  the 
nerve.  The  patient  can  often  point  out  the  most  sensitive  spots,  usually  at  the 
notch  or  in  the  middle  of  the  thigh;  and  on  pressure  these  are  exquisitely 
painful.  The  pain  is  described  as  gnawing  or  burning,  and  is  usually  con- 
stant, but  in  some  instances  is  paroxysmal,  and  often  worse  at  night.  On 
walking  it  may  be  very  great;  the  knee  is  bent  and  the  patient  treads  on  the 
toes,  so  as  to  relieve  the  tension  on  the  nerve.  In  protracted  cases  there  may 
be  much  wasting  of  the  muscles,  but  the  reaction  of  degeneration  can  seldom 
be  obtained.  In  these  chronic  cases  cramp  may  occur  and  fibrillary  contrac- 
tions. Herpes  may  develop  but  this  is  unusual.  In  rare  instances  the  neu- 
ritis ascends  and  involves  the  spinal  cord. 

Duration  and  Course. — The  duration  and  course  are  extremely  variable. 
As  a  rule,  it  is  an  obstinate  affection,  lasting  for  months,  or  even,  with  slight 
remissions,  for  years.  Eelapses  are  not  uncommon,  and  the  disease  may  be 
relieved  in  one  nerve  only  to  appear  in  the  other.  In  the  severer  forms  the 
patient  is  bedridden,  and  such  cases  prove  among  the  most  distressing  and 
trying  which  the  physician  is  called  upon  to  treat. 

Diagnosis. — In  the  diagnosis  it  is  important,  in  the  first  place,  to  de- 
termine whether  the  disease  is  primary,  or  secondary  to  some  affection  else- 
where. The  diagnosis  should  determine  the  cause;  lesions  of  the  lower  spine 
and  sacro-iliac  joints  should  be  searched  for  especially.  A  careful  rectal 
examination  should  be  made,  and,  in  women,  pelvic  tumor  should  be  excluded. 
"Lumbago"  may  be  confounded  with  it.  Affections  of  the  hip-joint  are  easily 
distinguished  by  the  absence  of  tenderness  in  the  course  of  the  nerve  and  the 
sense  of  pain  on  movement  of  the  hip-joint  or  on  pressure  in  the  region  of  the 
trochanter.  Pressure  on  the  nerve  trunks  of  the  cauda  equina,  as  a  rule, 
causes  bilateral  pain  and  disturbances  of  sensation,  and,  as  double  sciatica  is 
rare,  these  always  suggest  lesion  of  the  nerve  roots.  Between  the  severe  light- 
ning pains  of  tabes  and  sciatica  the  differences  are  usually  well  defined.  It  is 
not  to  be  forgotten  that  in  a  certain  number  of  cases  the  condition  is  a  fibro- 
sitis.  There  is  no  tenderness  along  the  course  of  the  sciatic  nerve,  but  there 
is  pain  in  the  gluteal  region,  with  disability  and  Lasegue's  sign,  i.  e.,  inability 
to  extend  the  leg  completely  when  the  thigh  is  flexed  on  the  abdomen. 

Treatment. — If  the  cause  can  be  determined,  treatment  should  be  directed 
to  correcting  this  as  soon  as  possible.  So  many  are  due  to  bone  conditions 
which  themselves  are  secondary  to  disease  elsewhere  (such  as  foci  of  infec- 
tion) that  a  very  complete  study  is  necessary.  The  removal  of  an  infected 
tooth  may  cause  a  rapid  improvement.     In  cases  associated  with  diabetes  or 


1058  DISEASES  OF  THE  NEEVOUS  SYSTEM 

gout  the  usual  treatment  for  these  should  be  carried  out.  In  all  cases  certain 
palliative  measures  are  indicated  and  may  be  the  only  ones  available  in  some 
cases.  The  most  important  is  rest  which  should  be  absolute  and  in  the 
position  which  gives  the  most  relief.  Fixation  of  the  leg  by  a  splint  may  be  of 
aid.  The  patient  should  not  be  allowed  up  for  any  purpose.  The  application 
of  heat  in  some  form  is  helpful.  An  electric  pad,  the  hot  water  bag  or  the 
cautery  may  be  used.  Hot  bottles  are  sometimes  of  value.  Counter-irrita- 
tion, especially  by  blisters,  sometimes  gives  relief.  Acupuncture  is  worth  a 
trial  in  obstinate  cases.  Injections  into  the  nerve  have  been  frequently  used 
and  various  solutions  have  been  employed,  e.  g.,  sterile  water  or  novocaine. 
Stretching  of  the  nerve  has  gone  out  of  fashion.  Electricity  may  give  tem- 
porary relief  but  is  often  disappointing.  In  some  cases  time,  usually  months, 
seems  necessary. 

As  to  drugs,  sedatives  are  usually  necessary,  the  simple  ones  being  pre- 
ferred, and  morphia  avoided  if  possible.  The  coal-tar  products  and  salicy- 
lates in  full  doses  are  worth  a  trial  and  often  give  relief  when  combined  with 
codeine.  The  use  of  suppositories  is  often  especially  helpful.  If  there  is 
any  suspicion  of  syphilis,  active  treatment  should  be  given. 


V.     HERPES  ZOSTER 

{Acute  Posterior  Ganglionitis) 

Definition. — An  acute  disease  with  localization  in  the  cerebral  ganglia  and 
in  the  ganglia  of  the  posterior  nerve  roots,  associated  with  a  vesicular  in- 
flammation of  the  skin  of  the  corresponding  cutaneous  areas. 

Distribution. — Herpes  most  frequently  occurs  in  the  region  of  the  dorsal 
roots  and  extends  in  the  form  of  a  half  girdle,  on  which  account  the  names 
'"^zona"  and  "zoster"  have  been  given.  The  trigeminal  region  is  very  often 
involved,  particularly  the  first  branch.  Common  forms  also  are  the  herpes 
sterno-nuchalis,  cervico-subclavicularis  and  dorso-ulnaris. 

Etiology. — A  curious  association  of  occurrence  with  chicken-pox  has  been 
noted.  It  occurs  with  the  acute  infections,  particularly  pneumonia,  malaria 
and  cerebro-spinal  fever.  Epidemics  have  been  described.  In  some  cases, 
especially  those  in  the  lower  part  of  the  body,  syphilis  co-exists.  Even  in  non- 
syphilitic  cases  the  spinal  fluid  may  show  increase  in  the  cells.  The  globulin 
is  rarely  much  increased.  Herpes  zoster  may  occur  with  traumatic  paraplegia 
or  injury  to  the  ganglia  (fracture)  or  tumors  may  be  responsible. 

Pathology. — Barensprung  first  showed  that  there  was  involvement  of  the 
spinal  ganglia.  The  disease  is  an  acute  hsemorrhagic  inflammation  of  the 
ganglia  of  the  posterior  nerve  roots  and  of  the  homologous  cranial  ganglia 
(Head  and  Campbell).  It  is  analogous  to  acute  anterior  poliomyelitis.  There 
are  inflammatory  foci,  haemorrhage  in  and  destruction  of  certain  of  the 
ganglion  cells  leading  to  degeneration 'of  the  axis-cylinders.  In  herpes  facialis 
accompanying  pneumonia  W.  T.  Howard  has  shown  that  similar  lesions  are 
demonstrable  in  the  Gasserian  ganglion,  and  Hunt  found  the  same  changes  in 
the  otic  ganglion  in  herpes  auricularis. 

Symptoms. — In  ordinary  zona  there  is  often  a  slight  prodromal  period 
in  which  the  patient  feels  ill,  has  moderate  fever,  and  pain  in  the  side,  some- 


PARALYSIS  AGITAXS  1059 

times  of  such  severity  as  to  suggest  pleurisy.  On  the  third  or  fourth  day  the 
rash  appears.  The  characteristic  group  of  vesicles  has  a  segmental  distribu- 
tion limited  to  one  side  of  the  body.  One  or  more  of  the  adjoining  skin  fields 
is  usually  affected.  With  involvement  of  the  cervical,  lumbar,  or  sacral  gan- 
glion the  zonal  or  girdle  form  of  the  vesicular  crop  is  naturally  lost  owing  to 
the  distortion  of  the  skin  fields  from  the  growth  of  the  limbs.  The  typical 
zonal  form  is  only  seen  in  involvement  of  the  thoracic  ganglia.  Groups  of 
vesicles  are  regularly  arranged  on  the  hypergemic  skin,  at  first  filled  with  a 
clear  or  sometimes  bloody  serum,  which  later  becomes  purulent.  The  crop 
varies  greatly,  and  the  individual  vesicles  may  be  superficial,  in  which  case 
they  leave  no  scar,  or  they  may  be  deep  and  in  healing  leave  superficial  scars. 
By  far  the  most  serious  form  is  that  seen  in  the  upper  division  of  the  fifth. 
The  fever  may  be  high  and  the  eruption  very  profuse  with  great  swelling  and 
much  pain.     Permanent  disfigurement  may  follow  the  scarring. 

It  seems  not  improbable,  as  Chauffard  suggests,  that  there  may  be  exten- 
sion of  the  disease  from  the  posterior  ganglia  to  the  neighboring  meninges  as 
there  may  be  pains  down  the  spine,  the  girdle  sensation,  exaggerated  knee- 
jerks,  the  Kernig  sign,  and  lymphocytosis  in  the  cerebro-spinal  fluid. 

Complications. — Perhaps  the  most  serious  of  these  is  that  occasionally 
seen  in  ophthalmic  zoster,  when  there  is  intense  inflammation  of  the  con- 
junctiva and  cornea  with  consecutive  panophthalmitis  and  destruction  of  the 
eye. 

In  a  few  cases  the  eruption  becomes  gangrenous.  Swelling  of  the  lymph 
glands  has  been  noted.  A  bilateral  distribution  has  occurred.  A  generalized 
herpes  zoster  is  occasionally  seen  with  a  widespread  vesicular  rash  on  the  face, 
neck,  trunk,  and  thighs.  A  facial  paralysis  may  develop  during  or  after  oph- 
thalmic or  cervical  herpes.  Swelling  of  the  parotid  gland  on  the  same  side 
may  occur.  In  rare  cases  paralysis  of  the  extremities  has  occurred.  By  far 
the  most  distressing  complication  is  post-zonal  neuralgia.  After  recovery  from 
the  herpes,  hot  burning  sejisations  are  not  uncommon  in  the  cutaneous  dis- 
tribution. In  other  instances,  particularly  in  old  people,  the  pain  persists 
and  for  years  may  be  a  terrible  affliction  resisting  all  treatment.  The  victim 
may  commit  suicide. 

Treatment. — Care  should  be  taken  to  protect  the  vesicles;  a  one  per  cent, 
cocaine  ointment  with  lanolin  carefully  applied  on  lint  gives  relief  to  the  pain. 
In  very  severe  involvement  of  the  ophthalmic  division  of  the  fifth  nerve  the 
greatest  care  should  be  taken  to  keep  the  conjunctiva  clean.  For  the  severe 
post-zonal  neuralgia,  injections  into  the  spinal  cord  have  been  tried,  and  in 
cases  of  great  severity  the  posterior  nerve  roots  may  be  cut. 


K.     GENERAL   AND  FUNCTIONAL  DISEASES. 
I.     PARALYSIS  AGITANS 

{Parkinson's  Disease;  Shaking  Pals'!/) 

Definition. — A  chronic  affection  of  the  nervous  system,  characterized  by 
disturbance  of  certain  automatic  and  associated  movements,  tremors,  and 
rigidity.     The  globus  pallidus  mechanism  is  affected. 


1060  DISEASES  OF  THE  NERVOIJS  SYSTEM 

Etiology. — ^By  no  means  uncommon,  the  disease  affects  men  more  than 
Women.  It  rarely  occurs  under  forty,  but  instances  have  been  reported  in 
which  the  disease  began  about  the  twentieth  year.  Direct  heredity  is  rare, 
but  the  patients  often  belong  to  families  in  which  there  are  other  nervous 
affections.  In  some  cases  it  may  be  caused  by  senile  degeneration  and  arterio- 
sclerotic changes.  Among  exciting  causes  may  be  mentioned  business  worries 
and  anxieties;  in  some  instances  the  disease  has  followed  directly  upon  severe 
mental  shock  or  trauma.     Cases  have  been  described  after  the  specific  fevers. 

Morbid  Anatomy. — There  are  changes  in  the  efferent  motor  system  of 
the  globus  pallidus  mechanism.  In  the  juvenile  type  there  are  atrophy  and 
decrease  in  number  of  the  large  motor  cells  of  the  globus  pallidus  system. 
These  are  regarded  as  a  primary  atrophy  (abiatrophy).  In  the  globus  pal- 
lidus system  the  large  cells  are  motor  and  the  small  ganglia  cells  are  inhibi- 
tory and  co-ordinating.  If  this  destructive  lesion  involves  both  types  of 
cells  in  the  caudate  nucleus  and  putamen,  the  Vogt  syndrome  results,  that  is 
double  athetosis  with  spastic  contractures  and  pseudo-bulbar  palsy.  If  the 
caudate  nucleus  and  lenticular  nucleus  are  the  seat  of  this  destructive  lesion 
there  results  progressive  lenticular  degeneration — Wilson's  disease — that  is 
the  paralysis  agitans  syndrome  with  rigidity,  tremor,  clonic  and  tonic  spasms 
and  perhaps  choreic  and  athetoid  movements  (Growers'  tetanoid  chorea). 

Symptoms. — The  disease  begins  gradually,  usually  in  one  or  other  hand, 
and  the  tremor  may  be  either  constant  or  intermittent.  With  this  may  be  asso- 
ciated weakness  or  stiffness.  At  first  these  symptoms  may  be  present  only 
after  exertion.  Although  the  onset  is  slow  and  gradual  in  nearly  all  cases, 
there  are  instances  in  which  it  sets  in  abruptly  after  fright  or  trauma.  When 
well  established  the  disease  is  very  characteristic.  The  following  are  the 
prominent  features. 

The  face — Paekinson's  mask. — Even  before  the  tremor  begins  the  ex- 
pressionless face,  slow  movement  of  the  lips,  the  elevated  eyebrows,  and  gen- 
eral facial  immobility  suggest  the  disease.  When  well  developed  it  is  the  most 
characteristic — and  pathetic — feature. 

Tremor. — This  may  be  in  the  four  extremities  or  confined  to  hands  or 
feet;  the  head  is  not  so  commonly  affected.  The  tremor  is  usually  marked  in 
the  hands,  and  the  thumb  and  forefinger  display  the  motion  made  in  the  act 
of  rolling  a  pill.  At  the  wrist  there  are  movements  of  pronation  and  supina- 
tion, and,  though  less  marked,  of  flexion  and  extension.  The  upper-arm  mus- 
cles are  rarely  involved.  In  the  legs  the  movement  is  most  evident  at  the 
ankle-joint,  and  less  in  the  toes  than  in  the  fingers.  Shaking  of  the  head  is 
less  frequent,  but  does  occur,  and  is  usually  vertical,  not  rotatory.  The  rate 
of  oscillation  is  about  five  per  second.  Any  emotion  exaggerates  the  move-, 
ment.  The  attempt  at  a  voluntary  movement  may  check  the  tremor  (the 
patient  may  be  able  to  thread  a  needle),  but  it  returns  with  increased  intensity. 
The  tremors  cease,  as  a  rule,  during  sleep,  but  persist  when  the  muscles  are 
not  in  use.  The  writing  of  the  patient  is  tremulous  and  zigzag.  For  months 
or  years  the  chief  tremor  may  be  in  one  arm  or  one  leg. 

Weakness. — Loss  of  power  is  present  in  all  cases,  and  may  occur  before 
the  tremor,  but  is  not  very  striking,  as  tested  by  the  dynamometer,  until  the 
late  stages.  The  weakness  is  greatest  where  the  tremor  is  most  developed. 
The  movements  are  remarkably  slow.     There  is  rarely  complete  loss  of  power. 


PAEALYSIS  AGITANS  1061 

Rigidity  may  early  be  expressed  in  a  slowness  and  stiffness  in  the  volun- 
tary movements,  which  are  performed  with  some  effort  and  difficulty,  and  all 
the  actions  of  the  patient  are  deliberate.  This  rigidity  is  in  all  the  muscles, 
and  leads  ultimately  to  the  characteristic  attitude. 

Attitude  and  Gait. — The  head  is  bent  forward,  the  back  bowed,  and  the 
arms  held  away  from  the  body,  somewhat  flexed  at  the  elbow-joints.  The 
fingers  are  flexed  and  in  the  position  assumed  when  the  hand  is  at  rest;  in 
the  late  stages  they  can  not  be  extended.  Occasionally  there  is  overextension 
of  the  terminal  phalanges.  The  hand  is  usually  turned  toward  the  ulnar  side 
and  the  attitude  somewhat  resembles  that  of  advanced  cases  of  arthritis  de- 
formans. In  the  late  stages  there  are  contractures  at  the  elbows,  knees,  and 
ankles.  The  movements  of  the  patient  are  characterized  by  great  deliberation. 
He  rises  from  the  chair  slowly  in  the  stooping  attitude,  with  the  head  project- 
ing forward.  In  attempting  to  walk  the  steps  are  short  and  hurried,  and, 
as  Trousseau  remarks,  he  appears  to  be  running  after  his  centre  of  gravity. 
This  is  termed  festination  or  propulsion,  in  contradistinction  to  a  peculiar 
gait  observed  when  the  patient  is  pulled  backward,  when  he  makes  a  number 
of  steps  and  would  fall  over  if  not  prevented — retropulsion. 

The  voice,  as  pointed  out  by  Buzzard,  is  at  first  shrill  and  piping,  and 
there  is  often  a  hesitancy  in  beginning  a  sentence;  then  the  words  are  uttered 
with  rapidity,  as  if  the  patient  was  in  a  hurry. 

The  REFLEXES  are  normal  in  most  cases,  but  in  a  few  they  are  exaggerated. 

Of  SENSOEY  disturbances  Charcot  noted  alterations  in  the  temperature 
sense.  The  patient  may  complain  of  subjective  sensations  of  heat,  either 
general  or  local — which  may  be  present  on  one  side  only  and  associated  with 
an  actual  increase  of  the  surface  temperature.  In  other  instances,  patients 
complain  of  cold.  Localized  sweating  may  be  present.  The  skin,  especially 
of  the  forehead,  may  be  thickened.  The  mental  condition  rarely  shows  any 
change. 

Variations  in  the  Symptoms. — The  tremor  may  be  absent,  but  the  rigid- 
ity, weakness,  and  attitude  are  sufficient  to  make  the  diagnosis.  The  disease 
may  be  hemiplegic  in  character,  involving  only  one  side  or  even  one  limb. 
Usually  these  are  but  stages  of  the  disease. 

Diagnosis. — In  well  developed  cases  the  disease  is  recognized  at  a  glance. 
The  attitude,  gait,  stiffness,  and  mask-like  expression  are  points  of  as  much 
importance  as  the  oscillations,  and  usually  serve  to  separate  the  cases  from 
senile  and  other  forms  of  tremor.  Disseminated  sclerosis  develops  earlier,  and 
is  characterized  by  the  nystagmus  and  the  scanning  speech,  and  does  not  pre- 
sent the  attitude  so  constant  in  paralysis  agitans.  Yet  Schultze  and  Sachs 
have  reported  cases  in  which  the  signs  of  multiple  sclerosis  have  been  asso- 
ciated with  those  of  paralysis.  The  hemiplegic  form  might  be  confounded 
with  post-hemiplegic  tremor,  but  the  history,  the  mode  of  onset,  and  the 
greatly  increased  reflexes  distinguish  the  two.  The  Parkinsonian  face  is  of 
great  importance  in  the  diagnosis  of  the  obscure  and  anomalous  forms. 

The  disease  is  incurable.  Periods  of  improvement  may  occur,  but  the 
tendency  is  for  the  affection  to  proceed  progressively  downward.  It  is  a  slow, 
degenerative  process  and  the  cases  last  for  years. 

Treatment. — There  is  no  method  which  can  be  recommended  as  satisfac- 
tory  in   any  respect.     Slowly   performed   muscular  movements,  with  strong 


1062  DISEASES  OF  THE  XEEYOUS  SYSTEM 

mental  concentration,  are  sometimes  useful  in  controlling  the  tremor.  Arsenic, 
opium  and  the  extract  of  the  parathyroid  gland  ma}"  be  tried  and  sometimes 
give  relief,  but  are  not  curative.  Hyoscine  seems  helpful  in  some  cases.  The 
friends  should  be  told  frankly  that  the  disease  is  incurable,  and  that  nothing 
can  be  done  except  to  attend  to  the  physical  comforts  of  the  patient. 

OTHER  FOEMS  OF  TREMOR 

Simple  Tremor. — This  is  occasionally  found  in  persons  in  whom  it  is 
impossible  to  assign  any  cause.  It  may  be  transient  or  persist  for  an  indefinite 
time.  It  is  often  extremely  slight,  and  is  aggravated  by  all  causes  which 
lower  the  vitality. 

Hereditary  Tremor. — C.  L.  Dana  has  reported  remarkable  cases  of  heredi- 
tary tremor.  It  occurred  in  all  the  members  of  one  family,  and  beginning 
in  infancy  continued  without  producing  any  serious  changes. 

Senile  Tremor. — With  advancing  age  tremulousness  during  muscular 
movements  is  extremely  common,  but  is  rarely  seen  under  seventy.  It  is 
always  a  fine  tremor,  which  begins  in  the  hands  and  often  extends  to  the 
muscles  of  the  neck,  causing  slight  movement  of  the  head. 

Toxic  tremor  is  seen  chiefly  as  an  effect  of  tobacco,  alcohol,  lead,  or 
mercury;  more  rarety  in  arsenical  or  opium  poisoning.  In  elderly  men  who 
smoke  much  it  may  be  entirely  due  to  tobacco.  One  of  the  commonest  forms 
is  the  alcoholic  tremor,  which  occurs  only  on  movement  and  has  considerable 
range.  Lead  tremor  is  considered  under  lead  poisoning,  of  which  it  consti- 
tutes a  very  important  symptom. 

Hysterical  tremor,  which  usually  occurs  under  circumstances  which  make 
the  diagnosis  easy,  will  be  considered  in  the  section  on  hysteria. 


II.     ACUTE  CHOREA 

(Sydenham's  Chorea;  St.  Vitus's  Dance) 

Definition. — A  disease,  probably  an  acute  infection,  chiefly  affecting 
children,  characterized  by  irregular,  involuntary  contraction  of  the  muscles, 
a  variable  amount  of  psychical  disturbance,  and  a  remarkable  liability  to 
acute  endocarditis. 

Etiology. — Sex. — Of  554  cases  analyzed  at  the  Philadelphia  Infirmary 
for  Nervous  Diseases,  71  per  cent,  were  in  females  and  29  per  cent,  in  males 
(Osier).  Of  808  Johns  Hopkins  Hospital  cases,  71.2  per  cent,  were  females 
(Tha3^er  and  Thomas). 

Age. — The  disease  is  most  common  between  the  ages  of  five  and  fifteen. 
Of  522  cases,  380  occurred  in  this  period ;  81.5  per  cent,  in  Thayer  and  Thomas' 
series.  It  is  rare  among  the  negroes  and  native  races  of  America.  Only  25 
of  the  Johns  Hopkins  Hospital  cases  were  in  negroes. 

Rheumatic  Feyee. — Of  the  551  cases,  in  15.5  per  cent,  there  was  a  history 
of  rheumatism  in  the  family.  In  88  cases,  15.8  per  cent.,  there  was  a  history 
of  articular  swelling,  acute  or  subacute.  In  33  cases  there  were  pains,  some- 
times described  as  "rheumatic/'  in  various  parts,  but  not  associated  with  joint 


ACUTE  CHOREA  1063 

trouble.  Adding  these  to  those  with  manifest  articular  trouble,  the  percentage 
is  raised  to  nearly  21.  It  is  rather  remarkable  that  in  the  Baltimore  series 
the  percentage  with  a  history  of  rheumatism  was  the  same — 21.6. 

In  one  group  of  cases  the  arthritis  antedates  by  some  months  or  years  the 
onset  of  the  chorea,  and  does  not  recur  before  or  during  the  attack.  In  th3 
other  the  chorea  sets  in  with  or  follows  immediately  upon  the  acute  arthritis. 
It  is  difficult  to  differentiate  the  cases  of  irregular  pains  without  definite  joint 
affection.  It  is  probable  that  many  of  them  are  rheumatic,  but  it  is  a  mistake 
to  regard  as  such  all  cases  in  children  in  which  there  are  complaints  of  vague 
pains  in  the  bones  or  muscles — so-called  growing  pains.  It  should  never  be 
forgotten,  however,  that  there  may  be  no  acute  arthritis  with  rheumatic  fever 
in  a  child. 

Heart-disease. — Endocarditis  is  believed  by  some  writers  to  be  the  cause 
of  the  disease.  On  this  view  chorea  is  the  result  of  an  embolic  process  occur- 
ring in  the  course  of  a  rheumatic  endocarditis. 

Infectious  Diseases. — Scarlet  fever  with  arthritic  manifestations  may 
be  a  direct  antecedent.  With  the  exception  of  rheumatic  fever,  there  is  no 
intimate  relationship  between  chorea  and  the  acute  diseases  incident  to  child- 
hood. It  may  be  noted  in  contrast  to  this  that  the  so-called  canine  chorea  is  a 
common  sequel  of  distemper.  Chorea  may  follow  gonorrhoea,  puerperal  fever, 
and  other  forms  of  sepsis.     The  tonsils  are  frequently  diseased. 

Syphilis.— There  is  a  small  group,  with  features  much  like  those  of 
chorea,  in  which  congenital  syphilis  is  apparently  the  cause.  The  clinical 
features  of  chorea  may  be  typical  and  specific  treatment  result  in  rapid  im- 
provement. 

Ax^EMiA  is  less  often  an  antecedent  than  a  sequence,  and  though  cases 
occur  in  children  who  are  anaemic  and  in  poor  health,  this  is  by  no  means 
the  rule.     Chorea  may  come  on  during  chlorosis. 

Pregnancy. — A  choreic  patient  may  become  pregnant;  more  frequently 
the  disease  occurs  during '  pregnancy ;  sometimes  after  delivery.  Buist,  of 
Dundee,  has  tabulated  226  cases:  in  6  the  chorea  preceded  and  in  105  it  oc- 
curred during  the  pregilancy;  in  31  in  recurrent  pregnancies;  45  cases  ter- 
minated fatally,  and  in  16  cases  the  attack  developed  post  partum.  The  alleged 
frequency  in  illegitimate  primipara  is  not  borne  out  by  his  figures.  Beginning 
in  the  first  three  months  were  108  cases,  in  the  second  three  months  70  cases, 
in  the  last  three  months  25  cases.  The  disease  is  often  severe,  and  maniacal 
symptoms  may  occur. 

A  tendency  to  the  disease  is  found  in  certain  families.  In  80  cases  there 
was  a  history  of  attacks  of  chorea  in  other  members.  In  one  instance  both 
mother  and  grandmother  had  been  affected.  High-strung,  excitable,  nervous 
children  are  especially  liable.  Fright  is  considered  a  frequent  cause,  but  in 
a  large  majority  of  the  cases  no  close  connection  exists  between  the  fright  and 
the  onset  of  the  disease.  Occasionally  the  attack  sets  in  at  once.  Mental 
worry,  trouble,  a  sudden  grief,  or  a  scolding  may  apparently  be  the  exciting 
cause.  The  strain  of  education,  particularly  in  girls  during  the  third  hemi- 
decade,  appears  to  be  an  important  factor.  Briglit,  intelligent,  active  minded 
girls  from  ten  to  fourteen,  ambitious  to  do  well  at  school,  often  stimulated 
in  their  efforts  by  teachers  and  parents,  form  a  large  contingent  of  the  cases — 
the  so-called  school-made  chorea.     Iniildlion,  wliicli   is  mentioned  as  an  ex- 


1064  DISEASES  OF  THE  NERVOUS  SYSTEM 

citing  cause;,  is  extremely  rarC;,  and  did  not  appear  to  have  influenced  the  onset 
in  a  single  case  in  the  Infirmary  records. 

The  disease  may  rapidly  follow  an  injury  or  a  slight  surgical  operation. 
Keflex  irritation  was  believed  to  play  an  important  role,  particularly  the  pres- 
ence of  worms  or  genital  irritation,  but  this  is  very  doubtful.  Ocular  defects 
do  not  occur  in  greater  proportion  in  choreic  than  in  other  children,  and  a  ma- 
jority of  the  cases  in  which  operation  has  been  followed  by  relief  have  been 
instances  of  tic,  local  or  general. 

Pathology. — Two  anatomical  changes  are  found:  (1)  Endocarditis,  usu- 
ally simple  (and  of  the  mitral  valve),  which  was  present  in  63  of  73  fatal 
cases  recorded.*  In  a  few  instances  the  lesion  was  ulcerative.  (3)  Foci  of 
softening  in  the  basal  ganglia,  regarded  as  embolic  by  Kirkes,  but  in  the  situa- 
tion and  with  the  appearance  of  an  acute  encephalitis.  Minute  haemorrhages 
have  been  found  elsewhere  in  the  brain.  Connected  with  the  endocarditis 
there  are  on  record  seven  cases  of  embolism  of  the  central  artery  of  the  retina 
(H.  M.  Thomas)   and  cerebral  embolism  has  been  found. 

The  pathology  is  still  obscure.  That  it  is  an  acute  infection  is  suggested 
by  (1)  the  frequent  association  with  rheumatic  fever;  (3)  the  character  of 
the  acute  febrile  cases;  (3)  the  frequency  of  involvement  of  the  tonsils;  (4) 
the  seasonal  relations;  (5)  the  presence  of  endocarditis;  (5)  the  finding  of 
micro-organisms — though  the  diplococcus  of  Poynton  is  not  generally  accepted 
as  the  cause ;  and  ( 7 )  the  occurrence  of  a  chorea  type  in  the  epidemic  encepha- 
litis in  which  the  lesions  are  very  similar  to  and  in  the  same  situation,  basal 
ganglia,  as  in  simple  chorea.  It  seems  not  improbable  that  it  is  a  form  of 
infective  encephalitis  with  a  special  localization. 

Symptoms.— Three  groups  of  cases  may  be  recognized — the  mild,  severe, 
and  maniacal  chorea. 

Mild  Chorea. — In  this  the  affection  of  the  muscles  is  slight,  the  speech 
is  not  seriously  disturbed,  and  the  general  health  not  impaired.  Premoni- 
tor}^  symptoms  are  shown  in  restlessness  and  inability  to  sit  still,  a  condition 
well  characterized  by  the  term  "fidgets."  There  are  emotional  disturbances, 
such  as  crying  spells,  or  sometimes  night  terrors.  There  may  be  pains  in  the 
limbs  and  headache.  Digestive  disturbances  and  anemia  may  be  present.  A 
change  in  the  temperament  is  frequently  noticed,  and  a  docile,  quiet  child 
may  become  cross  and  irritable.  After  these  symptoms  have  persistecTIor  a 
week  or  more  the  characteristic  involuntary  movements  begin,  and  are  often 
first  noticed  at  the  table,  when  the  child  spills  a  tumbler  of  water  or  upsets  a 
plate.  There  may  be  only  awkwardness  or  slight  incoordination  of  voluntary 
movements,  or  constant  irregular  clonic  spasms.  The  jerky,  irregular  char- 
acter of  the  movements  differentiates  them  from  almost  every  other  disorder 
of  motion.  In  the  mild  cases  only  one  hand,  or  the  hand  and  face,  are  affected,' 
and  it  may  not  spread  to  the  other  side. 

In  the  second  grade,  the  severe  form,  the  movements  become  general  and 
the  patient  may  be  unable  to  get  about  or  to  feed  or  undress  herself,  owing 
to  the  constant,  irregular,  clonic  contractions  of  the  various  muscle  groups. 
The  speech  is  also  affected,  and  for  days  the  child  may  not  be  able  to  talk. 
Often  with  the  onset  of  the  severer  symptoms  there  is  loss  of  power  on  one 
side  or  in  the  limb  most  affected. 

*  Osier,  "Chorea  and  Choreiform  Affections,"  Philadelphia,  1894. 


ACUTE  CHOEEA  1065 

The  third  and  most  extreme  form,  the  so-called  maniacal  chorea,  or  chorea 
insanienSj  is  truly  a  terrible  disease,  and  may  arise  out  of  the  ordinary  form. 
These  cases  are  more  common  in  adult  women  and  may  develop  during 
pregnancy. 

Chorea  begins,  as  a  rule,  in  the  hands  and  arms,  then  involves  the  face,  and 
subsequently  the  legs.  The  movements  may  be  confined  to  one  side — herai- 
chorea.  The  attack  begins  oftenest  on  the  right  side,  though  occasionally  it  is 
general  from  the  outset.  One  arm  and  the  opposite  leg  may  be  involved.  In 
nearly  one-fourth  of  the  cases  speech  is  affected;  this  may  amount  only  to  an 
embarrassment  or  hesitancy,  but  in  other  instances  it  becomes  an  incoherent 
jumble.  In  very  severe  cases  the  child  will  make  no  attempt  to  speak.  The 
inability  is  in  articulation  rather  than  in  phonation.  Paroxysms  of  panting 
and  of  hard  expiration  may  occur,  or  odd  sounds  may  be  produced.  As  a  rule 
the  movements  cease  during  sleep. 

Weakness. — A  prominent  symptom  is  muscular  weakness,  usually  no  more 
than  a  condition  of  paresis.  The  loss  of  power  is  slight,  but  the  weakness  may 
be  shown  by  an  enfeebled  grip  or  by  a  dragging  of  the  leg  or  limping.  In 
his  original  account  Sydenham  refers  to  the  "unsteady  movements  of  one  of 
the  legs,  which  the  patient  drags."  There  may  be  extreme  paresis  with  but 
few  movements — the  paralytic  chorea  of  Todd.  Occasionally  a  local  paralysis 
or  weakness  remains  after  the  attack. 

Mutism  is  an  interesting  feature;  for  weeks  the  child  may  not  speak.  It 
is  more  common  in  severe  cases,  but  is  not  marked  by  special  choreic  unrest 
of  the  muscles  of  speech ;  it  is  probably  a  motor  weakness.  Complete  recovery 
follows. 

Heart  Symptoms. — Neurotic. — As  so  many  of  the  subjects  of  chorea  are 
nervous  girls,  it  is  not  surprising  that  a  common  symptom  is  a  rapidly  acting 
heart.  Irregularity  is  not  so  special  a  feature  in  chorea  as  rapidity.  The 
patients  seldom  complain  of  pain  about  the  heart. 

Hcemic  Mua"murs. — "With  anaemia  and  debility,  not  uncommon  associates 
of  chorea  in  the  third  or  fourth  week,  we  find  a  corresponding  cardiac  condi- 
tion. The  impiilse  is  diffuse,  perhaps  wavy  in  thin  children.  The  carotids 
throb  visibly,  and  in  the  recumbent  posture  there  may  be  pulsation  in  the  cer- 
vical veins.  On  auscultation  a  systolic  murmur  is  heard  at  the  base,  perhaps, 
too,  at  the  apex,  soft  and  blowing  in  quality. 

Endocarditis. — Acute  valvulitis  rarely  gives  evidence  of  its  presence  by 
symptoms.  It  must  be  sought,  and  it  is  usually  associated  with  murmurs  at 
one  or  other  of  the  cardiac  orifices. 

For  the  guidance  of  the  practitioner  these  statements  may  be  made : 

(a)  In  thin,  nervous  children  a  systolic  murmur  of  soft  quality  is  ex- 
tremely common  at  the  base,  with  accentuation  of  the  second  sound,  par- 
ticularly at  the  second  left  costal  cartilage,  and  is  probably  of  no  moment. 

(&)  A  systolic  murmur  of  maximum  intensity  at  the  apex,  and  heard 
also  along  the  left  sternal  margin,  is  not  uncommon  in  anaemic,  enfeebled 
states,  and  does  not  necessarily  indicate  either  endocarditis  or  insufficiency. 

(c)  A  murmur  of  maximum  intensity  at  the  apex,  with  rough  quality,  and 
transmitted  to  the  axilla  or  angle  of  the  scapula,  indicates  an  organic  lesion  of 
the  mitral  valve,  and  is  usually  associated  with  enlargement  of  the  heart. 

(c/)   When  in  doubt  it  is  much  safer  to  trust  to  the  evidence  of  eye  and 


1066  DISEASES  OF  THE  NERVOUS  SYSTEM 

hand  than  to  that  of  the  ear.  If  the  apex  beat  is  in  the  normal  position, 
and  the  area  of  dulness  not  increased  vertically  or  to  the  right  of  the  sternum, 
there  is  probably  no  serious  valvular  disease. 

The  endocarditis  of  chorea  is  almost  invariably  of  the  simple  or  warty 
form,  and  in  itself  not  dangerous;  but  it  leads  to  those  sclerotic  changes  in 
the  valve  which  produce  incompetency.  Of  140  patients  examined  more  than 
two  years  after  the  attack,  the  heart  was  normal  in  only  51 ;  in  17  there  was 
functional  disturbance,  and  72  presented  signs  of  organic  heart-disease.  In 
an  analysis  of  the  cases  at  the  Johns  Hopkins  Hospital,  Thayer  found  evidence 
of  involvement  of  the  heart  in  25  per  cent,  of  the  out-patients  and  in  more 
than  50  per  cent,  of  the  cases  in  the  wards.  Cardiac  involvement  was  more 
common  in  the  cases  with  a  history  of  rheumatism,  and  was  much  more  fre- 
quent in  the  relapses.     Pericarditis  is  an  occasional  complication. 

Sensory  Disturbances. — Pain  in  the  affected  limbs  is  not  common, 
Occasionally  there  is  soreness  on  pressure.  There  are  cases,  usually  of  hemi- 
chorea,  in  which  pain  in  the  limbs  is  a  marked  symptom.  Weir  Mitchell  has 
spoken  of  these  as  painful  choreas.  Tender  points  along  the  lines  of  emergence 
of  the  spinal  nerves  or  along  the  course  of  the  nerves  of  the  limbs  are  rare. 

Psychical  disturbances  are  common.  Irritability  of  temper,  marked 
wilfulness,  and  emotional  outbreaks  may  indicate  a  complete  change  in  the 
character.  There  is  deficiency  in  the  powers  of  concentration,  the  memory 
is  enfeebled,  and  the  aptitude  for  study  is  lost.  Earely  there  is  progressive 
impairment  of  the  intellect  with  termination  in  actual  dementia.  Acute 
melancholia  has  been  described.  Hallucinations  of  sight  and  hearing  may 
occur.  Patients  may  behave  in  an  odd  and  strange  manner  and  do  aU  sorts 
of  meaningless  acts.  By  far  the  most  serious  manifestation  of  this  character 
is  the  maniacal  delirium,  occasionally  associated  with  the  very  ^severe  cases — 
cli  orea  insaniens. .  Usually  the  motor  disturbance  in  these  cases  is  aggravated, 
but  it  has  been  overlooked  and  patients  have  been  sent  to  an  asjdum. 

The  psychical  element  is  apt  to  be  neglected  and  it  is  always  a  good  plan 
to  tell  the  parents  that  it  is  not  the  muscles  alone  which  are  affected,  but  that 
the  general  irritability  and  change  of  disposition  really  form  part  of  the 
disease. 

The  condition  of  the  reflexes  is  usually  normal,  but  they  may  show  much 
variation.  T*rophic  lesions  rarely  occur  unless,  as  some  writers  have  done,  the 
joint  troubles  are  regarded  as  arthropathies  occurring  in  the  course  of  a  cerebro- 
spinal disease. 

Fever,  usually  slight,  was  present  in  all  but  one  of  110  cases  (Thayer). 
Endocarditis  may  occur  with  little  if  any  rise  in  temperature ;  but,  on*  the 
other  hand,  with  an  acute  arthritis,  severe  endocarditis  or  pericarditis,  and  in 
the  maniacal  cases  the  fever  may  range  from  102°  to  101°. 

Cutaneous  Affections. — The  pigmentation,  which  is  not  uncommon,  is 
due  to  the  arsenic.  Herpes  zoster  occasionally  occurs.  Erythema  nodosum 
and  a  purpuric  urticaria  have  been  described.  There  may,  indeed,  be  the  more 
aggravated  condition  of  rheumatic  purpura,  known  as  Schonlein's  peliosis 
rlieumatica.     Subcutaneous  fibrous  nodules  may  be  present. 

Duraition  and  Termination. — From  eight  to  ten  weeks  is  the  average  dura- 
tion of  an  attack  of  moderate  severity.  Cases  described  as  chronic  chorea  fol- 
lowing an  acute  attack  are  usually  instances  of  cerebral  sclerosis  or  Fried- 


ACUTE  CHOEEA  1067 

reich's  ataxia;  but  occasionally  an  attack  which  has  come  on  in  the  ordinary 
way  persists  for  months  or  years,  and  recovery  ultimately  takes  place.  A 
slight  grade,  particularly  noticeable  under  excitement,  may  persist  for  months 
in  nervous  children. 

The  tendency  to  recur  has  been  noticed  by  all  writers  since  Sydenham 
first  made  the  observation.  Of  410  cases  analyzed  for  this  purpose,  240  had 
one  attack,  110  had  two  attacks,  35  three  attacks,  10  four  attacks,  12  five 
attacks,  and  3  six  attacks.    The  recurrence  is  apt  to  be  vernal. 

Recovery  is  the  rule.  The  statistics  of  out-patient  departments  are  not 
favorable  for  determining  the  mortality.  A  reliable  estimate  is  that  of  the 
Collective  Investigation  Committee  of  the  British  Medical  Association,  in  which 
9  deaths  were  reported  among  439  cases,  about  2  per  cent.  There  were  102 
deaths  in  the  U.  S.  registration  area  in  1917. 

The  paralysis  rarely  persists.  Mental  dulness  may  be  present  for  a  time, 
but  usually  passes  away ;  permanent  impairment  of  the  mind  is  exceptional. 

Dia^osis. — In  a  majority  of  instances  the  nature  of  the  trouble  is  recog- 
nized at  a  glance;  but  there  are  several  affections  which  may  simulate  and  be 
mistaken  for  it. 

(a)  Multiple  and  diffuse  cere'bral  sclerosis.  The  cases  are  often  mistaken 
for  ordinary  chorea,  and  have  been  described  as  cJiorea  spastica.  As  a  rule, 
the  movernents  are  readily  distinguishable  from  those  of  true  chorea,  but  the 
simulation  is  sometimes  very  close;  the  onset  in  infancy,  the  impaired  intelli- 
gence, increased  reflexes  and  in  some  instances  rigidity  with  the  chronic  course 
separate  them  sharply  from  true  chorea. 

(&)  Friedreich's  ataxia.  Cases  of  this  well-characterized  disease  were  for- 
merly classed  as  chorea.  The  slow,  irregular,  incoordinate  movements,  the 
scoliosis,  the  scanning  speech,  the  early  talipes,  the  nystagmus,  and  the  fam-. 
ily  character  of  the  disease  are  points  which  render  the  diagnosis  easy. 

(c)  In  rare  cases  the  paralytic  form  of  chorea  may  be  mistaken  for  polio- 
myelitis or,  when  both  legs  are  affected,  for  paraplegia  of  spinal  origin;  but 
this  can  be  the  case  only  when  the  choreic  movements  are  very  slight. 

(d)  Hysteria  may  simulate  chorea  minor  most  closely,  and  unless  there 
are  other  manifestations  it  may  be  impossible  to  make  a  diagnosis.  Most 
commonly,  however,  the  movements  in  the  so-called  hysterical  chorea  are 
rhythmic  and  differ  entirely  from  those  of  ordinary  chorea. 

(e)  The  mental  symptoms  in  maniacal  chorea  may  mask  the  true  nature 
of  the  disease  and  patients  have  been  sent  to  an  asylum. 

Treatment. — Abnormally  bright,  active  minded  children  belonging  to  fam- 
ilies with  pronounced  neurotic  taint  should  be  carefully  watched  from  the  ages 
of  eight  to  fifteen  and  not  allowed  to  overtax  their  mental  powers.  So  fre- 
quently in  children  of  this  class  does  the  attack  of  chorea  date  from  the  worry 
and  stress  incident  to  school  examinations  that  the  competition  for  prizes  or 
places  should  be  emphatically  forbidden. 

The  treatment  of  the  attack  consists  largely  in  attention  to  hygienic  meas- 
ures, with  which  alone,  in  time,  a  majority  of  the  cases  recover.  Parents 
should  be  told  to  scan  gently  the  faults  and  waywardness  of  choreic  children. 
The  psychical  element,  strongly  developed  in  so  many  cases,  is  best  treated 
by  quiet  and  seclusion.  The  child  should  be  confined  to  bed  in  the  recumbent 
posture,  and  mental  as  well  as  bodily  quiet  enjoined.  ^  In  private  practice  this . 


1068  DISEASES  OF  THE  NEEVOUS  SYSTEM 

is  often  impossible,  but  with  well-to-do  patients  the  disease  is  always  serious 
enough  to  demand  the  assistance  of  a  skilled  nurse.  Toys  and  dolls  should 
not  be  allowed  at  first,  for  the  child  should  be  kept  amused  without  excitement. 
The  rest  allays  the  hyper-excitability  and  reduces  to  a  minimum  the  possibility 
of  damage  to  the  valve  segments  should  endocarditis  exist. 

The  child  should  be  kept  apart  from  other  children  and,  if  possible,  from 
other  members  of  the  family,  and  should  see  only  those  persons  directly  con- 
cerned with  the  nursing  of  the  case.  In  the  latter  period  of  the  disease  daily 
rubbings  may  be  resorted  to  with  great  benefit. 

The  medical  treatment  is  unsatisfactory;  with  the  exception  of  arsenic,  no 
remedy  seems  to  have  any  influence  in  controlling  the  progress  of  the  affection. 
Without  any  specific  action,  it  certainly  does  good  in  many  cases,  probably  by 
improving  the  general  nutrition.  It  is  conveniently  given  in  the  form  of 
Fowler's  solution,  and  the  good  effects  are  rarely  seen  until  maximum  doses 
are  taken.  It  may  be  given  as  Martin  originally  advised  (1813);  he  began 
"with  five  drops  and  increased  one  drop  every  day,  until  it  might  begin  to 
disagree  with  the  stomach  or  bowels.'^  When  the  dose  of  15  minims  is  reached, 
it  may  be  continued  for  a  week,  and  then  again  increased,  if  necessary,  every 
day  or  two,  until  physiological  effects  are  manifest.  On  the  occurrence  of 
these  the  drug  should  be  stopped  for  three  or  four  days.  The  practice  of 
resuming  the  administration  with  smaller  doses  is  rarely  necessary,  as  toler- 
ance is  usually  established  and  we  can  begin  with  the  dose  which  the  child 
was  taking  when  the  symptoms  of  saturation  occurred.  Usually  the  signs  of 
saturation  are  trivial  but  plain,  but  in  very  rare  instances  more  serious  symp- 
toms develop.  A  fatal  arsenical  neuritis  followed  in  the  case  of  a  child,  aged 
eight,  who  took  seven  drops  of  Fowler's  solution  three  times  a  day  for  ten 
days,  'then  stopped  for  a  week,  and  then  took  seven  drops  three  times  a  day  for 
fourteen  days  (Gary  Gamble). 

Sedatives  are  useful  in  the  severe  attacks.  Chloral  is  the  most  useful  and 
may  be  begun  in  doses  of  five  grains  (0.3  gm.),  gradually  increased  if  neces- 
sary. Sodium  bromide  in  the  same  dosage  may  be  added.  Belladonna  has 
been  found  useful  in  some  cases.  Syphilis,  if  present,  should  be  actively 
treated. 

Electricity  is  of  doubtful  value.  The  question  of  gymnastics  is  an  impor- 
tant one.  Early  in  the  disease,  when  the  movements  are  active,  they  are  not 
advisable ;  but  during  convalescence  carefully  graduated  exercises  are  undoubt- 
edly beneficial.  It  is  not  well,  however,  to  send  a  choreic  child  to  a  school 
gymnasium,  as  the  stimulus  of  other  children  and  the  excitement  of  the  violent 
play  are  very  prejudicial. 

Other  points  may  be  mentioned.  Food  should  be  simple  and  some  children 
do  best  on  a  milk  diet,  the  amount  being  rapidly  increased.  It  is  important 
to  regulate  the  bowels  and  to  attend  carefully  to  the  digestive  functions.  For 
the  anaemia  so  often  present  preparations  of  iron  are  indicated. 

In  the  severe  cases  with  incessant  movements^  sleeplessness,  dry  tongue, 
and  delirium,  the  important  indication  is  to  procure  rest,  for  which  purpose 
chloral  may  be  freely  given,  and,  if  necessary,  morphia.  Chloroform  inhala- 
tions may  be  necessary  to  control  the  intensity  of  the  paroxysms,  but  the  high 
rate  of  mortality  in  this  class  of  cases  illustrates  how  often  our  best  endeavors 
are  fruitless.     The  wet  pack  is  sometimes  very  soothing  and  should  be  tried. 


HABIT  SPASMS  AKD  TICS  1069 

As  these  patients  are  apt  to  sink  rapidly  into  a  low  typhoid  state  with  heart 
weakness,  a  supporting  treatment  is  required  from  the  outset. 

There  are  cases  which  drag  on  from  month  to  month  without  getting  better 
or  worse  and  resist  all  modes  of  treatment.  In  such  cases  a  combination  of 
suggestion  and  passive  movements,  followed  by  voluntary  movements  under 
control,  and  later  simple  exercises,  may  be  useful.  Change  of  air  and  scene 
is  sometimes  followed  by  rapid  improvement,  and  in  these  cases  the  treatment 
by  rest  and  seclusion  should  always  be  given  a  full  trial. 

Diseased  tonsils  should  be  removed  and  nasal  trouble  corrected.  Glaring 
ocular  defects  should  be  properly  corrected  by  glasses  or,  if  necessary,  by  oper- 
ation. 

After  the  child  has  recovered,  the  parents  should  be  warned  that  return 
is  by  no  means  infrequent,  and  is  particularly  liable  to  follow  overwork  at 
school  or  debilitating  influences.  These  relapses  are  apt  to  occur  in  the  spring. 
Sydenham  advised  purging  in  order  to  prevent  the  recurrence. 


ni.    HABIT  SPASMS  AND  TICS 

Habit  Spasm  (Habit  Chorea)  ;  Convulsive  Tic. — Two  groups  of  cases  may 
be  recognized  under  the  designation  of  habit  spasm — one  in  which  there  are 
simply  localized  spasmodic  movements,  and  the  other  in  which,  in  addition 
to  this,  there  are  explosive  utterances  and  psychical  symptoms,  a  condition 
to  which  French  writers  have  given  the  name  tic  convulsif. 

(a)  Habit  Spasm. — This  is  found  chiefly  in  childhood,  most  frequently  in 
girls  from  seven  to  fourteen  years  of  age  (Mitchell).  In  its  simplest  form 
there  is  a  sudden,  quick  contraction  of  certain  of  the  facial  muscles,  such  as 
rapid  winking  or  drawing  of  the  mouth  to  one  side,  or  the  neck  muscles  are 
involved  and  there  are  unilateral  movements  of  the  head.  The  head  is  given 
a  sudden,  quick  shake,  and  at  the  same  time  the  eyes  wink.  A  not  infrequent 
form  is  the  shrugging  of  one  shoulder.  The  grimace  or  movement  is  repeated 
at  irregular  intervals,  and  is  much  aggravated  by  emotion.  A  short  inspira- 
tory sniff  is  not  an  uncommon  symptom.  The  cases  are  found  most  frequently 
in  children  who  are  "out  of  sorts,"  or  who  have  been  growing  rapidly,  or  who 
have  inherited  a  tendency  to  neurotic  disorders.  Allied  to  or  associated  with 
this  are  some  of  the  curious  tricks  of  children.  A  boy  was  in  the  habit  every 
few  moments  of  putting  the  middle  finger  into  the  mouth,  biting  it,  and  at 
the  same  time  pressing  his  nose  with  the  forefinger.  Hartley  Coleridge  is 
said  to  have  had  a  somewhat  similar  trick,  only  he  bit  his  arm.  In  all  these 
cases  the  habits  of  the  child  should  be  examined  carefully,  the  nose  and  vault 
of  the  pharynx  thoroughly  inspected,  and  the  eyes  accurately  tested.  As  a 
rule  the  condition  is  transient,  and  after  persisting  for  a  few  months  or  longer 
gradually  disappears.  Occasionally  a  local  spasm  persists — twitching  of  the 
eyelids,  or  the  facial  grimace. 

Spasmus  nutans,  head  nodding,  is  a  coordinated  tic  in  young  infants 
usually  of  a  harmless  nature;  it  may  be  associated  with  nystagmus. 

(6)!  Impulsive  Tic  (Gilles  de  -lx  Tourette's  Disease.) — This  remark- 
able affection,  often  mistaken  for  chorea,  more  frequently  for  habit  spasm,  is 
really  a  psychosis  allied  to  hysteria,  though  in  certain  of  its  aspects  it  has 


1070  DISEASES  OT  THE  NERVOUS  SYSTEM 

the  features  of  monomania.  The  disease  begins,  as  a  rule,  in  young  children, 
occurring  as  early  as  the  sixth  year,  though  it  may  occur  after  puberty.  There 
is  usually  a  neurotic  family  history.    The  special  features  are: 

(1)  Involuntary  muscular  movements,  usually  affecting  the  facial  or 
brachial  muscles,  but  in  aggravated  cases  all  the  muscles  of  the  body  may 
be  involved  and  the  movements  may  be  extremely  irregular  and  violent. 

(2)  Explosive  utterances,  which  may  resemble  a  bark  or  an  inarticulate 
cry.  A  word  heard  may  be  mimicked  at  once  and  repeated  over  and  over 
again,  usually  with  the  involuntary  movements.  To  this  the  term  ecJiolalia 
has  been  applied.  A  much  more  distressing  disturbance  in  these  cases  is 
coprolalia,  or  the  use  of  bad  language.  A  child  of  eight  or  ten  may  shock  its 
mother  and  friends  by  constantly  using  the  word  damn  when  making  the 
involuntary  movements,  or  by  uttering  all  sorts  of  obscene  words.  Occasion- 
ally actions  are  mimicked — echoJcinesis. 

(3)  Associated  with  some  of  these  cases  are  curious  mental  disturbances; 
the  patient  becomes  the  subject  of  a  form  of  obsession  or  a  fixed  idea.  In 
other  cases  the  fixed  idea  takes  the  form  of  the  impulse  to  touch  objects,  or 
it  is  a  fixed  idea  about  words — onomatomania — or  the  patient  may  feel  com- 
pelled to  count  a  number  of  times  before  doing  certain  actions — arithmomania. 
The  disease  is  readily  distinguished  from  ordinary  chorea.  The  movements 
have  a  larger  range  and  are  explosive  in  character.  Tourette  regards  the 
coprolalia  as  the  most  distinctive  feature.  The  prognosis  is  doubtful,  but 
recovery  may  follow. 

Saltatory  Spasm  (Latah;  Myriacliit;  Jumpers). — Bamberger  has  described 
a  disease  in  which  when  the  patient  attempted  to  stand  there  were  strong 
contractions  in  the  leg  muscles,  which  caused  a  jumping  or  springing  motion. 
This  occurs  only  when  the  patient  attempts  to  stand.  The  affection  has 
occurred  in  both  men  and  women,  more  frequently  in  the  former,  and  the 
subjects  have  usually  shown  marked  neurotic  tendencies.  In  many  cases  the 
condition  has  been  transitory;  in  others  it  has  persisted  for  years.  Eemark- 
able  affections  similar  to  this  in  certain  points  occur  as  a  sort  of  epidemic 
neurosis.  One  of  the  most  striking  of  these  occurs  among  the  "jumping 
Frenchmen"  of  Maine  and  Canada.  As  described  by  Beard  and  Thornton; 
the  subjects  are  liable  on  any  sudden  emotion  to  jump  violently  and  utter  a 
loud  cry  or  sound,  and  will  obey  any  command  or  imitate  any  action  without 
regard  to  its  nature.  The  condition  of  echolalia  is  present  in  a  marked  degree. 
The  "jumping"  prevails  in  certain  families. 

A  very  similar  disease  prevails  in  parts  of  Russia  and  in  Java  and  Borneo, 
where  it  is  known  by  the  names  of  myriachit  and  latah,  the  chief  feature  of 
which  is  mimicry  by  the  patient  of  everything  he  sees  or  hears. 

Rhythmic  Chorea. — This  is  readily  recognized  by  the  rhythmical  character 
of  the  movements.  It  may  affect  the  muscles  of  the  abdomen,  producing  the 
salaam  convulsion,  or  involve  the  sterno-mastoid,  producing  a  rhythmical 
movement  of  the  head,  or  the  psoas,  or  any  group  of  muscles.  In  its  orderly 
rhythm  it  resembles  the  canine  chorea. 


INFANTILE  CONVULSIONS  1071 


IV.    INFANTILE  CONVULSIONS 


Convulsive  seizures  similar  to  those  of  epilepsy  are  not  infrequent  in  chil- 
dren. The  fit  may  be  identical  with  epilepsy,  from  which  the  condition  differs 
in  that  when  the  cause  is  removed  there  is  no  tendency  for  the  tits  to  recur. 
Occasionally,  however,  the  convulsions  continue  and  pass  into  true  epilepsy. 

Etiolo^. — A  convulsion  may  be  due  to  many  causes,  all  of  which  lead  to 
an  imstable  condition  of  the  nerve  centres,  permitting  sudden,  excessive,  and 
temporary  nervous  discharges.     The  following  are  the  most  important: 

(1)  Debility,  resulting  usually  from  gastro-intestinal  disturbance.  Con- 
vulsions frequently  supervene  toward  the  close  of  an  attack .  of  entero-colitis 
and  recur,  sometimes  proving  fatal.  The  death-rate  in  children  from  eclamp- 
sia rises  steadily  with  that  of  gastro-intestinal  disorders  (M.  J.  Lewis). 

(2)  Peripheral  Irritation. — Dentition  alone  is  rarely  a  cause,  but  is  ofteri 
one  of  several  factors  in  a  feeble,  unhealthy  infant.  The  greatest  mortality 
from  convulsions  is  during  the  first  six  months,  before  the  teeth  have  really 
cut  through  the  gums.  Other  irritative  causes  are  the  overloading  of  the 
stomach  with  indigestible  food.  It  has  been  suggested  that  some  of  these  cases 
are  toxic.  Worms,  to  which  convulsions  are  so  frequently  attributed,  prob- 
ably have  little  influence.  Among  other  sources  possible  are  phimosis  and 
otitis. 

(3)  Bickets. — Eickets  and  convulsions  are  often  associated  (Jenner).  The 
spasms  may  be  laryngeal,  the  so-called  child-crowing,  which,  though  convul- 
sive in  nature,  can  scarcely  be  reckoned  under  eclampsia.  The  influence  of 
this  condition  is  more  apparent  in  Europe  than  in  the  United  States,  although 
rickets  is  a  common  disease,  particularly  among  the  colored  people.  Spasms, 
local  or  general,  in  rickets  are  probably  associated  with  the  condition  of  debility 
and  malnutrition  and  with  eraniotabes. 

(4)  Fever. — In  young'  children  the  onset  of  the  infectious  diseases  is  fre- 
quently with  convulsions,  which  may  take  the  place  of  a  chill  in  the  adult. 
It  is  not  known  upon  what  they  depend.  Scarlet  fever,  measles,  and  pneu- 
monia are  most  often  preceded  by  convulsions. 

(5)  Congestion  of  the  Brain. — That  extreme  engorgement  of  the  blood- 
vessels may  produce  convulsions  is  shown  by  their  occasional  occurrence  in 
severe  whooping-cough,  but  their  rarity  in  this  disease  really  indicates  how 
small  a  part  mechanical  congestion  plays  in  the  production  of  fits. 

(6)  Severe  convulsions  usher  in  or  accompany  many  of  the  serious  dis- 
eases of  the  nervous  system  in  children.  The  acute  encephalitis  of  children, 
which  is  followed  by  hemiplegia,  usually  has  severe  convulsions  at  the  onset. 
They  less  frequently  precede  a  spinal  paralysis.  They  occur  with  meningitis, 
tuberculous  or  simple,  and  with  tumors  and  other  lesions  of  the  brain. 

And,  lastly,  convulsions  may  occur  immediately  after  birth  and  persist 
for  weeks  or  months.  In  sucli  instances  there  has  probably  been  meningeal 
haemorrhage  or  serious  injury  to  the  cortex. 

The  relation  of  convulsions  in  children  to  true  epilepsy  is  important.  In 
Gowers'  figures  of  1,450  cases  of  epilepsy,  the  attacks  began  in  180  during  the 
first  three  years  of  life.  Of  460  cavses  of  epilepsy  in  children,  in  187  the  fits 
began  within  the  first -three  years  and  the  greatest  number,  74,  was  in  the  first 


1072  DISEASES  OF  THE  NEEVOUS  SYSTEM 

year  (Osier),  In  nearly  all  these  instances  there  was  no  interruption  in  the 
convulsions.  J.  L.  Morse  regards  as  the  dangerous  forms  those  in  "which  the 
convulsions  occur  over  a  considerable  period  or  in  which  there  are  repeated 
attacks  suggesting  petit  mal. 

Symptoms. — The  attack  may  come  on  suddenly  without  any  warning ;  more 
commonly  it  is  preceded  by  restlessness,  twitchings  and  perhaps  grinding  of 
the  teeth.  The  convulsion  is  rarely  so  complete  in  its  stages  as  true  epilepsy. 
The  spasm  begins  usually  in  the  hands,  most  commonly  in  the  right  hand. 
The  eyes  are  fixed  and  staring  or  are  rolled  up.  The  body  becomes  stiff  and 
breathing  is  suspended  for  a  moment  or  two  by  tonic  spasm  of  the  respiratory 
muscles,  in  consequence  of  which  the  face  becomes  congested.  Clonic  convul- 
sions follow,  the  eyes  are  rolled  about,  the  hands  and  arms  twitch,  or  are  fixed 
and  extended  in  rhythmical  movements,  the  face  is  contorted,  and  the  head 
is  retracted.  The  attack  gradually  subsides  and  the  child  sleeps  or  passes  into 
a  state  of  stupor.  Following  indigestion  the  attack  may  be  single,  but  in 
rickets  and  intestinal  disorders  it  is  apt  to  be  repeated.  Sometimes  the  attacks 
follow  each  other  with  great  rapidity,  so  that  the  child  never  rouses  but  dies 
in  a  deep  coma.  If  the  convulsion  has  been  limited  chiefly  to  one  side  there 
may  be  slight  paresis  after  recovery,  or  if  the  convulsions  usher  in  infantile 
hemiplegia,  when  the  child  arouses,  one  side  is  completely  paralyzed.  During 
the  fit  the  temperature  is  often  raised.  Death  rarely  occurs  from  the  con- 
vulsion itself,  except  in  debilitated  children  or  when  the  attacks  recur  with 
great  frequency.  In  the  so-called  hydrocephaloid  state  in  connection  with 
protracted  diarrhoea  convulsions  may  close  the  scene. 

Diagnosis. — Coming  on  when  the  subject  is  in  full  health,  the  attack  is 
probably  due  either  to  an  overloaded  stomach,  to  some  peripheral  irritation,  or 
occasionally  to  trauma.  Setting  in  with  high  fever  and  vomiting,  it  may 
indicate  the  onset  of  an  exanthem,  or  occasionally  be  the  primary  symptom 
of  encephalitis,  or  whatever  the  condition  is  which  causes  infantile  hemiplegia. 
When  the  attack  is  associated  with  debility  and  with  rickets  the  diagnosis  is 
easily  made.  The  carpopedal  spasms  and  pseudo-paralytic  rigidity  which  are 
often  associated  with  rickets,  laryngismus  stridulus,  and  the  hydrocephaloid 
state  are  usually  confined  to  the  hands  and  arms  and  are  intermittent  and 
usually  tonic.  The  convulsions  associated  with  tumor  or  those  which  follow 
infantile  hemiplegia  are  usually  at  first  Jacksonian  in  character.  After  the 
second  year  convulsive  seizures  which  come  on  irregularly  without  apparent 
cause  and  recur  while  the  child  is  apparently  in  good  health,  are  likely  to 
prove  true  epilepsy. 

ProgTiosis. — Convulsions  play  an  important  part  in  infantile  mortality. 
In  chronic  diarrhoea  convulsions  are  usually  of  ill  omen.  Those  ushering  in 
fevers  are  rarely  serious,  and  the  same  may  be  said  of  the  fits  associated  .with 
indigestion  and  peripheral  irritation. 

Treatment. — Every  source  of  irritation  should  be  removed.  If  associated 
with  indigestible  food,  a  prompt  emetic  should  be  given,  followed  by  an  enema. 
The  teeth  should  be  examined,  and  if  the  gum  is  swollen,  hot,  and  tense,  it 
may  be  lanced ;  but  never  if  it  looks  normal.  When  seen  at  first,  if  the  parox- 
ysm is  severe,  no  time  should  be  lost  by  giving  a  hot  bath,  but  chloroform 
should  be  given  at  once,  and  repeated  if  necessary.  A  child  is  so  readily  put 
under  chloroform  and  with  such  a  small  quantity  that  this  procedure  is  quite 


EPILEPSY  1073 

harmless  and  saves  much  valuable  time.  The  practice  is  almost  universal  of 
putting  the  child  into  a  warm  bath,  and  if  there  is  a  fever  the  head  may  be 
douched  with  cold  water.  The  temperature  of  the  bath  should  not  be  above 
95°  or  96°.  The  very  hot  bath  is  not  suitable,  particularly  if  the  fits  are  due 
to  indigestion.  After  the  attack  an  ice-cap  may  be  placed  upon  the  head.  If 
there  is  much  irritability,  particularly  in  rickets  and  in  severe  diarrhoea,  small 
doses  of  opium  will  be  found  efficacious.  When  the  convulsions  recur  after 
the  child  comes  from  under  the  influence  of  chloroform  it  is  best  to  place  it 
rapidly  under  the  influence  of  opium,  which  may  be  given  as  morphia  hypo- 
dermically,  in  doses  of  gr.  1/25  to  1/30  (0.0026  to  0.0022  gm.)  for  a  child 
of  one  year.  Other  remedies  recommended  are  chloral  by  enema,  in  5  grain 
(0.3  gm.), doses,  and  nitrite  of  amyl.  After  the  attack  has  passed  the  bromides 
are  useful,  of  which  5  to  8  grains  (0.3  to  0.5  gm.)  may  be  given  in  a  day 
to  a  child  a  year  old.  Eecurring  convulsions,  particularly  if  they  come  on 
rt^ithout  special  cause,  should  receive  careful  treatment  with  bromides.  When 
associated  with  rickets  the  treatment  should  be  directed  to  improving  the  gen- 
eral condition. 

V.    EPILEPSY 

Definition. — An  affection  of  the  nervous  system  characterized  by  attacks 
of  unconsciousness,  with  or  without  convulsions.  The  transient  loss  of  con- 
sciousness without  convulsive  seizures  is  known  as  petit  mal;  the  loss  of  con- 
sciousness with  general  convulsive  seizures  is  known  as  gravid  mal.  Localized 
convulsions,  occurring  usually  without  loss  of  consciousness,  are  known  as 
epileptiform,  or  more  frequently  as  Jacksonian  or  cortical  epilepsy. 

Etiology,. — Idiopathic  or  essential  epilepsy,  the  form  with  an  luiknown  or 
indefinite  etiology,  appears  to  depend  upon  a  congenital  tendency  in  the  indi- 
vidual. Coarse  anatomical  changes  in  the  brain  are  not  present,  but  with  the 
development  of  technique  alterations  have  been  determined  in  an  increasing 
proportion  of  cases,  particularly  a  gliosis  of  the  superficial  layers  of  the  cortex 
described  by  Alzheimer.  Apart  from  this,  the  common  variety,  is  the  large 
group  of  symptomatic  epilepsies  due  to  toxemias,  tramna,  growths,  chronic 
infections  and  arterio-sclerosis. 

Age. — In  a  large  proportion  of  cases  the  disease  begins  before 
puberty.  Of  1,450  cases  observed  by  Gowers,  in  422  the  disease  began  be- 
fore the  tenth  year,  and  three-fourths  of  the  cases  began  before  the  twentieth 
year.  Of  427  cases  of  epilepsy  in  children,  the  age  of  onset  was  as  follows: 
First  year,  74;  second  year,  62;  third  year,  51;  fourth  year,  24;  fifth  year, 
17;  sixth  year,  18;  seventh  year,  19;  eighth  year,  23;  ninth  year,  17;  tenth 
year,  27;  eleventh  year,  17;  twelfth  year,  18;  thirteenth  year,  15;  fourteenth 
year,  21;  fifteenth  year,  34.  Arranged  in  hemidecades  the  figures  are  as 
follows:  From  the  first  to  the  fifth  year,  229;  from  the  fifth  to  the  tenth  year, 
104;  from  the  tenth  to  the  fifteenth  year,  95  (Osier).  These  figures  illustrate 
in  a  striking  manner  the  early  onset  in  a  large  proportion  of  cases.  It  is  well 
always  to  be  suspicious  of  "epilepsy"  beginning  in  adult  life,  for  in  a  ma- 
jority of  such  cases  the  convulsions  are  due  to  a  local  lesion. 

Sex. — ^No  special  influence  appears  to  be  discoverable,  certainly  not  in  chil- 
dren.    Of  435  cases,  232  were  males  and  303  were  females,  showing  a  slight 


1074  DISEASES  OF  THE  NEEVOUS  SYSTEM 

predominance  of  the  male  sex.  After  puberty  unquestionably,  if  a  large  num- 
ber of  cases  are  taken,  the  males  are  in  excess. 

Heredity. — Gowers  remarks  "there  are  few  diseases  in  the  production  of 
which  inheritance  has  a  more  marked  influence."  Of  2,523  epileptics,  16  per 
cent,  were  due  to  heredity  ( Spratling) .  The  study  of  the  American  Eugenics 
Bureau  (Bulletin  'No.  IV),  analyzing  the  data  of  206  epileptics,  shows  how 
potent  are  inherited  factors.  Pierce  Clark  considers  that  there  are  more  or 
less  definite  essential  defects  in  epileptics  which  account  in  part  for  the  pre- 
disposition. These  are  "egocentricity,  supersensitiveness,  an  emotional  pov- 
erty and  an  inherent  lack  of  adaptability  to  normal  social  life."  Stress  and 
annoyance,  and  an  intensive  regression  to  day-dreaming,  lethargy  and  somno- 
lence are  precipitating  factors.  "The  attack  occurs  at  the  final  break  of  a 
too  severe  tension." 

Chronic  alcoholism  in  the  parents  is  regarded  by  many  as  a  potent  pre- 
disposing factor.  Echeverria  analyzed  572  cases  bearing  upon  this  point  and 
divided  them  into  three  classes,  of  which  257  cases  could  be  traced  directly 
to  alcohol  as  a  cause;  126  cases  in  which  there  were  associated  conditions,  such 
as  syphilis  and  traumatism;  189  cases  in  which  the  alcoholism  was  probably 
the  result  of  the  epilepsy.  Figures  equally  strong  are  given  by  Martin,  who 
in  150  insane  epileptics  found  83  with  a  marked  history  of  parental  intem- 
perance. Spratling  found  15  per  cent,  with  marked  alcoholic  history  in  the 
parents. 

Syphilis. — This  in  the  parents  is  probably  less  a  predisposing  than  an 
actual  cause  of  epilepsy,  which  is  the  direct  outcome  of  local  cerebral  mani- 
festations. There  is  no  reason  for  recognizing  a  special  form  of  syphilitic 
epilepsy.  On  the  other  hand,  convulsive  seizures  due  to  acquired  syphilitic 
disease  of- the  brain  are  very  common. 

Alcohol. — Severe  epileptic  convulsions  may  occur  in  steady  drinkers. 

Of  exciting  causes  fright  is  believed  to  be  important,  but  probably  less  so 
than  is  usually  stated.  Trauma  is  present  in  a  certain  number  of  instances. 
An  important  group  depends  upon  a  local  disease  of  the  brain  existing  from 
childhood,  as  seen  in  the  post-hemiplegic  epilepsy.  Occasionally  cases  follow 
the  infectious  fevers.  Masturbation  is  stated  to  be  a  cause  but  its  influence 
is  probably  overrated.  A  large  group  of  convulsive  seizures  allied  to  epilepsy 
are  due  to  some  toxic  agent,  as  in  lead  poisoning  and  uraemia. 

Eeflex  Causes. — Eye  strain,  dentition,  and  worms,  the  irritation  of  a 
cicatrix,  some  local  afi^ection,  such  as  adherent  prepuce,  or  a  foreign  body  in 
the  ear  or  the  nose,  are  given  as  causes.  In  some  of  these  cases  the  fits  cease 
after  the  removal  of  the  cause,  so  that  there  can  be  no  question  of  the  associa- 
tion. In  others  the  attacks  persist.  Genuine  cases  of  reflex  epilepsy  are  rare. 
A  remarkable  instance  occurred  at  the  Philadelphia  Infirmary  for  Nervous 
Diseases,  in  a  man  with  a  testis  in  the  inguinal  canal,  pressure  upon  which 
would  cause  a  typical  fit.    Eemoval  of  the  organ  was  followed  by  cure. 

Cardio-vascular  "epilepsy"  is  usually  a  manifestation  of  advanced  arterio- 
sclerosis, and  is  associated  with  slow  pulse  (see  Stokes- Adams  Disease).  There 
may  be  palpitation  and  uneasy  sensations  about  the  heart  prior  to  the  attack. 
The  passage  of  a  gall-stone  or  the  removal  of  pleuritic  fluid  may  induce  a  fit. 
Gastric  troubles  are '  extremely  common  in  epilepsy,  and  the  eating  of  indi- 


EPILEPSY  1075 

gestible  articles  seems  often  to  precipitate  an  attack.  And  lastly,  epileptic 
seizures  may  occur  in  old  people  without  obvious  cause. 

Symptoms. — (a)  Grand  Mal. — Preceding  the  tits  there  is  usually  a  local- 
ized sensation,  known  as  an  aura,  in  some  part  of  the  body.  This  may  be 
somatic,  in  which  the  feeling  comes  from  some  particular  region  in  the  periph- 
ery, as  from  the  finger  or  hand,  or  is  a  sensation  felt  in  the  stomach  or  about 
the  heart.  The  peripheral  sensations  preceding  the  fit  are  of  great  value, 
particularly  those  in  which  the  aura  always  occurs  in  a  definite  region,  as  in 
one  finger  or  toe.  It  is  the  equivalent  of  the  signal  symptom  in  a  fit  from 
a  brain  tumor.  The  varieties  of  these  sensations  are  numerous.  The  epigas- 
tric sensations  are  most  common.  In  these  the  patient  complains  of  an  uneasy 
sensation  in  the  epigastrium  or  distress  in  the  intestines,  or  the  sensation  may 
not  be  unlike  that  of  heartburn  and  may  be  associated  with  palpitation. 
These  groups  are  sometimes  known  as  pneumogastric  aurge  or  warnings. 

Of  psychical  sluvsb  one  of  the  most  common,  as  described  by  Hughlings 
Jackson,  is  the  vague,  dreamy  state,  a  sensation  of  strangeness  or  sometimes 
of  terror.  The  aurae  may  be  associated  with  special  senses;  of  these  the  most 
common  are  the  visual,  consisting  of  flashes  of  light  or  sensations  of  color; 
less  commonly,  distinct  objects  are  seen.  The  auditory  aurae  consist  of  noises 
in  the  ear,  odd  sounds,  musical  tones,  or  occasionally  voices.  Olfactory  and 
gustatory  aurfe,  unpleasant  tastes  and  odors,  are  rare. 

Occasionally  the  fit  may  be  preceded  not  by  an  aura,  but  by  certain  move- 
ments ;  the  patient  may  turn  round  rapidly  or  run  with  great  speed  for  a  few 
minutes,  the  so-called  epilepsia  procursiva.  In  an  Elwyn  case  the  lad  stood 
on  his  toes  and  twirled  with  extraordinary  rapidity,  so  that  his  features  were 
scarcely  recognizable.  It  is  stated  that  the  pulse  sometimes  stops  just  before 
the  fit.  The  studies  of  Gibson  and  Good  show  that  no  alteration  in  the  pulse 
occurred  up  to  the  point  of  clonic  convulsions,  and  there  was  no  lowering  of 
the  blood  pressure  suggesting  ansemia  of  the  brain.  At  the  onset  of  the 
attack  the  patient  may  give  a  loud  scream  or  yell,  the  so-called  epileptic  cry. 
The  patient  drops  as  if  shot,  making  no  effort  to  guard  the  fall.  In  conse- 
quence, epileptics  frequently  injure  themselves,  cutting  the  face  or  head  or 
burning  themselves.  In  the  attack,  as  described  by  Hippocrates,  "the  patient 
loses  his  speech  and  chokes,  and  foam  issues  from  the  mouth,  the  teeth  are 
fixed,  the  hands  are  contracted,  the  eyes  distorted,  he  becomes  insensible,  and 
in  some  cases  the  bowels  are  affected.  And  these  symptoms  occur  sometimes 
on  the  left  side,  sometimes  on  the  right,  and  sometimes  on  both."  The  fit 
may  be  described  in  three  stages : 

(1)  Tonic  Spasm. — The  head  is  drawn  back  or  to  the  right,  and  the  jaws 
are  fixed.  The  hands  are  clinched  and  the  legs  extended.  This  tonic  contrac- 
tion affects  the  muscles  of  the  chest,  so  that  respiration  is  impeded  and  the 
initial  pallor  of  the  face  changes  to  a  dusky  or  livid  hue.  The  muscles  of 
the  two  sides  are  unequally  affected,  so  that  the  head  and  neck  are  rotated 
or  the  spine  is  twisted.  The  arms  are  usually  flexed  at  the  elbows,  the  hand 
at  the  wrist,  and  the  fingers  are  tightly  clinched  in  the  palm.  This  stage  lasts 
only  a  few  seconds,  and  then  the  clonic  stage  begins. 

(2)  Clonic  Stage. — The  muscular  contractions  become  intermittent;  at 
first  tremulous  or  vibratory,  they  gradually  become  more  rapid  and  the  limbs 
are  jerked  and  tossed  about  violently.    The  muscles  of  the  face  are  in  constant 


1076  DISEASES  OF  THE  NERVOUS  SYSTEM 

clonic  spasm,  the  eyes  roll,  the  eyelids  are  opened  and  closed  convulsively. 
The  movements  of  the  muscles  of  the  jaw  are  very  forcible  and  strong,  and 
at  this  time  the  tongue  is  apt  to  be  caught  between  the  teeth  and  lacerated. 
The  cyanosis,  marked  at  the  end  of  the  tonic  stage,  gradually  lessens.  A 
frothy  saliva,  which  may  be  blood  stained,  escapes  from  the  mouth.  The 
faeces  and  urine  may  be  discharged  involuntarily.  The  duration  of  this 
stage  is  variable.  It  rarely  lasts  more  than  one  or  two  minutes.  The  contrac- 
tions become  less  violent  and  the  patient  passes  into  the  condition  of  coma. 

(3)  Coma. — The  breathing  is  noisy  or  even  stertorous,  the  face  congested, 
but  no  longer  intensely  cyanotic.  The  limbs  are  relaxed  and  the  unconscious- 
ness is  profound.  After  a  variable  time  the  patient  can  be  aroused,  but  if 
left  alone  he  sleeps  for  some  hours  and  then  awakes,  complaining  only  of 
slight  headache  or  mental  confusion.  If  the  attack  has  been  severe,  petechial 
haemorrhages  may  be  scattered  over  the  neck  and  chest.  In  the  case  of  a 
young  man  in  good  health  in  a  severe  convulsion  both  subconjunctival  spaces 
were  entirely  filled  with  blood,  and  free  blood  oozed  from  them  (Walter 
James).     Haemoptysis  is  a  rare  sequel. 

(4)  Status  Epilepticus. — This  is  the  climax  of  the  disease,  in  which  attacks 
occur  in  rapid  succession,  and  the  patient  does  not  recover  consciousness.  The 
pulse,  respiration,  and  temperature  rise  in  the  attack.  It  is  a  serious  condi- 
tion, and  often  proves  fatal. 

After  the  attack  the  reflexes  are  sometimes  absent;  more  frequently  they 
are  increased  and  the  ankle  clonus  can  usually  be  obtained.  The  state  of  the 
urine  is  variable^  particularly  as  regards  the  solids.  The  quantity  is  usually 
increased  after  the  attack,  and  albumin  is  not  infrequently  present. 

(5)  Post-epileptic  symptoms  are  of  great  importance.  The  patient  may  be 
in  a  trance-like  condition,  in  which  he  performs  actions  of  which  subsequently 
he  has  no  recollection.  More  serious  are  the  attacks  of  mania,  in  which  the 
patient  is  often  dangerous  and  sometimes  homicidal.  It  is  held  by  some  that 
an  outbreak  of  mania  may  be  substituted  for  the  fit.  And,  lastly,  the  mental 
condition  of  an  epileptic  patient  is  often  seriously  impaired. 

(6)  Paralysis,  which  rarely  follows  the  epileptic  fit,  is  usually  hemiplegic 
and  transient.  Slight  disturbances  of  speech  may  occur;  in  some  instances, 
forms  of  sensory  aphasia.  Scripture  draws  attention  to  an  inflexibility  of 
speech  of  the  epileptic  which  sounds  "expressionless  or  wooden"  and  can  be 
recognized  by  a  trained  ear.  The  absence  of  flexibility  can  be  demonstrated 
by  graphic  records. 

The  attacks  may  occur  at  night,  and  a  person  may  be  epileptic  for  years 
without  know:"g  it.  As  Trousseau  truly  remarks,  when  a  person  tells  us  that 
in  the  night  he  has  incontinence  of  urine  and  awakes  in  the  morning  with 
headache  and  mental  confusion,  and  complains  of  difficulty  in  speech  owin^ 
to  the  fact  that  he  has  bitten  his  tongue,  if  also  there  are  purpuric  spots  on  the 
skin  of  the  face  and  neck,  the  probability  is  very  strong  indeed  that  he  is 
subject  to  nocturnal  epilepsy. 

(b)  Petit  Mal. — Epilepsy  without  the  convulsions  consists  of  transient 
unconsciousness,  which  may  come  on  at  any  time,  with  or  without  a  feeling 
of  faintness  and  vertigo.  Suddenly,  for  example,  at  the  dinner  table,  the  sub- 
ject stops  talking  and  eating,  the  eyes  become  fixed,  and  the  face  slightly 
pale.    Anything  which  may  have  been  in  the  hand  is  usually  dropped.     In  a 


EPILEPSY  1077 

moment  or  two  consciousness  is  regained  and  the  patient  resumes  conversation 
as  if  nothing  had  happened.  In  other  instances  there  is  slight  incoherency 
or  the  patient  performs  some  ahnost  automatic  action.  He  may  begin  to  un- 
dress himself  and  on  returning  to  consciousness  find  that  he  has  partially  dis- 
robed. He  may  rub  his  beard  or  face,  or  may  spit  about  in  a  careless  way. 
In  other  attacks  the  patient  may  fall  without  convulsive  seizures.  A  definite 
aura  is  rare.  Though  transient,  unconsciousness  and  giddiness  are  the  most 
constant  manifestations  of  petit  mal;  there  are  many  other  equivalent  mani- 
festations, such  as  sudden  jerkings  in  the  limbs,  sudden  tremor,  or  a  sudden 
visual  sensation.  Gowers  gave  no  less  than  seventeen  different  manifestations 
of  petit  mal.  Occasionally  there  are  cases  in  which  the  patient  has  a  sensa- 
tion of  losing  his  breath  and  may  even  get  red  in  the  face. 

After  the  attack  the  patient  may  be  dazed  for  a  few  seconds  and  perform 
certain  automatic  actions,  which  may  seem  to  be  volitional.  As  mentioned, 
undressing  is  a  common  action,  but  all  sorts  of  odd  actions  may  be  performed, 
some  of  which  are  awkward  or  even  serious.  One  patient  after  an  attack  was 
in  the  habit  of  tearing  anything  he  could  lay  hands  on,  particularly  books. 
Violent  actions  have  been  committed  and  assaults  made,  frequently  giving  rise 
to  questions  which  come  before  the  courts.  This  condition  has  been  termed 
masked  epilepsy,  or  epilepsia  larvata.  In  a  majority  of  the  cases  of  petit  mal 
convulsions  finally  occur,  at  first  slight,  but  ultimately  the  grand  mal  becomes 
well  developed,  and  the  attacks  may  then  alternate. 

(c)  Jacksonian  Epilepsy. — This  is  also  known  as  cortical,  symptomatic, 
or  partial  epilepsy.  It  is  distinguished  from  the  ordinary  epilepsy  by  the 
important  fact  that  consciousness  is  retained  or  is  lost  late.  The  attacks  are 
usually  the  result  of  irritative  lesions  in  the  motor  zone,  though  there  are 
probably  also  sensory  equivalents  of  this  motor  form.  In  a  typical  attack  the 
spasm  begins  in  a  limited  muscle  group  of  the  face,  arm,  or  leg.  The  zygo- 
matic muscles,  for  instance,  or  the  thumb  may  twitch,  or  the  toes  may  first 
be  moved.  Prior  to  the  twitching  the  patient  may  feel  a  sensation  of  numb- 
ness or  tingling  in  the  part  affected.  The  spasm  extends  and  may  involve  the 
muscles  of  one  limb  only  or  of  the  face.  The  patient  is  conscious  throughout 
and  watches,  often  with  interest,  the  march  of  the  spasm. 

The  onset  may  be  slow,  and  there  may  be  time  for  the  patient  to  place  a 
pillow  on  the  floor,  so  as  to  be  as  comfortable  as  possible  during  the  attack. 
The  spasms  may  be  localized  for  years,  but  there  is  a  great  risk  that  the  partial 
epilepsy  may  become  general.  The  condition  is  due,  as  a  rule,  to  an  irritative 
lesion  in  the  motor  zone.  Thus  of  107  cases  analyzed  by  Poland,  there  were 
48  of  tumor,  21  instances  of  inflammatory  softening,  14  instances  of  acute  and 
chronic  meningitis,  and  8  cases  of  trauma.  The  remaining  instances  were  due 
to  hgemorrhage  or  abscess,  or  were  associated  with  sclerosis  cerebri.  Two  other 
conditions  may  cause  typical  Jacksonian  epilepsy — uraemia  and  general  paresis. 
A  considerable  number  of  the  cases  of  Jacksonian  epilepsy  are  found  in  chil- 
dren following  hemiplegia,  the  so-called  post-hemiplegic  epilepsy.  The  convul- 
sions usually  begin  on  the  affected  side,  either  in  the  arm  or  leg,  and  the  fit 
may  be  unilateral  and  without  loss  of  consciousness.  Ultimately  they  become 
more  severe  and  general. 

Diagnosis". — In  major  epilepsy  the  suddenness  of  the  attack,  the  abrupt 
loss  of  consciousness,  the  order  of  the  tonic  and  clonic  spasm,  and  the  relaxation 


a078  DISEASES  OF  THE  NEEVOUS  SYSTEM 

of  the  sphincters  at  the  height  of  the  attack  are  distinctive  features.  The 
convulsive  seizures  due  to  uraemia  are  epileptic  in  character  and  usually  read- 
ily recognized  by  the  existence  of  greatly  increased  tension  and  the  condition 
of  the  urine.  Practically  in  young  adults  hysteria  causes  the  greatest  difficulty, 
and  may  closely  simulate  true  epilepsy.  A  careful  study  and  observation  of  an 
attack  usually  make  the  diagnosis  clear. 

Recurring  epileptic  seizures  in  a  person  over  thirty  who  has  not  had  pre- 
vious attacks  is  always  suggestive  of  organic  disease,  usually  syphilis. 

Petit  mal  must  be  distinguished  from  attacks  of  syncope,  and  the  vertigo 
of  Meniere's  disease,  of  a  cardiac  lesion,  and  of  indigestion.  In  these  cases 
there  is  no  actual  loss  of  consciousness,  which  forms  a  characteristic  though 
not  an  invariable  feature  of  petit  mal. 

Jacksonian  epilepsy  has  features  so  distinctive  and  peculiar  that  it  is  at 
once  recognized.  It  is,  however,  by  no  means  easy  always  to  determine  upon 
what  the  spasm  depends.  Irritation  in  the  motor  centres  may  be  due  to  a 
great  variety  of  causes,  among  which  tumors  and  localized  meningo-encepha- 
litis  are  the  most  frequent;  but  in  uremia  localized  epilepsy  may  occur.  The 
most  typical  Jacksonian  spasms  are  not  infrequent  in  general  paresis. 

Prognosis. — This  may  be  given  to-day  in  the  words  of  Hippocrates :  "The 
prognosis  in  epilepsy  is  unfavorable  when  the  disease  is  congenital,  and  when 
it  endures  to  manhood,  and  when  it  occurs  in  a  grown  person  without  any 
previous  cause.  .  .  .  The  cure  may  be  attempted  in  young  persons,  but  not 
in  old."  Of  cases  beginning  under  ten  years  few  are  arrested,  whereas  of  those 
beginning  at  puberty  the  opposite  is  true  (W.  A.  Turner). 

Death  during  the  fit  rarely  occurs,  but  it  may  happen  if  the  patient  falls 
into  water  or  if  the  fit  comes  on  while  he  is  eating.  Occasionally  the  fits 
stop  spontaneously.  This  is  particularly  the  case  in  the  epilepsy  in  children 
which  has  followed  the  convulsions  of  teething  or  of  the  fevers.  Frequency 
of  the  attacks  and  marked  mental  disturbance  are  unfavorable  indications. 
Hereditary  predisposition  is  apparently  of  no  moment  in  the  prognosis.  The 
outlook  is  better  in  males  than  in  females.  The  post-hemiplegic  epilepsy  is 
rarely  arrested.  Of  the  cases  coming  on  in  adults,  those  due  to  syphilis  and  to 
local  affections  of  the  brain  allow  a  more  favorable  prognosis. 

Treatment. — General. — In  the  case  of  children  the  parents  should  be 
made  to  understand  from  the  outset  that  epilepsy  in  the  great  majority  of 
cases  is  an  incurable  affection,  so  that  the  disease  may  interfere  as  little  as 
possible  with  the  education  of  the  child.  The  subjects  need  firm  but  kind 
treatment.  Indulgence  and  yielding  to  caprices  and  whims  are  followed  by 
weakening  of  the  moral  control,  which  is  so  necessary  in  these  cases.  The 
disease  does  not  incapacitate  a  person  for  all  occupation.  It  is  much  better 
for  epileptics  to  have  some  definite  pursuit.  The  individual  should  take  up 
an  out-of-door  occupation,  or  have  manual  training  suited  to  his  condition. 
This  is  best  done  in  an  institution  v/here  he  is  carefully  watched  and  studied. 
Psychoanalysis,  with  re-education,  over  a  prolono-ed  period  is  of  value  in  some 
patients.  There  are  many  instances  in  which  they  have  been  persons  of  ex- 
traordinary mental  and  bodily  vigor,  as,  for  example,  Julius  Ca?sar  and  Na- 
poleon. One  of  the  most  distressing  features  is  the  mental  impairment  which 
follows  in  a  certain  number  of  cases.  If  such  patients  become  extremely  ir- 
ritable or  show  signs  of  violence  they  should  be  placed  under  supervision  in  an 


EPILEPSY  1079 

institution.  Marriage  should  be  forbidden  to  epileptics.  During  the  attack 
a  cork  or  bit  of  rubber  should  be  placed  between  the  teeth  and  the  clothes 
should  be  loosened.  The  patient  should  be  in  the  recumbent  posture.  As  the 
attack  usually  passes  off  with  rapidity,  no  special  treatment  is  necessary,  but 
in  cases  in  which  the  convulsion  is  prolonged  a  few  whiffs  of  chloroform  or 
nitrite  of  amyl  or  a  hypodermic  of  a  quarter  of  a  grain  of  morphia  may  be 
given. 

Dietetic. — The  old  authors  laid  great  stress  upon  regimen  in  epilepsy, 
The  important  point  is  to  give  the  patient  a  light  diet  at  fixed  hours,  and 
on  no  account  to  permit  overloading  of  the  stomach.  Meat  should  not  be 
given  more  than  once  a  day.  There  are  cases  in  which  animal  food  seems 
injurious.  A  strict  vegetable  diet  is  sometimes  useful.  The  patient  should  not 
go  to  sleep  until  the  completion  of  gastric  digestion.  The  bowels  should  be 
kept  freely  open  and  colon  irrigations  are  useful. 

Medicinal. — The  bromides  have  been  extensively  used.  They  act  as  a 
motor  depressant  and  therefore  should  be  used  only  after  a  careful  study  of 
each  patient.  Sodium  bromide  is  probably  less  irritating  than  the  potassium 
salt  and  is  better  borne  for  a  long  period.  It  may  be  given  in  milk,  in  which 
it  is  scarcely  tasted.  In  all  instances  the  dilution  should  be  considerable.  The 
dose  for  an  adult  should  be  from  half  a  dram  to  a  dram  and  a  half  (2  to  6 
gm.)  daily.  The  diet  should  be  salt-free.  It  is  often  best  to  give  but  a  single 
dose  daily,  about  four  to  six  hours  before  the  attacks  are  most  likely  to  occur. 
For  instance,  in  the  case  of  nocturnal  epilepsy  a  dram  should  be  given  an 
hour  or  two  after  the  evening  meal.  If  the  attack  occurs  early  in  the  morning, 
the  patient  should  take  a  full  dose  when  he  awakes.  When  given  three  times 
a  day  it  is  less  disturbing  after  meals.  Each  case  should  be  carefully  studied 
to  determine  how  much  bromide  should  be  used.  The  individual  susceptibility 
varies  and  some  patients  require  more  than  others.  Fortunately,  children  take 
the  drug  well  and  stand  proportionately  larger  doses  than  adults.  Saturation 
is  indicated  by  certain  unpleasant  effects,  particularly  drowsiness,  mental  tor- 
por, and  gastric  and  cardiac  distress.  Loss  of  palate  reflex  is  one  of  the  earliest 
indications.  A  very  unpleasant  feature  is  the  development  of  acne,  which, 
however,  is  no  indication  of  bromism.  The  tendency  to  this  is  much  dimin- 
ished by  giving  the  drug  largely  diluted  in  alkaline  waters  and  administering 
arsenic  from  time  to  time.  Written  directions  should  be  given  to  the  mother 
or  to  the  friends  of  the  patient,  and  he  should  not  be  held  responsible  for  the 
administration  of  the  medicine.  The  addition  of  belladonna  to  the  bromide'is 
warmly  recommended  by  Black,  of  Glasgow.  Luminal  has  proved  useful  in 
some  cases,  beginning  with  doses  of  gr.  i  (0.065  gm.)  and  gradually  increased. 
In  very  obstinate  cases  Flechsig  uses  opium,  5  or  6  grains  (0.35  gm.),  in  three 
doses  daily;  then  at  the  end  of  six  weeks  opium  is  stopped  and  the  bromides 
in  large  amounts,  75  to  100  grains  (4  to  6  gm.)  daily,  are  used  for  two 
months. 

Among  other  remedies  recommended  are  chloral,  cannabis  indica,  and  nitro- 
glycerin. Nitroglycerin  is  sometimes  advantageous  in  petit  mal,  but  is  not  of 
much  service  in  the  major  form.  To  be  beneficial  it  must  be  given  in  full  doses, 
from  2  to  5  drops  of  the  1  per  cent,  solution,  and  increased  until  the  physiolog- 
ical effects  are  produced.  Calcium  lactate  in  20  grain  (1.3  gm.)  doses  daily 
has  been  recommended.    Counter-irritation  is  rarely  advisable.    When  the  aura 


1080  DISEASES  OF  THE  NERVOUS  SYSTEM 

is  very  definite  and  •constant  in  its  onset,  as  from  the  hand  or  from  the  toe, 
a  blister  about  the  part  or  a  ligature  tightly  applied  may  stop  the  oncoming  fit. 
In  children,  care  should  be  taken  that  there  is  no  source  of  peripheral  irrita- 
tion.   In  boys,  an  adherent  prepuce  may  occasionally  be  the  cause. 

The  subjects  of  a  chronic  and,  in  most  cases,  a  hopelessly  incurable  dis- 
ease, epileptic  patients  form.no  small  portion  of  the  unfortunate  victims  of 
charlatans  and  quacks,  who  prescribe  to-day,  as  in  the  time  of  the  father  of 
medicine,  "purifications  and  spells  and  other  illiberal  practices  of  like  kind." 

Surgical. — In  Jacksonian  epilepsy  the  propriety  of  surgical  interference 
is  universally  granted.  It  is  questionable,  however,  whether  in  the  epilepsy 
following  hemiplegia,  considering  the  anatomical  condition,  it  is  likely  to  be 
of  any  benefit.  In  idiopathic  epilepsy,  when  the  fit  starts  in  a  certain  region 
— the  thumb,  for  instance — and  the  signal  symptom  is  invariable,  the  centre 
controlling  this  part  may  be  removed.  Operation  in  the  traumatic  epilepsy,  in 
which  the  fit  follows  fracture,  is  much  more  hopeful. 

The  operation,  per  se,  appears  in  some  cases  to  have  a  curative  effect. 
The  operations  have  not  been  always  on  the  skull,  and  White  collected  an  in- 
teresting series  in  which  various  surgical  procedures  have  been  resorted  to, 
often  with  curative  effect,  such  as  ligation  of  the  carotid  artery,  castration, 
excision  of  the  superior  cervical  ganglia,  incision  of  the  scalp,  circumcision,  etc. 

VI.     MIGRAINE 

(Hemicrama;  Sick  Headache) 

Definition. — A  paroxysmal  affection  characterized  by  severe  headache,  usu- 
ally unilateral,  and  often  associated  with  disorders  of  vision. 

Etiologfy. — Heredity  plays  an  important  role  in  90  per  cent,  of  cases 
according  to  Mobius.  Women  and  members  of  neurotic  families  are  most 
frequently  attacked.  Many  distinguished  men  have  been  its  victims,  and 
the  astronomer  Airy  gave  a  classical  account  of  his  case.  The  nature  of  the 
disease  is  imknown,  and  many  views  have  been  entertained : 

(a)  That  it  is  a  toxsemia  from  disorder  of  the  intestinal  digestion  or  from 
some  self -manufactured  poison. 

(&)  That  it  is  a  vasomotor  affection  with  spasm  of  the  arteries,  in  favor 
of  which  are  the  facts  that  in  the  attack  the  temporal  arteries  on  the  affected 
side  may  be  felt  to  be  small,  the  retinal  arteries  may  sometimes  be  seen  in 
spasm,  and  sclerosis  of  the  arteries  on  the  same  side  is  found  in  a  certain 
number  of  cases  of  hemicrania.  A  still  more  striking  confirmation  is  the 
temporary  paralysis  which  may  be  associated  with  an  attack  of  monoplegic 
or  hemiplegic  character.  Mitchell  Clarke  has  reported  a  history  of  recurring 
motor  paralysis  in  eleven  members  in  three  generations  of  the  same  family. 
The  characteristic  visual  phenomena  preceded  the  unilateral  headache,  espe- 
cially the  hemiopia.  In  most  of  the  attacks  the  hemiplegia  was  on  the  right 
side.  It  lasted  from  a  few  hours  to  a  day  and  disappeared  completely,  leaving 
no  damage.  It  is  difficult  to  explain  such  cases  except  on  the  view  of  a  tran- 
sient spasm  of  the  arteries. 

(c)   Others  regard  the  affection  as  of  reflex  origin  arising  from  a  refracti^ 
error  in  the  eyes,  or  from  troubles  in  the  nose  or  sexual  organs.  < 


i 


MIGRAINE  1081 

(d)  The  disease  has  been  attributed  to  transient  plugging  of  the  foramen 
of  Monro  with  increased  pressure  in  the  ventricles  (Spitzner). 

The  majority  of  cases  begin  in  young  adults,  but  Sinclair  refers  to  a  case  in 
a  child  of  two  years.  Many  circumstances  bring  on  the  attack :  a  powerful  emo- 
tion of  any  sort,  mental  or  bodily  fatigue,  digestive  disturbances,  or  the  eat- 
ing of  some  particular  article  of  food.  The  paroxysmal  character  is  one  of 
the  most  striking  features  of  the  attacks  which  may  occur  on  the  same  day 
every  week,  every  fortnight,  or  every  month.  Headaches  of  the  migraine 
type  mav  occur  for  years  in  connection  with  chronic  nephritis,  and  it  is  well 
to  rememl)er  that  attacks  may  occur  in  connection  with  tumors  and  other 
lesions  of  the  base  of  the  brain. 

Symptoms. — Premonitory  signs  are  present  in  many  cases,  and  the  patient 
can  tell  when  an  attack  is  coming  on.  Eemarkable  prodromata  have  been 
described,  particularly  in  connection  with  vision.  Apparitions  may  appear — 
visions  of  animals,  such  as  mice,  dogs,  etc.  Transient  hemianopia  or  scotoma 
may  be  present.  In  other  instances  there  is  spasmodic  action  of  the  pupil  on 
the  affected  side,  which  dilates  and  contracts  alternately,  the  condition  known 
as  Jiippus.  Frequently  the  disturbance  of  vision  is  only  a  blurring,  or  there 
are  balls  of  light,  or  zigzag  lines,  or  the  so-called  fortification  spectra  (teichop- 
sia),  which  may  be  illuminated  with  gorgeous  colors.  Disturbances  of  the 
other  senses  are  rare.  Kumbness  of  the  tongue  and  face  and  occasionally  of 
the  hand  may  occur  with  tingling.  More  rarely  there  are  cramps  or  spasms 
in  the  muscles  of  the  affected  side.  Transient  aphasia  may  occur  and  be  in- 
termittent. The  paralysis  may  be  (1)  of  cerebral  origin — hemiplegia  or 
aphasia,  or  (2)  due  to  lesions  of  cranial  nerves — optic  nerve  and  ophthalmo- 
plegias; the  oculomotor  most  often,  abducens  rarely,  trochlearis  very  rarely. 
The  supposed  involvement  of  the  facial  is  relapsing  facial -palsy  in  migraine 
(Eamsay  Himt).  Some  patients  show  marked  psychical  disturbance,  either 
excitement  or,  more  commonly,  mental  confusion  or  great  depression.  Dizzi- 
ness occurs  in  some  cases.  The  headache  follows  a  short  time  after  the 
prodromal  symptoms  have  appeared.  It  is  cumulative  and  expansile  in  char- 
acter, beginning  as  a  localized  small  spot,  which  is  generally  constant  either 
on  the  temple  or  forehead  or  in  the  eyeball.  It  is  usually  described  as  of  a 
penetrating,  sharp,  boring  character.  The  pain  gradually  spreads  and  in- 
volves the  entire  side  of  the  head,  sometimes  the  neck,  and  may  pass  into  the 
arm.  In  some  cases  both  sides  are  affected.  Nausea  and  vomiting  are  com- 
mon and  if  the  attack  comes  on  when  the  stomach  is  full  vomiting  usually 
gives  relief.  Vasomotor  symptoms  may  be  present.  The  face  may  be  pale, 
and  there  may  be  a  marked  difference  between  the  two  sides.  Subsequently  the 
face  and  ear  on  the  affected  side  may  become  a  burning  red  from  the  vaso- 
dilator influences.  The  pulse  may  be  slow.  The  temporal  artery  on  the 
affected  side  may  be  firm  and  hard,  and  in  a  condition  of  arterio-sclerosis — 
a  fact  confirmed  anatomically  by  Thoma.  Few  affections  are  more  prostrating 
and  during  the  paroxysm  the  patient  may  scarcely  be  able  to  raise  the  head 
from  the  pillow.    The  slightest  noise  or  light  aggravates  the  condition. 

The  duration  of  the  attack  is  variable.     The  severer  forms  usually  in- 

capacHate  the  patient  for  at  least  three  days.     In  other  instances  the  entire 

ttack  is  over  in  a  day.     The  disease  recurs  for  years,  and  in  cases  with  a 

marked  hereditary  tendency  may  persist  throughout  life.     In   women   the 


1D82  DISEASES  OF  THE  NERVOUS  SYSTEM 

attacks  often  cease  after  the  climacteric,  and  in  men  after  the  age  of  fifty, 
Treatment. — The  patient  is  usually  aware  of  the  causes  which  precipitate 
an  attack.  Avoidance  of  excitement,  regularity  in  the  meals,  and  moderation 
in  diet  are  important  rules.  Some  patients  are  benefited  by  a  strict  vegetable 
diet.  The  treatment  should  be  directed  toward  the  removal  of  the  conditions 
upon  which  the  attacks  depend.  In  children  much  may  be  done  by  watchful- 
ness and  care  on  the  part  of  the  mother  in  regulating  the  bowels  and  watch- 
ing the  diet.  Errors  of  refraction  should  be  adjusted.  On  no  account  should 
'  such  children  be  allowed  to  compete  in  school  for  prizes.  A  prolonged  course, 
of  bromides  sometimes  proves  successful.  If  anaemia  is  present,  iron  and 
arsenic  should  be  given.  When  the  arterial  tension  is  increased  a  course  of 
nitroglycerin  may  be  tried.  Not  too  much,  however,  should  be  expected  from 
preventive  treatment  as  in  a  large  proportion  of  cases  the  headaches  recur  in 
spite  of  all  we  (including  the  refractionists)  can  do.  Lavage  of  the  stomach 
with  water  at  105°,  a  brisk  saline  cathartic  and  irrigation  of  the  colon  with 
hot  saline  solution  are  sometimes  of  value  at  the  onset.  Alkaline  water 
should  be  taken  freely  by  mouth.  During  the  paroxysm  the  patient  should 
be  kept  in  bed  and  absolutely  quiet.  If  the  patient  feels  faint  and  nause- 
ated a  small  cup  of  strong  coffee  may  give  relief.  A  prolonged  course  of 
cannabis  indica  may  be  tried.  Antipyrin,  antifebrin,  and  phenacetin  have 
been  much  used.  When  given  early,  at  the  very  outset  of  the  paroxysm,  they 
are  sometimes  effective.  Small,  repeated  doses  are  more  satisfactory.  Of 
other  remedies,  caffein,  in  5-grain  doses  of  the  citrate,  nux  vomica,  and  ergot 
have  been  recommended.  Electricity  does  not  appear  to  be  of  much  service. 
Ophthalmopleg^  Mi^siine. — This  term  was  applied  by  Charcot  to  a  special 
form  in  which  there  is  weakenss  or  paralysis  of  one  or  more  eye  muscles,  with 
or  after  a  migraine  attack.  The  oculo-motor  nerve  is  usually  involved. 
Ptosis,  loss  of  certain  movements,  and  double  vision  are  the  common  features, 
which  may  persist  for  some  days.  Local  causes,  especially  syphilis,  should  be 
excluded  before  the  diagnosis  is  established.  The  treatment  is  the  same  as 
for  migraine. 

Vn.     NEURALGIA 

Definitionj — A  painful  affection  of  the  nerves,  due  to  functional  disturb- 
ance of  their  central  or  peripheral  extremities  or  to  neuritis  in  their  course. 

Etiology. — Members  of  neuropathic  families  are  most  subject  to  the 
disease.  It  affects  women  more  than  men.  Children  are  rarely  attacked.  Of 
all  causes  debility  is  the  most  frequent.  It  is  often  the  first  indication  of  an 
enfeebled  nervous  system.  The  various  forms  of  anaemia  are  frequently  asso- 
ciated with  neuralgia.  It  may  be  a  prominent  feature  at  the  onset  of  certain 
acute  diseases,  particularly  typhoid  fever.  It  has  not  been  shown  that  neu- 
ralgia is  more  frequent  in  malarial  districts,  but  it  occasionally  occurs  in  ma- 
larial cachexia.  Exposure  to  cold  is  a  cause  in  very  susceptible  persons. 
Eeflex  irritation,  particularly  from  carious  teeth,  and  disease  of  the  antrum 
and  frontal  sinuses  are  common  causes  of  neuralgia  of  the  fifth  nerve.  The 
disease  occurs  sometimes  in  gout,  lead  poisoning,  and  diabetes.  Persistent 
neuralgia  may  be  a  feature  of  latent  nephritis. 

Symptoms. — Before  the  onset  of  the  pain  there  may  be  uneasy  sensations. 


NEUEALGIA  1083 

sometimes  tingling  in  the  part  which  will  be  affected.  The  pain  is  localized 
to  a  certain  group  or  division  of  nerves,  usually  affecting  one  side.  The  pain 
is  not  constant,  but  paroxysmal,  and  is  described  as  stabbing,  burning,  or 
darting  in  character.  The  skin  may  be  exquisitely  tender  in  the  affected 
region,  particularly  over  certain  points  along  the  course  of  the  nerve,  the 
so-called  tender  points.  Movements,  as  a  rule,  are  painful.  Trophic  and 
vaso-motor  changes  may  accompany  the  paroxysm;  the  skin  may  be  cool,  and 
subsequently  hot  and  burning;  occasionally  local  oedema  or  erythema  occurs. 
More  remarkable  still  are  the  changes  in  the  hair,  which  may  become  blanched 
(canities),  or  even  fall  out.  Fortunately,  such  alterations  are  rare.  Twitch- 
ings  of  the  muscles,  or  even  spasms,  may  be  present  during  the  paroxysm. 
After  lasting  a  variable  time — from  a  few  minutes  to  many  hours — the  attack 
subsides.  Eecurrence  may  be  at  definite  intervals — every  day  at  the  same 
hour,  or  at  intervals  of  two,  three,  or  even  seven  days.  Occasionally  the  parox- 
ysms develop  only  at  the  catamenia.  This  periodicity  is  quite  as  marked  in 
non-malarial  as  in  malarial  regions. 

CLINICAL    VARIETIES,    DEPENDING    ON    THE    NERVE    ROOTS    AFFECTED 

Trigeminal  Neuralgia;  Tic  Douloureux. — A  distinction  must  be  drawn 
between  the  minor  and  major  neuralgias  of  the  fifth  cranial  nerve.  The  former 
may  merely  be  symptomatic  of  the  involvement  of  one  or  another  of  its  periph- 
eral branches  in  some  disease  process — the  pressure  of  a  tumor,  carious  teeth, 
or  a  neuritis  due  to  the  proximity  of  suppurative  processes  in  the  bony  sinuses, 
etc.  There  may  be  referred  neuralgic  pains  in  this  area  from  morbid  processes 
within  the  cranium,  or  from  visceral  disease  elsewhere.  A  painful  neuralgia 
may  follow  an  attack  of  zoster  in  any  division  of  the  fifth  nerve. 

The  major  trigeminal  neuralgia  is  a  primary  affection  of  the  Gasserian 
ganglion.  The  designation  tic  is  not  descriptive;  there  is  usually  immobility.. 
The  sex  incidence  is  about  equal ;  the  majority  of  cases  begin  between  the  ages 
of  forty  and  sixty.  No  definite  etiological  factor  is  evident.  The  right  side  is 
involved  in  about  two-thirds  of  the  cases.  Patrick's  figures  show  that  the  sec- 
ond and  the  third  branches  are  involved  more  often  than  the  first.  It  begins 
most  often  in  the  second  branch  and  later  two  or  all  three  branches  may  be 
involved.  The  pain  is  of  sudden  onset,  usually  excruciating  and  in  paroxysms, 
which  may  recur,  usually  not  lasting  longer  than  two  minutes.  The  attacks 
are  excited  by  any  external  irritation  which  may  be  very  slight,  such  as  a 
draught  of  air,  touching  the  skin,  and  the  movements  in  speaking,  eating 
or  swallowing.  The  areas  over  which  irritation  excites  the  pain  are  termed 
doloro-genetic  or  "trigger"  zones.  These  do  not  always  correspond  to  the  pain 
zone.  The  pain  may  radiate  into  the  cervical  nerves  or  down  the  arms.  The 
attacks  tend  to  be  of  increasing  severity  and  in  advanced  cases  the  paroxysms 
may  recur  at  short  intervals  in  steady  succession. 

The  diagnosis  is  rarely  in  doul)t  but  minor  forms  should  not  be  mistaken 
for  the  major.  The  pain  is  paroxysmal,  so  that  a  steady  pain  about  the  face 
is  probably  not  trifacial  neuralgia.  If  the  area  has  been  rubbed  or  massaged, 
or  the  patient  touches  it  to  show  where  the  pain  is,  the  disease  is  probably  not 


1084  DISEASES  OF  THE  NERVOUS  SYSTEM 

the  major  form.  The  disease  may  be  remittent  but  tends  to  progress  and  in- 
crease in  severity  so  that  the  patient's  life  is  almost  insufferable. 

Cervico-occipital  neuralgia  involves  the  posterior  branches  of  the  first 
four  cervical  nerves,  particularly  the  inferior  occipital,  at  the  emergence  of 
which  there  is  a  painful  point  about  half-way  between  the  mastoid  process  and 
the  first  cervical  vertebra.  It  may  be  caused  by  cold,  or  be  due  to  cervical 
caries.     Surgical  measures  may  be  required  if  the  pain  is  severe. 

Cervico-bracliial  neuralgia  involves  the  sensory  nerves  of  the  brachial 
plexus,  particularly  in  the  cubital  division.  When  the  circumflex  nerve  is  in- 
volved the  pain  is  in  the  deltoid.  The  pain  is  most  commonly  about  the 
shoulder  and  down  the  course  of  the  ulnar  nerve.  There  is  usually  a  marked 
tender  point  upon  this  nerve  at  the  elbow.  This  form  rarely  follows  cold, 
but  more  frequently  results  from  arthritis  and  trauma. 

Neuralgia  of  the  phrenic  nerve  is  rare.  It  is  sometimes  found  in  pleurisy 
and  in  pericarditis.  The  pain  is  chiefly  at  the  lower  part  of  the  thorax  on  a 
line  with  the  insertion  of  the  diaphragm,  and  here  may  be  painful  points  on 
deep  pressure.  Full  inspiration  is  painful,  and  there  is  great  sensitiveness  on 
coughing  or  any  movement  by  which  the  diaphragm  is  suddenly  depressed. 

Intercostal  Neuralgia. — This  is  most  frequent  in  Avomen  and  common  in 
hysteria.  Post-zoster  neuralgias  are  common  in  this  situation.  The  possi- 
bility of  spinal  disease,  of  tumor,  spondylitis,  caries,  or  aneurism  must  be 
borne  in  mind. 

lumbar  Neuralgia. — The  posterior  fibres  of  the  lumbar  plexus,  particu- 
larly the  ilio-scrotal  branch,  are  affected.  The  pain  is  in  the  region  of  the 
iliac  crest,  along  the  inguinal  canal,  in  the  spermatic  cord,  and  in  the  scrotum 
or  labium  majus.  The  affection  known  as  irritable  testis,  probably  a  neuralgia 
of  this  nerve,  may  be  severe  and  accompanied  by  syncopal  sensations. 

Coccydynia, — This  is  regarded  as  a  neuralgia  of  the  coccygeal  plexus. 
It  is  most  common  in  women,  and  is  aggravated  by  the  sitting  posture.  It 
is  very  intractable,  and  may  necessitate  the  removal  of  the  coccyx,  an  operation, 
however,  which  is  not  always  successful. 

Neuralgias  of  the  Nerves  of  the  Feet. — Many  of  these  cases  accompany 
varying  degrees  of  fiat-foot.  The  condition  is  brought  about  by  weakness  or 
fatigue  of  the  muscles  supporting  the  arches  of  the  foot,  which  consequently 
settle  until  the  strain  of  the  superimposed  body-weight  falls  upon  the  liga- 
mentous and  aponeurotic  attachments  between  the  metatarsal  and  tarsal  bones. 
Eest,  massage,  exercises,  and  orthopedic  measures  are  indicated. 

Painpul  Heel. — Both  in  women  and  men  there  may  be  about  the  heel 
severe  pains  which  interfere  seriously  with  walking — the  pododynia  of  S.  D. 
Gross.  There  may  be  little  or  no  swelling,  no  discoloration,  and  no  arthritis. 
Some  cases  follow  a  gonococcus  infection  and  are  due  to  a  bony  spur. 

Plantar  Neuralgia. — This  is  often  associated  with  a  definite  neuritis, 
such  as  follows  typhoid  fever,  and  has  been  seen  in  an  aggravated  form  in 
caisson  disease  (Hughes).  The  pain  may  be  limited  to  the  tips  of  the  toes 
or  to  the  ball  of  the  great  toe.  Numbness,  tingling,  and  hyperesthesia  or 
sweating  may  occur  with  it.  In  typhoid  fever  it  is  not  uncommon  for  patients 
to  complain  of  great  sensitiveness  in  the  toes. 

Metatarsalgia. — Thomas  G.  Morton's  "painful  affection  of  the  'fourth 


NEUEALGIA  1085 

metatarso-ijhalaugeal  articulation"  is  a  peculiar  and  very  trying  disorder,  seen 
most  frequently  in  women,  and  usually  in  one  foot.  Morton  regards  it  as  due 
to  a  pinching  of  the  metatarsal  nerve.  The  condition  usually  requires  oper- 
ation. The  red,  painful  neuralgia — erythromelalgia — is  described  under  the 
vaso-motor  and  trophic  disturbances. 

Causalgia  {Thermalgia). — A  form  of  neuralgia  following  gunshot 
wounds,  most  frequently  of  the  median  and  of  the  sciatic  branches,  character- 
ized by  burning  pains  of  the  greatest  intensity,  glossy  skin,  vaso-motor  dis- 
turbances, and  at  last  a  condition  of  general  hyperaesthesia  and  nervousness 
that  makes  life  unbearable.  Nothing  has  been  added  to  Weir  Mitchell's  classi- 
cal description  (1864),  and  later  he  gave  the  above  name  from  the  Greek 
words  for  burning  and  pain.  Many  cases  have  been  seen  in  the  late  war,  and 
Stopford  has  suggested  the  name  thermalgia.  An  explanation  of  causalgia  is 
difficult.  The  median  and  post-tibial  nerves  have  a  large  number  of  vaso- 
motor fibres,  interference  with  which  may  cause  the  peculiar  character  of  the 
pain;  indeed,  it  has  been  suggested  that  the  pain  is  caused  by  irritation  of  the 
peri-arterial  sympathetic  fibres  and  not  by  the  wound  of  the  nerve  itself. 
Anatomically  partial  division  and  intra-neural  fibrosis  are  present,  but  these 
are  found  in  scores  of  cases  in  which  causalgia  is  not  present. 

Visceral  Neuralgias. — The  more  important  of  these  have  been  noted  in 
connection  with  the  cardiac  and  the  gastric  neuroses.  They  are  most  frequent 
in  women,  often  with  neurasthenia  and  hysteria.  The  pains  are  common  in  the 
pelvic  region,  particularly  about  the  ovaries.  Nephralgia  is  of  great  interest, 
as  the  symptoms  may  closely  simulate  those  of  stone. 

TREATMENT  OF  NEURALGIA 

Causes  of  reflex  irritation  should  be  carefully  removed.  The  neuralgia,  as 
a  rule,  recurs  unless  the  general  health  improves;  so  that  tonic  and  hygienic 
measures  of  all  sorts  should  be  employed.  Often  a  change  of  air  or  surround- 
ings will  relieve  a  severe  neuralgia.  Obstinate  cases  may  be  cured  by  a  pro- 
longed residence  in  the  mountains,  with  an  out-of-door  life  and  plenty  of 
exercise.  A  strict  vegetable  diet  will  sometimes  relieve  the  neuralgia  or  head- 
ache of  a  gouty  person.  Of  general  remedies,  iron  is  often  a  specific  in  the 
cases  associated  with  chlorosis  and  anemia.  Arsenic,  too,  is  very  beneficial 
in  these  forms,  and  should  be  given  in  ascending  doses.  The  value  of  quinine 
has  been  much  overrated.  It  probably  has  no  more  influence  than  any  other 
bitter  tonic,  except  in  the  rare  instances  in  which  the  neuralgia  is  definitely  as- 
sociated with  malaria.  Strychnine,  cod-liver  oil,  and  phosphorus  are  advan- 
tageous. Of  remedies  for  the  pain,  antipyrin,  antifebrin,  phenacetin  and 
acetyl-salicylic  acid  should  first  be  tried,  for  they  are  sometimes  of  service. 
Morphia  should  be  given  with  great  caution,  and  only  after  other  remedies 
have  been  tried  in  vain.  On  no  consideration  should  the  patient  be  allowed 
to  use  the  hypodermic  syringe.  Gelsemium  is  highly  recommended.  Of  nerve 
stimulants,  valerian  and  ether,  which  often  act  well  together,  may  be  giyen. 
In  the  minor  form  of  trigeminal  neuralgia  nitroglycerin  in  large  doses  may 
be  tried.  Dana  has  seen  good  results  follow  rest  with  large  doses  of  strychnia 
given  hypodermically.  Aconitin  in  doses  of  one  two-hundredth  of  a  orain 
(0.00032  gm.)  may  be  tried.    Diathermy  may  be  useful. 


1086  DISEASES  OF  THE  NERVOUS  SYSTEM 

,  Of  local  applications,  the  thermo-cautery  is  invaluable,  particularly  in  zona 
and  the  more  chronic  forms  of  neuralgia.  Acupuncture  may  be  used.  Chloro- 
form liniment,  camphor  and  chloral,  menthol,  the  oleates  of  morphia,  atropia, 
and  belladonna  used  with  lanolin  may  be  tried.  Freezing  over  the  tender  point 
with  ether  spray  is  sometimes  successful.  The  continuous  current  may  be 
used.  The  sponges  should  be  warm,  and  the  positive  pole  should  be  placed 
near  the  seat  of  the  pain.  The  strength  of  the  current  should  be  such  as  to 
cause  a  slight  tingling  or  burning,  but  not  pain. 

For  trigeminal  neuralgia  there  are  two  successful  measures,  (1)  injection 
of  alcohol  into  the  branch,  the  trunk  or  the  ganglion  itself,  often  satisfactory 
in  skilled  hands;  and  (2)  removal  of  the  ganglion.  Cushing"s  results  show 
the  remarkable  benefit  which  may  result. 


VIII.     PROFESSIONAL  SPASMS;  OCCUPATION  NEUROSES 

The  continuous  and  excessive  use  of  the  muscles  in  performing  a  certain 
movement  may  be  followed  by  an  irregular,  involuntary  spasm  or  cramp,  which 
may  completely  check  the  performance  of  the  action.  The  condition  is  found 
most  frequently  in  writers,  hence  the  term  writer's  cramp  or  scrivener's  palsy ; 
but  it  is  also  common  in  piano  and  violin  players  and  in  telegraph  operators. 
The  spasms  occur  in  many  other  persons,  such  as  milkmaids,  weavers,  and 
cigarette-rollers. 

The  most  common  form  is  wnter's  cramp,  which  is  much  more  frequent 
in  men  than  in  women.  Of  75  cases  of  impaired  writing  power  reported  by 
Poore,  all  of  the  instances  of  undoubted  writer's  cramp  were  in  men.  An 
investigation  by  Thompson  and  Sinclair  into  telegraphist  cramp  in  England 
shows  that  the  disease  is  rare,  only  13  cases  among  between  7,000  and  8,000 
employees.  Persons  of  a  nervous  temperament  are  more  liable  to  the  disease. 
Occasionally  it  follows  slight  injury.  In  a  majority  of  the  cases  a  faulty 
method  of  writing  has  been  employed,  using  either  the  little  finger  or  the  wrist 
as  the  fixed  point.  Persons  who  write  with  the  middle  of  the  forearm  or  the 
elbow  as  the  fixed  point  are  rarely  afl^ected. 

No  anatomical  changes  have  been  found.  The.  most  reasonable  explanation 
of  the  disease  is  that  it  results  from  a  deranged  action  of 'the  nerve  centres 
presiding  over  the  muscular  movements  involved  in  the  act  of  writing,  a  con- 
dition which  has  been  termed  irritable  weakness. 

Symptoms. — These  may  be  described  under  five  heads  (Lewis). 

(ft)  Cramp  or  Spasm. — This  is  often  an  early  symptom  and  most  com- 
monly affects  the  forefinger  and  thumb;  or  there  may  be  a  combined  move- 
ment of  flexion  and  adduction  of  the  thumb,  so  that  the  pen  may  be  twisted 
from  the  grasp  and  thrown  to  some  distance.  Weir  Mitchell  described  a  lock- 
spasm,  in  which  the  .fingers  become  so  firmly  contracted  upon  the  pen  that  it 
can  not  be  removed. 

[h]  Paresis  and  Paralysis. — This  may  occur  with  the  spasm  or  alone. 
The  patient  feels  a  sense  of  weakness  and  debility  in  the  muscles  of  the 
hand  and  arm  and  holds  the  pen  feebly.  Yet  the  grasp  of  the  hand  may 
be  strong  and  there  may  be  no  paralysis  for  ordinary  acts. 


HYSTERIA  1087 

(c)  Teemor. — This  is  most  commonly  seen  in  the  forefinger  and  may  be 
a  premonitory  symptom  of  atrophy.  It  is  not  an  important  symptom,  and  is 
rarely  sufficient  to  produce  disability. 

(d)  Pain. — Abnormal  sensations,  particularly  a  tired  feeling  in  the  mus- 
cles, are  very  constantly  present.  Actual  pain  is  rare,  but  there  may  be  irregu- 
lar shooting  pains  in  the  arm.  Numbness  or  soreness  may  exist.  If,  as  some- 
times happens,  a  subacute  neuritis  develops,  there  may  be  pain  over  the  nerves 
and  numbness  or  tingling  in  the  fingers. 

(e)  Vaso-motor  Disturbances. — These  may  occur  in  severe  cases.  There 
may  be  hyperaesthesia.  Occasionally  the  skin  becomes  glossy,  or  there  is  a 
condition  of  local  asphyxia  resembling  chilblains.  In  attempting  to  write,  the 
hand  and  arm  may  become  flushed  and  the  veins  increased  in  size.  Early  the 
electrical  reactions  are  normal,  but  in  advanced  cases  there  may  be  diminution 
of  faradic  and  sometimes  increase  in  the  galvanic  irritability. 

Diagnosis. — A  well  marked  case  of  writer's  cramp  or  palsy  could  scarcely 
be  mistaken  for  any  other  affection.  Care  must  be  taken  to  exclude  the  exist- 
ence of  any  cerebro-spinal  disease,  such  as  progressive  muscular  atrophy  or 
hemiplegia,  or  local  affection,  such  as  cervical  rib.  The  physician  is  sometimes 
consulted  by  nervous  persons  who  fancy  they  are  becoming  subject  to  the  dis- 
ease and  complain  of  stiffness  or  weakness  without  displaying  any  character- 
istic features. 

Prognosis.^ — The  course  of  the  disease  is  usually  chronic.  If  taken  in 
time  and  if  the  hand  is  allowed  perfect  rest,  the  condition  may  improve  rapidly, 
but  too  often  there  is  a  strong  tendency  to  recurrence.  The  patient  may  learn 
to  write  with  the  left  hand,  but  this  also  may  after  a  time  be  attacked. 

Treatment. — Various  prophylactic  measures  have  been  advised.  It  is  im- 
portant that  a  proper  method  of  writing  be  adopted.  Gowers  suggested  that  if 
all  persons  wrote  from  the  shoulder  writer's  cramp  would  practically  not  occur. 
Various  devices  have  been  invented  for  relieving  the  fatigue,  but  none  of  them 
are  very  satisfactory.  The  use  of  the  type-writer  has  diminished  the  fre- 
quency of  scrivener's  palsy.  Rest  is  essential  and  no  measures  are  of  value 
without  it.  Massage  and  manipulation,  when  combined  with  systematic  gym- 
nastics, give  the  best  results.  The  patient  should  systematically  practise  the 
opposite  movements  to  those  concerned  in  the  cramp.  This  muscle  training 
often  gives  good  results.  Poore  recommends  the  galvanic  current  applied  to 
the  muscles,  which  are  at  the  same  time  rhythmically  exercised.  In  very  ob- 
stinate cases  the  condition  remains  incurable. 


IX.     HYSTERIA 

Definition. — A  disorder  of  personality  manifested  by  a  heightened  and 
perverted  suggestibility,  a  change  in  character,  together  with  certain  mental 
and  bodily  states  induced  by  suggestion — auto  or  hetero — and  cured  by  per- 
suasion. 

Etiology. — Persons  with  mobile  emotional  dispositions,  especially  women, 
are  the  chief  subjects.  In  periods  of  great  stress,  as  in  the  recent  war,  it  be- 
comes a  widespread  and  serious  disorder.  A  community  disease,  often  spread- 
ing widely  in  institutions,  such  as  schools  and  convents,  it  may  behave  like 


1088  DISEASES  OF  THE  NEEVOUS  SYSTEM 

an  epidemic,  as  in  the  dancing  mania.  The  essential  element  under  the  above 
definition  is  the  first — heightened  suggestibility. —  (a)  With  the  chameleon  we 
take  the  color  of  our  surroundings.  The  company,  physical  conditions,  the 
weather,  etc.,  send  our  spirits  up  and  down  like  the  mercury  in  a  barometer. 
Suggestion,  deliberate  by  speech,  unconscious  through  imitation,  is  the  most 
important  part  of  education,  and  to  free  the  mind  as  far  as  possible  from 
the  mastery  of  these  external  influences  has  been  the  goal  from  the  days  of  the 
Greeks.  Love,  hate  and  fear,  the  three  powerful  emotions,  control  us  indi- 
vidually or  sway  us  in  herds  as  the  cattle  on  the  plains.  The  dominant  influ- 
ence of  suggestion  is  everywhere  in  the  story  of  human  progress;  just  as  it  is 
in  the  black  chapters  of  superstition,  folly,  and  crime.  Unconscious  imitation, 
or  an  imitation  against  which  the  individual  is  powerless  to  fight,  has  been 
the  important  factor  in  outbreaks  of  hysteria  as  the  dancing  mania,  the  epi- 
demic chorea,  and  such  tragedies  as  led  to  the  persecutions  for  witchcraft. 

(&)  Eight  judgments  are  indispensable  conditions  to  right  action  in  mind' 
or  muscl'e  and  it  is  in  this  Stoic  doctrine  of  the  control  of  the  will — the  will 
to  do  and  the  will  to  avoid — that  we  find  the  key  to  many  of  the  problems  of 
hysteria.  It  may  be  a  knee  "locked'^  for  months.  An  injury  or  pain  induces 
the  fixed  belief  that  the  joint  can  not  be  moved,  loss  of  muscle  judgment — 
there  have  been  scores  of  such  war  cases — but  ten  minutes  at  Seale-Hayne  or 
a  trip  to  Lourdes  and  the  joint  is  flexible.  After  the  shock  of  an  explosion 
a  man  is  blind  (Mathout  a  lesion),  the  condition  persists — the  visual  judg- 
ment has  been  lost — to  be  restored  months  afterwards  at  a  temple  of  tEscu- 
lapius  or  by  some  modern  Galen.  An  emotional  girl  takes  an  aversion  to 
her  mistress.  The  moral  judgment  is  lost  and  she  begins  to  play  pranks,  some- 
times .harmless,  but  often  serious  as  entailing  great  inconvenience  and  loss, 
as  in  the  recent  i^orfolk  case  in  which  the  walls  of  a  house  were  so  covered 
with  parafiin,  sandal  oil  and  water  that  it  had  to  abandoned.  Or  craving 
sympathy,  she  will  inflict  all  sorts  of  injuries,  even  v^round  herself  to  such  an 
extent  as  to  necessitate  amputation  of  a  limb.  Loss  of  right  judgment  then 
in  muscle  action,  sense  action,  and  conduct  are  essential  factors.  As  the  im- 
pulse— suggestion — is  spontaneous  we  speak  of  it  as  auto-suggestion — and  in 
direct  proportion  to  the  feebleness  of  control  by  the  will  is  the  readiness  with 
which  muscles,  sense  and  mind  yield  to  impulses  not  prompted  by  right  judg- 
ment. 

Charcot  and  his  followers  regarded  hysteria  as  a  psychosis,  in  which  mor- 
bid states  are  induced  by  ideas.  The  capability  of  responding  to  suggestion 
is  the  test  of  its  existence.  It  is  a  disturbance  in  the  sphere  of  personality,  in 
which  the  emotions  have  an  exaggerated  influence  on  the  sensory,  motor  and 
secretory  functions.  Babinski  holds  that  hysteria  is  a  mental  condition  with 
certain  primary  phenomena  and  certain  secondary  accidental  symptoms.  The 
essence  of  the  primary  features  is  that  they  may  be  produced  by  suggestion, 
and  may  be  made  to  disappear  by  persuasion  (pithiatism).  The  primary  symp- 
toms include  hemi-anaesthesia,  paralysis,  contractures,  etc. ;  secondary  features, 
as  muscular  atrophy,  are  directly  dependent  upon  the  primary  and  cannot 
themselves  be  induced  by  suggestion. 

In  the  Breuer-Freud  theory  we  return  to  the  days  of  Aretgeus,  who  orig- 
inated (  ?)  the  views  of  sexual  hysteria  and  believed  the  womb,  "like  an  animal 
within  an  animal"  and  altogether  erratic,  caused  all  sorts  of  trouble  in  its 


HYSTEEIS  1089 

wanderings.  Freud's  view  is  thus  analyzed  by  Jelliffe  in  his  article  in  our 
"System  of  Medicine"  (2nd  Ed.,  Vol.  V.).  "There  develop  usually  on  a 
constitutional  basis,  in  the  period  before  puberty,  definite  sexual  activities 
which  are  mostly  of  a  perverse  nature.  These  activities  do  not,  as  a  rule,  lead 
to  a  definite  neurosis  up  to  the  time  of  puberty,  which  in  the  psychic  sphere 
appears  much  earlier  than  in  the  body,  but  sexual  phantasy  maintains  a  per- 
verse constellated  direction  by  reason  of  the  infantile  sexual  activities.  On 
constitutional  (affect)  grounds  the  increased  fantasy  of  the  hysteric  leads  to 
the  formation  of  complexes  which  are  not  taken  up  by  the  personality  and 
by  reason  of  shame  or  disgust  remain  buried.  There,  therefore,  results  a  con- 
flict between  the  characteristic  normal  libido  and  the  sexual  repressions  of  these 
buried  infantile  perversions.  These  conflicts  give  rise  to  the  hysterical  symp- 
toms. It  is  in  his  contributions  to  the  sexual  theory  that  Freud  develops  his 
later  thoughts  of  the  sexual  origin  of  the  hysterical  reaction.  By  sexual  it  is 
important  to  remember  that  Freud  is  not  speaking  of  sensual. 

"The  signiflcance  of  Freud's  theory  is  the  tracing  of  every  case  to  sexual 
traumata  during  early  childhood.  Sexual  experiences  differ,  however,  from 
ordinary  experiences — the  latter  have  a  tendency  to  fade  out,  while  the  idea 
of  the  former  grows  with  increasing  sexual  maturity.  There  results  a  dis- 
proportionate capacity  for  increased  reaction  which  takes  place  in  the  sub- 
conscious.   This  is  the  cause  of  the  mischief. 

"There  must  be,  however,  a  connecting  link  between  the  infantile  sexual 
traumata  and  the  later  manifestations.  This  connection  Freud  finds  in  the 
so-called  'hysterical  fancies.'  These  are  the  day-dreams  of  erotic  coloring, 
wish-gratifications,  originating  in  privation  and  longing.  These  fancies  hark 
back  to  the  original  traumatic  moment,  and,  either  originating  in  the  sub- 
conscious or  shortly  becoming  conscious,  are  transformed  into  hysterical  symp- 
toms. They  constitute  a  defence  of  the  ego  against  the  revival,  as  reminis- 
cences, of  the  repressed  traumatic  experiences  of  childhood"  (White). 

The  affection  is  most  common  in  women,  and  usually  appears  first  about 
the  time  of  puberty,  but  the  manifestations  may  continue  until  the  menopause, 
or  even  until  old  age.  Men  are  by  no  means  exempt,  and  hysteria  in  the  male 
is  not  rare.  It  occurs  in  all  races,  but  is  much  more  prevalent,  particularly  in 
its  severer  forms,  in  members  of  the  Latin  race.  In  England  and  the  United 
States  the  milder  grades  are  common,  but  the  graver  forms  are  rare  in  com- 
parison with  the  frequency  with  which' they  are  seen  in  France. 

Children  under  twelve  years  of  age  are  not  very  often  affected,  but  the 
disease  may  be  well  marked  as  early  as  the  fifth  or  sixth  year.  One  of  the 
saddest  chapters  in  the  history  of  human  deception,  that  of  the  Salem  witches, 
might  be  headed  hysteria  in  children,  since  the  tragedy  resulted  directly  from 
the  hysterical  pranks  of  girls  under  twelve  years  of  age. 

Of  predisposing  causes,  two  are  important — heredity  and  education.  The 
former  acts  by  endowing  the  child  with  a  mobile,  abnormally  sensitive  nervous 
organization.  We  see  cases  most  frequently  in  families  with  marked  neuro- 
pathic tendencies,  the  members  of  which  have  suffered  from  neuroses  of  vari- 
ous sorts.  Education  at  home  too  often  fails  to  inculcate  habits  of  self-control. 
A  child  grows  to  girlhood  with  an  entirely  erroneous  idea  of  her  relations  to 
others,  and  accustomed  to  have  every  whim  gratified  and  abundant  sympathy 
lavished  on  every  woe,  however  trifling;  she  reaches  womanhood  with  a  moral 


1090"  DISEASES  OF  THE  NEEVOUS  SYSTEM 

organization  unfitted  to  withstand  the  cares  and  worries  of  every-day  life..  At 
school,  between  the  ages  of  twelve  and  fifteen,  when  the  vital  energies  are 
absorbed  in  the  rapid  development  of  the  body,  she  is  often  cooped  in  close 
school  rooms  for  six  or  eight  hours  daily.  The  result  too  frequently  is  an 
active,  bright  mind  in  an  enfeebled  body,  ill  adapted  to  subserve  the  functions 
for  which  it  was  framed,  easily  disordered,  and  prone  to. react  abnormally  to 
the  ordinary  stimuli  of  life.  Among  the  more  direct  influences  are  emotions 
of  various  kinds,  fright  occasionally,  more  frequently  love  affairs,  grief,  and 
domestic  worries.  Physical  causes  less' often  bring  on  hysterical  outbreaks,  but 
they  may  follow  an  injury  or  develop  during  the  convalescence  from  an  acute 
illness  or  be  associated  with  disease  of  the  generative  organs. 

"Chorea  Major":  "Pandemic  Chorea." — The  common  name,  St.  Vitus's 
dance,  applied  to  chorea  has  come  to  us  from  the  middle  ages,  when  under  the 
influence  of  religious  fervor  there  were  epidemics  characterized  by  great  ex- 
citement, gesticulations,  and  dancing.  For  the  relief  of  these  symptoms,  when 
excessive,  pilgrimages  were  made,  and,  in  the  Ehenish  provinces,  particularly 
to  the  Chapel  of  St.  Vitus  in  Zebern,  Epidemics  of  this  sort  occurred  also 
during  the  nineteenth  century,  and  descriptions  of  them  among  the  early  set- 
tlers in  Kentucky  have  been  given  by  Eobertson  and  Yandell.  It  was  unfor- 
tunate that  Sydenham  applied  the  term  chorea  to  an  affection  in  children 
totally  distinct  from  this  chorea  major,  which  is  in  reality  an  hysterical 
manifestation  under  the  influence  of  religious  excitement. 

Symptoms. — A  useful  division  is  into  the  convulsive  and  non-convulsive 
varieties. 

Convulsive  Hysteeia. —  (a)  Minor  Forms. — The  attack,  commonly  fol- 
lowing emotional  disturbance,  sets  in  suddenly  or  may  be  preceded  by  symp- 
toms, called  by  the  laity  "hysterical,"  such  as  laughing  and  crying  alternately, 
or  a  sensation  of  constriction  in  the  neck,  or  of  a  ball  rising  in  the  throat — 
the  globus  hystericus.  Sometimes,  preceding  the  convulsive  movements,  there 
may  be  painful  sensations  arising  from  the  pelvic,  abdominal,  or  thoracic 
regions.  From  the  description  these  sensations  resemble  aurse.  They  become 
more  intense  with  the  rising  sensation  of  choking  in  the  neck  and  difficulty  in 
getting  breath,  and  the  patient  falls  into  a  more  or  less  violent  convulsion. 
The  fall  is  not  sudden,  as  in  epilepsy,  but  the  subject  goes  down,  as  a  rule, 
easily,  often  picking  a  soft  spot,  like  a  sofa  or  an  easy-chair,  and  in  the  move- 
ments apparently  exercises  care  to  do  herself  no  injury.  Yet  at  the  same  time 
she  appears  to  be  unconscious.  The  movements  are  clonic  and  disorderly, 
with  the  head  and  arms  thrown  about  in  an  irregular  manner.  The  paroxysm 
after  a  few  minutes  slowly  subsides,  then  the  patient  becomes  emotional,  and 
gradually  regains  consciousness.  When  questioned  the  patient  may  confess 
to  having  some  knowledge  of  the  events  which  have  taken  place,  but,  as  a  rule, 
has  no  accurate  recollection.  During  the  attack  the  abdomen  may  be  much 
distended  with  flatus,  and  subsequently  a  large  amount  of  clear  urine  may  be 
passed.  These  attacks  vary  greatly;  there  may  be  scarcely  any  movements  of 
the  limbs,  but  after  a  nerve  storm  the  patient  sinks  into  a  torpid,  semi-uncon- 
scious condition,  from  which  she  is  roused  with  difficulty.  In  some  cases  the 
patient  passes  from  this  state  into  a  condition  of  catalepsy. 

(h)  Major  Forms;  Hystero-epilepsy. — Typical  instances  are  very  rare  in 
the  United  States  and  in  England.    The  attack  is  initiated  by  certain  prodro- 


HYSTEEIA  lO&l 

mata,  chiefly  minor  hysterical  manifestations,  either  foolish  or  unseemly  be- 
havior, excitement,  sometimes  dyspeptic  symptoms  with  tympanites,  or  fre- 
quent micturition.  Areas  of  hypersesthesia  may  be  marked,  the  so-called  hys- 
terogenic spots  so  elaborately  described  by  Eichet.  These  are  usually  sym- 
metrical and  situated  over  the  upper  dorsal  vertebra,  and  in  front  in  a  series 
of  symmetrically  placed  areas  on  the  chest  and  abdomen,  the  most  marked 
being  over  the--  ovaries.  Painful  sensations  or  a  feeling  of  oppression  and  a 
globus  rising  in  the  throat  may  be  complained  of  prior  to  the  onset  of  the 
convulsion,  which,  according  to  French  writers,  has  four  distinct  stages:  (1) 
Epileptoid  condition,  which  closely  simulates  a  true  epileptic  attack  with  tonic 
spasm  (often  leading  to  opisthotonos),  grinding  of  the  teeth,  congestion  of 
the  face,  followed  by  clonic  convulsions,  gradual  relaxation,  and  coma.  (2) 
Succeeding  this  is  the  period  which  Charcot  has  termed  cloivnism,  in  which 
there  is  an  emotional  display  and  a  remarkable  series  of  contortions  or  of 
cataleptic  poses.  (3)  Then  in  typical  cases  there  is  a  stage  in  which  the 
patient  assumes  certain  attitudes  expressive  of  the  various  passions — ecstasy, 
fear,  beatitude,  or  erotism.  (4)  Finally  consciousness  returns  and  the  patient 
enters  upon  a  stage  in  which  she  may  display  very  varied  symptoms,  chiefly 
manifestations  of  a  delirium  with  extraordinary  hallucinations.  Visions  are 
seen,  voices  heard,  and  conversations  held  with  imaginary  persons.  In  this 
stage  patients  will  relate  with  the  utmost  solemnity  imaginary  events,  and 
make  extraordinary  and  serious  charges  against  individuals.  This  sometimes 
gives  a  grave  aspect  to  these  seizures,  for  not  only  does  the  patient  make  and 
believe  the  statements,  but  when  recovery  is  complete  the  hallucination  some- 
times persists.  After  an  attack  a  patient  may  remain  for  days  in  a  state 
of  lethargy  or  trance. 

Non-convulsive  Forms. — So  complex  and  varied  is  the  picture  that  the 
manifestations  are  best  considered  according  to  the  systems  involved. 

(a)  Disorders  of  Motion. —  (1)  Paralysis. — These  may  be  hemiplegic,  para- 
plegic, or  monoplegic.  Hysterical  diplegia  is  extremely  rare.  The  paralysis 
either  sets  in  abruptly  or  gradually,  and  may  take  weeks  to  attain  its  full 
development.  There  is  no  type  or  form  of  organic  paralysis  which  may  not 
he  simulated  in  hysteria.  Sensation  is  either  lessened  or  lost  on  the  affected 
side.  The  hysterical  paraplegia  is  more  common  than  hemiplegia.  The  loss 
of  power  is  not  absolute;  the  legs  can  usually  be  moved,  but  do  not  support  the 
patient.  The  reflexes  may  be  increased,  though  the  knee-jerk  is  often  normal. 
A  spurious  ankle  clonus  may  sometimes  be  present.  The  feet  are  usually  ex- 
tended and  turned  inward  in  the  equino-varus  position.  The  muscles  do  not 
waste  and  the  electrical  reactions  are  normal.  Other  manifestations,  such  as 
paralysis  of  the  bladder  or  aphonia,  are  usually  associated.  Hysterical  mono- 
plegias may  be  facial,  crural,  or  brachial.  A  condition  of  ataxia  sometimes 
occurs  with  paresis.  Incoordination  may  be  a  marked  feature,  and  there  are 
usually  sensory  manifestations. 

The  following  points  are  important  in  deciding  between  functional  and 
organic  hemiplegia.  The  absence  of  epigastric  and  cremasteric  reflexes  with 
Babin'ski's  sign  suggests  organic  disease.  If  the  patient  folds  the  arms  and 
attempts  to  rise  from  the  recumbent  to  the  sitting  posture  the  thigh  on  the 
affected  side  flexes  at  the  hip  and  the  whole  extremity  will  be  raised,  to  fall 
back  later.    This  does  not  occur  in  the  functional  cases.    Another  test  is  made 


1092  DISEASES  OF  THE  NERVOTTS  SYSTEM 

with  the  patient  lying  on  the  back.  ^Yhen  asked  to  raise  the  "unaffected  leg, 
the  opposite  leg,  paralyzed  for  voluntary  effort,  is  strongly  pressed  down 
(Hoover). 

(2)  Contractures  and  Spasms. — The  hysterical  contractures  may  attack 
almost  any  group  of  voluntary  muscles  and  be  of  the  hemiplegic,  paraplegic, 
or  monoplegic  type.  They  may  come  on  suddenly  or  slowly,  persist  for  months 
or  years,  and  disappear  rapidly.  The  contracture  is  most  commonly  seen  in 
the  arm,  which  is  flexed  at  the  elbow  and  wrist,  while  the  fingers  tightly  grasp 
the  thumb  in  the  palm  of  the  hand;  more  rarely  the  terminal  phalanges  are 
hyperextended.  It  may  occur  in  one  or  in  both  legs,  more  commonly  in  one. 
The  ankle  clonus  is  present;  the  foot  is  inverted  and  the  toes  are  strongly 
flexed.  These  cases  may  be  mistaken  for  lateral  sclerosis  and  the  difficulty  in 
diagnosis  may  really  be  very  great.  The  spastic  gait  is  typical,  and  with 
the  exaggerated  knee-jerk  and  ankle  clonus  the  picture  may  be  characteristic. 
Other  forms  of  contracture  may  be  in  the  muscles  of  the  hip,  shoulder,  oi 
neck;  more  rarely  in  those  of  the  jaws — hysterical  trismus — or  in  the  tongue. 
Eemarkable  indeed  are  the  local  contractures  in  the  diaphragm  and  abdominal 
muscles,  producing  a  phantom  tumor,  in  which  just  below  and  in  the  neigh- 
borhood of  the  umbilicus  is  a  firm,  apparently  solid  growth.  According  to 
Gowers,  this  is  produced  by  relaxation  of  the  recti  and  a  spasmodic  contraction 
of  the  diaphragm,  together  with  inflation  of  the  intestines  with  gas  and  an 
arching  forward  of  the  vertebral  column.  They  are  apt  to  occur  in  middle- 
aged  women  about  the  menopause,  and  are  frequently  associated  with  symp- 
toms of  spurious  pregnancy — pseudo-cyesis.  The  resemblance  to  a  tumor  may 
be  striking.  The  only  safeguard  is  to  be  found  in  complete  ansesthesia,  when 
the  tumor  entirely  disappears.  Mitchell  reported  an  instance  of  a  phantom 
tumor  in  the  left  pectoral  region  just  above  the  breast,  which  was  tender,  hard, 
and  dense. 

Bliytlxmic  Hysterical  Spasm. — The  movements  may  be  of  the  arm,  either 
flexion  and  extension,  or,  more  rarely,  pronation  and  supination.  Clonic  con- 
tractions of  the  sterno-cleido-mastoid  or  of  the  muscles  of  the  jaws  or  of  the 
rotatory  muscles  of  the  head  may  produce  rhythmic  movements  of  these  parts. 
The  spasm  may  be  in  one  or  both  psoas  muscles,  lifting  the  leg  in  a  rhythmic 
manner  eight  or  ten  times  in  a  minute.  In  other  instances  the  muscles  of  the 
trunk  are  affected,  and  every  few  moments  there  is  a  bowing  movement — 
salaam  convulsions — or  the  muscles  of  the  back  may  contract,  causing  strong 
arching  of  the  vertebral  column  and  retraction  of  the  head. 

Tremor  may  be  a  purely  hysterical  manifestation,  occurring  either  alone  or 
with  paralysis  and  contracture.  It  most  commonly  involves  the  hands  and 
arms;  more  rarely  the  head  and  legs.  The  movements  are  small  and  quick. 
In  the  type  described  by  Eendu  the  tremor  may  or  may  not  persist  during 
repose,  but  it  is  increased  or  provoked  by  volitional  movements.  Volitional 
or  intention  tremor  may  exist,  simulating  closely  that  of  insular  sclerosis. 
Many  instances  of  this  disease  are  mistaken  for  hysteria. 

(&)  Disorders  of  Sensation. — Ana'stliesia  is  most  common,  and  usually  con- 
fined to  one  half  of  the  body.  It  may  not  be  noticed  by  the  patient.  Usually 
it  is  accurately  limited  by  the  middle  line  and  involves  the  mucous  surfaces  and 
deeper  parts.  The  conjunctiva,  however,  is  often  spared.  There  may  be  hemi- 
anopsia.    This  symptom  may  come  on  slowly  or  follow  a  convulsive  attack. 


HYSTEEIA  1093 

Sometimes  the  various  sensations  are  dissociated  and  the  anaesthesia  may  be 
only  to  pain  and  to  touch.  Tlie  skin  of  the  affected  side  is  usually  pale  and 
cool,  and  a  pin-prick  may  not  be  followed  by  blood.  With  the  loss  of  feeling 
there  may  be  loss  of  muscular  power.  Curious  trophic  changes  may  be  pres- 
ent, such  as  unilateral  swelling  of  the  hemiplegic  side. 

By  metallotherapy,  the  application  of  certain  metals,  the  anaesthesia  or 
analgesia  can  be  transferred  to  the  other  side  of  the  body.  This  phenomenon 
may  be  caused  by  the  electro-magnet  and  by  wood  and  various  other  agents, 
and  is  an  effect  of  suggestion. 

HypercEsthesia. — Increased  sensitiveness  and  pains  occur  in  various  parts 
of  the  body.  One  of  the  most  frequent  complaints  is  of  pain  in  the  head, 
usually  over  the  sagittal  suture,  less  frequently  in  the  occiput.  This  is  de- 
scribed as  agonizing,  and  is  compared  to  the  driving  of  a  nail  into  the  part; 
hence  the  name  clavus  hystericus.  Neuralgias  are  common.  Hypergesthetic 
areas,  the  hysterogenic  points,  exist  on  the  skin  of  the  thorax  and  abdomen, 
pressure  upon  which  may  cause  minor  manifestations  or  even  a  convulsive 
attack.  Increased  sensitiveness  in  the  ovarian  region  is  not  peculiar  to 
hysteria.  Pain  in  the  back  is  an  almost  constant  complaint.  The  sensitive- 
ness may  be  limited  to  certain  spinous  processes,  or  may  be  diffuse.  In 
hysterical  women  the  pains  in  the  abdomen  may  simulate  those  of  gastric 
ulcer,  or  the  condition  may  be  almost  identical  with  that  of  peritonitis ;  more 
rarely  the  abdominal  pains  closely  resemble  those  of  appendix  disease. 

Special  Senses. — Disturbances  of  taste  and  smell  are  not  uncommon  and 
may  cause  much  distress.  Of  ocular  symptoms,  retinal  hypergesthesia  is  com- 
mon, and  the  patients  prefer  to  be  in  a  darkened  room.  Retraction  of  the 
field  of  vision  is  common  and  usually  follows  a  convulsive  seizure.  It  may 
persist  for  years.  The  color  perception  may  be  normal  even  with  complete 
ansesthesia.  Hysterical  deafness  may  be  complete  and  alternate  or  come 
on  with  hysterical  blindness.  Hysterical  amaurosis  may  occur  in  children. 
One  must  distinguish  between  functional  loss  of  power  and  simulation. 

(c)  Visceral  Maivifestations. — Respiratory  Apparatus. — Of  disturbances  in 
the  respiratory  rhythm,  the  most  frequent,  perhaps,  is  an  exaggeration  of  the 
deeper  breath,  which  is  taken  normally  every  fifth  or  sixth  inspiration,  or 
there  may  be  a  "catching"  breathing,  such  as  is  seen  when  cold  water  is 
poured  over  a  person.  In  hysterical  dyspnaa  there  is  no  special  distress  and 
the  pulse  is  normal.  In  what  is  known  as  the  syndrome  of  Briquet  there  are 
shortness  of  breath,  suppression  of  the  voice,  and  paralysis  of  the  diaphragm. 
The  anhelation  is  extreme.  In  rare  instances  there  is  bradypnoea.  Among 
laryngeal  manifestations  aphonia  is  frequent  and  may  persist  for  months  or 
even  years  without  other  special  symptoms.  Spasm  of  the  muscles  may  occur 
with  violent  inspiratory  efforts  and  great  distress,  and  even  lead  to  cyanosis. 
Hiccough,  or  sounds  resembling  it,  may  be  present  for  weeks  or  months  at 
a  time.  Among  the  most  remarkable  of  the  respiratory  manifestations  are 
the  hysterical  cries.  These  may  mimic  the  sounds  produced  by  animals,  such 
as  barking,  mewing,  or  grunting,  and  in  France  epidemics  of  them  have  been 
observed.     Attacks  of  gaping,  yawning,  and  sneezing  may  also  occur. 

The  hysterical  cougli.  is  a  frequent  symptom,  particularly  in  younty  o'irls 
It  may  occur  in  paroxysms,  but  is  often  a  dry,  persistent,  croaking  cough, 
extremely  monotonous  and  unpleasant  to  hear.     Sir  Andrew  Clark  ha?  called 


1094:  DISEASES  OP  THE  NERVOUS  SYSTEM 

attention,  to  a  loud,  barking  cough  {ctjnolex  liebetica)  occurring  about  the 
time  of  puberty,  chiefly  in  boys  belonging  to  neurotic  families.  The  attacks, 
which  last  about  a  minute,  recur  frequently.  A  form  of  hysterical  hcemoptysis 
may  be  deceptive  and  lead  to  a  diagnosis  of  pulmonary  disorder.  The  sputum 
is  a  pale-red  fluid,  not  so  bright  in  color  as  in  ordinary  haemoptysis,  and  con- 
tains particles  of  food,  pavement  epithelium,  red  corpuscles,  and  micrococci,  but 
no  cylindical  or  ciliated  epithelium.  It  probably  comes  from  the  mouth  or 
pharynx. 

Digestive  System. — Disturbed  or  depraved  appetite,  dyspepsia,  and  gastric 
pains  are  common.  The  patient  may  have  difficulty  in  swallowing,  apparently 
from  spasm  of  the  gullet.  There  are  instances  in  which  the  food  seems  to 
be  expelled  before  it  reaches  the  stomach.  In  other  cases  there  is  incessant 
gagging.  In  the  hysterical  vomiting  the  food  is  regurgitated  without  much 
efl^ort  and  without  nausea.  This  feature  may  persist  for  yearf^  without  great 
disturbance  of  nutrition.  The  most  striking  and  remarkable  digestive  dis- 
turbance in  hysteria  is  the  anorexia  nervosa  described  by  Sir  William  Gull. 
"To  call  it  loss  of  appetite — anorexia — but  feebly  characterizes  the  symptom. 
It  is  rather  an  annihilation  of  appetite,  so  complete  that  it  seems  in  some 
cases  impossible  ever  to  eat  again.  Out  of  it  grows  an  antagonism  to  food 
which  results  at  last  and  in  its  worst  forms  in  spasm  on  the  approach  of  food, 
and  this  in  turn  gives  rise  to  some  of  those  remarkable  cases  of  survival  for 
long  periods  without  food"  (Mitchell).  There  are  three  special  features  in 
anorexia  nervosa :  First,  and  most  important,  a  psychical  state,  usually  depres- 
sant, occasionally  excited  and  restless.  It  is  not  always  hysterical.  Secondly, 
stomach  symptoms,  loss  of  appetite,  regurgitation,  vomiting,  and  the  whole 
series  of  phenomena  associated  with  nervous  dyspepsia.  Thirdly,  emaciation, 
which  reaches  a  grade  seen  only  in  cancer  and  dysentery.  The  patient  finally 
takes  to  bed,  and  in  extreme  cases  lies  upon  one  side  with  the  thighs  and  legs 
flexed,  and  contractures  may  occur.  Eood  is  either  not  taken  at  all  or  only 
upon  urgent  compulsion.  The  skin  becomes  wasted,  dry,  and  covered  with 
bran-like  scales.  No  food  may  be  taken  for  several  weeks  at  a  time,  and 
attempts  to  feed  may  be  followed  by  severe  spasms.  Although  the  condition 
looks  so  alarming,  these  patients,  when  removed  from  their  home  surroundings 
and  treated  by  isolation,  sometimes  recover  in  a  remarkable  way.  It  may 
take  many  months  before  any  improvement  is  noted.  Deatli,  however,  may 
follow  with  extreme  emaciation.  In  one  fatal  case  the  girl  weighed  only  49 
pounds.     Ko  lesions  were  found  post  mortem. 

Hysterical  tympanites  is  common,  caused  usually  by  tonic  contraction  of 
the  diaphragm  and  retraction  of  the  abdominal  muscles.  It  may  be  associated 
with  peristaltic  unrest.  Frequent  discharges  of  fgeces  may  be  due  to  dis- 
turbance in  the  small  or  large  bowel.  An  obstinate  form  of  diarrhoea  is  found 
in  some  hysterical  patients,  which  proves  very  intractable  and  is  associated 
especially  with  the  taking  of  food.  It  seems  an  aggravated  form  of  the 
looseness  of  bowels  to  which  many  nexvous  people  are  subject  on  emotion  or 
of  the  tendency  which  some  have  to  .diarrhoea  immediately  after  eating.  An 
entirely  different  form  is  that  produced  by  what  Mitchell  calls  the  irritable 
rectum,  in  which  scybala  are  passed  frequently,  sometimes  with  great  violence. 
Constipation  is  more  frequent  and  may  be  due  to  lack  of  attention  to  the 
need  for  defecation  or  to  spasm  (Vagotonia).     In  extreme  cases  the  bowels  may 


HYSTEEIA  1095 

not  be  moved  for  two  or  three  weeks.  Other  disturbances  are  aho-spasm  or 
intense  pain  in  the  rectum  apart  from  any  fissure.  Hysterical  ileus  and  faecal 
vomiting  are  among  the  most  remarkable  of  hysterical  phenomena.  Follow- 
ing a  shock  there  are  constipation,  tympanites,  vomiting,  sometimes  hgematem- 
esis.  The  constipation  grows  worse,  everything  taken  by  the  mouth  is  re- 
jected, the  vomitus  becomes  faecal  in  character,  even  scybala  are  brought  up, 
and  suppositories  and  enemata  are  vomited.  The  symptoms  may  continue  for 
weeks  and  then  gradually  subside.  Laparotomy — even  thrice  in  one  patient — 
has  shown  a  perfectly  normal-looking  condition  of  the  bowels  (Parkes  Weber). 

Cardio-vascuJar. — Eapid  action  of  the  heart  on  slight  emotion,  with  or 
without  the  su])jective  sensation  of  palpitation,  is  often  a  source  of  great  dis- 
tress. A  slow  pulse  is  less  frequent.  Pains  al)out  the  heart  may  simulate 
angina.  Flushes  in  various  parts  are  common.  Sweating  may  occur,  or  the 
sehorrluea  nigrlcan.^,  causing  a  darkening  of  the  skin  of  the  eyelids. 

Among  the  more  remarkable  vaso-motor  phenomena  are  the  so-called  stig- 
mata or  hemorrhages  in  the  skin,  such  as  were  present  in  the  celebrated  case 
of  Louise  Lateau.  In  many  cases  these  are  undoubtedly  fraudulent,  but  if, 
as  appears  credible,  such  bleeding  may  occur  in  the  hypnotic  trance,  there 
seems  no  reason  to  doubt  its  possibility  in  the  trance  of  religious  ecstasy. 

{d)  Joint  Affections. — To  Sir  Benjamin  Brodie  and  Sir  James  Paget  we 
owe  the  recognition  of  these  extraordinary  manifestations.  Perhaps  no  single 
affection  has  brought  more  discredit  upon  the  profession,  for  the  cases  are 
very  refractory,  and  often  fall  into  the  hands  of  a  charlatan  or  faith-healer, 
under  whose  touch  the  disease  may  disappear  at  once.  Usually  it  affects  the 
knee  or  the  hip,  and  may  follow  a  trifling  injury.  The  joint  is  usually  fixed, 
sensitive,  and  swollen.  The  surface  may  be  cool,  but  sometimes  the  local  tem- 
perature is  increased.  To  the  touch  it  is  very  sensitive  and  movement  causes 
great  pain.  In  protracted  cases  the  muscles  are  somewhat  wasted,  and  in 
consequence  the  joint  looks  larger.  The  pains  are  often  nocturnal,  at  which 
time  the  local  temperature  may  be  increased.  While,  as  a  rule,  neuromimetic 
joints  yield  to  proper  management,  there  are  instances  in  the  literature  in 
which  organic  change  has  succeeded  the  functional  disturbance.  Intermittent 
hydrarthrosis  may  be  a  manifestation  of  hysteria,  sometimes  with  transient 
paresis. 

(e)  Mental  Symptoms. — Mental  perversions  of  all  kinds  are  common  in 
hysterical  patients  and  not  much  dependence  can  be  placed  on  statements  either 
about  themselves  or  about  others.  A  morbid  craving  for  sympathy  may  lead  to 
the  commission  of  all  sorts  of  bizarre  and  foolish  acts. 

Hallucinations  and  delirium  may  alternate  with  emotional  outbursts  of  an 
aggravated  character.  There  is  a  condition  which  may  be  spoken  of  as  the 
status  hystericus.  For  weeks  or  months  they  may  be  confined  to  bed,  entirely 
oblivious  to  their  surroundings,  with  a  delirium  which  may  simulate  that  of 
delirium  tremens,  particularly  in  being  associated  with  loathsome  and  un- 
pleasant animals.  The  nutrition  may  be  maintained.  l)ut  there  is  a  heavy, 
foul  breath.  With  seclusion  and  care  recovery  usually  takes  place  within  three 
or  four  months.  At  the  onset  of  these  attacks  and  during  convalescence  the 
patients  must  be  incessantly  watched,  as  a  suicidal  tendency  is  not  uncommon. 

Of  hysterical  manifestations  in  the  higher  centres  that  of  trance  is  the 
most  remarkable.     This  may  develop  spontaneously  without  any  convulsiye 


1096  DISEASES  OF  THE  NERVOUS  SYSTEM 

seizure,  but  more  frequently  it  follows  hysteroid  attacks.  Catalepsy  may  be 
present,  a  condition  in  which  the  limbs  are  plastic  and  remain  in  any  position 
in  which  they  are  placed. 

(/)  Manifestations. —  (1)  ffidema,  Puffiness  of  the  face,  even  unilateral, 
and  swelling  of  the  hands  are  not  uncommon  and  the  features  of  Raynaud's 
disease  may  be  met  with.  A  white  and  a  blue  type  of  cedema  is  recognized, 
and  either  may  be  associated  with  paralyses,  motor  and  sensory.  (2)  Stig- 
mata.— Local  bleedings  have  been  described,  sometimes,  as  in  the  so-called 
marks  of  the  cross,  on  forehead,  hands,  feet  and  side,  as  in  the  famous  case 
of  Louise  Lateau,  Organic  lesions  of  the  skin  (blisters)  are  claimed  to  have 
been  produced  by  hypnotic  suggestion  (Hadiield)  and  the  stigmata  are  prob- 
ably produced  by  auto-suggestion  in  the  trance  state.  (3)  PatJiomimia,  the 
self-inflicted  injuries,  usually  of  the  skin,  by  caustics,  etc.  In  a  case  seen 
at  the  Hotel  Dieu  with  Dieulafoy,  the  patient,  supposed  to  be  the  subject  of 
severe  trophic  disorder,  submitted  to  amputation  of  the  arm  before  a  con- 
fession was  obtained  that  the  lesions  were  self-inflicted. 

{g)  Hysterical  Fever. — In  hysteria  the  temperature,  as  a  rule,  is  normal. 
The  cases  with  fever  may  be  grouped  as  follows:  (1)  Instances  in  which  the 
fever  is  the  sole  manifestation^  These  are  rare,  but  there  are  cases  in  which 
the  chronic  course,  the  retention  of  nutrition,  and  the  entirely  negative  con- 
dition of  the  organs  leaves  no  other  diagnosis  possible.  In  one  case  the  patient 
had  for  four  or  five  years  an  afternoon  rise  of  temperature,  usually  to  103° 
or  103°.  She  was  well  nourished  and  had  no  pronounced  hysterical  symp- 
toms, beyond  the  interrupted  sighing  respiration  so  often  seen. 

(2)  Cases  of  hysterical  fever  with  spurious  local  manifestations.  These 
are  very  troublesome  and  deceptive  cases.  The  patient  may  be  suddenly  taken 
ill  with  pain  in  various  regions  and  elevation  of  temperature.  The  case  may 
simulate  meningitis.  There  may  be  pain  in  the  head,  vomiting,  contracted 
pupils,  and  retraction  of  the  neck — symptoms  which  may  persist  for  weeks — 
and  some  anomalous  manifestation  during  convalescence  may  alone  indicate 
to  the  physician  that  he  has  had  to  deal  with  hysteria,  and  has  not,  as  he 
perhaps  flattered  himself,  cured  a  case  of  meningitis.  Mary  Putnam  Jacobi, 
in  an  article  on  hysterical  fever,  mentions  a  case  in  the  service  of  Cornil 
which  was  admitted  with  dyspnoea,  slight  cyanosis,  and  a  temperature  of 
39°  C.  The  condition  proved  to  be  hysterical.  There  is  also  an  hysterical 
pseudo-phthisis  with  pain  in  the  chest,  slight  fever,  and  the  expectoration  of  a 
blood-stained  mucus.     The  cases  of  hysterical  peritonitis  may  also  show  fever. 

(3)  Hyperpyrexia. — It  is  a  suggestive  fact  that  the  cases  of  paradoxical 
temperatures  in  which  the  thermometer  has  registered  112°  to  120°  have 
been  in  women.     Fraud  has  been  practised  in  nearly  all  these  cases. 

Astasia;  Abasia. — These  terms,  indicating  respectively  inability  to  stand 
and  inability  to  walk,  have  been  applied  by  Charcot  and  Blocq  to  conditions 
characterized  by  loss  of  the  power  of  standing  or  of  walking,  with  retention 
of  muscular  power,  coordination,  and  sensation.  Blocq's  definition  is  as 
follows:  '^A  morbid  state  in  which  the  impossibility  of  standing  erect  and 
walking  normally  is  in  contrast  with  the  integrity  of  sensation,  of  muscular 
strength,  and  of  the  coordination  of  the  other  movements  of  the  lower  extrem- 
ities." The  condition  forms  a  symptom  group,  not  a  morbid  entity,  and  is 
a  functional  neurosis.     Knapp   analyzed   50   cases,   of  which   half  were  in 


HYSTEEIA  109? 

women.  In  21  cases  hysteria  \7as  present;  in  S,  chorea;  in  2,  epilepsy;  and 
in  4,  intention  psychoses.  As  a  rule^  the  patients,  though  able  to  move  the 
feet  and  legs  perfectly  when  in  bed,  are  eitlier  unable  to  walk  properly  or 
can  not  stand  at  all.  The  disturbances  have  been  very  varied,  and  different 
forms  have  been  recognized.  The  commonest,  according  to  Knapp's  analysis 
of  the  recorded  cases,  is  the  paralytic,  in  which  the  legs  give  out  as  the  patient 
attempts  to  walk  and  "bend  under  him  as  if  made  of  cotton."  "There  is  no 
rigidity,  no  spasm,  no  incoordination.  In  bed,  sitting,  or  even  while  sus- 
pended, the  muscular  strength  is  found  to  be  good.''  Other  cases  are  asso- 
ciated with  spasm  or  ataxia;  thus  there  may  be  movements  which  stiffen  the 
legs  and  give  to  the  gait  a  somewhat  spastic  character.  In  other  instances 
there  are  sudden  flexions  of  the  legs,  or  even  of  the  arms,  or  a  saltatory,  spring- 
like spasm.     The  condition  is  a  manifestation  of  hysteria. 

Diagnosis. — Inquiry  into  the  occurrence  of  previous  manifestations  and 
the  mental  conditions  may  give  important  information.  These  questions,  as 
a  rule,  should  not  be  asked  the  mother,  who  of  all  others  is  least  likely  to  give 
satisfactory  information.  The  occurrence  of  the  globus  hystericus,  of  emo- 
tional attacks,  of  weeping  and  crying  is  always  suggestive.  The  points  of 
difference  between  the  convulsive  attacks  and  true  epilepsy  may  give  difficulty 
at  first.  The  hysterical  paralyses  are  very  variable  and  apt  to  be  associated 
with  anaesthesia.  The  contractures  may  be  deceptive,  but  the  occurrence  of 
areas  of  anaesthesia,  of  retraction  of  the  visual  field,  and  the  development  of 
minor  hysterical  manifestations  give  valuable  indications.  The  contractures 
disappear  under  full  ansesthesia.  Special  care  must  be  taken  not  to  confound 
the  spastic  paraplegia  of  hysteria  with  lateral  sclerosis. 

The  visceral  manifestations  are  usually  recognized  without  much  difficulty. 

The  practitioner  has  constantly  to  bear  in  mind  the  strong  tendency  in  hys- 
terical patients  to  practise  deception. 

Treatment — The  prophylaxis  may  be  gathered  from  the  remarks  on  the 
relation  of  education  to  the  disease.  The  successful  treatment  of  hysteria 
demands  qualities  possessed  by  few  physicians.  The  first  element  is  a  due 
appreciation  of  the  nature  of  the  disease  on  the  part  of  the  physician  and 
friends.  It  is  pitiable  to  think  of  the  misery  which  has  been  inflicted  on 
these  unhappy  victims  by  the  harsh  and  unjust  treatment  which  has  resulted 
from  false  views  of  the  nature  of  the  trouble;  on  the  other  hand,  worry  and 
ill  health,  often  the  wrecking  of  mind,  body,  and  estate,  are  entailed  upon 
the  near  relatives  in  the  nursing  of  a  protracted  case.  The  minor  manifes- 
tations, attacks  of  the  vapors,  the  crying  and  weeping  spells,  are  not  of  much 
moment  and  rarely  require  treatment.  The  physical  condition  should  be  care- 
fully looked  into  and  the  mode  of  life  regulated  so  as  to  insure  system  and 
order  in  everything.  A  congenial  occupation  offers  the  best  remedy  for  many 
of  the  manifestations.  Any  functional  disturbance  should  be  attended  to 
and  tonics  prescribed.  Special  attention  should  be  paid  to  the  action  of  the 
bowels. 

Psychotherapy,  in  which  the  important  features  are  hypnosis,  sugges- 
tion, and  reeducation. 

Hypnosis. — The  majority  of  hysterical  patients  can  be  hypnotized,  but  the 
general  opinion  of  those  who  know  most  on  the  subject  is  that  by  hypnosis 
alone  hysteria  is  rarely  cured.     Sometimes  a  brilliant  miracle  is  wrought  in 


1098  DISEASES  OF  THE  I^EEVOUS  SYSTEM 

the  case  of  hysterical  paraplegia  or  hemiplegia^  but  as  a  routine  treatment  it 
has  fallen  into  disfavor  even  in  France. 

Suggestion. — Babinski  defines  suggestion  as  "the  action  by  which  one  en- 
deavors to  make  another  accept  or  realize  an  idea  which  is  manifestly  un- 
reasonable." On  the  other  hand,  persuasion  is  applied  when  the  ideas  are 
reasonable,  or  at  least  are  not  in  opposition  to  good  sense.  Most  writers,  how- 
ever, use  the  word  "suggestion"  as  meaning  the  introduction  of  mental  associa- 
tions and  modifications  of  the  patient's  mental  state  leading  to  betterment.  In 
proper  hands  it  is  a  most  powerful  instrument,  particularly  when  the  patient 
has  faith  in  the  person  who  makes  it.  After  a  careful  and  sympathetic  ex- 
amination and  testing  the  electrical  reactions  of  the  muscles  of  a  paralyzed 
limb  the  suggestion  to  the  hysteric,  "Now  you  will  be  able  to  move  it"  may 
be  all-sufficient.     A  strong,  imperative  command  may  have  the  same  effect. 

Reeducation. — In  both  hysteria  and  neurasthenia  this  should  be  the  aim  of 
all  reasonable  practice,  but  it  is  not  always  feasible:  some  of  our  patients 
would  have  to  be  rebuilt  from  the  blastoderm.  With  patience  and  method 
much  may  be  done,  and  the  special  merit  of  Weir  Mitchell's  work  and  of  his 
system  (which  is  not  simply  a  rest  cure,  as  many  suppose)  is  that  it  is  an 
elaborate  plan  of  reeducation.  The  essentials  are  that  the  patient  should  be 
isolated  from  his  friends  and  under  the  charge  of  an  intelligent  nurse.  The 
physical  condition  is  carefully  studied  and  a  rigid  daily  regime  carried  out: 
A  milk  diet  of  three  to  four  quarts  daily,  rising  to  five  or  six,  varying  the  food 
as  the  patient  improves,  and  as  the  weight  increases.  This  may  be  followed 
by  a  rapid  gain  in  weight  and  the  disappearance  of  the  unpleasant  abdominal 
symptoms.  Massage,  hydrotherapy,  and  electricity  are  adjuncts,  but  very 
much  depends  upon  the  tact,  patience,  and,  above  all,  the  personality  of  the 
physician;  the  man  counts  more  than  the  method.  The  mental  condition  has 
to  be  carefully  studied  and  the  patient's  attitude  toward  life  influenced  by 
specially  selected  literature,  careful  conversation,  and  suggestion. 

The  Analytical  Method. — Introduced  by  Breuer  and  extended  by  Freud, 
it  is  partly  the  method  of  the  confessional,  in  which  the  sinner  poured 
out  his  soul  in  the  sympathetic  ear  of  the  priest,  but  it  also  enables  the  patient 
to  bring  out  into  the  open  what  he  may  not  consciously  know.  It  is  a  difficult 
procedure,  not  for  all  to  attempt,  exhausting  alike  to  patient  and  doctor,  and, 
when  thoroughly  carried  out,  time  consuming.  In  the  hands  of  those  who 
have  practised  it,  very  good  results  have  been  obtained,  particularly  in  young 
and  carefully  selected  cases.  This  statement  of  the  method  is  taken  from 
Jelliffe  ("System  of  Medicine,"  2nd  Ed.,  vol.  v.)  : 

"His  (Freud's)  general  procedure  is  to  place  the  patient  in  a  recumbent 
position,  the  physician  sitting  behind  the  patient's  head  at  the  end  of  the 
lounge.  The  physician  thus  remains  practically  out  of  sight  of  the  patient, 
who  is  then  asked  to  give  a  detailed  account  of  his  troubles,  and  to  say  every- 
thing that  comes  to  the  mind  irrespective  of  its  seeming  logic  or  sense,  and 
apart  from  disturbing,  mortifying,  or  unnice  suggestions.  In  all  such  his- 
tories gaps  are  inevitable.  These  the  patient  is  urged  to  fill  in  by  thinking 
closely  of  the  attendant  circumstances,  speaking  aloud  all  of  the  flitting 
thoughts  that  pass  during  this  search  ('free  association').  All  the  thoughts 
are  requested  to  be  uttered,  notwithstanding  their  disagreeable  nature.  The 
patient  must  exercise  no  critique  and  remain  passive.     It  will  be  found  that 


HYSTERIA  1099 

the  disagreeable  thoughts  are  pushed  back  with  the  greatest  resistance.  This 
is  made  all  the  more  striking  since  the  hysterical  reaction,  i.  e.,  the  symptom, 
is  the  symbolic  expression  of  the  realization  of  a  repressed  wish  and  gives  the 
patient  some  gratification.  A  great  effort  is  made  to  retain  the  symptom, 
especially  as  its  origin  is  not  really  perceived,  and  since  it  represents,  in 
symbol,  the  individual's  former  conscious  strivings.  In  psycho-analysis  one 
attempts  to  overcome  all  of  these  resistances,  and  by  a  series  of  judicious  and 
tactful  probings  reconduct  into  the  patient's  consciousness  the  hidden  thoughts 
which  underlie  these  symptoms.  Every  symptom  has  some  meaning ;  behind  it 
there  lies  some  associated  mechanism,  the  origin  of  which  the  patient  uncon- 
sciously or  partly  consciously  represses.  In  the  psycho-neurotic  symbol  may 
be  read  the  cryptic  expression  of  the  original  thought  driven  back  and  hidden. 

"To  slowly  analyze  and  pick  apart  the  mechanism  is  the  object  of  the  ana- 
lytical method.  One  needs  not  only  special  tact  for  such  excursions  into  the 
subtleties  of  the  mental  life  of  some  individuals,  but  also  a  developed  method 
of  interpretation.  Every  act,  every  symbolic  expression  or  action,  lapse  in 
speech,  mannerism,  needs  to  be  carefully  noted  and  its  bearing  coordinated. 
Ereud  lays  particular  emphasis  on  the  analysis  of  dreams,  since  he  believes 
that  in  the  dream  the  subconscious,  or  the  '^repressed  conscious'  is  more  apt  to 
reveal  itself.  Hence  a  careful  reading  of  Freud's  'Significance  of  Dreams'  is 
of  the  greatest  value  in  this  study,  also  his  'Psychopathology  of  Every-day 
Life.'  In  his  work  on  dreams  he  has  developed  to  the  full  the  chief  directions 
along  which  his  mind  has  traveled  in  the  psychoanalytical  method. 

"It  is  of  the  utmost  importance  to  trace  back  into  the  earliest  years  the 
striking  emotional  influences  that  have  come  into  experience,  as,  for  Freud, 
the  hysterical  reaction  consists  in  a  perverted  type  of  reaction  to  these  ex- 
periences. As  is  known,  the  blurring,  or  loss  of  an  emotional  influence — an 
affect,  in  short — is  due  to  a  number  of  factors.  In  normal  life  forgetting  is 
the  commonest  type  of  a  corrective  adaptation,  and  forgetting  is  carried  out 
with  special  ease  if  the  emotional  stress  has  not  been  excessive.  Forgetting, 
however,  is  only  a  secondary  phenomenon,  and  usually  is  more  successful  if 
the  immediate  reaction  has  been  an  adequate  one.  Such  immediate  reactions 
express  themselves  as  tears,  as  ang'er,  as  impulsive  acts,  etc.,  and  in  such 
reactions  the  effect  is  discharged.  In  every-day  life  one  calls  it  giving  vent  to 
one's  feelings.  If,  however,  the  reaction  is  suppressed,  the  effect  becomes 
united  to  the  memory  of  the  experience,  and  an  emotional  complex,  or,  to  use 
a  rather  broad  simile,  a  psychic  boil,  results,  which  must  heal  by  absorption, 
by  discharge,  or  by  other  means.  Freud  uses  the  term  ab-rcact  (abreagieren) 
to  signify  the  adequate  reaction,  or  discharge  of  such  effects  or  their  resulting 
complexes.  Talking  the  whole  thing  over,  giving  vent  to  one's  secrets  and 
confessions  are  well-known  abreactions. 

"In  hysteria  certain  of  these  complexes  remain  prominent ;  they  are  neither 
reacted  too  promptly,  nor  is  their  unpleasant  feeling  tone  diminished  by  the 
blurring  process  of  forgetting,  although  it  is  characteristic  of  the  Freiid  point 
of  view  that  the  actual  oxpcrieiue  which  gives  rise  to  them  becomes  forgotten 
and  the  cause  of  the  affect  disturbance  which  becomes  later  converted,  it  may 
be  into  physical  signs,  remains  a])])arontly  unknown  to  the  patient.  It  must 
be  dug  out  by  psycho-analysis,  and  when  once  discovered  catharsis  takes  place 
and  the  patient  becomes  cured." 


1100  DISEASES  OF  THE  NERVOUS  SYSTEM 

Hydrotherapy  is  of  great  value,  especially  wet  packs,  salt  baths,  and 
various  douches.  General  tonics,  such  as  arsenic  and  iron,  may  be  helpful, 
especially  if  the  patients  are  nervous  and  anaemic.  Sedatives  are  rarely  indi- 
cated. Occasionally  bromides  may  be  necessary,  but  for  the  relief  of  sleepless- 
ness all  possible  measures  should  be  resorted  to  before  the  employment  of 
drugs.     The  wet  pack  given  hot  or  cold  at  night  will  usually  suffice. 


X.     NEURASTHENIA 

( Psych  as  til  enia) 

Definition. — A  condition  of  weakness  or  exhaustion  of  the  nervous  system, 
giving  rise  to  various  forms  of  mental  and  bodily  inefficiency. 

The  term,  an  old  one,  but  first  popularized  by  Beard,  covers  an  ill-defined, 
motley  group  of  symptoms,  which  may  be  either  general  and  the  expression 
of  derangement  of  the  entire  system,  or  local,  limited  to  certain  organs;  hence, 
the  terms  cerebral,  spinal,  cardiac,  and  gastric  neurasthenia. 

Etiology. — The  causes  may  be  grouped  as  hereditary  and  acquired. 

(a)  Hereditary. — We  do  not  all  start  in  life  with  the  same  amount  of 
nerve  capital.  Parents  who  have  led  irrational  lives,  indulging  in  excesses  of 
various  kinds,  or  who  have  been  the  subjects  of  nervous  complaints  or  of  men- 
tal trouble,  may  transmit  to  their  children  an  organization  which  is  defective 
in  what,  for  want  of  a  better  term,  we  must  call  "nerve  force.'''  Such  indi- 
viduals start  handicapped  with  a  neuropathic  predisposition,  and  furnish  a 
considerable  proportion  of  our  neurasthenic  patients.  As  van  Gieson  sonor- 
ously puts  it,  "the  potential  energies  of  the  higher  constellations  of  their 
association  centres  have  been  squandered  by  their  ancestors."  So  long  as 
these  individuals  are  content  to  transact  a  moderate  business  with  their  life 
capital,  all  may  go  well,  but  there  is  no  reserve,  and  in  the  exigencies  of  mod- 
ern life  these  small  capitalists  go  under  and  come  to  us  as  bankrupts. 

(&)  Acquired. — The  functions,  though  perverted  most  readily  in  persons 
who  have  inherited  a  feeble  organization,  may  also  be  damaged  in  persons  with 
no  neuropathic  predisposition  by  exercise  which  is  excessive  in  proportion  to 
the  strength — i.  e.,  by  strain.  The  cares  and  anxieties  attendant  upon  the 
gaining  of  a  livelihood  may  be  borne  without  distress,  but  in  many  persons  the 
strain  becomes  excessive  and  is  first  manifested  as  worry.  The  individual  loses 
the  distinction  between  essentials  and  non-essentials,  trifles  cause  annoyance, 
and  the  entire  organism  reacts  with  unnecessary  readiness  to  slight  stimuli, 
and  is  in  a  state  which  the  older  writers  called  "irritable  weakness."  If  such 
a  condition  be  taken  early  and  the  patient  given  rest,  the  balance  is  quickly 
restored.  In  this  group  may  be  placed  a  large  proportion  of  the  neurasthenia 
which  we  see  among  business  men,  teachers,  and  journalists.  Neurasthenia 
may  follow  the  infectious  diseases,  particularly  influenza,  typhoid  fever,  and 
syphilis.  The  abuse  of  certain  drugs,  alcohol,  tobacco,  morphine  may  lead  to 
neurasthenia,  though  the  drug  habit  is  more  often  a  result  than  a  cause. 

(c)  Sexual  Causes. — TJndoubtedly  the  part  played  in  the  production  of 
hysteria  and  allied  neurosis  by  sexual  factors  is  of  the  first  importance.  As 
already  stated,  Freud  regards  sexual  trauma  as  the  basis  of  hysteria,  and  he 


NETJRASTHF.NiA  1101 

also  regards  neurasthenia  as  largely  a  product  of  disturbance  in  the  sexual 
sphere.  For  him  and  his  school  the  sexual  impulses  furnish  the  basis  of  the 
psychoneuroses.  Eepressed  as  they  have  to  be  in  so  many  in  our  modern 
civilization,  without  normal  outlet,  the  thought  formations,  retained  in  the 
unconscious  state,  express  themselves  by  means  of  somatic  phenomena — the 
objective  features  of  hysteria  and  neurasthenia.  Cherchez  la  femme  is  a  safe 
rule  in  investigating  a  neurotic  case.  Freud  may  have  ridden  his  hobby  too 
hard,  particularly  in  the  insistence  upon  the  importance  of  infantile  sexuality, 
but  in  recognizing  the  role  of  the  younger  Aphrodite  in  the  lives  of  men  and 
women  he  has  but  followed  the  great  master,  Plato,  who  saw,  while  he  de- 
plored, the  havoc  wrought  by  her  universal  dominance. 

The  traumatic  forms  will  be  considered  separately. 

Symptoms. — These  are  extremely  varied,  and  may  be  general  or  localized; 
more  often  a  combination  of  both.  The  appearance  of  the  patient  is  sug- 
gestive, sometimes  characteristic,  but  difficult  to  describe.  Important  in- 
formation can  be  gained  by  the  physician  if  he  observes  the  patient  closely  as 
he  enters  the  room — the  way  he  is  clothed,  the  manner  in  which  he  holds  his 
body,  his  facial  expression,  and  the  humor  which  he  is  in.  Loss  of  weight  and 
slight  anaemia  may  be  present.  The  physical  debility  may  reach  a  high  grade 
and  the  patient  may  be  confined  to  bed.  Mentally  the  patients  are  usually 
low-spirited  and  despondent;  women  are  frequently  emotional. 

The  local  symptoms  may  dominate  the  situation,  and  there  have  accord- 
ingly been  described  a  whole  series  of  types  of  the  disease — cerebral,  spinal, 
eardio-vascular,  gastric,  and  sexual.  In  all  forms  there  is  a  striking  lack  of 
accordance  between  the  symptoms  of  which  the  patient  complains  and  the 
objective  changes  discoverable  by  the  physician.  In  nearly  every  clinical  type 
of  the  disease  the  predominant  symptoms  are  referable  to  pathological  sensa- 
tions and  the  psychic  effects  of  these.  Imperfect  sleep  is  complained  of 
by  a  majority  of  patients,  or,  if  not  complained  of,  is  found  to  exist  on  inquiry. 

In  the  cerebral  or  "psychic  form  the  symptoms  are  chiefly  connected  with 
an  inability  to  perform  the  ordinary  mental  work.  Thus,  a  row  of  figures 
can  not  be  correctly  added,  the  dictation  or  the  writing  of  a  few  letters  is  a 
source  of  the  greatest  worry,  the  transaction  of  petty  details  in  business  is  a 
painful  effort,  and  there  is  loss  of  power  of  fixed  attention.  With  this  condi- 
tion there  may  be  no  headache,  the  appetite  may  be  good,  and  the  patient 
may  sleep  v/ell.  As  a  rule,  however,  there  are  sensations  of  fulness  and  weight 
or  flushes,  if  not  actual  headache.  Sleeplessness  is  frequent  in  this  form, 
and  may  be  the  first  manifestation.  Some  patients  are  good-tempered  and 
cheerful  but  a  majority  are  moody,  irritable,  and  depressed. 

Eijpera'stliesia,  especially  to  sensations  of  pain,  is  one  of  the  main  charac- 
teristics of  almost  all  neurasthenic  individuals.  The  sensations  are  nearly 
always  referred  to  some  special  region — the  skin,  eye  muscles,  the  joints,  the 
blood-vessels,  or  the  viscera.  It  is  frequently  possible  to  localize  a  number 
of  points  painful  to  pressure  (A^alleix's  points).  In  some  patients  there  is 
marked  vertigo,  occasionally  resembling  that  of  Meniere's  disease. 

If  such  pathological  sensations  continue  for  a  long  time  the  mood  and 

character  of  the  patient  gradually  alter.     The   so-called   "irritable  humor" 

develops.     Many  obnoxiously  egoistic  individuals  met  with  in  daily  life  are  in 

.  reality  examples  of  psychic  neurasthenia.     Everything  is  complained  of.     The 


1102  DISEASES  OF  THE  NEEVOUS  SYSTEM 

patient  demands  the  greatest  consideration  for  his  condition;  he  feels  that  he 
has  been  deeply  insulted  if  his  desires  are  not  always  immediately  granted. 
He  may  at  the  same  time  have  but  little  consideration  for  others.  Indeed,  in 
the  severer  forms  he  may  show  a  malicious  pleasure  in  attempting  to  make 
people  who  seem  happier  than  himself  uncomfortable.  Such  patients  com- 
plain frequently  that  they  are  "misunderstood"  by  their  fellows. 

In  many  cases  the  so-called  "anxiety  conditions"  gradually  come  on;  one 
scarcely  ever  sees  a  case  of  advanced  neurasthenia  without  the  existence  of 
some  form  of  "anxiety."  In  the  simpler  forms  of  anxiety  (nosophobie)  there 
may  be  only  a  fear  of  impending  insanity  or  of  approaching  death  or  of  apo- 
plexy. More  frequently  the  anxious  feeling  is  localized  somewhere  in  the 
body — in  the  prgecordial  region,  in  the  head;,  in  the  abdomen,  in  the  thorax, 
or  more  rarely  in  the  extremities. 

In  some  cases  the  anxiety  becomes  intense  and  the  patients  are  restless,  and 
declare  that  they  do  not  know  what  to  do  with  themselves.  They  may  throw 
themselves  upon  a  bed,  crying  and  complaining,  and  making  convulsive  move- 
ments with  the  hands  and  feet.  Suicidal  tendencies  are  not  uncommon  in 
such  cases,  and  the  patients  may  in  desperation  actually  take  their  own  lives. 

Involuntary  mental  activity  may  be  very  troublesome;  the  patient  com- 
plains that  when  he  is  overtired  thoughts  which  he  cannot  stop  or  control 
run  through  his  head  with  lightning-like  rapidity.  In  other  cases  there  is 
marked  absence  of  ideas,  the  individual's  mind  being  so  filled  up  owing  to  the 
overexcitability  of  latent  memory  pictures  that  he  is  unable  to  form  the  proper 
associations  for  ideas  called  up  by  external  stimuli.  Sometimes  a  patient 
complains  that  a  definite  word,  a  name,  a  number,  a  melody,  or  a  song  keeps 
running  in  his  head  in  spite  of  all  he  can  do  to  abolish  it. 

In  the  severer  cases  the  so-called  "phohias"  are  common.  A  frequent  form 
is  agoraphohia,  in  which  patients  when  they  come  into  an  open  space  are 
oppressed  by  a  feeling  of  anxiety.  They  seem  "frightened  to  death,"  and 
commence  to  tremble;  they  complain  of  compression  of  the  thorax  and  pal- 
pitation of  the  heart.  They  may  break  into  profuse  perspiration  and  assert 
that  they  feel  as  though  chained  to  the  ground  or  that  they  can  not  move  a 
step.  It  is  remarkable  that  in  some  such  cases  the  open  space  can  be  crossed 
if  the  individual  be  accompanied  by  some  one,  even  by  a  child,  or  if  he  carry 
a  stick  or  an  umbrella  !  Other  people  are  afraid  to  be  left  alone  (monophobia) , 
especially  in  a  closed  compartment  (claustrophobia). 

The  fear  of  people  and  of  society  is  known  as  anthropophobia.  A  whole 
series  of  other  phobias  has  been  described — batophobia,  or  the  fear  that  high 
things  will  fall;  pathophobia,  or  fear  of  disease;  siderodromophobia,  or  fear 
of  a  railway  Journey;  siderophobia  or  astrophobia,  fear  of  thunder  and  light- 
ning. Occasionally  we  meet  with  individuals  who  are  afraid  of  eveiything  and 
every  one — victims  of  the  so-called  pantophobia.  By  psycho-analysis  it  is  pos- 
sible to  explain  the  mechanism  of  these  fears. 

The  special  senses  may  be  disturbed,  particularly  vision.  An  aching  or 
weariness  of  the  eyeballs  after  reading  a  few  minutes  or  flashes  of  light  are 
common  symptoms.  The  "irritable  eye/'  the  so-called  nervous  or  neurasthenic 
asthenopia,  is  familiar  to  every  physician.  There  may  be  acoustic  disturbances 
• — hyperalgesia  and  even  true  hyperacusia. 

One  of  the  most  common  symptoms  is  pressure  in  the  head.     This  symp- 


NEUEASTHENIA  1103 

torn,  variously  described,  may  be  diffuse,  but  is  more  frequently  referred  to 
some  one  region — frontal,  temporal,  parietal,  or  occipital. 

When  the  spinal  symptojns  predominate — spinal  irritation  or  spinal  neuras- 
thenia— in  addition  to  many  of  the  features  just  mentioned,  the  patients  com- 
plain of  weariness  on  the  least  exertion,  of  weakness,  pain  in  the  back,  inter- 
costal neuralgiform  pains,  and  of  aching  pains  in  the  legs.  There  may  be 
spots  of  local  tenderness  on  the  spine.  The  rachialgia  may  be  spontaneous, 
or  may  be  noticed  only  on  pressure  or  movement.  Occasionally  there  may  be 
disturbances  of  sensation,  particularly  numbness  and  tingling,  and  the  reflexes 
may  be  increased.  Visceral  neuralgias,  especially  in  connection  with  the 
genital  organs,  are  frequent.  The  aching  pain  in  the  back  or  in  the  back  of 
the  neck  is  the  most  constant  complaint.  In  women  it  is  often  impossible 
to  say  whether  the  condition  is  neurasthenia  or  hysteria.  It  is  in  these  cases 
that  the  disturbances  of  muscular  activity  are  most  pronounced,  and  in  the 
French  writings  amyostJienia  plays  an  important  role.  The  symptoms  may  b3 
irritative  or  paretic,  or  a  combination  of  both.  Disturbances  of  coordination 
are  not  uncommon  in  the  severer  forms.  These  are  particularly  prone  to 
involve  the  associated  movements  of  the  eye  muscles,  leading  to  asthenopic 
lack  of  accommodation.  Drooping  of  one  eyelid  is  common,  probably  owing 
to  insuflficient  innervation  on  the  part  of"  the  sympathetic  rather  than  to 
paresis  of  the  oculomotor  nerve.  Occasionally  Eomberg's  symptom  is  present, 
and  the  patient,  or  his  physician,  may  fear  a  beginning  tabes.  More  rarely 
there  is  disturbance  of  such  coordinated  acts  as  writing  and  articulation,  not 
unlike  those  seen  at  the  onset  of  general  paresis.  Such  symptoms  are  always 
alarming,  and  the  greatest  care  must  be  taken  in  establishing  a  diagnosis. 
That  they  may  be  the  symptoms  of  pure  neurasthenia  can  not  be  doubted. 

The  reflexes  are  usually  increased,  the  deep  reflexes  especially  never  being 
absent.  The  condition  of  the  superficial  reflexes  is  less  constant,  though  these, 
too,  are  usually  increased.  The  pupils  are  often  dilated,  and  the  reflexes  are 
usually  normal.  There  may  be  inequality  of  the  pupils.  Errors  in  refraction 
are  common,  the  correction  of  which  may  give  great  relief. 

In  another  type  the  muscular  weakness  is  extreme,  and  may  go  on  to 
complete  motor  helplessness.  Very  thorough  examination  is  necessary  before 
deciding  as  to  the  nature  of  the  affection,  since  in  some  instances  serious  mis- 
takes have  been  made.  Here  belong  the  atremia  of  Neftel,  the  akinesia  algera 
of  Mobius,  and  the  neurasthenic  form  of  astasia  abasia  described  by 
Binswanger. 

In  other  cases  the  cardio-vascular  symptoms  are  the  most  distressing,  and 
may  occur  with  only  slight  disturbance  of  the  cerebro-spinal  functions,  though 
the  conditions  are  nearly  always  combined.  Palpitation  of  the  heart,  irregular 
and  very  rapid  action  (neurasthenic  tachycardia),  and  pains  and  oppressive 
feelings  in  the  cardiac  region  are  the  most  common  symptoms.  Some  of  these 
are  due  to  the  "dropped"  heart  which  may  be  dilated.  The  slightest  excite- 
ment may  be  followed  by  increased  action  of  the  heart,  sometimes  associated 
with  sensations  of  dizziness  and  anxiety,  and  the  patients  frequently  have  the 
idea  that  they  suffer  from  serious  disease  of  this  organ.  Attacks  of  "pseudo- 
angina"  may  occur. 

Vaso-motor  disturbances  constitute  a  special  feature  of  many  cases. 
Flushes  of  heat,  especially  in  the  head,  and  transient  hyperaemia  of  the  skin 


1104  DISEASES  OF  THE  NERVOUS  SYSTEM 

may  be  very  distressing  symptoms.  Profuse  sweating  may  occur,  either  local 
or  general,  and  sometimes  nocturnal.  The  pulse  may  show  interesting 
features,  owing  to  the  extreme  relaxation  of  the  peripheral  arterioles.  The 
arterial  throbbing  may  be  everywhere  visible,  almost  as  much  as  in  aortic 
insufficiency.  The  pulse,  too,  may  have  a  somewhat  collapsing  quality  and  the 
capillary  pulse  may  be  seen.  A  characteristic  symptom  in  some  cases 
is  the  throhhing  aorta.  This  "preternatural  pulsation  in  the  epigastrium," 
as  Allan  Burns  calls  it,  may  be  extremely  forcible  and  suggest  abdominal 
aneurism.  The  subjective  sensations  associated  with  it  may  be  very  un- 
pleasant, particularly  when  the  stomach  is  empty. 

In  women  especially,  and  sometimes  in  men,  the  peripheral  blood-vessels 
are  contracted,  the  extremities  are  cold,  the  nose  is  red  or  blue,  and  the  face 
has  a  pinched  expression.  These  patients  feel  much  more  comfortable  when 
the  cutaneous  vessels  are  distended,  and  resort  to  various  means  to  favor  this 
(wearing  of  heavy  clothing,  use  of  diffusible  stimulants). 

The  general  features  of  g astro-intestinal  neurasthenda  have  been  dealt  with 
under  the  section  on  nervous  dyspepsia.  The  connection  with  dilatation  of 
the  stomach,  floating  kidney,  and  enteroptosis  has  been  mentioned. 

In  sexual  neurasthenia  there  is  an  irritable  weakness  of  tlie  sexual 
organs  manifested  by  nocturnal  emissions,  unusual  depression  after  inter- 
course, and  often  by  a  dread  of  impotence.  The  mental  condition  of  these 
patients  is  most  pitiable,  and  they  fall  an  easy  prey  to  quacks  and  charlatans. 
In  males  these  symptoms  are  frequently  due  to  diseased  conditions  in  the  deep 
urethra,  especially  of  the  verumontanum,  and  prostate.  Spermatorrhoea  is 
the  bugbear  of  the  majority.  They  complain  of  continued  losses  especially 
with  defecation  or  micturition.  Microscopic  examination  sometimes  reveals 
the  presence  of  spermatozoa.  Actual  nervous  impotence  is  not  uncommon. 
The  "painful  testicle"  is  a  well-known  neurasthenic  phenomenon.  In  tlie 
severer  cases,  especially  those  bearing  the  stigmata  of  degeneration,  there  may 
be  sexual  perversion.  In  females  it  is  common  to  find  a  tender  ovary,  and 
painful  or  irregular  menstruation.  There  may  be  disturbances  in  the  sexual 
sphere. 

Diagnosis. — Psychasthenia. — Under  this  term  Janet  would  separate  from 
neurasthenia  the  cases  characterized  by  mental,  emotional,  and  psychical  dis- 
turbances, imperative  ideas,  phobias  of  all  sorts,  doubts,  enfeebled  will,  uncon- 
trollable movements,  and  many  of  the  borderland  features  of  the  insanity  of 
young  persons.  It  is  really  an  inherited  psychoneurosis,  while  neurasthenia 
is  usually  acquired.  Obsessions  of  all  sorts  characterize  the  condition  and 
there  may  be  a  feeling  of  unreality  and  even  of  loss  of  personality.  How  com- 
plicated the  condition  may  be  is  shown  from  the  following  varieties  distin- 
guished by  Janet:  (1)  The  doubter,  in  whom  obsessive  ideas  are  not  very 
precise,  more  of  the  nature  of  a  general  indication  rather  than  a  specific  idea, 
such  as  a  craze  for  research,  for  explanation,  for  computing.  (2)  The  scrupu- 
lous, whose  obsessions  are  of  a  moral  nature.  Their  manias  are  of  literalness 
of  statement,  of  exact  truth,  of  conjuration,  of  reparation,  of  symbols,  etc. 
(3)  The  criminal,  whose  obsessive  ideas  are  of  homicide,  theft,  and  other  overt 
acts.  The  impulsive  idea  is  stronger  in  this  than  in  the  other  varieties.  (-1) 
The  inebriates,  morphinomaniac,  etc.,  in  whom  the  impulse  seems  to  be  least 


NEURASTHENIA  1105 

resistible.  (5)  The  genesicaUy  perverted.  (0)  Delirious  psijchasthenia,  in 
which  a  delirious  state  of  mind  occurs,  connected  with  the  obsession. 

Neurasthenia  is  a  disease  above  all  others  which  has  to  be  diagnosed  from 
the  subjective  statements  of  the  patient,  and  from  an  observation  of  his  general 
behavior  rather  than  from  the  physical  examination.  The  physical  examina- 
tion is  of  the  highest  importance  in  excluding  other  diseases  likely  to  be  con- 
founded with  it.  That  somatic  changes  occur  and  that  physical  signs  are  often 
to  be  made  out  is  very  true,  but  there  is  nothing  typical  or  pathognomonic  in 
these  objective  changes. 

The  hypochondriac  differs  from  the  neurasthenic  in  the  excessive  psychic 
distortion  of  the  pathological  sensations  to  which  he  is  subject.  He  is  the 
victim  of  actual  delusions  regarding  his  condition. 

The  confusion  of  neurasthenia  with  hysteria  is  still  more  frequent;  in 
women  especially  a  diagnosis  of  hysteria  is  often  made  when  in  reality  the 
condition  is  one  of  neurasthenia.  In  the  absence  of  hysterical  paroxysms,  of 
crises,  and  of  those  marked  emotional  and  intellectual  characteristics  of  the 
hysterical  individual  the  diagnosis  of  hysteria  should  not  be  made.  If 
hysterical  stigmata  (paralyses,  convulsions,  contractures,  angesthesias,  altera- 
tions in  the  visual  field,  etc.)  are  present,  the  diagnosis  is  not  difficult. 

Epilepsy  is  not  likely  to  be  confounded  with  neurasthenia  if  there  be 
definite  epileptic  attacks,  but  the  cases  of  petit  mal  may  be  puzzling. 

The  onset  of  exophthalmic  goitre  may  be  mistaken  for  neurasthenia,  espe- 
cially if  there  be  no  exophthalmos  at  the  beginning.  The  emotional  disturb- 
ances and  the  irritability  of  the  heart  may  mislead  the  physician.  Tubercu- 
losis should  always  be  excluded  and  careful  search  made  for  signs  of  any  in- 
ternal secretion  disturbance.  In  pronounced  cases  of  nervous  prostration  the 
differential  diagnosis  from  the  various  psychoses  may  be  extremely  difficult. 

The  two  forms  of  organic  disease  of  the  nervous  system  with  which  neuras- 
thenia is  most  likely  .to  be  confounded  are  tabes  and  general  paresis.  The 
symptoms  of  the  spinal  form  of  neurasthenia  may  resemble  those  of  the  former 
disease,  while  the  symptoms  of  the  psychic  or  cerebral  form  of  neurasthenia 
may  be  very  similar  to  those  of  general  paresis.  The  diagnosis,  as  a  rule, 
presents  no  difficulty  if  the  physician  makes  a  thorough  routine  examination. 
It  is  only  the  superficial  study  of  a  case  that  is  likely  to  lead  one  astray.  In 
tabes  a  consideration  of  the  sensory  disturbances,  of  the  deep  reflexes,  and  of 
the  pupillary  findings  will  establish  the  presence  or  absence  of  the  disease. 
In  general  paresis  there  is  sometimes  more  difficulty.  The  onset  is  often 
characterized  by  symptoms  quite  like  those  of  ordinary  neurasthenia,  and  the 
physician  may  overlook  the  grave  nature  of  the  malady.  The  mistake  in  the 
other  direction  is,  however,  perhaps  just  as  common.  A  physician  who  has 
seen  a  case  of  general  paresis  arise  out  of  what  appeared  to  be  one  of  pro- 
nounced neurasthenia  is  too  prone  afterward  to  suspect  every  neurasthenic 
to  be  developing  the  malign  affection.  The  most  marked  symptoms  of  psychic 
exhaustion  do  not  justify  a  diagnosis  of  general  paresis  even  when  the  history 
is  suspicious,  unless  along  with  it  there  is  a  definite  paresis  of  the  pupils,  of 
the  facial  muscles,  or  of  the  muscles  of  articulation.  The  physician  should 
be  sharply  on  the  lookout  for  intellectual  defects,  paraphasia,  facial  paresis, 
and  sluggishness  of  the  pupils.  The  examination  of  the  spinal  fluid  will  re- 
move any  doubt. 


1106  DISEASES  OF  THE  NEEVOUS  SYSTEM 

Treatment. — Prophylaxis. — Many  patients  come  under  our  care  a  gen- 
eration too  late  for  satisfactory  treatment,  and  it  may  be  imjDossible  to  restore 
the  exhausted  cajoitah  The  greatest  care  should  be  taken  in  the  rearing  of 
children  of  neuropathic  predisposition.  From  a  very  early  age  they  should 
be  submitted  to  a  process  of  "psychic  hardening,"  every  effort  being  made  to 
strengthen  the  bodily  and  mental  condition.  Even  in  infancy  the  child  should 
not  be  pampered.  Later  on  the  greatest  care  should  be  exercised  with  regard 
to  food,  sleep,  and  school  work.  Complaints  of  children  should  not  be  too 
seriously  considered.  Much  depends  upon  the  example  set  by  the  parents.  An 
emotional,  constantly  complaining  mother  will  rack  the  nervous  system  of  a 
delicate  child.  In  some  instances,  for  the  welfare  of-  a  developing  boy  or 
girl,  the  physician  may  find  it  necessary  to  advise  removal  from  home. 

ISTeurotic  children  are  especially  liable  during  development  to  fits  of  temper 
and  of  emotional  disturbance.  These  should  not  be  too  lightly  considered. 
Above  all,  violent  chastisement  in  such  cases  is  to  be  avoided,  and  loss  of 
temper  on  the  part  of  the  parent  or  teacher  is  particularly  pernicious  for  the 
nervous  system  of  the  child.  ■  Where  possible,  in  such  instances,  the  best  treat- 
ment is  to  put  the  obstreperous  child  immediately  to  bed,  and  if  the  excite- 
ment and  temper  continue  a  warm  bath  followed  by  a  cool  douche  may  be 
effective.    If  he  be  put  to  bed  after  the  bath  sleep  soon  follows. 

Special  attention  is  necessary  at  puberty  in  both  boys  and  girls.  If  there 
be  at  this  period  any  marked  tendency  to  emotional  disturbance  or  to  intellec- 
tual weakness  the  child  should  be  removed  from  school  and  every  care  taken 
to  avoid  unfavorable  influences. 

Personal  Hygiene. — Throughout  life  individuals  of  neuropathic  predis- 
position- should  obey  scrupulously  certain  hygienic  and  prophylactic  rules.  In- 
tellectual work  especially  should  be  judiciously  limited  and  alternate  fre- 
quently with  periods  of  repose.  Excitement  of  all  kinds  should  be  avoided, 
and  such  individuals  will  do  well  to  be  abstemious  in  the  use  of  tobacco,  tea, 
coffee,  and  alcohol,  if,  indeed,  they  be  permitted  to  use  them  at  all.  The  habit 
of  taking  at  least  once  a  year  a  prolonged  holiday  in  the  woods,  in  the  moun- 
tains, or  at  the  seashore,  should  be  urgently  enjoined  upon  every  neuropathic 
individual.  In  many  instances  it  is  found  to  be  the  greatest  relief  and  rest 
if  the  patient  can  take  his  holiday  away  from  his  relatives. 

During  ordinary  life  nervous  people  should,  during  some  portion  of  each 
day,  pay  rational  attention  to  the  body.  Cold  baths,  swimming,  exercises  in 
the  gymnasium,  gardening,  golf,  lawn  tennis,  cricket,  hunting,  shooting,  row- 
ing, sailing,  and  bicycling  are  of  value  in  maintaining  the  general  nutrition. 
Such  exercises  are  to  be  recommended  only  to  individuals  physically  equal 
to  them.  If  neurasthenia  be  once  well  established  the  greatest  care  must  be 
observed  in  the  ordering  of  exercise.  Many  nervous  girls  have  been  com- 
pletely broken  down  by  following  injudicious  advice  with  regard  to  long  walks. 

Teeatment. — The  treatment  of  neurasthenia  when  once  established  pre- 
sents a  varied  problem  to  the  thoughtful  physician.  Every  case  must  be  han- 
dled upon  its  own  merits,  no  two,  as  a  rule,  requiring  exactly  the  same  methods. 
In  general  it  will  be  the  aim  to  remove  the  patient  as  far  as  possible  from 
the  influences  which  have  led  to  his  downfall,  and  to  restore  to  normal  the 
nervous  mechanisms  which  have  been  weakened  by  injurious  influences.     The 


NEUEASTHENIA  1107 

general  character  of  the  individual,  his  physical  and  social  status,  must  be 
considered  and  the  therapeutic  measures  carefully  adjusted  to  these. 

The  diagnosis  having  been  settled,  the  physician  may  assure  the  patient 
that  with  prolonged  treatment,  during  which  his  cooperation  is  absolutely 
essential,  he  may  expect  to  get  well.  He  must  be  told  that  much  depends  upon 
himself  and  that  he  must  make  a  vigorous  effort  to  overcome  certain  of  his 
tendencies,  and  that  all  his  strength  of  will  will  be  needed  to  further  the 
progress  of  the  cure.  In  business  or  professional  men,  in  whom  the  con- 
dition develops  as  a  result  of  overwork  or  overstudy,  it  may  be  sufficient  to 
enjoin  absolute  rest  with  change  of  scene  and  diet.  A  trip  abroad  or,  if  there 
are  symptoms  of  nervous  dyspepsia,  a  residence  at  one  of  the  Spas  will  usually 
prove  sufficient.  The  excitement  of  large  cities  should  be  avoided.  The  longer 
the  disease  has  lasted  and  the  more  intense  the  symptoms  have  been,  the  longer 
the  time  necessary  for  the  restoration  of  health.  In  cases  of  any  severity  the 
patient  must  be  told  that  at  least  six  months'  complete  absence  from  busi- 
ness, under  strict  medical  guidance,  will  be  necessary.  Shorter  periods  may 
be  of  benefit,  which,  however,  as  a  rule,  will  be  only  temporary. 

It  will  often  be  found  advisable  to  make  out  a  daily  programme,  which 
shall  occupy  almost  the  whole  time  of  the  patient.  At  first  he  need  know 
nothing  about  this,  the  case  being  given  over  entirely  to  the  nurse.  As  im- 
provement advances,  moderate  physical  and  intellectual  exercises,  alternating 
frequently  with  rest  and  the  administration  of  food,  may  be  undertaken. 
Some  one  hour  of  the  day  may  be  left  free  for  reading,  correspondence,  con- 
versation, and  games.  In  some  instances  the  writing  of  letters  is  particularly 
harmful  and  must  be  prohibited  or  limited.  Cultured  individuals  may  find 
benefit  from  attenuo^.  to  drawing,  painting,  modelling,  translating  from  i 
foreign  language,  the  making  of  abstracts,  etc.,  for  short  periods  in  the  day. 

In  some  cases,  including  a  large  proportion  of  neurasthenic  women,  a  sys- 
tematic rest  treatment  rigidly  carried  out  should  be  tried.  The  patient  must 
be  isolated  from  her  friends,  and  any  regulations  undertaken  must  be  strictly 
adhered  to,  the  consent  of  the  patient  and  the  family  having  first  been  gained. 
The  treatment  of  the  gastric  and  intestinal  symptoms  has  been  considered. 
For  the  irregular  pains,  particularly  in  the  back  and  neck,  the  cautery  is  in- 
valuable. 

I-Iydrotherapy  is  indicated  in  nearly  every  case  if  it  can  be  properly  applied. 
Much  can  be  done  at  home  or  in  an  ordinary  hospital,  but  for  systematic 
hydrotherapeutic  treatment  residence  in  a  suitable  sanitarium  is  necessary. 
The  wet  pack  is  of  especial  value  and,  particularly  at  night,  in  cases  of  sleep- 
lessness, is  perhaps  the  best  remedy  against  insomnia  we  have.  Salt  baths 
are  more  helpful  to  some  patients.  The  various  forms  of  douches,  partial 
packs,  etc.,  may  be  valuable  in  individual  cases.  Electrotherapy  is  of  some 
value,  though  only  in  combination  with  psychic  treatment  and  hydrotherapy. 

Special  care  should  be  given  to  the  recognition  of  local  disease  and  proper 
measures  instituted.  Attention  to  the  eyes  is  important.  Infection  of  the 
naso-pharynx,  teeth  or  tonsils,  sinus  disease,  visceroptosis,  or  anfemia  should 
be  corrected.  In  women  the  pelvic  organs  and  in  men  the  deep  urethra  and 
prostate  may  require  treatment. 

Treatment  by  drugs  should  be  avoided  as  much  as  possible.  They  are  of 
benefit  chiefly  in  the  combating  of  single  symptoms.    Alcohol,  morphia,  chloral. 


1108  DISEASES  OE  THE  NERVOUS  SYSTEM 

or  cocaine  should  never  be  given.  General  tonics  may  be  helpful,  especially 
if  the  individual  be  ansemic,  when  arsenic  and  iron  are  indicated.  Eor  the 
severer  pains  and  nervous  attacks  some  sedative  may  be  necessary,  especially 
at  the  beginning  of  the  treatment.  The  bromides  may  be  given  with  advan- 
tage. An  occasional  dose  of  phenacetin  or  acetyl  salicylic  acid  may  be  re- 
quired, but  the  less  of  these  substances  we  can  get  along  with  the  better.  Eor 
the  relief  of  sleeplessness  all  possible  measures  should  be  resorted  to  before  the 
employment  of  drugs.  The  wet  pack  will  usually  suffice.  If  absolutely  neces- 
sary to  give  a  drug,  sulphonal,  trional,  or  barbital  may  be  employed. 

In  cases  in  which  the  anxiety  conditions  are  disturbing  the  cautious  use 
of  opium  in  pill  form  may  be  necessary,  since,  as  in  the  psychoses,  opium  here 
will  sometimes  yield  permanent  relief.  A  prolonged  treatment  with  opium  is, 
however,  never  necessary  in  neurasthenia. 

PsYCHOTHEEAPT. — Hypnotism  is  rarely  indicated.  Carefully  practised 
suggestion  is  most  helpful  and  psycho-analysis  is  of  value. 

The  use  of  religious  ideas  and  practices  may  be  most  helpful,  and  this  has 
come  into  vogue  in  various  forms,  as  Christian  Science,  Mental  Healing,  etc. 
It  is  an  old  story.  In  all  ages,  and  in  all  lands,  the  prayer  of  faith,  to  use 
the  words  of  St.  James,  has  healed  the  sick;  and  we  must  remember  that 
amid  the  JEsculapian  cult,  the  most  elaborate  and  beautiful  system  of  faith 
healing  the  world  has  seen,  scientific  medicine  took  its  rise.  As  a  profession, 
consciously  or  unconsciously,  more  often  the  latter,  faith  has  been  one  of  our 
most  valuable  assets,  and  Galen  expressed  a  great  truth  when  he  said,  "He 
cures  most  successfully  in  whom  the  people  have  the  greatest  confidence."  It 
is  in  these  cases  of  neurasthenia  and  psychasthenia,  the  weak  brothers  and  the 
weak  sisters,  that  the  personal  character  of  the  physician  comes  into  play,  and 
once  let  him  gain  the  confidence  of  the  patient,  he  can  work  just  the  same 
sort  of  miracles  as  Our  Lady  of  Lourdes  or  Ste.  Anne  de  Beaupre.  Three 
elements  are  necessary :  first,  a  strong  personality  in  whom  the  individual  has 
faith — Christ,  Buddha,  ^sculapius  (in  the  days  of  Greece),  one  of  the  saints, 
or,  what  has  served  the  turn  of  common  humanity  very  well,  a  physician. 
Secondly,  certain  accessories — a  shrine,  a  sanctuary,  the  services  of  a  temple, 
or  for  us  a  hospital  or  its  equivalent,  with  a  skillful  nurse.  Thirdly,  sugges- 
tion, either  of  the  "only  believe,"  "feel  it,"  "will  it"  attitude  of  mind,  which 
is  the  essence  of  every  cult  and  creed,  or  of  the  active  belief  in  the  assurance  of 
the  physician  that  the  precious  boon  of  health  is  within  reach. 


XI.     THE  TRAUMATIC  NEUROSES 

{Railway  Brain  and  Bailway  Spi7ie;  Traumatic  Hysteria) 

Definition. — A  morbid  condition  following  shock  which  presents  the  symp- 
toms of  neurasthenia  or  hysteria  or  of  both. 

Erichsen  regarded  the  condition  as  the  result  of  inflammation  of  the  men- 
inges and  cord,  and  gave  it  the  name  "railway  spine."  Walton  and  J.  J.  Put- 
nam, of  Boston,  were  the  first  to  recognize  the  hysterical  nature  of  many  of 
the  cases,  and  to  Westphal's  pupils  we  owe  the  name  traumatic  neurosis. 

Etiology. — The  condition  follows  an  accident,  often  in  a  railway  train,  in 


THE  TRAUMATIC  NEUROSES  1109 

which  injury  has  been  sustained,  or  succeeds  a  shock  or  concussion,  from  which 
the  patient  may  apparently  not  have  suffered  in  his  body.  A  man  may  appear 
perfectly  well  for  several  days,  or  even  a  week  or  more,  and  then  develop  the 
symptoms  of  the  neurosis.  Bodily  shock  or  concussion  is  not  necessary.  The 
affection  may  follow  a  profound  mental  impression;  thus,  an  engine-driver 
ran  over  a  child,  and  received  thereby  a  very  severe  shock,  subsequent  to  which 
the  most  pronounced  symptoms  of  ueurasthenia  developed.  .  Severe  mental 
strain  combined  with  bodily  exposure  may  cause  it,  as  in  a  case  of  a  naval 
officer  who  was  wrecked  in  a  violent  storm  and  exposed  for  more  than  a  day 
in  the  rigging  before  he  was  rescued.  A  slight  blow,  a  fall  from  a  carriage 
or  on  the  stairs  may  suffice.  The  possibility  of  actual  injury  of  the  spine  should 
always  be  considered. 

Symptoms.— The  cases  may  be  divided  into  three  groups:  simple  neuras- 
thenia, cases  with  marked  hysterical  manifestations,  and  cases  with  severe 
symptoms  indicating  or  simulating  organic  disease. 

(1)  Simple  Traumatic  Neurasthenia. — The  first  symptoms  usually  de- 
velop a  few  weeks  after  the  accident,  which  may  or  may  not  have  been  asso- 
ciated with  an  actual  trauma.  The  patient  complains  of  headache  and  tired 
feelings.  He  is  sleepless  and  finds  himself  unable  to  concentrate  his  attention 
properly  upon  his  work.  A  condition  of  nervous  irritability  develops,  which 
may  have  a  host  of  trivial  manifestations,  and  the  entire  mental  attitude  of 
the  person  may  for  a  time  be  changed.  He  dwells  constantly  upon  his  condi- 
tion, gets  very  despondent  and  low-spirited,  and  in  extreme  cases  melancholia 
may  develop.  He  may  complain  of  numbness  and  tingling  in  the  extremities, 
and  in  some  cases  of  much  pain  in  the  back.  The  bodily  functions  may  be 
well  performed,  though  such  patients  usually  have,  for  a  time  at  least,  dis- 
turbed digestion  and  loss  in  weight.  The  physical  examination  may  be  entirely 
negative.  The  reflexes  are  slightly  increased,  as  in  ordinary  neurasthenia. 
The  pupils  may  be  unequal;  eardio-vascular  changes  may  be  present  in  a 
marked  degree, 

(2)  Cases  v^^ith  Marked  Hysterical  Features. — ^Following  an  injury 
of  any  sort,  neurasthenic  symptoms,  like  those  described  above,  may  develop, 
and  in  addition  symptoms  regarded  as  characteristic  of  hysteria.  The  emo- 
tional element  is  prominent,  and  there  is  but  slight  control  over  the  feelings. 
The  patients  have  headache,  backache,  and  vertigo.  A  violent  tremor  may  be 
present,  and  constitute  the  most  striking  feature.  In  an  engineer  who  de- 
veloped subsequent  to  an  accident  a  series  of  nervous  phenomena  the  most 
marked  feature  was  an  excessive  tremor  of  the  entire  body,  which  was  spe- 
cially manifest  during  emotional  excitement.  The  most  pronounced  hysterical 
symptoms  are  the  sensory  disturbances.  As  first  noted  by  Putnam  and  Wal- 
ton, hemiansesthesia  may  occur  as  a  consequence  of  trauma.  This  is  a  com- 
mon symptom  in  France,  but  rare  in  England  and  the  United  States.  Achro- 
matopsia may  exist  on  the  anesthetic  side.  A  second,  more  common,  mani- 
festation is  limitation  of  the  field  of  vision,  similar  to  that  in  hysteria. 

(3)  Cases  ix  which  the  Symptoms  Suggest  Organic  Disease  of  the 
Bratn  and  Cord. — As  a  result  of  spinal  concussion,  without  fracture  or  ex- 
ternal injury,  there  may  subsequently  develop  symptoms  suggestive  of  organic 
disease,  which  may  come  on  rapidly  or  at  a  late  date.  In  a  case  reported  by 
Levden  the  symptoms  following  the  concussion  were  at  first  slight  and  the 


1110  DISEASES  OF  THE  FERVOUS  SYSTEM 

patient  was  regarded  as  a  simulator,  but  finally  the  condition  became  aggra- 
vated and  death  resulted.  The  post  mortem  showed  a  chronic  pachymeningitis, 
which  had  doubtless  resulted  from  the  accident.  The  cases  in  this  group 
about  which  there  is  so  much  discussion  are  those  which  display  marked  sen- 
sory and  motor  changes.  Following  an  accident  in  which  the  patient  has  not 
received  external  injury  a  condition  of  excitement  may  develop  within  a  week 
or  ten  days;  he  complains  of  headache  and  backache,  and  on  examination  sen- 
sory disturbances  are  found,  either  hemianaesthesia  or  areas  in  which  the  sensa- 
tion is  much  benumbed;  or  painful  and  tactile  impressions  may  be  distinctly 
felt  in  certain  regions,  and  the  temperature  sense  is  absent.  The  distribution 
may  be  bilateral  and  symmetrical  in  limited  regions  or  hemiplegic  in  type. 
Limitation  of  the  field  of  vision  is  usually  marked,  and  there  may  be  dis- 
turbance of  the  senses  of  taste  and  smell.  The  superficial  reflexes  may  be 
diminished;  usually  the  deep  reflexes  are  exaggerated.  The  pupils  may  be 
unequal;  the  motor  disturbances  are  variable.  The  French  writers  describe 
cases  of  monoplegia  with  or  without  contracture,  symptoms  upon  which  Charcot 
laid  great  stress  as  a  manifestation  of  profound  hysteria.  The  combination 
of  sensory  disturbances — anesthesia  or  hypergesthesia — with  paralysis,  particu- 
larly if  monoplegic,  and  the  occurrence  of  contractures  without  atrophy  and 
with  normal  electrical  reactions,  may  be  regarded  as  distinctive  of  hysteria. 

In  rare  cases  following  trauma  and  succeeding  to  symptoms  which  may 
have  been  regarded  as  neurasthenic  or  hysterical  there  are  organic  changes 
which  may  prove  fatal.  That  this  occurs  is  demonstrated  clearly  by  post 
mortem  examinations.  The  features  upon  which  the  greatest  reliance  can  be 
placed  as  indicating  organic  change  are  optic  atrophy,  bladder  symptoms, 
particularly  in  combination  with  tremor,  paresis,  and  exaggerated  reflexes. 

The  anatomical  changes  in  this  condition  have  not  been  very  definite. 
When  death  follows  spinal  concussion  within  a  few  days  there  may  be  no 
apparent  lesion,  but  in  some  instances  the  brain  or  cord  has  shown  puncti- 
form  haemorrhages.  Edes  reported  4  cases  in  which  a  gradual  degeneration 
in  the  pyramidal  tracts  followed  concussion  or  injury  of  the  spine;  but  in  all 
these  cases  there  was  marked  tremor  and  the  spinal  symptoms  developed  early, 
or  followed  immediately  upon  the  accident. 

Diagnosis. — A  condition  of  fright  and  excitement  following  an  accident 
may  persist  for  days  or  even  weeks,  and  then  gradually  pass  away.  The  symp- 
toms of  neurasthenia  or  of  hysteria  which  subsequently  develop  present  nothing 
peculiar  and  are  identical  with  those  which  occur  under  other  circumstances. 
Care  must  be  taken  to  recognize  simulation,  and,  as  in  these  cases  the  condition 
is  largely  subjective,  this  is  sometimes  extremely  difficult.  In  a  careful  exam- 
ination a  simulator  will  often  reveal  himself  by  exaggeration  of  certain  symp,- 
toms,  particularly  sensitiveness  of  the  spine,  and  by  increasing  voluntarily  the 
reflexes.  Maunkopff  suggests  as  a  good  test  to  take  the  pulse  rate  before,  dur- 
ing, and  after  pressure  upon  an  area  said  to  be  painful.  If  the  rate  is  quick- 
ened, it  is  held  to  be  proof  that  the  pain  is  real.  This  is  not,  however,  always 
the  case.  It  may  require  careful  study  to  determine  whether  the  individual 
is  honestly  sufi^ering  from  the  symptoms  of  which  he  complains.  A  still  more 
important  question  is.  Has  the  patient  organic  disease?  The  symptoms  given 
under  the  first  two  groups  of  cases  may  exist  in  a  marked  degree  and  may 
persist  for  several  years  without  the  slightest  evidence  of  organic  change. 


EAYNAUD'S  DISEASE  1111 

Hemiangesthesia,  limitation  of  the  field  of  vision,  monoplegia  with  contracture, 
may  all  be  present  as  hysterical  manifestations,  from  which  recovery  may  be 
complete.  The  diagnosis  of  an  organic  lesion  should  be  limited  to  those  cases 
in  which  optic  atrophy,  bladder  troubles,  and  signs  of  sclerosis  of  the  cord  are 
well  marked — indications  either  of  degeneration  of  the  lateral  columns  or  of 
multiple  sclerosis.  Examination  by  the  X-rays  is  an  important  aid  and  has 
showed  in  some  cases  definite  injury  to  the  spine. 

Prognosis. — A  majority  of  patients  with  traumatic  hysteria  recover.  In 
railway  cases,  so  long  as  litigation  is  pending  and  the  patient  is  in  the  hands 
of  lawyers,  the  symptoms  usually  persist.  Settlement  is  often  the  starting- 
point  of  a  speedy  and  perfect  recovery.  On  the  other  hand,  there  are  a  few 
eases  in  which  the  symptoms  persist  even  after  the  litigation  has  been  closed ; 
the  patient  goes  from  bad  to  worse  and  psychoses  develop,  such  as  melancholia, 
dementia,  or  occasionally  progressive  paresis.  And,  lastly,  in  extremely  rare 
cases  organic  lesions  may  result  as  a  sequence. 

The  function  of  the  physician  acting  as  medical  expert  in  these  cases  con- 
sists in  determining  (a)  the  existence  of  actual  disease,  and  (b)  its  character, 
whether  simple  neurasthenia,  severe  hysteria,  or  an  organic  lesion.  The  out- 
look for  ultimate  recovery  is  good  except  in  cases  which  present  the  more 
serious  symptoms  above  mentioned.  Nevertheless  it  must  be  borne  in  mind 
that  traumatic  hysteria  is  one  of  the  most  intractable  affections  which  we  are 
called  upon  to  treat.  In  the  treatment  of  the  traumatic  neuroses  the  practi- 
tioner may  be  guided  by  the  principles  laid  down  for  the  treatment  of  hys- 
teria and  neurasthenia. 


L.   VASO-MOTOR  AND  TROPHIC  DISEASES 

I.     RAYNAUD'S  DISEASE 

Definition. — A  vascular  change,  without  organic  disease  of  the  vessels, 
chiefly  seen  in  the  extremities,  but  occurring  also  in  the  internal  parts,  in 
which  a  persistent  ischsemia  or  a  passive  hypersemia  leads  to  disturbance  of 
function  or  to  loss  of  vitality  with  necrosis. 

Etiolo^. — It  is  a  comparatively  rare  disease.  There  were  only  19  cases 
in  about  20,000  medical  patients  admitted  to  the  Johns  Hopkins  Hospital. 
Women  are  more  frequently  attacked  than  men — 62.5  to  37.5  per  cent,  in 
Monro's  series.  Sixty  per  cent,  of  the  cases  occurred  in  the  second  and  third 
decades,  but  no  age  is  exempt.  A  case  has  been  reported  in  a  six-months-old 
child  and  in  a  woman  of  77  years. 

Several  members  of  a  family  may  be  affected.  jSTeurotic  and  hysterical 
patients  are  more  prone  to  the  disease.  Damp  and  cold  weather,  as  in  Great 
Britain,  appears  to  favor  its  occurrence.  Severe  chilblain  leading  to  super- 
ficial necrosis  represents  a  type  of  the  malady.  In  the  infectious  diseases  areas 
of  multiple  necrosis  occur,  but,  as  a  rule,  the  distribution  is  very  different,  and 
such  cases  should  not  be  included  under  Eaynaud's  disease,  nor  should  the 
local  gangrene  associated  with  arteritis. 

Pathology. — According   to    the    definition,    cases    are    excluded    in   which 


1112  DISEASES  OF  THE  NEEYOUS  SYSTEM 

organic  disease  of  the  vessels  is  present.  In  advanced  cases  sclerosis  of  the 
blood-vessels  has  been  found;  and  neuritis  has  been  described,  but  neither  is 
an  essential  factor.  Changes  in  the  spinal  cord  have  been  reported,  but  in  a 
majority  of  all  cases  the  examination  has  been  negative.  The  local  syncope  is 
an  expression  of  a  widespread  constrictor  influence  causing  spasm  of  the 
arteries  and  arterioles,  so  that  not  a  drop  of  blood  enters  a  part.  This  may 
be  followed  in  an  hour  or  two,  or  less,  by  active  hyperaemia ;  the  arteries  and 
arterioles  dilate  widely  and  the  dead-white  finger  becomes  a  bright  pink. 
While  hypergemia  may  follow  the  ischeemia  directly,  more  commonly  there  is 
an  intervening  period  of  asphyxia  in  which  the  finger  becomes  blue.  In 
frost-bitej  active  hyperaemia,  cyanosis,  and  local  syncope  is  the  order.  In  Eay- 
naud's  disease  the  order  is  usually  syncope,  asphyxia,  and  hyperasmia.  In 
frost-bite  it  seems  clear  that  the  asphyxia  is  due  to  a  backward  flow  from  the 
veins,  to  which  the  local  syncope  yields  as  the  part  thaws,  before  the  arteries 
passing  to  the  part  can  be  felt  to  pulsate.  The  asphyxia  of  Eaynaud's  dis- 
ease may  be  due  to  the  same  cause;  contraction  of  the  veins  has  been  seen  by 
Barlow  and  by  Weiss,  but  that  was  when  the  asphyxia  already  existed.  The 
first  thing  must  be  the  relaxation  of  the  spasm  of  the  venules  and  veins  to 
permit  of  the  blood  entering  the  empty  capillaries.  In  moderate  grades  of 
asphyxia  some  little  blood  trickles  through  the  sluice  gates,  but  in  the  deep 
purple  skin  of  a  typical  example  of  Eaynaud's  disease  the  circulation  has 
ceased  and  death  of  the  part  is  imminent.  The  necrosis  is  a  simple  matter,  as 
simple  as  if  a  string  is  tied  tightly  about  the  finger-tip. 

The  disease  is  the  result  of  some  as  yet  unknown  instability  of  the  vaso- 
motor system. 

Symptoms. — There  are  various  grades  of  the  disease,  of  which  mild,  moder- 
ate, and  severe  types  may  be  recognized.  In  the  mild  forms  the  disease  never 
gets  beyond  the  stage  of  siTch  vascular  disturbance  as  is  frequently  seen  in 
chilblains.  The  hands  alone  may  be  afi^ected.  In  the  winter,  on  the  slightest 
exposure,  there  is  acro-cyanosis,  which  gives  place  in  the  warmth  to  active 
hyperaemia,  sometimes  with  swelling,  throbbing,  and  aching.  The  so-called 
"beefsteak"  hand  is  often  a  great  annoyance  to  women.  It  is  a  vaso-motor 
disturbance  representing  a  potential  case  of  Eaynaud's  disease.  In  these  mild 
attacks  one  finger  may  be  white  and  the  adjacent  ones  red  and  blue. 

The  condition  may  persist  for  years  and  never  pass  on  to  necrosis.  In  a 
case  of  moderate  severity  a  woman,  aged  say  twenty  or  twenty-five,  after  a 
period  of  worry  or  ill  health,  has  pains  in  the  fingers,  or  a  numbness  or 
tingling;  then  she  notices  that  they  are  white  and  cold,  and  in  an  hour  or  so 
they  become  red  and  hot.  Within  a  day  or  two  a  change  occurs;  they  remain 
permanently  blue  perhaps  as  far  as  the  second  joint  or  to  the  knuckles.  There- 
is  pain,  sometimes  severe  enough  to  require  morphia.  The  cyanosis  persists 
and  the  tip  of  one  finger  or  the  terminal  joint  of  another  gets  darker  and  a 
few  blebs  form.  The  other  fingers  show  signs  of  restored  circulation,  but 
necrosis  has  occurred  in  the  pad  of  one  finger  and  perhaps  the  terminal  inch 
of  another.  The  necrotic  parts  gradually  separate,  and  the  patient  may  never 
have  another  attack,  or  in  a  year  or  two  there  is  a  recurrence. 

The  severer  form  is  a  terrible  malady,  and  may  affect  fingers  and  toes  at 
once  and  with  them  sometimes  the  tip  of  the  nose  and  the  ears.  The  pain 
is  of  great  severity.     Both  feet  may  be  syi^ollen  to  the  ankle  with  the  toes 


RAYNAUD'S  DISEASE  1113 

black.  It  may  look  as  if  both  feet  would  become  gangrenous,  but  as  a  rule 
the  process  subsides^,  and  in  a  case  even  of  great  severity  only  the  tips  of  the 
toes  are  lost.  A  severe  attack  of  this  sort  may  last  three  or  four  months,  when 
the  patient  recovers  with  the  loss  of  two  or  three  fingers  or  toes,  a  snip  off 
the  edge  of  both  ears  and  a  scar  on  the  tip  of  the  nose.  Attacks  of  this  severity 
may  occur  year  by  year,  and  there  are  terrible  instances  in  which  the  patients 
have  lost  both  hands  and  feet. 

Of  the  parts  affected  Monro  states  that  in  43  per  cent,  of  the  cases  one  or 
both  of  the  upper  extremities  is  involved.  Parts  other  than  the  extremities 
may  be  attacked,  as  the  chin,  lips,  nates,  and  eyelids. 

Complications. — Temporary  amblyopia  due  to  spasm  of  the  retinal  vessels, 
transient  aphasia,  and  transient  hemiplegia  have  been  met  with.  In  one  case 
there  were  three  attacks  of  aphasia  with  hemiplegia  from  which  complete  re- 
covery took  place.  Associated  with  these  were  the  features  of  Raynaud's  dis- 
ease. The  patient  died  in  a  severe  attack  with  pain  in  the  right  hand,  gangrene 
to  the  elbow,  and  coma.  Epilepsy  has  been  reported  in  a  great  number  of 
cases,  and  in  one  case,  reported  by  Thomas,  the  attacks  only  occurred  in  the 
winter  when  he  had  Raynaud's  disease. 

Albuminuria,  may  occur  during  the  attacks.  Haemoglobinuria  has  been 
present  in  a  number  of  cases,  and  was  well  studied  by  the  well-known  surgeon, 
Druitt,  in  his  own  case.  It  is  of  the  same  nature  as  the  paroxysmal  haemo- 
globinuria already  described. 

Sclerodeif'ma  of  the  fingers  may  follow  recurring  attacks.  Occasionally  true 
generalized  scleroderma  begins  with  the  features  of  Raynaud's  disease. 
Arthritis  has  been  present  in  certain  cases. 

Diagnosis. — There  is  rarely  any  difficulty  in  the  diagnosis.  One  condition 
closely  simulates  it,  namely,  local  gangrene  of  the  toes  associated  with  oblitera- 
tive  arteritis ;  but  this  occurs  most  frequently  in  older  persons,  in  diabetic  sub- 
jects, or  in  connection  with  well  marked  arterio-sclerosis.  As  a  rule,  the  pulse 
in  such  cases  is  not  to  Tie  felt  in  the  dorsal  artery.  Allied  to  this  form  is  an 
affection  described  by  Buerger,  thrombo-angeitis  obliterans.  In  the  early 
stages  the  resemblance  to  Raynaud's  disease  is  very  close. 

In  the  acute  infections,  particularly  typhus  fever,  occasionally  in  epidemics 
of  typhoid  fever,  and  in  malaria,  areas  of  multiple  gangrene  occur.  The  dis- 
tribution is  usually  different,  and  there  is  rarely  any  difficulty  in  distinguish- 
ing this  form  from  Raynaud's  disease. 

Lastly,  there  are  cases  of  multiple  neurotic  skin  gangrene  met  with  in 
hysterical  and  nervous  patients,  in  the  majority  of  which  the  lesions  are  self- 
inflicted.  In  military  recruits  local  gangrene  of  the  big  toe  has  been  caused 
by  carbolic  acid,  and  it  seems  probable  that  all  of  those  so-called  trophic  and 
hysterical  lesions  are  simulated. 

Treatment. — In  many  ca.ses  the  attacks  recur  for  years  uninfluenced  by 
treatment.  Mild  attacks  require  no  treatment.  In  the  severer  forms  of  local 
asphyxia,  if  in  the  feet,  the  patient  should  bo  kept  in  bed  with  the  legs  ele- 
vated. The  toes  should  be  wrapped  in  cotton  wool.  The  pain  is  often  very 
intense  and  may  require  morphia.  Carefully  applied,  systematic  massage  of 
the  extremities  is  sometimes  of  benefit.  Galvanism  may  be  tried.  Nitro- 
glycerin has  been  warmly  recommended.  Calcium  lactate  in  15  grain  (1  gm.) 
doses,  three  or  four  times  a  day,  is  sometimes  very  effectual,    It  often  relieves 


1114  DISEASES  OF  THE  NEKYOUS  SYSTEM 

chilblains.  Small  doses  of  thyroid  extract  sometimes  are  useful.  Gushing 
introduced  a  plan  of  treatment  with  the  tourniquet  which  has  proved  very 
successful  in  several  cases.  The  elastic  bandage,  or,  better,  a  pneumatic  tourni- 
quet, is  applied  to  an  extremity  tight  enough  to  shut  off  the  arterial  circula- 
tion and  left  for  some  minutes.  On  releasing  the  constriction  the  member 
flushes  brightly,  owing  to  the  vaso-motor  relaxation.  The  application  in  cases 
of  severe  spasm  may  have  to  be  repeated  at  frequent  intervals  before  the  vascu- 
lar constriction  in  the  affected  parts  will  be  overcome,  and  the  normal  tem- 
perature and  color  return  in  them. 


II.    ERYTHROMELALGIA 

{Red  Neuralgia) 

Definition. — "A  chronic  disease  in  which  a  pai  or  parts — usually  one  or 
more  extremities — suffer  with  pain,  flushing,  and  local  fever,  made  far  worse 
if  the  parts  hang  down"  (Weir  Mitchell).  The  name  signifies  a  painful,  red 
extremity. 

Symptoms. — In  1872  (Phila.  Med.  Times,  November  33d),  in  a  lecture  on 
certain  painful  affections  of  the  feet.  Weir  Mitchell  described  the  case  of  a 
sailor,  aged  forty,  who  after  an  African  fever  began  to  have  "dull,  heavy  pains, 
at  first  in  the  left  and  soon  after  in  the  right  foot.  There  was  no  swelling  at 
first.  When  at  rest  he  was  comfortable  and  the  feet  were  not  painful.  After 
walking  the  feet  were  swollen.  They  scarcely  pitted  on  pressure,  but  were 
purple  with  congestion;  the  veins  were  everywhere  singularly  enlarged,  and 
the  arteries  were  throbbing  visibly.  The  whole  foot  was  said  to  be  aching  and 
burning,  but  above  the  ankle  there  was  neither  swelling,  pain,  nor  flushing." 
As  the  weather  grew  cool  he  got  relief.  Nothing  seemed  to  benefit  him.  This 
brief  summary  of  Mitchell's  first  case  gives  an  accurate  clinical  picture  of  the 
disease.  His  second  communication.  On  a  Eare  Vaso-Motor  Neurosis  of  the 
Extremities,  appeared  in  the  Am.  Jour,  of  the  Medical  Sciences  for  July,  1878, 
while  in  his  Clinical  Lessons  on  Nervous  Diseases,  1897,  will  be  found  addi- 
tional observations. 

The  disease  is  rare.  The  feet  are  much  more  often  affected  than  the  hands. 
The  pain  may  be  of  the  most  atrocious  character.  It  is  usually,  but  not  always, 
relieved  by  cool  weather;  in  one  case  the  winter  aggravated  the  trouble. 

Mitchell  speaks  of  it  as  a  "painful  nerve-end  neuritis."  Dehio  suggests 
that  there  may  be  irritation  in  the  cells  of  the  ventral  horns  of  the  cord  at 
certain  levels.  Excision  of  the  nerves  passing  to  the  parts  has  been  followed 
by  relief.  In  one  of  Mitchell's  cases  gangrene  of  the  foot  followed  excision 
of  four  inches  of  the  musculo-cutaneous  nerve  and  stretching  of  the  posterior 
tibial.  Sclerosis  of  the  arteries  was  found.  Of  9  cases  in  which  the  local  con- 
ditions were  studied  anatomically,  the  only  constant  change  was  a  chronic 
endarteritis  (Batty  Shaw). 


ANGIO-NEUROTIC  (EDEMA  1115 


m.     ANGIO-NEUROTIC  (EDEMA 

{Quincke  s  Disease) 

Definition. — An  affection  characterized  by  the  occurrence  of  local  cedema- 
tous  swellings,  more  or  less  limited  in  extent,  and  of  transient  duration. 
Severe  colic  is  sometimes  associated  with  the  outbreak.  There  is  a  marked 
hereditary  disposition  in  the  disease.  Some  cases  appear  to  be  due  to  hyper- 
susceptibility  to  certain  food. 

Symptoms. — The  oedema  appears  suddenly  and  is  usually  circumscribed. 
It  may  appear  in  the  face;  the  eyelid  is  a  common  situation;  or  it  may 
involve  the  lips  or  cheek.  The  backs  of  the  hands,  the  legs,  or  the  throat  may 
be  attacked.  Usually  the  condition  is  transient,  associated  perhaps  with  slight 
gastro-intestinal  distress,  and  the  affection  is  of  little  moment.  There  may  be 
a  remarkable  periodicity  in  the  outbreak  of  the  oedema.  In  Matas'  case  this 
periodicity  was  very  striking;  the  attack  came  on  every  day  at  eleven  or  twelve 
o'clock.  The  disease  may  be  hereditary  through  many  generations  In  one 
family  five  generations  had  been  affected,  including  twenty-two  members 
(Osier).  The  swellings  appear  in  various  parts;  only  rarely  are  they  con- 
stant in  one  locality.  The  hands,  face,  and  genitalia  are  the  parts  most 
frequently  affected.  Itching,  heat,  redness,  or  in  some  instances  urticaria, 
may  precede  the  outbreak.  Sudden  oedema  of  the  larynx  may  prove  fatal. 
Two  members  of  the  family  just  referred  to  died  of  this  complication.  In 
one  member  of  this  family  the  swellings  came  on  in  different  parts;  for  ex- 
ample, the  under  lip  would  be  swollen  to  such  a  degree  that  the  mouth  could 
not  be  opened.  The  hands  enlarge  suddenly,  so  that  the  fingers  can  not  be 
bent.  The  attacks  recur  every  three  or  four  weeks.  Accompanying  them  are 
usually  gastro-intestinal  attacks,  severe  colic,  pain,  nausea,  and  sometimes 
vomiting.  It  is  quite  possible  that  some  of  the  cases  of  Leyden's  intermittent 
vomiting  may  belong  to  this  group.  The  colic  is  of  great  intensity  and  usually 
requires  morphia.  Arthritis  apparently  does  not  occur.  Periodic  attacks  of 
cardialgia  have  also  been  met  with  during  the  outbreak  of  the  oedema.  Hsemo- 
globinuria  has  occurred  in  several  cases.  There  is  a  hysterical  variety  in 
which  the  oedema  affects  geometrical  areas,  has  abrupt  edges  and  may  be 
accompanied  by  sensory  disturbances  but  not  by  gastro-intestinal  attacks. 

The  disease  has  affinities  with  urticaria,  the  giant  form  of  which  is  prob- 
ably the  same  disease,  and  with  Henoch's  purpura.  Quincke  regards  the  con- 
dition as  a  vaso-motor  neurosis,  under  the  influence  of  which  the  permeability 
of  the  vessels  is  suddenly  increased. 

The  treatment  is  unsatisfactory.  In  the  cases  associated  with  anfemia 
and  general  nervousness,  tonics,  particularly  large  doses  of  strychnia,  do  good. 
Improvement  may  follow  the  prolonged  use  of  nitroglycerin;  and  calcium 
lactate  may  be  tried,  in  doses  of  15  grains  (1  gm.)  thrice  daily.  Epinephrine 
(TTL  vii,  0.5  c.  c.)  given  hypodermically  and  repeated  in  fifteen  minutes  has 
been  helpful.  In  cases  proved  to  be  due  to  food  susceptibility,  a  small  dose 
of  the  causal  material  may  be  given  an  hour  before  the  usual  feeding  is  taken. 
In  one  case  in  which  there  was  susceptibility  to  any  albumin,  the  administra- 
tion of  peptone  was  successful. 


1116  DISEASES  OF  THE  NERVOUS  SYSTEM 


IV.    PERSISTENT  HEREDITARY  CEDEMA  OF  THE  LEGS 

{Milroy's  Disease) 

This  remarkable  condition,  first  described  by  Milroy  of  Omaha,  is  char- 
acterized by  persistent  oedema  of  the  legs,  without  any  traceable  cause  or  any 
constitutional  features.  It  is  a  fairly  common  complaint,  affecting  males  and 
females  equally.  As  many  as  23  persons  in  Milroy's  series  were  affected 
among  97  in  six  generations;  in  Hope  and  French's  series  13  of  42  persons 
in  five  generations.  The  oedema  is  strictly  limited  to  the  lower  limbs  and 
varies  very  slightly.  In  some  instances  there  are  remarkable  acute  attacks, 
with  chill,  fever,  and  increase  of  swelling.  Except  mechanically  the  condition 
does  not  seriously  interfere  with  health. 

Here  may  be  mentioned  a  remarkable  familial  affection  described  by  Edge- 
worth  of  Bristol  {Lancet,  July  22,  1911),  of  a  general  subcutaneous  oedema. 
Of  six  infants  born  of  healthy  parents,  all  but  one  died  within  the  first  few 
months,  with  general  oedema,  following  upon  diarrhoea.  The  cases  differ 
essentially  from  those  of  oedema  neonatorum. 

V.     FACIAL  HEMIATROPHY 

A  rare  affection  characterized  by  progressive  wasting  of  the  bones  and  soft 
tissues  of  one  side  of  the  face.  The  atrophy  starts  in  childhood,  but  in  a  few 
cases  has  not  come  on  until  adult  life.  Perhaps  after  a  trifling  injury  or  dis- 
ease the  process  begins,  either  diffusely  or  more  commonly  at  one  spot  on  the 
skin.  It  gradually  spreads,  involving  the  fat,  then  the  bones,  more  particu- 
larly the  upper  jaw,  and  last  and  least  the  muscles.  The  wasting  is  sharply 
limited  at  the  middle  line,  and  the  appearance  of  the  patient  is  very  remark- 
able, the  face  looking  as  if  made  up  of  two  halves  from  different  persons. 
There  is  usually  change  in  the  color  of  the  skin  and  the  hair  falls.  Owing  to 
the  wasting  of  the  alveolar  processes  the  teeth  become  loose  and  ultimately 
drop  out.  The  eye  on  the  affected  side  is  sunken,  owing  to  loss  of  orbital 
fat.  There  is  usually  hemiatrophy  of  the  tongue  on  the  same  side.  Disturb- 
ance of  sensation  and  muscle  twitching  may  precede  or  accompany  the  atrophy. 
In  a  majority  of  the  cases  the  atrophy  has  been  confined  to  one  side  of  the 
face,  but  there  are  instances  on  record  in  which  the  disease  was  bilateral,  and 
a  few  cases  in  which  there  were  areas  of  atrophy  on  the  back  and  on  the  arm 
of  the  same  side. 

In  Mendel's  case  there  was  found  the  terminal  stage  of  an  interstitial 
neuritis  in  all  the  branches  of  the  trigeminus,  from  its  orgin  to  tlie  periphery, 
most  marked  in  the  superior  maxillary  branch. 

The  disease  is  recognized  at  a  glance.  The  facial  asymmetry  associated 
with  congenital  wryneck  must  not  be  confounded  with  progressive  facial  hemi- 
atrophy. Other  conditions  to  be  distinguished  are :  Facial  atrophy  in  anterior 
polio-myelitis,  and  in  the  hemiplegia  of  infants  and  adults;  the  atrophy  fol- 
lowing nuclear  lesions  and  sympathetic  nerve  paralysis;  acquired  facial  hemi- 
hypertrophy,  which  may  by  contrast  give  to  the  other  side  an  atrophic  appear- 
ance; and  scleroderma  (a  closely  related  affection),  if  confined  to  one  side  of 


SCLEEODEEMA  1117 

the  face.  The  precise  nature  of  the  disease  is  doubtful,  but  it  is  a  suggestive 
fact  that  in  many  cases  the  atrophy  followed  the  acute  infections.  It  is  in- 
curable. 

VI.     SCLERODERMA 

Definition. — A  condition  of  localized  or  diffuse  induration  of  the  skin. 

Varieties. — Two  forms  are  recognized :  the  circumscribed,  which  corre- 
sponds to  the  keloid  of  Addison,  and  to  morphoea;  and  the  diffuse,  in  which 
large  areas  are  involved. 

The  disease  affects  females  more  frequently  than  males.  The  cases  occur 
most  commonly  at  the  middle  period  of  life.  The  sclerema  neonatorum  is  a 
different  affection.  The  disease  is  more  common  in  the  United  States  than 
statistics  indicate.    The  senior  author  saw  20  cases  in  sixteen  years. 

In  the  circumscribed  form  there  are  patches,  ranging  from  a  few  centime- 
tres in  diameter  to  the  size  of  the  hand  or  larger,  in  which  the  skin  has  a 
waxy  or  dead-white  appearance,  and  to  the  touch  is  brawny,  hard,  and  in- 
elastic. Sometimes  there  is  a  preliminary  hypersemia  of  the  skin,  and  sub- 
sequently there  are  changes  in  color,  either  areas  of  pigmentation  or  of  com- 
plete atrophy  of  the  pigment — leucoderma.  The  sensory  changes  are  rarely 
marked.  The  secretion  of  sweat  is  diminished  or  entirely  abolished.  The 
disease  is  more  common  in  women  than  in  men,  and  is  situated  most  fre- 
quently about  the  breasts  and  neck,  sometimes  in  the  course  of  the  nerves. 
The  patches  may  develop  with  great  rapidity,  and  may  persist  for  months  or 
years;  sometimes  they  disappear  in  a  few  weeks. 

The  diffuse  form,  though  less  common,  is  more  serious.  It  begins  in  the 
extremities  or  in  the  face,  and  the  patient  notices  that  the  skin  is  unusually 
hard  and  firm,  or  that  there  is  a  sense  of  stiffness  or  tension  in  making  accus- 
tomed movements.  Gradually  the  skin  becomes  firm  and  hard,  and  so  united 
to  the  subcutaneous  tissues  that  it  cannot  be  picked  up  or  pinched.  It  may 
look  natural,  but  more  commonly  is  glossy,  drier  than  normal,  and  unusually 
smooth.  With  reference  to  the  localization,  in  Lewin  and  Heller's  statistics 
in  QQ  observations  the  disease  was  universal;  in  203,  regions  of  the  trunk  were 
affected;  in  193,  parts  of  the  head  or  face;  in  287,  portions  of  one  or  other 
of  the  upper  extremities;  and  in  123,  portions  of  the  lower  extremities.  In 
80  cases  there  were  disturbances  of  sensation.  The  disease  may  gradually 
extend  and  involve  the  skin  of  an  entire  limb.  When  universal,  the  face  is 
expressionless,  the  lips  can  not  be  moved,  mastication  is  hindered,  and  it  may 
become  extremely  difficult  to  feed  the  patient.  The  hands  become  fixed  and 
the  fingers  immobile,  on  account  of  the  extreme  induration  of  the  skin  over  the 
joints.  Eemarkable  vaso-motor  disturbances  are  common,  as  extreme  cyanosis 
of  the  hands  and  legs.  Tachycardia  may  be  present.  The  disease  is  chronic, 
lasting  for  months  or  years.  There  are  instances  on  record  of  its  persistence 
for  more  than  twenty  years.  Eecovery  may  occur,  or  the  disease  may  be 
arrested.  One  patient,  with  extensive  involvement  of  the  face,  ears,  and  hands, 
improved  very  much.  The  patients  are  apt  to  succumb  to  pulmonary  com- 
plaints or  to  nephritis.  Arthritic  troubles  have  been  noticed  in  some  in- 
stances; in  others,  endocarditis.  Eaynaud's  disease  may  be  associated  with  it. 
The  pigmentation  of  the  skin  may  be  as  deep  as  in  Addison's  disease,  for 


1118  DISEASES  OF  THE  NERVOUS  SYSTEM  . 

which  cases  have  been  mistaken;  scleroderma  may  occur  as  a  complication 
of  exophthalmic  goitre. 

The  remarkable  dystrophy  known  as  sclerodactylie  belongs  to  this  disorder. 
There  are  S}Tnmetrical  involvements  of  the  fingers,  which  become  deformed, 
shortened,  and  atrophied;  the  skin  becomes  thickened,  of  a  waxy  color,  and 
is  sometimes  pigmented.  Multiple  calcareous  nodules,  not  unlike  tophi,  but 
not  uratic,  occur  about  the  fingers.  Bullae  and  ulcerations  have  been  met 
with  in  some  instances,  and  a  great  deformity  of  the  nails.  The  disease  has 
usually  followed  exposure,  and  the  patients  are  much  worse  during  the  winter, 
and  are  curiously  sensitive  to  cold.  There  may  be  changes  in  the  skin  of 
the  feet,  but  the  deformity  similar  to  that  which  occurs  in  the  hand  has  not 
been  noted.  Some  of  the  cases  present  in  addition  diffuse  sclerodermatous 
changes  of  the  skin  of  other  parts.  In  Lewin  and  Heller's  monograph  there 
are  35  cases  of  isolated  sclerodactylism,  and  106  cases  in  which  it  was  com- 
bined with  scleroderma. 

The  pathology  is  unknown.  It  is  usually  regarded  as  a  tropho-neurosis, 
probably  dependent  upon  changes  in  the  arteries  of  the  skin  leading  to  con- 
nective tissue  overgrowth.     The  thyroid  has  been  found  atrophied. 

Treatment. — The  patients  require  to  be  Avarmly  clad  and  to  be  guarded 
against  exposure,  as  they  are  particularly  sensitive  to  changes  in  the  weather. 
Warm  baths  folloM^ed  by  frictions  with  oil  should  be  systematically  used. 
Thyroid  feeding  should  be  tried  thoroughly  in  the  diffuse  form.  In  one  case 
the  disease  appeared  to  be  arrested;  the  patient  took  the  extract  for  seven 
years.  In  a  second  case,  after  a  year  the  face  became  softer,  and  there  was 
permanent  improvement.  In  a  case  of  quite  extensive  localized  scleroderma 
the  patches  became  softer  and  the  pigmentation  much  less  intense.  Salol  in 
15  grain  (1  gm.)  doses  three  times  a  day  is  stated  to  have  been  helpful. 

Vn.     AINHUM 

This  is  a  disease  of  the  fifth,  rarely  of  the  fourth  and  other  toes  in  which 
a  groove  forms  at  the  digito-plantar  fold  and  deepens  until  the  toe  drops  off. 
Described  first  by  Da  Silva  Lima  in  1852,  it  has  since  been  met  with  in  many 
tropical  regions,  in  the  southern  states  of  America,  and  very  rarely  in  tem- 
perate regions,  as  Canada  and  Italy.  Nothing  has  been  determined  as  to  the 
etiology.  It  may  occur  in  families,  and  is  more  common  in  males.  There  is 
endarteritis,  with  proliferation  of  the  epidermis.  Parasites  have  not  been 
found.  It  is  a  local  disease  without  symptoms  and  in  the  affected  toe  there 
is  no  disability  and  rarely  any  pain,  except  when  the  skin  of  the  groove  ulcer- 
ates. The  toe  drops  off  in  about  two  years.  In  about  10  per  cent,  of  cases 
the  fourth  toe  is  affected.  It  is  said  that  the  affection  may  occur  in  the  fingers. 
A  longitudinal  section  across  the  groove  will  sometimes  stop  the  progress. 

VIII.     LIPODYSTHOPHIA  PROGRESSIVA 

A  rare  affection,  possibly  confined"  to  females,  in  which  the  subcutaneous 
fat  gradually  disappears  from  the  face,  arms,  and  trunk.  The  cause  of  the 
condition  is  unknown.  Beginning  usually  about  the  tenth  to  thirteenth  year, 
the  wasting  is  progressive,  but  limited  to  the  parts  mentioned.  The  buttocks 
and  legs  remain  normal  and  look  by  contrast  abnormally  plump.  The  breasts 
are  spared.    In  the  early  stages  it  resembles  the  "bilateral  atrophy  of  the  face." 


SECTION  XIII 

DISEASES  OF  THE  LOCOMOTOR  SYSTEM 

A.   DISEASES  OF  THE  MUSCLES 

I.    MYOSITIS 

Definition. — Inflammation  of  the  voluntary  muscles, 

A  primary  myositis  occurs  as  an  acute,  subacute,  or  chronic  affection.  It 
is  seen  in  two  chief  forms — the  suppurative  and  non-suppurative. 

I.  Suppurative  myositis  (infectious  myositis)  is  especially  frequent  in 
Japan,  where,  according  to  Miyake,  some  250  cases  have  been  reported;  but 
he  claims  that  some  of  these  belong  to  other  affections.  Miyake  personally 
saw  33  cases  in  Japan  in  twenty-one  months,  and  took  cultures  from  all  but 
one  of  them.  In  2  cases  the  results  were  negative,  but  in  27  a  pure  culture 
of  the  staphylococcus  pyogenes  aureus  was  obtained,  while  in  another  the 
streptococcus  and  in  2  more  the  albus  with  the  aureus  was  grown.  The  malady 
may  involve  one  or  many  muscles,  and  is  usually  sudden  in  its  onset  with  high 
fever  and  marked  prostration.  Subsequently  abscesses  occur  in  the  indurated 
muscles,  and  pyagmia  may  ensue  if  the  implicated  areas  are  not  thoroughly 
evacuated. 

II.  Dermato-myositis. — An  acute  or  subacute  inflammation  of  the  mus- 
cles of  unknown  origin  associated  with  oedema  and  dermatitis.  Steiner  col- 
lected 28  cases  from  the  literature  and  reported  two  cases  from  the  Hopkins 
clinic.  The  muscle  inflammation  is  multiple,  and  associated  with  oedema  and 
a  dermatitis.  The  case  of  E.  Wagner  may  be  taken  as  a  typical  example.  A 
tuberculous  but  well-built  woman  entered  the  hospital,  complaining  of  stiff- 
ness in  the  shoulders  and  a  slight  oedema  of  the  back  of  the  hands  and  fore- 
arms. There  was  pargesthesia,  the  arms  became  swollen,  the  skin  tense,  and  the 
muscles  felt  doughy.  Gradually  the  thighs  became  affected.  The  disease 
lasted  about  three  months.  The  post  mortem  showed  slight  pulmonary  tuber- 
culosis; all  the  muscles  except  the  glutei,  the  calf,  and  abdominal  muscles  were 
stiff'  and  firm,  but  fragile,  and  there  were  serous  infiltration,  great  prolifera- 
tion of  the  interstitial  tissue,  and  fatty  degeneration.  The  duration  is  usually 
from  one  to  three  months,  though  there  are  instances  in  which  it  has  been 
longer.  The  swelling  and  tenderness  of  the  muscles,  the  oedema,  and  the 
pain  naturally  suggest  trichinosis,  and  Hepp  speaks  of  it  as  a  pseudo-trichi- 
nosis. The  nature  of  the  fliscase  is  unknown.  Of  tlie  28  cases  collected  by 
Steiner  17  died.  The  anatomical  changes  are  those  mentioned  as  found  in 
Wagner's  cases.  One  of  Senator's  cases  presented  marked  disorders  of  sensa- 
tion and  has  been  named  nouro-myositis.  Wagner  suggests  that  some  of  these 
cases  were  examples  of  acute  progressive  muscular  atrophy.     The  differentia- 

1119 


1120  DISEASES  OF  THE  LOCOMOTOE  SYSTEM 

tion  from  trichinosis  is  possible  only  by  removing  a  portion  of  the  muscle.' 
It  has  not  been  determined  whether  eosinophilia  is  peculiar  to  the  trichinosis 
myositis. 

III.  Polymyositis  Haemorrhagica. — This  form  resembles  the  dermato- 
myositis  in  general  features,  but  differs  in  the  presence  of  haemorrhages  into 
and  between  the  muscles.  Of  the  ten  cases  analyzed  by  Thayer  four  recov- 
ered.   Purpura  and  haemorrhages  from  the  mucous  membranes  may  occur. 


n.    MYOSITIS  OSSIFICANS  PROGRESSIVA 

This  is  a  progressive  inflammatory  affection  of  the  locomotor  system  of 
Unknown  origin,  characterized  by  the  gradual  formation  of  bony  masses  in 
the  fasciae,  muscles,  aponeuroses,  tendons,  ligaments,  and  bones,  with  resulting 
ankylosis  of  most  of  the  articulations  (Steiner).  About  100  cases  have  been 
reported.  The  process  begins  in  the  neck  or  back,  usually  with  swelling  of 
the  affected  muscles,  redness  of  the  skin,  and  slight  fever,  or  with  small 
nodules  in  the  muscles  which  appear  and  disappear.  After  subsiding  an 
induration  remains,  which  becomes  progressively  harder  as  the  transformation 
into  bone  takes  place.  The  disease  may  ultimately  involve  a  majority  of  the 
skeletal  muscles.  Nothing  is  known  of  the  etiology.  Malformation,  micro- 
dactylism of  the  thumbs  and  big  toes,  is  present  in  75  per  cent,  of  the  cases. 


'  m.     PIBROSITIS 

{Myalgia,  Myositis) 

Definitiosi. — A  painful  affection  of  the  voluntary  muscles  and  of  the  fascias 
and  periosteum  to  which  they  are  attached.  It  is  probable  that  the  fibrous 
tissue  is  especially  affected — a  fibrositis.  It  is  by  no  means  certain  that  the 
muscular  tissues  are  involved.  Many  writers  claim  that  in  some  cases  it  is 
a  neuralgia  of  the  sensory  nerves  of  the  muscles. 

Etiology. — The  attacks  follow  cold  and  exposure,  and  trauma  is  often  a 
factor.  It  is  most  commonly  met  with  in  men,  particularly  those  exposed  to 
cold  and  whose  occupations  are  laborious.  It  is  apt  to  follow  exposure  to  a 
draft  of  air,  as  from  an  open  window  in  a  railway  carriage.  A  sudden  chill- 
ing after  heavy  exertion  may  bring  on  an  attack  of  lumbago.  Persons  of  a 
gouty  habit  are  more  prone  to  this  affection,  and  one  attack  renders  an  indi- 
vidual more  liable  to  another.  It  is  usually  acute,  but  may  become  subacute 
or  even  chronic,  the  last  being  more  common  in  later  life.  In  many  cases  the 
condition  is  secondary  to  an  area  of  focal  infection. 

Pathology. — The  changes  are  usually  in  the  white  fibrous  tissue  and  are 
of  an  inflammatory  nature.  In  acute  cases  there  is  a  serous  exudation  in  the 
affected  parts  and  following  this  there  may  be  proliferation  of  the  fibrous 
tissue.  This  may  extend  between  the  muscle  fibres  and  cause  stiffness  and 
pain.  Disability  with  muscular  atrophy  may  result  from  this.  Nodules  some- 
times form  which  may  be  painful. 

Symptoms. — In  the  acute  forms  the  affection  is  entirely  local.    The  consti- 


riBEOSITIS  1121 

tutional  disturbance  is  slight,  and,  even  in  severe  cases,  there  may  be  no 
fever.  Pain  is  a  prominent  feature  and  may  be  constant  or  occur  only  when 
the  muscles  are  in  certain  positions.  It  may  be  a  dull  ache,  like  the  pain  of 
a  bruise,  or  sharp,  severe,  and  cramp-like.  It  is  often  sufficiently  intense  to 
cause  the  patient  to  cry  out.  Pressure  on  the  affected  part  usually  gives  relief. 
As  a  rule,  pain  is  transient,  lasting  from  a  few  hours  to  a  few  days,  although 
occasionally  it  is  prolonged  for  weeks.    It  is  very  apt  to  recur. 

Much  attention  has  been  given  to  a  form  occurring  chiefly  in  the  muscles 
of  the  head  and  neck,  causing  at  first  swelling  and  puffiness,  later  indurations. 
They  are  found  particularly  in  the  muscles  at  the  back  of  the  neck,  but  they 
are  occasionally  present  in  the  muscles  of  the  abdomen  and  limbs.  The  affec- 
tion of  the  muscles  of  the  head  and  neck  may  be  associated  with  headache,  the 
so-called  indurative  headache.  Some  are  very  similar  to  migraine.  In  the 
abdominal  muscles  these  limited  swellings  may  cause  pain  and  suggest  ap- 
pendicitis. 

The  following  are  the  principal  varieties: 

(1)  "Lumhago,"  a  term  which  means  nothing  more  than  pain  in  the  lower 
back,  is  due  to  many  causes,  {a)  Fibrositis  is  a  common  cause  and  may  recur 
at  short  intervals.  It  comes  on  suddenly  and  may  incapacitate  the  patient, 
any  movement,  particularly  stooping  or  turning,  causing  severe  pain.  (&) 
Isclicemic  lumbago,  described  as  a  type  of  intermittent  claudication,  may  be 
bilateral  or  unilateral  and  is  excited  by  movement.  The  pain  is  between  the 
twelfth  rib  and  the  crest  of  the  ilium  and  may  radiate  forward.  The  area  is 
not  tender  and  the  pain  is  dependent  on  muscular  exertion,  (c)  Static  con- 
ditions, due  to  faulty  posture,  which  may  be  lateral  (one  leg  shorter)  or 
antero-posterior,  flat  feet,  stooping,  occupation,  etc.  (d)  Anatomical  varia- 
tions of  the  transverse  processes. of  the  flfth  lumbar  vertebra,  (e)  Arthritis  of 
the  spine.  (/)  Sacro-iliac  joint  strain  or  relaxation,  (g)  Neuritis  of  the 
posterior  nerve  roots,  (h)  Pain  due  to  pelvic  disease  in  males  (prostate,  etc.) 
or  females,  (i)  Traurha,  especially  with  lifting  in  a  stooped  position.  The 
diagnosis  of  "backache"  as  being  due  to  fibrositis  should  only  be  made  after 
other  possibilities  are  excluded.  In  every  case  the  effort  should  be  made  to 
arrive  at  an  etiological  diagnosis  as  only  then  is  proper  treatment  possible. 
For  the  cases  due  to  strain  some  form  of  fixation  is  useful;  faulty  posture 
should  be  corrected  and  flat  feet  receive  attention. 

(2)  Stiff  neck  or  torticollis  affects  the  muscles  of  the  antero-lateral  or 
back  region  of  the  neck.  It  is  very  common,  often  unilateral,  and  occurs  most 
frequently  in  the  young.  The  patient  holds  the  head  in  a  peculiar  manner 
turned  to  one  side,  and  rotates  the  whole  body  in  attempting  to  turn  it. 

(3)  Pleurodynia  involves  the  intercostal  muscles  on  one  side,  and  in  some 
instances  the  pectorals  and  serratus  magnus.  This  is,  perhaps,  the  most  pain- 
ful form  of  the  disease,  as  the  chest  can  not  be  at  rest.  It  is  more  common  on 
the  left  than  on  the  right  side.  A  deep  breath,  or  coughing,  causes  a  very 
intense  pain  on  pressure,  sometimes  over  a  very  limited  area.  It  may  be 
difficult  to  distinguish  from  intercostal  neuralgia,  in  which,  however,  the  pain 
is  usually  more  circumscribed  and  paroxysmal,  and  there  are  tender  points 
along  the  course  of  the  nerves.  It  is  sometimes  mistaken  for  pleurisy,  but 
careful  examination  readily  distinguishes  between  the  two  affections. 

(4)  Among  other  forms  are  cephalodynia,  affecting  the  muscles  of  the 


1122  DISEASES  OF  THE  LOCOMOTOE  SYSTEM 

head;  scapulodynia,  omodynia,  and  dorsodynia,  affecting  the  muscles  about 
the  shoulder  and  upper  part  of  the  back.  Fibrositis  may  also  occur  in  the 
abdominal  muscles  and  in  the  muscles  of  the  extremities.  In  the  legs  it  causes 
tenderness  and  pain,  increased  by  use.  Areas  of  infiltration  may  be  palpated. 
Nodules  are  sometimes  felt  in  the  sole  of  the  foot.  The  chronic  forms  are 
distinguished  by  soreness  or  pain  associated  with  varying  degrees  of  disability. 
There  may  be  marked  stiffness  of  the  muscles,  which  are  sometimes  painful 
on  pressure  and  may  show  definite  tender  areas  of  induration. 

Treatment. — Eest  of  the  affected  muscles  is  of  the  first  importance,  and 
it  is  well  to  protect  them  from  cold  by  a  covering  of  flannel.  Strapping  of 
the  side  will  sometimes  completely  relieve  pleurodj^nia.  No  belief  is  more 
widespread  among  the  public  than  in  the  efficacy  of  porous  plasters  for  mus- 
cular pains  of  all  sorts.  If  the  pain  is  severe  and  agonizing,  a  hypodermic 
of  morphia  gives  immediate  relief.  For  lumbago  acupuncture  is,  in  acute 
cases,  an  efficient  treatment.  Needles  of  from  three  to  four  inches  in  length 
(ordinary  bonnet-needles,  sterilized,  will  do)  are  thrust  into  the  lumbar  mus- 
cles at  the  seat  of  pain,  and  withdrawn  after  five  or  ten  minutes.  The  con- 
stant current  is  sometimes  beneficial.  In  many  forms  of  myalgia  the  thermo- 
cautery gives  great  relief  and  in  obstinate  cases  blisters  may  be  tried.  Heat 
or  counter-irritation  in  any  form  is  useful  and  at  the  outset  a  Turkish  bath 
may  cut  short  the  attack.  The  bowels  should  be  freely  opened  and  large 
amounts  of  water  taken.  The  salicylates  are  usually  effectual ;  sodium  salicylate 
(gr.  X  to  XV,  0.6  to  1  gm.),  acetyl-salicylic  acid  (gr.  x,  0.6  gm.),  or  salol  (gr. 
V,  0.3  gm.)  may  be  given.  Some  patients  respond  well  to  colchicum  (ni,  xv, 
1  c.  c.  of  the  wine).  In  chronic  cases  potassium  iodide  may  be  used.  Persons 
subject  to  this  affection  should  be  warmly  clothed,  and  avoid,  if  possible, 
exposure  to  cold  and  damp.  Massage  sometimes  gives  relief;  it  should  be 
given  gently  at  first  and  more  vigorously  later.  For  the  lumbar  form,  fixation 
is  most  useful  by  strapping,  or  some  form  of  support. 


IV.     MYOTONIA 

(Thomsens  Disease) 

Definition. — An  affection  characterized  by  tonic  cramp  of  the  muscles  on 
attempting  voluntary  movements.  The  disease  received  its  name  from  the 
physician  who  first  described  it,  in  whose  family  it  existed  for  five  generations. 

"While  the  disease  is  in  a  majority  of  cases  hereditary,  hence  the  name 
myotonia  congenita,  there  are  other  forms  of  spasm  very  similar  which  may 
be  acquired,  and  others  still  which  are  quite  transitory. 

Etiology. — All  the  typical  cases  have  occurred  in  family  groups;  a  few 
isolated  instances  have  been  described  in  which  similar  symptoms  have  been 
present.  Males  are  much  more  frequentl}^  affected  than  females.  In  102 
recorded  cases,  91  were  males  and  only  11  females  (Hans  Koch).  The  disease 
is  rare  in  America  and  in  England;  it  seems  more  common  in  Germany  and 
in  Scandinavia. 

Symptoms.— Tlie  disease  comes  on  in  childhood.  It  is  noticed  that  on 
account  of  the  stiffness  the  children  are  not  able  to  take  part  in  ordinary 


PARAMYOCLONUS  MULTIPLEX  1123 

games.  The  peculiarity  is  uoticed  only  during  voluntary  movements.  The 
contraction  which  the  patient  wills  is  slowly  accomplished;  the  relaxation 
M^hich  the  patient  wills  is  also  slow.  The  contraction  often  persists  for  a  little 
time  after  he  has  dropped  an  object  which  he  has  picked  up.  In  walking,  the 
start  is  difficult;  one  leg  is  put  forward  slowly,  it  halts  from  stiffness  for  a 
second  or  two,  and  then  after  a  few  steps  the  legs  become  limber  and  he  walks 
without  any  difficulty.  The  muscles  of  the  arms  and  legs  are  those  usually 
implicated ;  rarely  the  facial,  ocular,  or  laryngeal  muscles.  Emotion  and  cold 
aggravate  the  condition.  In  some  instances  there  is  mental  weakness.  The 
sensation  and  reflexes  are  normal.  G.  M.  Hammond  reported  three  remark- 
able cases  in  one  family,  in  which  the  disease  began  at  the  eighth  year  and 
was  confined  entirely  to  the  arms.  It  was  accompanied  with  some  slight 
mental  feebleness.  The  condition  of  the  muscles  is  interesting.  The  patients 
appear  and  are  muscular,  and  there  is  sometimes  definite  muscular  hyper- 
trophy. The  force  is  scarcely  proportionate  to  the  size.  Erb  described  a 
characteristic  reaction  of  the  nerve  and  muscle  to  the  electrical  currents — the 
so-called  myotonic  reaction,  the  chief  feature  of  which  is  that  normally  the 
contractions  caused  by  either  current  attain  their  maximum  slowly  and  relax 
slowly,  and  vermicular,  wave-like  contractions  pass  from  the  cathode  to  the 
anode. 

The  disease  is  incurable,  but  may  be  arrested  temporarily.  The  nature 
of  the  affection  is  unknown.  Dejerine  and  Sottas  found  hypertrophy  of  the, 
primitive  fibres  with  multiplication  of  the  nuclei  of  all  the  muscles,  includ- 
ing the  diaphragm,  but  not  the  heart.  The  spinal  cord  and  the  nerves 
were  intact.  From  Jacoby's  studies  it  is  doubtful  whether  these  changes  in 
the  muscles  are  in  any  way  characteristic  or  peculiar  to  the  disease.  J.  Koch 
found,  in  addition  to  the  muscle  hypertrophy,  degenerative  and  regenerative 
changes,  which  he  considers  sufficient  to  account  for  the  myotonic  disorder. 
Karpinsky  and  von  Bechterew  regard  the  affection  as  due  to  an  auto-intoxi- 
cation of  the  muscle  tissue,  caused  by  some  faulty  metabolism.  No  treatment 
is  known. 

V.     PARAMYOCLONUS  MULTIPLEX 

(Essential  Myoclonia) 

Definition. — An  affection  described  by  Friedreich,  characterized  by  irregu- 
lar clonic  contractions,  chiefly  of  the  muscles  of  the  extremities,  occurring 
either  constantly  or  in  paroxysms. 

Etiology. — The  subjects  are  usually  degenerate  young  males.  Hysteria, 
emotion,  fright,  trauma,  sexual  excesses  and  parathyroid  disease  have  been 
suggested  as  possible  causes.     The  disease  may  occur  in  several  generations. 

Pathology. — The  nature  of  the  disease  is  unknown.  Pierce  Clark  suggests 
that  it  is  an  abiotrophy  of  the  corpus  striatum — the  region  of  control  of  the 
automatic  and  associated  movements. 

Symptoms. — The  characteristic  features  are  the  short,  sudden  and  light- 
ning-like contractions,  not  rhythmic  and  of  equal  intensity,  and  without  the 
svnergic  quality  of  a  purposive  movement.  The  two  sides  may  be  unequally 
involved,  and  single  muscles  may  be  all'ected.     The  face  and  fingers  are  not 


1124  DISEASES  OF  THE  LOCOMOTOE  SYSTE^^I 

often  affected.  Sensation  is  not  involved;  the  reflexes  are  increased.  The 
movements  are  usually  absent  during  sleep. 

Diagnosis. — The  disease  may  be  confounded  with  the  various  symptomatic 
myoclonias  seen  in  the  tics,  chronic  chorea,  and  the  rhythmic  movements  asso- 
ciated with  mid-brain  lesions.  The  myoclonia  with  epilepsy  (Unverricht) 
is  described  elsewhere. 

Treatment. — Various  forms  of  suggestion  may  be  tried,  but  the  disease 
may  prove  very  resistant.     The  movements  may  cease  spontaneously. 


VI.     MYASTHENIA  GRAVIS 

(Asthenic  Bulbar  Paralysis;  Erh-Goldflam's  Symptom-Complex) 

Definition. — A  disease  with  fatigue  symptoms  referable  to  the  muscular 
system^  due  to  failure  of  innervation  without  definite  changes  in  muscles  or 
nerves. 

Of  180  cases  collected  by  McCarthy,  83  were  males  and  96  females.  In 
women  the  disease  usually  occurs  before  the  age  of  twenty-five,  in  males  in 
middle  life.  Of  56  autopsies  since  1901,  in  IT  there  was  hyperplasia  or  per- 
sistence of  the  thymus  and  in  10  a  thymic  tumor,  only  one  of  which  was  malig- 
nant. Examination  of  the  nervous  system  has  revealed  no  abnormality.  Hun, 
Bloomer,  and  Streeter  described  an  infiltration  of  the  muscles  and  of  the 
th}Tnus  gland  with  lymphoid  cells  and  a  proliferation  of  the  glandular  ele- 
ments of  the  thymus. 

The  muscles  innervated  by  the  bulb  are  first  affected — those  of  the  eyes, 
the  face,  of  mastication,  and  of  the  neck.  After  effort  the  muscles  show 
fatigue,  and  if  persisted  in  they  fail  to  act  and  a  condition  of  paresis  or  com- 
plete paralysis  follows.  All  the  voluntary  muscles  may  become  involved. 
After  rest  the  power  is  recovered.  In  severe  cases  paralysis  may  persist.  The 
myastlienic  reaction  of  Jolly  is  the  rapid  exhaustion  of  the  muscles,  by  farad- 
ism,  not  by  galvanism.  There  are  marked  remissions  and  fluctuations  in  the 
severit}^  of  the  symptoms. 

The  diagnosis  is  easy — from  the  ptosis,  the  facial  expression,  the  nasal 
speech,  the  rapid  fatigue  of  the  muscles,  the  myasthenic  reaction,  the  absence 
of  atrophy,  tremors,  etc.,  and  the  remarkable  variations  in  the  intensity  o£ 
the  symptoms.  .  Of  180  collected  cases  72  proved  fatal;  sudden  death  may 
occur.  The  patient  may  live  many  years;  recovery  may  take  place.  Eest, 
strychnia  in  full  doses,  massage,  and  alternate  courses  of  iodide  of  potassium 
and  mercury  may  be  tried. 


Vn.    AMYOTONIA  CONGENITA 

{Op I) en h ei m's  Dis ease ) 

A  congenital  affection  characterized  by  general  or  local  hypotonus  of  the 
voluntary  muscles.  Oppenheim  called  the  disease  myatonia,  but  this  is  pho- 
netically so  similar  to  myotonia.  (Thomsen's  disease)  that  the  name  amyoto- 


AETHEITIS  DEFOEMANS  1125 

nia  of  English  writers  is  preferable.  Collier  and  Wilson  give  the  following 
definition :  "A  condition  of  extreme  flaccidity  of  the  muscles,  associated  with 
an  entire  loss  of  the  deep  reflexes,  most  marked  at  the  time  of  birth  and 
always  showing  a  tendency  to  slow  and  progressive  amelioration.  There  is 
great  Aveakness,  but  no  absolute  paralysis  of  any  of  the  muscles.  The  limbs 
are  most  affected;  the  face  is  almost  always  exempt.  The  muscles  are  small 
and  soft,  but  there  is  no  local  wasting.  Contractures  are  prone  to  occur  in  the 
course  of  time.  The  faradic  excitability  in  the  muscles  is  lowered  and  strong 
faradic  stimuli  are  borne  without  complaint.  No  other  symptoms  indicative 
of  lesions  of  the  nervous  system  occur." 

Faber  has  collected  115  cases  (1917).  Eecovery  has  not  been  reported,  but 
improvement  was  noted  in  41  cases.  The  post-mortem  changes  are  variable 
— increase  in  the  muscle  nuclei,  and  in  the  fat  and  connective  tissue ;  defective 
myelinization  of  the  peripheral  nerves;  absence  of  the  nerve  endings  in  the 
muscle  fibres,  without  changes  in  the  central  nervous  system.  The  disease 
seems  to  come  in  the  group  of  Gowers'  abiotrophies — a  failure  in  the  proper 
development  of  the  lower  motor  neurone. 


B.    DISEASES  OF  THE  JOINTS 

I.     ARTHRITIS  DEFORMANS 

Definition. — A  disease  of  the  joints,  the  result  of  infection,  characterized 
by  changes  in  the  synovial  membranes,  cartilage,  and  peri-articular  structures, 
and  in  some  cases  by  atrophic  and  hypertrophic  changes  in  the  bones.  A 
tendency  to  a  chronic  course  is  the  rule. 

Long  believed  to  be  intimately  associated  with  gout  and  rheumatism 
(whence  the  names  rheumatic  gout  and  rheumatoid  arthritis),  this  relation- 
ship seems  disproved.  There  is  a  difference  of  opinion  as  to  whether  there 
are  two  distinct  diseases  or  varying  forms  of  the  same  disease  included  under 
this  heading.  Those  who  hold  the  former  view  consider  that  in  one  disease 
the  synovial  membranes  and  the  peri-articular  tissues  are  particularly  affected 
(rheumatoid  arthritis)  and  in  the  other  disease  the  cartilage  and  bone  (osteo- 
arthritis). The  disease  occurs  frequently  and  to  it  belong  many  of  the  cases 
termed  "chronic  rheumatism." 

Etiology. — Age. — A  majority  of  the  cases  are  between  the  ages  of  twenty 
and  fifty.  In  A.  E.  Garrod's  analysis  of  500  cases  there  were  only  25  under 
twenty  years  of  age.  In  40  per  cent,  of  our  series  of  500  cases,  the  onset  was 
before  the  age  of  thirty  years.  In  the  group  with  peri-articular  changes  pre- 
dominating the  age  of  onset  is  usually  lower  than  in  the  group  with  special 
cartilaginous  and  bony  changes. 

Sex. — Among  Garrod's  cases  there  were  411  in  women.  Practically  half 
of  our  series  were  males.  The  incidence  as  to  sex  is  influenced  by  the  in- 
clusion of  the  cases  of  spondylitis,  of  which  a  large  majority  is  in  males.  In 
women  a  close  association  with  the  menopause  has  been  noted. 

Predisposition. — Two  or  three  children  in  a  family  may  be  affected.  In 
America  the  incidence  in  the  negro  is  relatively  much  less  than  in  the  white. 


1126  DISEASES  OF  THE  LOCOMOTOR  SYSTEM 

Occupation  and  the  station  in  life  do  not  seem  to  have  any  special  influence. 

Exposure  to  cold,  wet  and  damp,  errors  in  diet,  worry  and  care,  and 
local  injuries  are  spoken  of  as  possible  exciting  causes,  but  probably  play  but 
a  small  part. 

Arthritis  Deformans  as  a  Chronic  Infection. — This  view  is  steadily 
gaining  ground  and  the  evidence  suggests  certain  varieties  of  streptococci  as 
the  causal  organism.  This  seems  more  probable  than  that  the  disease  is  due 
to  a  specific  organism.  The  work  of  Hastings  suggests  Streptococcus  viridans 
as  Ithe  organism  in  many  cases.  The  arthritis  is  secondary  to  a  focus  of  in- 
fection somewhere.  The  possible  sources  are  many  but  infection  of  the  mouth 
and  throat  probably  takes  first  place.  Abscesses  about  the  teeth  should  always 
be  searched  for  (X-ray  study)  and  the  tonsils  carefully  examined.  Other 
sources  are :  infection  of  the  nose  or  sinuses,  pyorrhoea  alveolaris,  otitis  media, 
chronic  bronchitis,  infection  of  the  biliary  or  urinary  tract,  pelvic  disease  in 
women,  and  infection  of  the  prostate  and  seminal  vesicles  in  men.  The  possi- 
bility of  chronic  infection  from  the  intestinal  tract  must  be  considered  although 
this  is  difficult  to  prove. 

The  acute  onset,  with  fever  in  many  cases,  the  polyarthritis,  the  presence 
of  enlarged  glands,  the  frequent  enlargement  of  the  spleen,  the  occurrence  of 
pleurisy,  endocarditis,  and  pericarditis  in  some  cases  are  all  suggestive  of  an 
infection.  The  likeness  of  the  lesions  to  those  due  to  arthritis  from  a  specific 
cause,  such  as  the  gonococcus,  is  suggestive,  and  also  the  association  of  the 
arthritis  with  definite  foci  of  infection  in  many  cases. 

:Metabolic.— While  the  nutrition  suffers  in  many  cases  there  does  not 
seem  any  evidence  to  support  the  view  that  the  disease  is  primarily  due  to 
disturbance  of  metabolism.  Metabolic  changes  are  probably  secondary  Just  as 
are  the  trophic  changes. 

Morbid  Anatomy. — The  usual  descriptions  are  of  the  late  stages  when 
extensive  damage  has  occurred,  'for  there  have  been  few  opportunities 
to  study  the  early  changes,  although  more  frequent  operations  have  extended 
our  knowledge  of  them  and  radiographs  have  aided  much.  There  are  three 
main  forms  of  change :  ( 1 )  Lesions  principally  in  the  synovial  membranes 
and  peri-articular  tissues  (the  so-called  rheumatoid  arthritis),  (2)  with  atro- 
phic changes  in  the  cartilage  and  bones  predominating,  and  (3)  with  hyper- 
trophy and  overgrowth  of  bone  (so-called  osteo-arthritis).  The  first  and 
second  are  seen  most  frequently  in  the  joints  of  the  extremities,  the  third 
in  the  spine.  In  many  cases  all  forms  of  change  are  found,  which  speaks 
against  the  view  that  there  are  two  distinct  diseases.  The  changes  in  general 
are:  (1)  Effusion,  which  is  not  constant  and  shows  no  special  features.  (2) 
Changes  in  the  synovial  membrane.  These  are  inflammatory  and  often  hsemor- 
rhagic  at  the  onset.  There  may  be  marked  thickening  and  proliferation  of  the 
.synovial  fringes  with  the  formation  of  villi — villous  arthritis.  (3)  The  capsule 
and  surrounding  tissues  may  be  infiltrated  and  much  swollen.  The  peri-articu- 
lar tissues  show  infiltration  and  swelling,  and  the  enlargement  of  the  joint  is 
more  often  due  to  swelling  about  it  than  to  bony  changes.  (4)  Cartilage. 
This  may  show  erosion,  ulceration,  atrophy,  or  proliferation.  The  cartilage 
may  disappear  entirely,  but  the  changes  are  often  very  irregular  and  uneven 
and  the  cartilage  may  be  replaced  by  fibrous  tissue  or  by  bone,  the  latter  being 
most  common  at  the  edge  of  the  cartilage.     The  cartilages  may  be  soft  and 


AETHRITIS  DEFORMANS  1127 

gradually  absorbed  or  thinned  (this  often  begins  opposite  the  point  of  greatest 
involvement  of  the  synovial  membrane).  (5)  Bone.  This  may  show  atrophy 
of  varying  grade.  If  the  cartilage  is  completely  absorbed  the  surface  of  the 
bone  often  becomes  hard  and  eburnated.  In  the  form  spoken  of  as  liijper- 
iropltic  there  is  new  bone  formation  which  is  most  common  at  the  edge  of 
the  articular  surfaces.  In  the  hip  joint  this  may  form  an  irregular  ring  of 
bone  about  the  joint  cavity.  The  commonest  example  of  overgrowth  of  bone 
is  seen  in  the  so-called  "Heberden's  nodes,"  which  are  bony  outgrowths  at  the 
terminal  interphalangeal  joints.  There  may  be  deposit  of  new  bone  in  the 
ligaments,  particularly  in  the  spine.  Proliferation  of  bone  usually  occurs  at 
the  margins  of  the  joints  in  the  form  of  irregular  nodules — the  osteophytes. 
The  formation  of  bone  may  also  occur  in  ligaments,  especially  of  the  spine, 
which  may  be  converted  into  a  rigid  bony  column.  Bony  ankylosis  rarely 
occurs  in  the  peripheral  joints,  but  is  common  in  the  spine. 

There  may  be  extensive  secondary  changes.  Muscular  atrophy  is  common 
and  may  appear  with  great  rapidity.  Subluxation  may  occur,  especially  in 
the  knee  and  finger  joints.  The  hands  often  show  great  deformity,  particu- 
larly ulnar  deflection.  Contractures  may  follow  and  the  joints  become  fixed 
in  a  flexed  position.  Xeuritis  and  trophic  disturbances  may  be  associated; 
the  neuritis  is  sometimes  due  to  direct  extension  of  the  inflammatory  process. 
Subcutaneous  nodules  occasionally  occur. 

The  radiographs  show  the  changes  very  well.  Erosion  of  the  cartilage  is 
easily  seen.  In  the  type  with  predominant  peri-articular  changes  the  carti- 
lage and  bone  often  show  little  alteration.  The  occurrence  of  various  changes 
in  difi^erent  joints  or  even  in  the  same  joint  is  common  and  bony  change  may 
occur  with  marked  involvement  of  the  peri-articular  tissues. 

Symptoms. — The  onset  may  be  acute  or  gradual.  In  the  acute  form  a 
number  of  joints  may  be  involved,  there  may  be  high  fever  and  the  whole 
condition  be  suggestive  of  rheumatic  fever.  In  other  cases  the  onset  is  acute 
in  one  joint  and  others  are  involved  a  few  days  later.  With  the  gradual 
onset  one  joint  is  attacked  and  others  follow.  Some  cases  are  between  and 
may  be  termed  subacute.  In  cases  with  an  acute  onset  the  attack  may  not 
persist  very  long;  with  the  chronic  onset  the  duration  is  usually  prolonged. 
The  acute  onset  occurs  more  frequently  in  the  form  in  which  changes  in  the 
soft  parts  predominate. 

Arthritis. — In  the  acute  form  the  joints  are  swollen,  tender,  and  hot  to 
the  touch,  but  do  not  often  show  marked  redness.  There  may  be  efi'usion  in 
the  larger  joints.  Pain  is  a  marked  feature  and  is  increased  by  movement, 
the  patient  usually  taking  the  position  in  which  he  has  the  greatest  ease. 
When  a  joint  is  once  attacked,  the  process  does  not  subside  quickly,  and  when 
the  arthritis  lessens  some  change  remains  in  the  joint  which,  however,  ma}^  be 
very  slight.  The  joints  of  the  spine,  especially  in  the  cervical  region,  are 
often  involved  in  the  more  acute  forms,  and  in  these  there  is  rarely  any  per- 
manent change.  The  temporo-maxillary  joint  is  often  involved,  and  arthritis 
here  is  always  suggestive  of  this  disease.  The  hands,  when  involved,  show 
very  characteristic  changes.  The  knuckle  joints  are  red,  swollen,  tender,  and 
show  limitation  of  motion.  The  fingers  are  often  involved ;  swelling  of  the 
interphalangeal  joints  is  common  with  a  resulting  thickening  which  gives  a 
fusiform   appearance  to  the  finger.     Partial   dislocation,   particularly  at  the 


1128  DISEASES  OF  THE  LOCOMOTOE  SYSTEM 

terminal  joint,  is  common.  The  knee-joints  are  often  affected,  with  pain, 
effusion,  limitation  of  motion,  and  later  villous  arthritis  or  subluxation. 
Thickening  of  the  capsule  usually  occurs  early. 

In  the  hypertrophic  (osteo-arthritis  form)  the  process  is  rarely  as  acute 
as  when  the  peri-articular  parts  are  particularly  involved  (rheumatoid  ar- 
thritis), but  is  usually  polyarticular.  The  terminal  finger  joints,  the  hip  joint, 
and  the  spine  are  especially  affected.  Pain  is  usually  severe  and  the  local 
features  are  not  so  marked.     This  form  is  more  likely  to  be  chronic. 

Heberden's  Nodes.— These  are  small  bony  outgrowths  ("little  hard 
knobs'' — Heberden)  g,t  the  terminal  phalangeal  joints,  which  develop  gradu- 
ally, at  the  sides  of  the  distal  phalanges.  They  are  much  more  common  in 
women  than  in  men.  Heberden  says  "they  have  no  connection  with  gout, 
being  found  in  persons  who  have  never  had  it,"  yet  they  are  often  regarded 
as  indicating  gout.  In  the  early  stage  the  joints  may  be  swollen,  tender,  and 
slightly  red,  particularly  when  injured.  The  attacks  of  pain  and  swelling  may 
come  on  at  long  intervals  or  follow  injury.  Sometimes  they  are  the  first 
manifestation  of  a  general  arthritis.  Their  distribution  is  not  always  regular 
and  they  are  often  largest  on  the  fingers  most  used.  They  may  be  found  in 
patients  in  whose  other  joints  the  arthritis  is  of  the  other  form.  The  condi- 
tion is  not  curable;  but  there  is  this  hopeful  feature — the  subjects  whose 
arthritis  begins  in  this  way  rarely  have  severe  involvement  of  the  larger 
joints. 

The  MON-AETicuLAR  FOEM  affccts  chiefly  old  persons,  and  is  seen  particu- 
larly in  the  hip  and  shoulder.  It  is  identical  with  the  general  disease  in  its 
anatomical  features.  The  muscles  show  wasting  early  and  in  the  hip  the  con- 
dition ultimately  becomes  that  described  as  morbus  coxce  senilis.  These  cases 
seem  not  infrequently  to  follow  an  injury.  They  differ  from  the  polyarticu- 
lar form  in  occurring  chiefly  in  men  and  at  a  later  period  of  life. 

The  Vertebral  Form  (Spondylitis) . — ^This  may  occur  alone  or  with  in- 
volvement of  the  peripheral  joints.  With  the  acute  polyarthritis  of  the  periph- 
eral joints  the  spine  may  be  involved,  but  there  is  usually  no  permanent  change. 
With  the  hypertrophic  form  there  is  often  bony  proliferation  and  some  spinal 
rigidity  results  which  may  involve  the  whole  spine  or  only  a  part ;  in  the  latter 
case  the  lower  dorsal  and  lumbar  regions  suffer  most  frequently.  The  condi- 
tion may  not  involve  more  than  a  few  vertebrse.  The  features  are  as  variable 
as  in  the  peripheral  joints  and  there  may  be  repeated  acute  attacks  or  a  steady 
progressive  process.  In  the  general  spine  involvement  the  ribs  may  be  fixed, 
the  thorax  immobile,  and  the  breathing  abdominal.  There  are  two  varieties 
of  the  general  involvement  which  are  sometimes  regarded  as  special  diseases. 
In  one  (von  Bechterew)  the  spine  alone  is  involved,  and  there  are  pronounced 
nerve-root  symptoms — pain,  anaesthesia,  atrophy  of  the  muscles,  and  ascending 
degeneration  of  the  cord.  Von  Bechterew  thinks  it  begins  as  a  meningitis, 
leads  to  compression  of  the  nerve  roots,  loss  of  function  of  the  spinal  muscles, 
atrophy  of  the  intervertebral  disks,  and  gradually  ankylosis  of  the  spine.  In 
the  other — Striimpell-Marie  type — the  hip  and  shoulder  joints  may  be  in- 
volved (spondylose  rhizomeHque),  and  the  nervous  symptoms  are  less  promi- 
nent. Both  appear  to  be  forms  of  arthritis  deformans,  and  should  neither  be 
regarded  nor  described  as  separate  diseases.  Spondylitis  deformans  is  more 
frequent  in  males,  and  trauma  probably  plays  an  important  part  in  its  etiology. 


AETHEITIS  DEFOEMAXS  1129 

Local  involvement  is  particularly  common  in  the  lumbar  region  and  may 
cause  sciatica  and  a  great  variety  of  referred  pains.  Pressure  on  the  nerve- 
roots  causes  pain,  paresthesia,  and  atrophy  of  the  muscles.  Movement  of 
the  spine  is  usually  restricted. 

Arthritis  Deformans  in  Children. — Some  cases  resemble  closely  the 
disease  in  adults,  in  others  there  are  very  striking  differences.  A  variety  has 
been  differentiated  by  Still,  in  which  the  general  enlargement  of  the  joints 
is  associated  with  swelling  of  the  lymph  glands  and  the  spleen.  The  onset  is 
almost  always  before  the  second  dentition,  and  girls  are  more  frequently 
affected  than  boys.  At  first  there  is  usually  slight  stiffness  in  one  or  two 
joints;  gradually  others  become  involved.  The  onset  may  be  acute  with  fever 
or  even  with  chills.  The  enlargement  of  the  joints  is  due  rather  to  a  general 
thickening  of  the  soft  tissues  than  to  bony  enlargement.  The  limitation  of 
movement  may  be  extreme,  and  there  may  be  much  muscular  wasting.  The 
enlargement  of  the  lymph  glands  is  striking,  increases  with  fever,  and  may  be 
general;  even  the  epitrochlear  glands  may  be  as  large  as  hazel  nuts.  The 
spleen  can  usually  be  felt  below  the  costal  margin.  Sweating  is  often  profuse 
and  there  may  be  anaemia,  but  heart  complications  are  rare.  The  children 
look  puny  and  generally  show  arrest  of  development. 

General  Features. — Temperature. — In  the  acute  attacks  this  may  rise  to 
102°  or  103°  F.,  but  is  frequently  lower  and  often  persists  for  weeks  with 
a  maximum  about  100°  F.  The  pulse  is  rapid  in  proportion  to  the  fever,  the 
most  frequent  range  being  from  90  to  110.  Cardiac  changes  are  found  in 
a  small  proportion  of  cases.  Glandular  enlargement  is  common  and  may  be 
general  or  especially  marked  in  the  glands  related  to  the  affected  joints.  The 
spleen  is  enlarged  in  some  cases,  the  frequency  being  greater  in  the  younger 
patients.  Subcutaneous  nodules  occur  in  a  few  cases  and  are  sometimes 
tender.  The  Hood  often  shows  a  slight  anaemia,  which  is  not  as  marked  as 
might  be  expected  from  the  appearance  of  the  patients.  There  is  rarely  much 
increase  in  the  leucocytes  and  the  differential  count  shows  no  peculiarity. 
The  urine  does  not  show  any  change  of  moment.  The  shin  sometimes  shows 
irregular  areas  of  yellow  pigmentation,  especially  on  the  face  and  arms.  It 
may  have  a  glossy  appearance  over  the  affected  joints.  Profuse  sweating  of 
the  hands  and  feet  is  common.  The  reflexes  are  usually  increased  in  acute 
cases  and  a  return  to  normal  is  of  good  significance.  They  are  sometimes 
absent.  Muscular  atrophy  is  common  and  sometimes  advances  very  rapidly. 
It  is  most  marked  in  the  hands.     Twitching  of  the  muscles  is  not  uncommon. 

In  some  patients  the  bony  atrophy  is  very  marked.  This  is  most  common 
in  females.  In  these  disorganization  of  the  joints  occurs  and  the  cartilage 
rapidly  disappears.  These  cases  usually  progress  rapidly  downward.  This 
atrophy  is  to  be  distinguished  from  that  due  to  disuse. 

Course. — General  Progressive  Form. — This  occurs  in  two  varieties,  acute 
and  chronic.  The  acute  form  may  resemble,  at  its  outset,  rheumatic  fever. 
There  is  involvement  of  many  joints;  swelling,  particularly  of  the  synovial 
sheaths  and  bursoe,  but  not  often  redness;  there  is  moderate  fever  which 
is  often  persistent  and  may  be  from  99°  to  100°  F.  for  weeks.  The  pulse 
rate  is  usually  high  in  proportion  to  the  fever.  In  this  form  there  may 
be  repeated  acute  attacks,  perhaps  at  intervals  of  years,  or  there  may  be 
repeated  attacks  in  various  joints.    These  usually  leave  definite  changes,  which 


1130  DISEASES  OF  THE  LOCOMOTOE  SYSTEM 

may  be  slight  at  first,  but  tend  to  increase  with  subsequent  attacks.  Acute 
cases  may  occur  at  the  menopause.  Some  cases  progress  very  rapidly;  they 
lose  weight  and  strength;  atrophy  and  arthritic  deformity  are  marked;  and 
they  suggest  a  progressive  septic  process  without  suppuration. 

The  chronic  form  is  the  most  common,  althougli  most  of  these  have  had  at 
some  time  an  acute  attack,  especially  at  the  onset.  The  first  symptoms  are 
pain  on  movement  and  slight  swelling,  which  may  be  in  the  joint  itself  or 
in  the  peri-articular  sheaths.  In  some  cases  the  effusion  is  marked,  in  others 
slight.  The  local  conditions  vary  greatly,  and  periods  of  improvement  alter- 
nate with  attacks  of  swelling,  redness,  and  pain.  At  first  only  one  or  two 
joints  are  affected;  gradually  others  are  involved,  and  in  extreme  cases  every 
joint  in  the  body  is  affected.  Pain  is  a  variable  symptom.  Some  cases  proceed 
to  the  most  extreme  deformity  without  severe  pain;  in  others  the  suffering  is 
very  great,  particularly  at  night  and  during  exacerbations  of  the  disease. 
There  are  cases  in  which  pain  of  an  agonizing  character  is  almost  constant, 
quite  apart  from  the  occurrence  of  acute  disturbances.  Pain  has  an  important 
influence  in  the  production  of  deformity,  as  it  hinders  movement  and  the 
joints  are  kept  in  the  position  of  greatest  ease. 

Gradually  the  shape  of  the  joints  is  greatly  altered,  partly  by  the  thick- 
ening of  the  capsule  and  surrounding  tissues,  perhaps  by  osteophytes,  and 
often  by  muscular  contraction.  Crepitus  may  be  felt  in  the  affected  joint. 
Ultimately  the  joints  may  be  completely  immobile,  not  by  a  true  bony  anky- 
losis, although  it  may  be  by  the  osteophytes  which  form  around  the  articular 
surfaces,  but  more  often  from  adhesions  and  peri-articular  thickening.  There 
is  often  an  acute  atrophy  of  the  muscles  and  atrophy  from  disuse  supervenes, 
so  that  contractures  tend  to  flex  the  thigh  upon  the  abdomen  and  the  leg  upon 
the  thigh.  ISTumbness,  tingling,  pigmentation  or  glossiness  of  the  skin,  and 
onychia  may  be  present.  In  extreme  cases  the  patient  is  completely  helpless, 
and  lies  with  the  legs  drawn  up  and  the  arms  fixed.  Fortunately,  it  often 
happens  in  these  severe  general  cases  that  the  joints  of  the  hand  are  not  so 
much  affected,  and  the  patient  may  be  able  to  knit  or  write,  though  unable 
to  walk  or  use  the  arms.  In  many  cases,  after  involving  two  or  three  joints, 
the  disease  becomes  arrested.  A  majority  of  the  patients  finally  reach  a 
quiescent  stage,  in  which  they  are  free  from  pain  and  enjoy  fair  health,  suf- 
fering only  from  the  inconvenience  and  crippling  associated  with  the  disease. 
Coincident  affections  are  not  uncommon.  A  small  percentage  show  cardiac 
lesions,  and  the  pulse  rate  is  usually  higher  than  normal. 

Diagnosis. — The  cases  with  an  acute  onset  may  be  diificult  to  distinguish 
from  rheumatic  fever.  The  affected  joints  are  rarely  as  tender  as  in  rheu- 
matic fever,  and  the  smaller  joints  are  more  often  involved.  The  presence  of 
thickening  in  a  joint,  rapid  muscular  atrophy,  a  relatively  high  pulse  rate 
in  relation  to  the  fever  (in  the  absence  of  endocarditis),  and  the  absence  of 
marked  response  to  salicylate  medication  speak  against  rheumatic  fever.  The 
diagnosis  from  gonorrhcecd  arthritis  may  be  diificult,  but  in  this  the  small 
joints  are  usually  not  attacked  so  often,  and  after  an  onset  with  polyarthritis 
the  majority  of  the  affected  joints  usually  clear,  leaving  one  joint  particularly 
involved.  This  rarely  occurs  in  arthritis  deformans.  A  careful  search  for 
gonococci  is  a  great  aid  in  diagnosis.  In  the  chronic  stage  there  may  be 
considerable  difficulty  in  distinguishing  thi§  disease  from  gout.    This  is  par- 


ARTHRITIS  DEFORMAJ^S  1131 

ticularly  marked  in  either  disease  witiiout  marked  joint  changes.  Tlie  study 
of  the  radiographs  is  particularly  helpful  and  marked  peri-articular  changes 
speak  for  arthritis  deformans.  The  finding  of  tophi  or  the  estimation  of  the 
uric  acid  content  of  the  blood  may  give  the  diagnosis  of  gout.  It  is  important 
to  distinguish  suh-deltoid  bursitis  from  the  mon-articular  form  in  the  shoulder; 
the  radiographs  are  a  great  aid.  They  are  also  important  in  the  recognition  of 
disease  of  the  sacro-iliac  joint  and  tuberculosis  of  the  liip-joint.  Special  im- 
portance attaches  to  the  diagnosis  of  the  spinal  forms.  There  is  no  difficulty  in 
the  case  of  general  involvement,  but  with  local  changes  in  the  lower  spine  it  is 
not  so  easy.  Pain  on  and  restriction  of  movement  are  important ;  the  patient  is 
careful  to  limit  any  motion  of  the  spine.  Tuberculosis  of  the  spine  rarely 
ofi^ers  any  difficulty,  especially  with  skiagrams. 

Prognosis. — The  age,  general  circumstances,  character  of  the  patient,  the 
extent  of  arthritis,  and  the  variety  are  all  important.  The  outlook  is  not  as 
dark  as  is  usually  described.  If  the  source  of  infection  can  be  found  early 
and  properly  treated  the  prognosis  is  encouraging.  In  many  patients  the  dis- 
ease runs  a  certain  course,  and,  if  they  can  be  brought  through  it  with  a  mini- 
mum of  damage,  the  ultimate  outlook  is  good.  In  the  form  with  peri-articular 
changes  predominating,  early  diagnosis,  treatment  of  the  point  of  infection, 
the  preservation  of  good  nutrition,  and  a  patient  who  is  willing  to  fight  are 
all  encouraging  factors.  The  outlook  in  the  cases  with  the  acute  attacks  is 
usually  better  than  in  those  with  a  more  chronic  progressive  course.  Rapid 
muscular  atrophy  is  of  grave  import.  Cases  in  women  beginning  about  the 
menopause  should  always  have  a  grave  prognosis.  Rapid  advancement  in  the 
joint  changes  is  serious.  In  the  form  in  children  the  outlook  is  not  good, 
but  some  recover  entirely.  The  group  with  marked  hypertrophic  changes 
(osteo-arthritis)  usually  do  well.  Heber den's  nodes  are  permanent,  but  in 
the  larger  joints  it  is  rare  for  the  condition  to  advance  to  absolute  crippling, 
although  there  may  be  considerable  interference  with  function.  Spondylitis 
rarely  advances  to  complete  immobility  of  the  whole  spine.  The  outlook  is 
good  in  the  local  cases,  but  depends  somewhat  on  the  occupation  and  possi- 
bility of  trauma.  The  general  condition  is  of  importance  in  estimating  the 
outlook.     In  those  with  marked  nervous  features  the  prognosis  is  not  good. 

Treatment. — Much  depends  on  proper  management  and  the  pessimistic 
attitude  is  not  justified.  Certain  things  are  important :  early  diagnosis  so 
that  treatment  can  be  begun  early,  the  avoidance  of  harmful  measures,  careful 
attention  to  the  general  condition,  and  every  effort  to  limit  the  damage  in  the 
joints.  Too  much  stress  can  not  be  placed  on  the  need  of  early  diagnosis; 
the  disease  is  often  regarded  as  "rheumatic"  and  the  treatment  directed  to 
this  (especially  restriction  of  diet  and  the  giving  of  salicylates  for  long 
periods)   is  usually  harmful. 

Source  of  Infection. — Every  effort  should  be  made  to  find  any  such  and 
prompt  treatment  carried  out.  Infection  of  the  teeth  and  tonsils  has  always 
to  be  excluded.  The  possil)ility  of  infection  of  the  bile  passages  should  be 
considered.  Whenever  possible  an  autogenous  vaccine  should  be  prepared  and 
used  if  the  removal  of  the  focus  is  not  enough.  Serums  have  not  been  of 
benefit  in  our  experience. 

General  Measures. — The  patient  should  be  kept  out  of  doors  as  much 
as  possible  and  every  effort  made  to  improve  the  general  health.     The  diet 


1132  DISEASES  OF  THE  LOCOMOTOR  SYSTEM 

should  be  the  most  nourishing  possible.  The  mistake  of  cutting  down  the 
proteins  is  often  made.  Eegard  must  be  had  to  the  digestion,  and  it  is  more 
often  the  carboh3-drates  which  should  be  reduced.  Water  should  be  freely 
given,  as  elimination  is  important.  The  bowels  should  be  kept  open,  and  for 
this  the  salines  are  useful.  It  is  important  to  see  that  the  patients  are  warmlj' 
clad  in  cold  weather  and  guarded  against  chilling.  Hydrotherdpy  is  useful 
locally  in  the  form  of  compresses,  but  the  hot  bath  treatment,  so  often  given, 
more  frequently  does  harm  than  good,  particularly  in  acute  cases.  Baths, 
when  taken,  should  be  of  very  short  duration.  In  more  chronic  cases  bathing 
is  sometimes  of  value.  Massage  is  especially  useful  in  the  cases  with  synovial 
and  peri-articular  changes,  and  in  them  passive  motion  should  be  used  early. 
Climate  is  of  value  in  so  far  as  patient  is  able  to  be  out  of  doors  and  is  saved 
from  rapid  changes  of  temperature. 

Medicinal. — There  is  no  drug  which  essentially  influences  the  disease. 
The  salicylates  may  aid  in  relieving  pain,  but  should  not  be  given  for  long 
periods.  Iron,  arsenic,  and  iodine  are  often  useful.  Iodine  may  be  given  as 
the  tincture  in  doses  of  five  to  ten  drops.  Potassium  iodide  is  sometimes  of 
value  when  given  for  a  long  period.  Thyroid  and  thymus  gland  extracts  given 
persistently  are  sometimes  beneficial.  For  the  pain  it  is  necessary  to  give 
drugs,  although  local  measures  should  be  used  as  much  as  possible.  There  are 
many  which  are  available.  Acetyl-salicylic  acid  (gr.  x,  0.6  gm.),  guaiacol 
carbonate  (gr.  v,  0.3  gm.),  antipyrin  (gr.  iii,  0.2  gm.),  and  sometimes  codein 
(gr.  %,  0.03  gm.),  are  useful.  Morphia  should  not  be  given  on  account  of  the 
danger  of  a  habit. 

Local. —  [a)  L"se  of  the  joints  must  be  governed  by  the  condition.  When 
the  cartilage  and  bones  are  not  involved,  passive  motion  and  massage  are 
useful,  followed  later  by  active  motion.  The  patient  should  be  taught  simple 
exercises.  When  the  cartilages  and  bones  are  involved,  rest  is  usually  advisa- 
ble for  a  time.  Every  effort  should  be  made  to  avoid  contracture  and  dis- 
placement, and  in  this  the  use  of  splints  during  the  night  is  often  valuable. 
Caution  should  be  exercised  in  advising  complete  fixation.  This  is  sometimes 
useful  for  short  periods  in  the  osteo-arthritic  form,  but  may  result  in  fixation 
in  the  other  form  and  is  usually  not  advisable  for  it.  (&)  Counter-irritation. 
This  is  usually  an  aid,  and  the  Paquelin  cautery,  blisters,  mustard,  and  iodine 
may  be  used.  It  is  usually  better  to  use  light  counter-irritation  frequently  than 
severe  at  longer  intervals,  (c)  Hypercemia.  This  may  be  active,  and  baking 
is  a  favorite  method,  but  it  should  not  be  given  for  more  than  thirty  minutes 
at  a  time.  The  temperature  should  be  as  high  as  the  patient  can  stand.  Pas- 
sive hypersemia  may  be  used  for  a  short  period  at  first,  and  later  for  many 
hours  at  a  time,  (d)  Hydrotherapy.  The  persistent  use  of  compresses  is 
often  of  value.     They  may  be  put  on  in  the  evening  and  left  on  all  night. 

Surgical  Measures. — These  are  useful  for  the  correction  of  deformities. 
In  the  case  of  villous  arthritis  operation  is  usually  indicated.  In  the  group 
with  marked  hypertrophy  of  bone  removal  of  the  outgrowths  may  be  helpful. 

Special  Forms. —  (a)  Heberdens  nodes.  x4voidance  of  irritation  and  in- 
jury is  important,  and  in  the  case  of  pain  the  use  of  compresses  is  helpful. 
(&)  Spondylitis.  During  the  acute  stages  rest  is  essential  and  should  be 
secured  by  a  plaster  jacket  or  simple  apparatus.  In  the  milder  forms  firm 
strapping  may  give  relief.     Trauma  should  be  especially  avoided,     (c)  Knee 


INTEEMITTENT  HYDRARTHROSIS  1133 

joint.  In  many  cases  a  simple  elastic  support  is  useful  and  may  save  the 
joint  from  injury. 

Foreign  Protein. — This  has  proved  useful  in  some  cases,  given  intrave- 
nously in  the  form  of  proteose  (1-2  c.c.  of  a  4  per  cent,  solution)  or  as  typhoid 
vaccine  (75-150  millions).  A  sharp  reaction  is  necessary  if  any  benefit  is  to 
result. 

Arthritis  Secondary  to  Acute  Infection. — While  the  majority  of  cases  of 
arthritis  are  secondary  to  some  form  of  infection,  it  is  important  to  recognize 
various  forms.  (1)  Those  with  a  definite  bacterial  cause,  such  as  gonorrhoeal- 
or  tuberculous  arthritis.  These  usually  have  fairly  well  defined  features. 
(2)  Those  secondary  to  infections  of  doubtful  etiology,  such  as  scarlet  fever 
or  measles.  In  some  of  these  the  arthritis  is  due  to  a  secondary  infection,  but 
in  others  it  appears  to  be  due  to  the  specific  cause  of  the  disease.  (3)  Ar- 
thritis secondary  to  definite  infections  in  which  there  is  no  evidence  of  any 
organism  in  the  joint.  These  are  comparatively  common  and  are  difficult 
to  designate.  For  example,  arthritis,  which  may  not  be  severe  and  subsides 
rapidly,  occurs  with  an  attack  of  tonsillitis.  It  has  been  suggested  that  these 
might  be  termed  "toxic"  or  "toxemic"  arthritis.  The  term  "infectious" 
arthritis,  sometimes  applied,  is  not  a  satisfactory  one.  The  cases  in  this  group 
usually  clear  without  leaving  permanent  damage,  but  if  long  continued  they 
may  result  in  the  changes  included  under  the  heading  of  arthritis  deformans. 

"Chronic  Rheumatism." — This  term  deserves  mention  because  it  is  so 
commonly  used,  but  it  is  a  question  whether  its  retention  is  justified.  There 
is  no  uniformity  in  its  usage  and  it  is  applied  without  discrimination  to  all 
kinds  of  arthritis  and  frequently  to  conditions  which  have  nothing  to  do  with 
the  joints.  Painful  conditions  of  the  joints,  muscles,  fasciae,  bones,  and 
nerves  are  all  termed  "rheumatism."  There  is  no  disease  entity  to  which  the 
term  can  be  applied,  and  it  would  be  an  advantage  to  give  it  up  entirely. 


II.     INTERMITTENT  HYDRARTHROSIS 

The  condition  was  described  by  Perrin  in  1845.  The  affection  is  charac- 
terized by  a  remarkable  periodic  swelling  of  one  or  several  of  the  joints  with- 
out fever.  The  swelling  may  take  place  with  great  rapidity,  and  there  may 
even  be  a  sensation  of  water  rushing  into  the  joint.  There  are  usually  pain 
and  stiffness.  The  periods  may  be  from  ten  to  twelve  days,  or  a  month  or 
even  three  months.  Many  of  the  cases  have  been  in  women  and  sometimes 
with  marked  hysterical  symptoms.  While  some  of  the  cases  are  secondary 
and  only  represent  a  phase  in  the  evolution  of  various  articular  lesions,  there 
appears  to  be  a  primary  form  characterized  by  a  periodic  swelling  and  nothing 
else.  It  is  sometimes  the  joint  equivalent  to  Quincke's  oedema  and  may  be 
associated  with  erythema,  with  angio-neurotic  oedema,  and  in  one  of  Garrod's 
patients  there  was  at  the  same  time  circumscribed  oedema  of  the  lips  and  eye- 
lids. Some  cases  are  due  to  anaphylaxis.  A  mother  and  daughter  have  been 
affected.  The  prognosis  is  not  good;  the  attacks  are  apt  to  recur  in  spite  of 
all  forms  of  treatment. 


1134  DISEASES  OF  THE  LOCOMOTOE  SYSTEM 

C.    DISEASES  OF  THE  BONES 

I.    HYPERTROPHIC  PULMONARY  ARTHROPATHY 

Definition. — A  symmetrical  enlargement  of  the  bones  of  the  hands  and 
feet,  and  of  the  distal  ends  of  the  long  bones,  occurring  in  association  with 
•certain  chronic  diseases,  particularly  affections  of  the  lungs. 

Bamberger  in  1889  reported  a  condition  of  abnormal  thickening  of  the 
long  bones  in  bronchiectasis,  and  the  next  year  Marie  described  other  cases 
and  named  the  condition. 

EtiolO'^i. — Clubbing  of  the  fingers,  or  the  Hippocratic  fingers,  represent 
a  minor  manifestation  of  this  condition.  Many  varieties  occur;  indeed,  there 
is  a  monograph  with  sketches  of  some  thirty  or  forty  forms.  It  is  met  with 
perhaps  most  constantly  in  congenital  disease  of  the  heart,  in  tuberculosis 
and  in  other  affections  of  the  lungs,  particularly  bronchiectasis,  in  congenital 
syphilis,  in  chronic  jaundice,  and  in  other  chronic  affections.  In  thoracic 
aneurism  it  may  involve  only  the  fingers  of  one  hand.  It  usually  comes  on 
very  slowly,  but  cases  have  been  described  of  an  acute  appearance  within  a 
week  or  a  fortnight.  It  may  disappear.  There  is  no  bony  alteration,  but  there 
is  a  fibrous  thickening  of  the  connective  tissues  with  turgescence  of  the  ves- 
sels. The  condition  is  by  no  means  easy  to  explain.  The  mechanical  effect 
of  congestion,  the  usual  feature,  explains  the  heart  and  lung  cases,  but  not 
those  of  congenital  syphilis  and  diseases  of  the  liver,  in  which  this  is  not 
present.     Others  have  attributed  it  to  a  toxin. 

Marie's  syndrome  is  met  with:  (1)  In  diseases  of  the  lungs  and  pleura. 
This  was  the  case  in  43  out  of  55  cases  collected  by  Thayer,  and  in  68  of 
Wynn's  100  cases.  Bronchiectasis  is  the  most  common,  then  pulmonary  tuber- 
culosis and  empyema.  (2)  Other  affections,  such  as  chronic  diarrhoea,  chronic 
jaundice,  nephritis,  and  congenital  syphilis. 

Marie  regards  the  process  as  resulting  from  the  absorption  of  toxins  caus- 
ing a  periostitis;  others  have  regarded  it  as  a  low  form  of  tuberculous  infec- 
tion. The  bones  most  frequently  involved  are  the  lower  ends  of  the  radius 
and  ulna  and  the  metacarpals,  more  rarely  the  lower  end  of  the  humerus,  and 
the  lower  ends  of  the  tibia  and  fibula. 

Symptoms. — The  affection  comes  on  gradually,  unnoticed  by  the  patient. 
In  other  cases  there  is  great  sensitiveness  of  the  ends  of  the  long  bones  and 
of  the  fingers  and  toes.  In  one  of  our  cases  this  was  present  in  an  extreme 
degree.  The  fully  developed  condition  is  easily  recognized.  The  hands  are 
large,  the  terminal  phalanges  swollen,  the  nails  large  and  much  curved. 
Similar  changes  occur  in  the  toes,  and  the  feet  look  large,  especially  the  toes 
and  the  malleoli.  The  bones  of  the  fore-arms  are  diffusely  thickened,  par- 
ticularly near  the  wrist,  and  the  tibiae  and-  fibulge  are  greatly  enlarged.  Some- 
times in  advanced  cases  both  ankles  and  knee-joints  stand  out  prominently. 
The  hypertrophy  rarely  affects  the  other  long  bones,  though  occasionally  the 
extremities  of  the  humerus  and  femur  may  be  involved.  The  bones  of  the 
head  are  not  attacked.     Kyphosis  may  occur. 

Dia^osis. — There  is  rarely  any  difficulty,  as  the  picture  presented  by  the 


OSTEITIS  DEFOEMANS  1135 

hands  and  feet  differs  from  that  in  acromegaly,  and  in  practically  all  cases 
it  is  a  secondary  condition. 


11.     OSTEITIS  DEFORMANS 

{Paget's  Disease) 

Definition. — A  chronic  affection  of  the  bones  characterized  by  enlargement 
of  the  head,  dorso-cervical  kyphosis,  enlargement  of  the  clavicles,  spreading 
of  the  base  of  the  thorax  and  an  outward  and  forward  bowing  of  the  legs. 

The  affection  was  described  first  by  Sir  James  Paget,  in  1877. 

Etiology. — In  the  generalized  form  it  is  a  rare  disease,  only  two  cases 
occurring  among  about  20,000  medical  cases  at  the  Johns  Hopkins  Hospital. 
The  etiology  is  unknown.  Mother  and  daughter  have  been  affected.  Some 
have  regarded  it  as  luetic,  others  as  due  to  the  arterio-sclerosis,  which  is  a 
constant  lesion.  It  may  possibly  be  due  to  perversion  of  some  internal  secre- 
tion. 

Pathology. — The  skull,  spine,  and  long  bones  are  chiefly  affected;  those 
of  the  face,  hands  and  feet  are  less  involved.  The  skull  may  be  as  much  as 
three  quarters  of  an  inch  in  thickness,  and  its  circumference  is  increased.  In 
one  of  Paget's  cases  it  measured  71  cm.  The  shafts  of  the  long  bones  are 
greatly  thickened  and  they  may  weigh  twice  as  much  as  a  healthy  bone  of  the 
same  length.  The  femur  is  bent,  the  convexity  forward ;  the  tibiae  may  be  huge 
and  very  much  bowed  anteriorly.  The  bones  of  the  upper  extremities  are 
less  often  involved,  the  spine  shows  a  marked  kyphosis,  sometimes  partial 
ankylosis;  the  pelvis  is  broadened. 

The  process  is  a  rarefying  osteitis  which  gradually  involves  the  centre 
of  the  bones  with  the  formation  of  Howship's  lacunae.  Haversian  spaces,  and 
perforating  canals.-  There  is  also  new  bone  formation,  both  subperiosteal  and 
myelogenous;  the  latter  process  gradually  gains,  and  so  the  bones  thicken. 

Symptoms. — The  disease  begins,  as  a  rule,  in  the  sixth  decade,  sometimes 
with  indefinite  pains,  but  more  frequently  the  patient  notices  first  that  the 
head  begins  to  enlarge,  so  that  he  has  to  buy  a  larger  hat.  Then  his  friends 
notice  that  he  is  growing  shorter,  and  that  the  legs  are  getting  more  and  more 
bowed.  There  is  a  painful  variety  with  great  soreness  of  the  arms  and  legs, 
which  may  be  much  worse  at  night.  Headache,  bronchitis,  pigmentation  of 
the  skin,  have  been  noted.  The  reduction  in  stature  is  very  remarkable;  one 
patient  lost  13  inches  in  height. 

Diagnosis. — The  disease  is  readily  recognized.  The  face  differs  from 
acromegaly,  in  which  it  is  ovoid  or  egg-shaped  with  the  large  end  down,  while 
in  Paget's  disease  the  face  is  triangular  with  the  base  upward.  In  a  few 
cases  the  disease  may  be  limited  to  a  few  bones.  There  is  a  variety  involving 
the  tibiae  and  fibulae  alone,  and  in  some  the  femurs  to  a  slight  extent.  These 
bones  gradually  enlarge,  are  bowed  anteriorly  and  laterally,  so  that  the  only 
obvious  features  are  a  reduction  in  height  with  bowing  of  the  legs.  There 
is  also  a  variety,  sometimes  known  as  tumor-forming  osteitis  deformans,  in 
which  the  bones  are  much  deformed  with  multiple  hyperostosis  and  new 
growths.     The  relation  of  this  to  Paget's  disease  is  doubtful, 


1136  DISEASES  OE  THE  LOCOMOTOE  SYSTEM 


ni.     LEONTIASIS  OSSEA 

In  a  remarkable  condition  known  as  leontiasis  ossea  there  is  hyperostosis 
of  the  bones  of  the  cranium,  and  sometimes  those  of  the  face.  The  descrip- 
tion is  largely  based  upon  the  skulls  in  museums,  but  Allen  Starr  reported 
an  instance  in  a  woman,  who  presented  a  slowly  progressing  increase  in  tho 
size  of  the  head,  face,  and  neck,  the  hard  and  soft  tissues  both  being  afEected. 
He  applied  the  term  megalo-cephaly  to  the  condition.  Putnam  states  that  the 
disease  begins  in  early  life,  often  as  a  result  of  injury.  There  may  be  osteo- 
phytic  growths  from  the  outer  or  inner  tables,  which  in  the  latter  situation 
may  give  the  symptoms  of  tumor. 


IV.     OSTEOGENESIS  IMPERFECTA 

{Fragilitas  Ossium,  Osteopsathyrosis,  Lohsteins  Disease) 

Definition. — A  prenatal  and  postnatal  defective  activity  of  the  osteoblasts, 
rendering  the  bones  abnormally  brittle.  The  condition  is  often  hereditary 
and  is  sometimes  associated  with  a  peculiar  shape  of  the  head  and  blue 
sclerotics. 

History. — Lobstein  described  the  disease  as  osteopsathyrosis  in  1833,  while 
Vrolik  in  1849  described  the  prenatal  idiopathic  type  as  osteogenesis  imper- 
fecta. Eecklinghausen  and  others  have  thought  the  conditions  were  not  iden- 
tical, but  the  general  opinion  now  seems  to  be  that  they  are  the  same,  and 
that  idiopathic  fragilitas  ossium,  whether  prenatal  or  postnatal,  is  due  to  a 
deficient  activity  of  the  osteoblasts,  whether  in  sub-periosteal  or  chondral 
ossification  (Bronson).  The  terms  osteogenesis  imperfecta  congenita  and 
tarda  best  describe  the  two  conditions. 

Etiology. — Nothing  is  known  except  the  single  factor  of  heredity  which 
occurs  in  a  variable  number  of  cases.  Davenport  and  Conrad  state  that  the 
heredity  is  typically  direct  and  that  the  factor  determining  the  irregular  bone 
formation  is  a  dominant  one.  The  younger  half  of  the  family  of  an  osteo- 
psathyrotic  parent  will  be  affected,  "but  if  neither  parent,  though  of  affected 
stock,  has  shown  the  tendency,  then  the  expectation  is  that  none  of  the  chil- 
dren will  have  brittle  bones."  Biotypes  occur,  in  some  families  the  femur 
only,  in  some  the  humerus  only  is  affected,  and  in  some  any  pressure  causes  a 
break,  while  others  show  a  much  greater  resistance. 

Symptoms. — In  the  prenatal  cases  the  child  is  often  premature  and  still- 
born, the  extremities  short  and  thick  with  many  fractures  in  all  stages  of 
healing.  The  head  may  feel  like  a  crepitant  bag  of  bones.  The  character- 
istic bitemporal  enlargement  has  been  described  by  Cameron.  In  the  post- 
natal cases  the  onset  is  usually  after  infancy.  While  the  liability  to  fracture, 
as  a  rule,  decreases  with  years,  it  may  persist  until  the  age  of  fifty.  Slight 
blows  may  cause  a  fracture,  of  which  a  child  may  have  a  score  or  more  before 
puberty.     As  a  rule,  they  are  painless  and  heal  readily. 

Blue  Sclerotics. — Eddowes  first  described  this  remarkable  condition  which 
is  more  common  in  the  inherited  form,     It  may  occur  in  individuals  of  the 


ACHONDEOPLASIA  1137 

family  who  have  never  had  fractures.  It  is  not  due  to  any  color  in  the 
sclera  itself  but  to  increased  transparency,  possibly  depending  upon  the 
absence  of  lime  salts  in  the  connective  tissue. 


V.     OSTEOMALACIA 

(Mollities  Ossium) 

This  disease  is  characterized  by  pain,  muscular  weakness,  and  softness  of 
the  bones,  due  to  decalcification,  resulting  in  fractures  and  deformity.  The 
great  majority  of  the  cases  are  in  women;  repeated  pregnancies  may  play  a 
part.  A  relationship  to  rickets  is  doubtful.  Disturbance  of  internal  secre- 
tions may  be  responsible.  The  onset  is  usually  between  the  ages  of  twenty 
and  thirty.  The  bones  are  soft  and  show  both  decalcification  and  new  for- 
mation. The  earliest  symptom  is  pain,  especially  in  the  back  and  sacral  re- 
gions, increased  by  movement.  Weakness  is  marked  and  there  may  be  stiff- 
ness with  contractures.  The  gait  may  be  uncertain,  sometimes  spastic.  The 
bony  deformity  is  usually  first  in  the  spine  or  pelvis.  Later  there  is  marked 
deformity  with  fractures,  callus  formation  and  muscular  wasting.  The 
course  is  usually  over  some  years  and  death  may  result  from  exhaustion  or 
a  terminal  infection.  The  early  diagnosis  is  difficult  and  may  only  be  made 
when  deformities  appear.  The  X-rays  are  of  value.  In  treatment,  phosphorus 
in  oil  should  be  given  (gr.  1/20-1/12,  0.003-0.005  gm.).  The  removal  of  the 
ovaries  has  been  useful  in  some  cases.  Proper  treatment  for  the  symptoms 
should  be  given. 

VI.    ACHONDROPLASIA 

(Chondrodystrophia  Fetalis) 

Definition. — A  dystrophy  of  the  epiphyseal  cartilages  due  to  connective 
tissue  invasion  from  the  periosteum,  in  consequence  of  which  the  epiphyses 
and  diaphyses  are  prematurely  united  and  there  is  failure  of  the  normal  growth 
of  the  long  bones.  In  consequence  the  subjects  become  dwarfs  with  normal 
heads  and  trunks,  but  short,  stumpy  extremities. 

Description. — Achondroplasic  dwarfs  are  easily  recognized.  They  are  well 
nourished  and  strong,  and  of  average  intelligence.  Their  height  varies  from 
3  to  4  feet;  the  head  and  trunk  are  of  about  normal  size,  but  the  extremities 
are  very  short,  the  fingers,  when  the  arms  are  at  the  sides,  reaching  little 
below  the  crest  of  the  ilium.  The  important  point  is  that  in  the  shortness  of 
the  limbs  it  is  the  proximal  segments  which  are  specially  involved,  the  humerus 
and  femur  being  even  shorter  than  the  ulna  and  tibia  (rhizomelia).  The  limbs 
are  considerably  bent,  but  this  is  more  an  exaggeration  of  normal  curves  and 
abnormalities  in  the  joints  than  pathological  curves.  The  features  of  rickets 
are  absent.  The  hand  is  short,  and  has  a  trident  shape,  since  the  fingers, 
which  are  of  almost  equal  length,  often  diverge  somewhat.  The  root  of  the 
nose  is  depressed,  the  back  flat,  and  the  lumbar  lordosis  abnormally  deep, 
owing  to  a  tilting  forward  of  the  sacrum.     The  scapulae  are  short,  the  fibulas 


1138  DISEASES  OF  THE  LOCOMOTOE  SYSTEM 

longer  than  the  tibiae,  and  the  pelvis  is  contracted ;  hence,  the  number  of  these 
cases  reported  by  obstetricians.     Heredity  plays  little  part. 

Pathology. — Anatomically  it  is  a  dystrophy  of  the  epiphyseal  cartilages, 
the  cells  of  which  are  irregularly  scattered,  and  the  ground  substances  in- 
vaded by  connective  tissues  from  the  periosteum,  which  sends  in  bands  of 
tissues  across  the  end  of  the  diaphysis.  The  development  of  the  bones  with 
a  membranous  matrix  seems  normal. 

Virchow  described  the  disease  as  fetal  cretinism,  others  as  fetal  rickets. 
Of  late  naturally  its  origin  has  been  associated  with  disturbance  of  the  pitui- 
tary function,  or  of  its  hormonic  relations.  On  the  other  hand,  Jansen  of 
Leyden,  in  a  monograph  (1912),  brings  forward  evidence  to  show  that  it 
results  from  a  disturbance  of  the  direct  and  indirect  amniotic  pressure,  and 
brings  it  into  relationship  with  a  number  of  other  fetal  malformations.  He 
states  that  the  anatomical  evidence  is  against  changes  in  the  sella  turcica. 
But  it  is  an  argument  in  favor  of  some  associated  disturbance  of  the  pituitary 
gland  that  achondroplasics  often  show  precocious  sexual  development. 


VII.    HEREDITARY  DEFORMING  CHONDRODYSPLASIA 

(Multiple  Cartilaginous  Exostoses) 

The  disease  is  characterized  by  the  occurrence  of  multiple,  usually  sym- 
metrical, cartilaginous  or  osteo-cartilaginous  growths,  generally  benign,  which 
result  from  proliferation  and  ossification  of  bone-forming  cartilage,  and  cause 
bony  deformities.  The  disease  is  hereditary  in  many  instances;  in  one  fam- 
ily there  were  26  cases  in  four  generations.  The  American  cases  have  been 
collected  by  Ehrenfried,  who  found  that  males  were  more  often  affected 
(3  to  1).  The  changes  begin  in  infancy  or  early  childhood,  increase  with 
skeletal  growth  and  cease  about  the  age  of  22  years.  The  height  is  often 
less  than  normal.  There  are  "irregular  juxta-epiphyseal  hyperostoses"  most 
marked  at  the  hips,  knees,  ankles,  shoulders  and  wrists.  There  is  often  knock- 
knee  and  pes  valgus,  and  the  ulna  may  be  relatively  shortened.  There  may 
be  symptoms  due  to  pressure  of  the  exostoses  on  nerves  or  vessels.  Eemoval  of 
the  exostoses  is  indicated  if  they  cause  troublesome  symptoms. 


VIII.     OXYCEPHALY 

Definition. — A  cranial  deformity  associated  with  exophthalmos  and  im- 
pairment of  vision. 

Bescription. — The  condition,  known  as  tower  or  steeplehead,  is  character- 
ized by  great  height  of  the  forehead,  sloping  to  a  pointed  vertex,  with  feebly 
marked  supra-orbital  ridges,  and  the  hairy  scalp  may  be  raised  above  the  nor- 
mal level,  looking  as  if  perched  on  the  top  of  a  comb.  The  intelligence  is 
unimpaired.  The  condition  is  usually  present  at  birth,  though  in  some  in- 
stances it  develops  from  the  second  to  the  sixth  year.  As  this  curious  growth 
of  the  head  proceeds,  headache  may  be  present,  exophthalmos  develops,  and 
the  vision  becomes  impaired,  due  to  progressive  optic  atrophy.     Smell  is  often 


OXYCEPHALY  1139 

completely  lost.  The  deformity  appears  to  be  due  to  premature  synostosis 
of  certain  sutures,  notably  the  sagittal  and  coronal.  As  a  result  of  the  pre- 
mature union  of  these  two  sutures  the  growth  of  the  vault  of  the  skull  is 
restricted  in  both  its  antero-posterior  and  transverse  diameters,  and  to  accom- 
modate the  increasing  bulk  of  the  brain  a  compensatory  increase  in  height 
takes  place.  Eventually  the  anterior  fontanel  le  closes,  but  there  is  reason  to 
think  that  this  occurs  at  a  later  date  than  the  normal,  and  its  former  site 
is  marked  by  a  slight  protuberance  with  thinning  of  the  bone.  (Morley 
Fletcher,  Quarterly  Jour.  Med.,  IV,  1911.) 

The  optic  neuritis  and  atrophy  are  the  result  of  pressure  exerted  by  the 
growing  brain  and  may  be  compared  to  that  of  cerebral  tumor.  As  yet  we 
do  not  know  the  cause  of  this  premature  synostosis.  The  condition  is  one  for 
which  a  decompression  operation  with  ventricular  puncture  is  indicated. 


INDEX 


Abasia,   1096,   1103. 

Abdominal  pain  in  typhoid  fever,  22. 

Abducens  nerve  paralysis  {see  sixth 
nerve),  1030. 

Aberrant  thyroid,  863. 

Abortion  in  relapsing  fever,  261;  in  syph- 
ilis, 283;   in  typhoid,  31. 

Abortive  smallpox,  325. 

Abortive  typhoid  fever,  30. 

Abscess,  actinomycotic,  232. 

Abscess,  amoebic,  239;  appendicular,  597; 
atheromatous,  835;  in  glanders,  147;  of 
brain,  1009;  of  liver,  574;  of  liver  in  ty- 
phoid fever,  24 ;  of  lung,  645 ;  of  lung  in 
pneumonia,  98;  of  mediastinum,  669; 
nephritic,  720;  pharyngeal,  458;  pysemic, 
54;  salivary,  455;  tonsillar,  458;  ty- 
phoid, 29. 

Acanthocephali,  315. 

Aeardia,  824. 

Acarus,  316. 

Accentuated  aortic  second  sound  in  arte- 
rio-sclerosis,  837;  in  chronic  interstitial 
nephritis,  703. 

Accessory  sinus  disease,   1010. 

Accessory  spasm,   1046. 

Acholuric  congenital  jaundice,  549;  hsemo- 
lytic  jaundice,  884. 

Achondroplasia,  1137. 

Achylia  gastrica,  502. 

Acidosis,  445;  blood  and  urine  in,  447; 
carbon  dioxide  tension  in  alveolar  air, 
447;  definition,  445;  diagnosis,  446;  in 
children,  446;  in  diabetes,  426-446;  in 
ileo-colitis,  518,  520;  nephritis  and,  689, 
703;  occurrence  of,  446;  prognosis  and 
treatment,  447;  renal,  446. 

Acne  rosacea  in  alcoholism,  389. 

Acromegaly,  877. 

Actinomycosis,  231;  cerebral,  233;  clinical 
forms  of,  232;  cutaneous,  233;  diagno- 
sis of,  233 ;  digestive  tract  involvement, 
232;  etiology  of,  231;  mode  of  infection, 
231;  pathology  of,  232;  pulmonary, 
232;  treatment,  233. 

Acute  catarrhal  fever,  371. 

Acute  dyspepsia,  468. 

Acute  miliary  tuberculosis  of  the  perito- 
neum, 180. 


Acute  yellow  atrophy  of  liver,  549. 

Addison's  disease,  856. 

Addison's  pill,  287. 

Adenie   {see  Hodgkin's  disease),   738. 

Adenitis,  in  scarlet  fever,  343;  syphilitic, 
273;   tuberculous,  174. 

Adenoids,  460 ;  and  deafness,  462 ;  and  de- 
formities of  the  chest,  461;  treatment, 
463. 

Adeno-lipomatosis,  443. 

Adherent  pericardium,  760. 

Adhesions,  gastric,  483,  487;  peritoneal, 
597,  599. 

Adiodochokinesis,  972. 

Adiposis  dolorosa,  442. 

Adrenals   {see  suprarenals) ,  855. 

Aerophagia,  500. 

.A<]stivo-autumnal   fever,   251. 

Afebrile  typhoid  fever,  31. 

Affections  of  the  blood  vessels  of  the  liver, 
552;  of  the  mediastinum,  666;  of  the 
mesentery,  543 ;  of  the  mucous  glands, 
454;  of  the  myocardium,  777. 

Age  influence  in  amcebiasis,  237;  in  ap- 
pendicitis, 522 ;  in  broncho-pneumonia, 
105;  in  lobar  pneumonia,  79,  99;  in 
small  pox,  321;  in  tuberculosis,  159;  in 
typhoid  fever,  3. 

Aged,  pneumonia  in,  95;  pulmonary  tu- 
berculosis in,  210. 

Agenesia  cerebri,  1000. 

Ageusia,  1042. 

Agglutination  test  in  typhoid  fever,  33. 

Agoraphobia,   1102. 

Ainhum,  1118. 

Air  hunger  in  diabetes,  429. 

Akinesia  algera,  1103. 

Akoria,  504. 

Albini,  nodules  of,  826. 

Albuminuria,  adolescent,  679;  appendicu- 
lar, 524;  epilepsy,  1075;  erysipelas,  59; 
familial,  680 ;  functional,  679 ;  in  diph- 
theria, 70;  in  typhoid,  28;  life  insur- 
ance, 679 ;  nervous,  680 ;  orthostatic, 
679;  physiological,  679;  prognosis,  681; 
with  renal 'lesions,  681 ;  J'ellow  fever,  265. 

Albuminuric  retinitis,  1023. 

Albumosuria,  681;   myelopathic,  681. 

Alcohol  as  factor  in  gout,  414. 

Alcoholic  neuritis,  1017;  subjects  and 
pneumonia,  95. 


1141 


1142 


INDEX 


Alcoholism,  acute  and  chronic,  3S7;  and  tu- 
berculosis, 389;  chronic,  nervous  changes 
in,  388;  digestive  changes,  388;  treat- 
ment, 390. 

Aleppo  boil,  260. 

Alexia,  977. 

Algid  form  of  malaria,  253. 

Alimentary  canal,  tuberculosis  of,  211. 

Alkalis,  use  of,  in  pneumonia,  101. 

Alkaptonuria,  687. 

AUocheiria,  910. 

Alopecia,  syphilitic,  272. 

Alternation  of  the  heart,  776. 

Altitude,  effect  of,  384;  in  tuberculosis, 
225. 

Alzheimer  's  disease,  980. 

Amaurosis,  hysterical,  1023,  1093;  in  hse- 
matemesis,  199 ;  toxic,  1023,  urismie, 
691. 

Amaurotic  family  idiocy,  932. 

Ambulatory  typhoid  fever,  11,  31. 

Amnesia  verbalis,  977. 

Amoeba  carriers,   242. 

Amcebiasis,  237;  acute  dysenteric,  240; 
age  incidence  of,  237;  definition  of,  237; 
distribution  of,  237;  dysenteric,  chronic, 
240;  hepatic,  239;  liver  abscess,  240; 
lung  lesions,  239 ;  perforation  and  haem- 
orrhage, 240;  quinine  injections,  242; 
racial  incidence  of,  237;  relapse,  241; 
sex  incidence  of,  237;  urinary,  241. 

AmcEbie  dysentery    (see  amcebiasis),  237. 

Amcebic  hepatitis,  239. 

Ammonisemia,  710. 

Amphistoma  hominis,  290. 

Amphoric  sounds,  201,  665. 

Amputation  neuromata,  1021. 

Amyloid  kidney,  707;  liver,  581. 

Amyloid  liver,  581. 

Amyosthenia,  1103. 

Amyotonia   congenita,    1124. 

Amyotrophic  lateral  sclerosis,  918. 

Anacidity,  gastric,  502. 

.■Anaemia,  722;  aplastic,  728;  cerebral,  980; 
from  hsemorrhage,  728;  in  Hodgkin  "s 
disease,  744;  in  horses,  728;  local,  722; 
leukfemic,  734;  pernicious,  727;  pri- 
mary, 725;  secondary,  723;  spinal  cord, 
960;"  toxic,   724. 

Ana?mia,  pernicious  or  Addisonian,  727; 
blood  picture,  730;  historical  note,  727; 
nervous  system,  730 ;  pathology,  728 ; 
pregnancy,  728;  prognosis,  732;  sex  in- 
fluence, 728. 

Anaemic  necrosis    78-^ 

Amesthesia  and  acidosis,  446. 

Anaesthesia    dolorosa,    952. 

^napsthesia    pneumonia,    97. 

Anaesthetic    leprosy,    154. 

Analgesia,  hysterical,  1093. 


Anaphylaxis,  402;  dangers  of,  77;  from 
serum,  77;  relation  to  tuberculin  reac- 
tion,  161. 

Anarthria,  974. 

Anchmerompa  luteola,  319. 

Aneurism,  822,  841;  arterio-venous,  853; 
classification  of,  841 ;  determining  causes, 
842;  dissecting,  852;  etiology,  841; 
pathology,   842;   vessels  affected,  843. 

Aneurism  of  abdominal  aorta,  850 ;  of  aor- 
ta, 843;  of  coeliac  axis,  853;  of  hepatic 
artery,  853;  of  pulmonary  artery,  853; 
of  renal  artery,  853 ;  of  superior  mesen- 
teric artery,  853. 

Aneurism  of  thoracic  aorta,  843;  diet,  849; 
heemorrhage,  847;  heart  symptoms,  847; 
of  ascending  arch,  843 ;  of  descending 
arch,  144;  of  descending  thoracic,  844; 
of  sinuses  of  A^alsalva,  843;  of  trans- 
verse arch,  843;  physical  signs,  844;  pu- 
pil signs,  847;  surgical  measures,  850; 
tracheal  tug,   846. 

Aneurism,  parasitic,  in  horse,  842. 

Angina,  abdominalis,  832,  838;  Ludoviei, 
458;  membranous,  64;  pectoris,  828; 
age,  829 ;  cardiovascular  disease,  829 ; 
death,  831;  definition,  828;  extra-pecto- 
ral features,  832;  heredity,  829;  his- 
torical note,  828;  major,  831;  minor, 
831;  occupation,  829;  pathogenesis,  830; 
race,  829 ;  sex,  829 ;  status  angiosus, 
831;    syphilitic,   833;    simplex,  456. 

Angiocholitis,  chronic  catarrhal,  555;  sup- 
purative and  ulcerative,  555. 

Angiomata,  spider,  570. 

Angio-neurotic  hydrocephalus,  1012;  cede- 
ma,  1115. 

Angiopathic   paralysis,   1019. 

Angio-selerosis,  836. 

Angor  animi,  831. 

Anguillula  aceti,  315. 

Anisocoria,   1030. 

Ankylostoma  duodenale,  307. 

Ankylostomiasis,  307;  parasites,  forms  of, 
307. 

Anopheles  mosquito,  246. 

Anorexia,  in  pulmonary  tuberculosis,  204; 
in  typhoid  fever,   20;   nervosa,  504. 

Anosmia,  1022. 

Anthomy   (see  Myiasis),  318. 

Anthracaemia,    151. 

Anthracosis,  636 ;   and  tuberculosis,  637. 

Anthrax,    149;    external,   150;    in  animals, 

-  149;  in  man,  150;  internal,  151;  intesti- 
nal, 151;  malignant  oedema,  150;  malig- 
nant pustule,  150;  rag  pickers'  disease, 
151 ;  types  of,  150. 

Antibodies  in  typhoid  fever,  32. 

Antipneumococcic   serum,    102. 

Antitoxin  administration,  dangers  of,  77; 


INDEX 


114^ 


diphtheria,  75;  pneumocoecic,  102;  tet- 
anus, 146. 

Antityphoid  serum,  40. 

Anuria,  675,  714. 

Anus,  imperforate,  530. 

Anxiety  states,  1102. 

Aorta,  throbbing  of,  hysterical,  1104. 

Aortic  aneurism,  843. 

Aortic  insufficiency,  803;  arteries  in,  806; 
arteriosclerotic  group,  803;  compensa- 
tion, 807;  efifects,  804;  endocarditic, 
803 ;  Flint  murmur,  806 ;  mental  symp- 
toms, 805;  relative,  803;  syphilitic,' 803. 

Aortic  stenosis,  808. 

Aortitis,  839;  acute  type,  839;  chronic 
type,  840. 

Apex  pneumonia,  94. 

Aphasia,  973;  auditory,  976;  in  tj^phoid 
fever,  12,  27;  medico-legal  aspects  of, 
978;  motor,  977;  optic,  1028;  visual, 
977. 

Aphemia,   974. 

Aphonia,  hysterical,  1093. 

Aphthous  fever,  376. 

Aphthous  stomatitis,  448. 

Apoplexy,  cerebral  {see  cerebral  haemor- 
rhage), 982. 

Apoplexy  of  lungs,  630. 

Appendicitis,  521;  abscess  in,  597;  age 
and  sex,  522;  and  pregnancy,  527; 
chronic,  526;  gastro-intestinal  disturb- 
ance, 523,  526;  leucocytosis,  524;  remote 
effects,  525;   types  of,  522. 

Appendix,  f jecal  concretions,  522 ;  foreign 
bodies,  523;  general  peritonitis,  525;  lo- 
cal abscess,   524;    tuberculosis   of,   213. 

Apraxia,  977. 

Aprosoxia.      {Hee   mouth-breathing.) 

Aran-Duchenne  syndrome.  {See  muscular 
atrophy.) 

Argas  moubata,  316. 

Argyll   Robertson  pupil,   912,   1030. 

Arithomania,  1070. 

Arrhythmia,  cardiac,  768. 

Arsenical   paralysis,    398;    poisoning,   397. 

Arterial  trunks,  transposition  of,  826. 

Arteries,  diseases  of,  833. 

Arterio-sclerosis,  833;  abdon.inal  type, 
838;  cardiac  involvement,  837;  cerebral 
type,  978;  diffuse  type,  835;  hyperten- 
sion, 834;  in  lead  workers,  396;  inter- 
mittent claudication,  838;  intoxications, 
834;  of  pulmonary  artery,  836;  of  ves- 
sels of  legs,  838;  senile  type,  836;  syph- 
ilitic t;vT)e,  836;  thrombo-angeitis  oblit- 
erans,  838;    tuberculosis   with,    210. 

Arteritis  in  typhoid  fever,  19. 

Arthralgia,  from  lead,  395;  gonococcic, 
127;  in  scarlet  fever,  343;  in  typhoid 
fever,   11,   29, 


Arthritis  deformans,  1125;  Heberden's 
nodes,  1128;  in  children,  1129;  infec- 
tious  origin,    1126;    spondylitis,    1128. 

Ascariasis,  301  ;   toxicity  in,  301. 

Ascaris  lumbricoides,  301. 

Ascites,  181,  600;  causes,  600;  chylous, 
602;  differential  diagnosis,  601;  in  tu- 
berculosis, 181;  nature  of  fluid,  601;  pal- 
pation,  601;    percussion,   601. 

Asiatic  Cholera.    {See  Cholera  asiatica.) 

Aspergillus  in  lung,  194. 

Aspergillosis,  236. 

Aspiration   pneumonia,   105. 

Astasia,   973. 

Asthenic  bulbar  paralysis,  1124. 

Asthenic  pneumonia,  96. 

Asthma,  bronchial,  618. 

Astrophobia,  1102. 

Asynchronous  respiration  in  pneumonia, 
87. 

Asynergia,  972. 

Ataxic  paraplegia,  949. 

Atelectatic  lung,  105. 

Athetosis,  1002". 

Athlete's  heart,  803. 

Athyrea.      {See  myxoedema.) 

Atmospheric  pressure  in  caisson  disease, 
383. 

Atremia,   1103. 

Atropine,  in  lobar  pneumonia,  103;  test 
(Harris),  in  typhoid  fever,  34. 

Auditory  nerve,  lesions,  cochlear  nerve, 
1038;   vestibular  nerve,  1040. 

Auditory  speech  centre,  974. 

Aura,  epileptic,  1075. 

Auricular   fibrillation,   772. 

Auricular  flutter,  771. 

Automatism  in  petit  mal,  1077. 

Autumnal  catarrh  {see  hay  fever), 
618. 

Avelli's  syndrome,  1049. 

Aviators'  sickness,  385. 

Axis-cylinder  process,  886. 

Ayerza's  disease,  750,  836. 

Azotorrhcea,   583. 


B 


Baccelli's  sign  in  pleurisy,  652. 
Bacillaimia,   with   colon   bacillus,   45. 
Bacillary  dysentery.      {See  dysentery,  ba- 

cillary.) 
Bacilluria  in  typhoid  fever,  28;  treatment, 

42. 
Bacillus  aerogencs  capsulatus,  591 ;  anthra- 

cis,    149 ;     botulinus,    400 ;     of    cholera, 

134;    coli   communis,   variations   of,   45; 

diphtheria\     61;     dyscnteriae,     129;     en- 

teritidis,  399,  400 ;  Flexner-Harris,  128; 

Klebs-Loefflcr,  63;  leprif,  152,  153;  mal- 


1144 


INDEX 


lei,  147;  pertussis,  122;  pestis,  141;  of 
Pf eiffer,  119 ;  pneumoniEe  of  Friedlan- 
der,  81 ;  proteus,  53 ;  pyocyaneus,  caus- 
ing septiceemia,  53;  of  Shiga,  128;  tet- 
ani,  toxicity  of,  144;  tuberculosis,  155, 
157;  typhi  exanthematici,  48;  typho- 
sus, 1. 

Bacteria,  causative  of  terminal  infections, 
58. 

Bacteriuria,  682. 

Bagdad  sore,  260. 

Balanitis  in  diabetes,  429. 

Balantidium  coli,   288. 

Ball  thrombus,  814. 

Ball-valve  stone,  564. 

Banti's  disease,  882. 

Banting's  treatment,  442. 

Barlow's  disease,  411. 

Barrel  chest  and  adenoids,  461. 

Basal  ganglia  tumors,  1006. 

Basedow's  disease,  869. 

Basilar  meningitis  in  pulmonary  tubercu- 
losis, 204. 

Bedbugs,  318;  and  African  relapsing  fe- 
ver, 261;  and  leprosy,  153;  and  kala 
azar,  259. 

Bed-sores  in  typhoid  fever,  17. 

Beef  tape  worm,   292. 

Bence  Jones  protein,  681. 

Benedict's  syndrome,  969. 

Beri-beri,  406 ;  acute  pernicious  form, 
407;  atrophic  form,  407;  distribution 
of,  406;  droi^sical  form,  407;  rudimen- 
tary form,  407. 

Biermer's  "boxtone"  in  asthma,  621. 

"Big-jaw"  in  cattle  (see  actinomycosis), 
231. 

Bile  ducts,  cancer  of,  558;  catarrh  of,  553; 
congenital  obliteration  of,  559;  obstruc- 
tion of,  559 ;   stenosis  of,  559. 

Bilharzia   hsematobia,   290. 

Bilharziasis,  290. 

Biliary  fistula,  565. 

Bilious  remittent  fever,  252. 

Birth   palsies,   1000. 

Black  death,  140. 

Black  small  pox,  325. 

Black  vomit  of  yellow  fever,  265,  266. 

Black-water  fever,  243,  253. 

Bladder,  gummata  of,  283;  tuberculosis  of, 
219. 

Blastomycosis,  235. 

Bleeding,  in  lobar  pneumonia,  102. 

Blepharospasm,  1038. 

Blood,   analysis  in   nephritis,    703 ;    in  ure- 
mia,   690;     changes    in    lead    poisoning,    j 
394. 

Blood  moulds,  of  bronchi  in  hsemoptysis, 
630;  in  kidney  tumor,  718;  picture  in 
pulmonary    tuberculosis,    204;    pressure, 


in  lobar  pneumonia,  89;  in  typhoid  fe- 
ver, 18;  studies  in  typhoid  fever,  18; 
vessels,  lesions  of,  in  typhoid  fever,  12. 

Blue  disease,  827. 

Blue  scleroties,   1136. 

Bone  lesions  in  typhoid  fever,  28;  treat- 
ment of,  42. 

Bone  marrow  changes  in  typhoid  fever, 
10. 

Bone,   s^'philis   of,   273. 

Boring  pain  in  neuritis,  1015. 

Botulism,  400. 

Brachial  plexus,  lesions  of,  1051;  cervical 
rib,  symptoms  of,  1051;  combined  pa- 
ralysis, 1051;  individual  nerve  lesions, 
1053;    Yolkmann's  paralysis,   1055. 

Bradycardia,  types  of,  767. 

Brain,  abscess  of,  1009;  affections  of  the 
blood  vessels,  978;  ansemia  of,  980;  and 
cord,  tuberculosis  of,  214;  aneurism  of, 
997;  aphasia,  973;  arterio-sclerosis  of, 
978;  psychical  changes,  979;  auditory 
impressions,  900 ;  auditory  speech  cen- 
tre, 974;  cortical  influence,  897;  dia- 
,  gram  of  cerebral  localization,  893;  dia- 
gram of  motor  and  sensory  paths  in 
crura,  895;  diffuse  and  focal  disease  of, 
965;  embolism  of,  992;  hsemorrhage  of, 
982;  hyperaemia  of,  980;  inflammation 
of,  1009;  localization,  890;  motor  seg- 
ments, 888;  motor  speech  centre,  974; 
oedema  of,  981;  senile  conditions,  980; 
sensory  areas,  897;  sinus  thrombosis, 
998;  thalamic  influence,  897;  thrombo- 
sis, 993;  transient  paralyses,  978;  tu- 
mors of,  1003;  visual  impressions,  900; 
visual  speech  centre,  975. 

Brass  itch,  397;  poisoning,  397;  workers' 
ague,  397. 

Brauer  's  operation,  761. 

Break-bone  fever,  357. 

Breast  pang,  828. 

Brill's  disease,  simulating  typhoid,  35. 

Brissaud  type  of  infantilism,  880. 

Broadbent's  sign,  761. 

Broca's  centre,  974. 

Bromides  in  epilepsy,  1079. 

Bronchi,  foreign  bodies  in,  626. 

Bronchial  asthma,  618;  exciting  agents, 
620. 

Bronchiectasis,    615. 

Bronchitis,  acut:,  610;  in  typhoid  fever, 
25;     and    bronchiolitis,     106;     capillary 

.     (see  pneumonia,  broncho-),   107. 

Bronchitis,  chronic,  613;  and  gout,  419; 
clinical  varieties,  614;  dry  catarrh,  614; 
putrid  form,  614;   fibrinous,  624. 

Broncho-biliary  fistula,  565. 

Bronehocele    (see  thyroid   gland),   864. 

Broncho-pneumonia      and     measles,     351; 


INDEX 


1145 


chronic,  633;  tuberculous,  185.  {See 
also  pneumonia.) 

Bronchorrhcea,   614. 

Bronchus,  pathology  of,  in  broncho-pneu- 
monia,  106. 

Brown-Sequard's  paralysis,  958. 

Brudzinski 's  sign,   116,  938. 

Bubonic  plague,  141. 

Buhl's  disease,  747. 

Bulbar  paralysis,  921. 

Bulimia,  504. 


O 


Caecum,  movable,  539;  tuberculosis  of, 
212,  213. 

Caisson   disease,   383;    "the  bends,"   384. 

Calcareous  arteries,  836. 

Calcareous  bodies  in  lungs,  189,  194. 

Calcified  pericardium,   762. 

Calculus,  "coral,"  713;  pancreatic,  585, 
591;    renal,   709;   tonsillar,  462. 

Calmette  's  tuberculin  reaction,  160. 

Caloric  value  of  food  in  typhoid  fever,  38. 

Cammidge's  pancreatic   reaction,   583. 

Camp  fever  {see  typhus),  47. 

Cancer,  and  tuberculosis,  210;  of  the  bile 
passages,  558;  of  heart,  823;  of 
oesophagus,  466;  of  liver,  primary 
and  secondary,  578 ;  of  the  peri- 
toneum, 599 ;  of  the  stomach,  489 ; 
age  incidence,  489 ;  complications, 
494;  gastric  contents,  492;  metastases, 
494;  perforation,  491,  494;  secondary, 
490;  of  suprarenals,  860. 

Cancerous  ulcers,  512. 

Cancrum  oris,  450. 

Canities  (in  neuralgia),  1083. 

Capillaiy  bronchitis  {see  pneumonia,  bron- 
cho-). 

Capillary   pulse,   806. 

Capsular  cirrhosis,   573. 

Caput,   Medusa?,   601;    quadratum,   439. 

Capsule,  internal,  lesions,  967. 

Carbohydrate  indigestion,  509. 

Carboluria,  687. 

Carbon  bisulphide  poisoning,  385. 

Carbon   monoxide   poisoning,    385. 

Carcinoma  and  peptic  ulcer,  484. 

Carcinoma  of  brain,  1004. 

Carcinoma  of  lung,  646. 

Cardiac   arrhythmia,   768. 

Cardiac  complications  of  rheumatic  fever, 
364. 

Cardiac  dilatation,  779. 

Cardiac  innervation,  1043. 

Cardiac  insufficiency,  781. 

Cardiac  lesions  in  pulmonary  tuberculosis, 
209. 

Cardiac  murmurs.      {See  heart  murmurs.) 


Cardiac  symptoms  in  diphtheria,  71. 

Cardiocentcsis,   823. 

Cardiacos  negros,  751. 

Cardiolysis,  761. 

Cardioptosis,   764,   787. 

Cardiorespiratory  murmur,  in  tuberculo- 
sis, 201. 

Cardiospasm,  501. 

Cardio-vascular  symptoms  in  pulmonary 
tuberculosis,  203. 

Caries  of  spine,  952. 

Carotid  glands,  860. 

Carotid    pressure,    inhibiting   vagus,    1044. 

Carriers,  cholera,  136;  diphtheria,  62,  63; 
meningococcus.  111,  116;   typhoid,  6. 

Casts  in  urine,  693,  698,  702. 

Catalepsy,   hysterical,   1096. 

Catarrhal  enteritis,  506. 

Catarrhal    fever,   acute,    371. 

Catarrhal  jaundice,  553. 

Caterpillar  rash,  320. 

Catgut,  contamination  by  B.  tetani,  144. 

Cats  and  dogs,  as  carriers  of  infection,  74. 

Cauda  equina,  neuritis  of,  959;  tumor  of, 
959. 

Causalgia,  1085. 

Cavity,  pulmonary,  189,  201. 

Central  neuritis,  950. 

Centrum  semiovale,  966. 

Cerebellar   gait,   972. 

Cerebellar   tumors,   1007. 

Cerebellum,  bilateral  lesions,  973;  unilat- 
eral lesions,  971. 

Cerebral   abscess,   1009. 

Cerebral  adiposity,  443. 

Cerebral   actinomycosis,   233. 

Cerebral  arteries,  aneurism,  997. 

Cerebral  arterio -sclerosis,  978. 

Cerebral  cortex,  destructive  lesions,  965; 
irritative  lesions,  966. 

Cerebral  embolism,  992. 

Cerebral  haemorrhage,  982 ;  age,  982 ; 
apoplectic  attack,  985;  crossed  hemi- 
plegia, 989;  heredity,  982;  location  of, 
982 ;  meningeal  haemorrhage,  983 ;  mul- 
tiple, 984;  reflexes,  989;  secondary 
symptoms,  990;  sensory  disturbance, 
989;    sex,  982. 

Cerebral  localization,  893. 

Cerebral  nerves,  diseases  of,  1021. 

Cerebral  oedema,  981. 

Cerebral  palsies  of  children,  1000;  acute 
sporadic  encephalitis,  1001;  aplasia, 
1000 ;   meningeal  haemorrhage,   1000. 

Cerebral  sinus  thrombosis,  998. 

Cerebral  symptoms  in  lobar  pneumonia,  91. 

Cerebral  thrombosis,  993 ;  arteries  in- 
volved, 995;  symptoms  of,  994;  treat- 
ment of,  996. 

Cerebral  tumors,  1003, 


1146 


INDEX 


Cerebro-spinal  fever,  110;  anomalous  forms 
of,  113,  114;  Brudzinski's  sign  in,  116; 
ear  involvement  in,  115;  epidemiology  of, 
111;  eye  involvement  in,  115;  historical 
note,  110;  hydrotherapy  in,  117;  inter- 
mittent form,  115;  leucocytosis  in,  114; 
lumbar  puncture  in,  116,  117;  fever, 
malignant  form  of,  113 ;  nose,  involve- 
ment in,  116;  pneumonia  in,  115;  psy- 
chical symptoms,  113;  serum  therapy  of, 
117;  skin  lesions  in,  114;  special  sense 
involvement,   115. 

Cerebro-spinal  meningitis  in  pulmonary 
tuberculosis,  204. 

Cervical  plexus,  diseases  of,  1049;  rib, 
1051. 

Cervico-brachial   neuralgia,   1084. 

Cervico-occipital  neuralgia,  1084. 

Cestodes,   291. 

Chalicosis,   636. 

Charbon.     {See  anthrax.) 

Charcot's  crystals,  508,  622,  734. 

Charcot's  joints,  911. 

Charcot-Marie-Tooth  type  of  muscular 
atrophy,  926. 

Chaulmoogra  oil,  in  leprosy,  155. 

Cheese  poisoning,  400. 

Chest,  type  of,  in  pulmonary  tuberculosis, 
198. 

Chicken   pox.      {See  varicella,   336.) 

Child-bearing  and  tuberculosis,  222. 

Child-crowing,  607,  1070. 

Children,  cerebral  palsies,  1000;  consti- 
pation in,  536;  convulsions  in,  1071;  dia- 
betes in,  425;  diarrhceal  disease  in,  425; 
rickets  in,  436;  tuberculosis,  tracheo- 
bronchial, in,  177;  tj^phoid  in,  31. 

Chills,  in  typhoid  fever,  16. 

Chloasma  phthisicorum,  205. 

Chloride  retention  in  pneumonia,  91. 

Chloroma,   737. 

Chlorosis,   725. 

Choked  discs,  1024. 

Cholaemia,  547. 

Cholangitis,  infective,  564;  suppurative, 
565. 

Cholecystitis,  acute,  infections,  556;  due 
to  B.  coli,  46 ;  in  typhoid,  8,  24,  42 ;  sup- 
purative, 563 ;  chronic,  557, 

Cholelithiasis,  560 ;  age  and  sex,  561 ;  ball 
valve  stone,  564;  character  of  stones, 
561 ;  cholesterol,  560 ;  fistulse,  565 ;  in- 
fection, 560 ;  obstruction  incomplete, 
565;  obstruction  of  bowel,  566;  obstruc- 
tion of  common  duct,  564 ;  of  the  cystic 
duct,  563 ;  perforation,  566 ;  remote  ef- 
fects of,  565;  stasis,  560;  surgical  mor- 
tality, 567. 

Cholera  asiatiea,  134;  Hamburg  epidemic, 
136;     historical    note,    134;     immunity, 


135;  modes  of  infection,  135;  reaction 
state,   138;   stages  of,   137. 

Cholera   carriers,   136. 

Cholera  infantum,  516. 

Cholera  sicca,  138. 

Cholera  toxin,  135. 

Cholera-typhoid,   138. 

Chondrodysplasia,  fetalis,  1137;  heredi- 
tary,   deforming,   1138. 

Chorea,  acute,  1062. 

Chorea,  definition,  1062;  duration, 
1066;  heart  affections,  1065;  ma- 
niacal type,  1065;  mild  type,  1065; 
mutism,  1065 ;  pregnancy,  1063 ; 
psychical  disturbance,  1066;  school 
made  type,  1063;  severe  type,  1064. 

Chorea,  chronic  hereditary,  929. 

Chronic   catarrhal   angiocholitis,   555. 

Chronic  interstitial  pneumonia,  633. 

Chvostek  's  sign  in  tetany,  874. 

Chyluria,  683. 

Cimex  lectularius,  318. 

Circulatory  disturbances  in  the  lungs, 
627. 

Circulatory  system,  diseases  of,   753. 

Circumcision,  tuberculous  infection  in, 
163. 

Circumflex  nerve  lesions,  1053. 

Cirrhosis,  alcoholic,  568 ;  atrophic,  568 ; 
capsular,  573;  fatty,  568;  hypertrophic 
biliary,  571;  infectious,  567. 

Cirrhosis  of  liver,  567;  portal,  568;  toxic 
symptoms,  570;  syphilitic,  568,  572; 
toxic,  567;  ventriculi,  477. 

Claustrophobia,  1102. 

Climatic  conditions  favorable  for  the  tu- 
berculous, 226. 

Clownism  in  hysteria,  1091. 

Clubbing  of  fingers,  1134. 

Coal-miner's  disease,   636. 

Coceidiosis,  236. 

Coccydynia,  1084. 

Cochlear  nerve  lesions,  1038 ;  cortical  cen- 
tre, 1038;  diminished  function,  1039; 
pressure  symptoms,  1039;  tinnitus  auri- 
um,  1039. 

Coeliac  afi'ection,  509. 

Coin  sound,  665. 

Cold  sponging  in  typhoid  fever,  29;  pack 
in  typhoid  fever,  39. 

Colitis,  mucous,  540;   ulcerative,  511. 

Colles'  law,  270. 

Colon  bacillus  infections,  45;  arthritic, 
46;  cholecystic,  46;  gastro -intestinal, 
46;  general  hjemic  type,  45;  meat  poi- 
soning, 399  ;  meningitic,  46 ;  peritonitis, 
46;    urinary,   46. 

Colon,  dilatation  of,  541;  idiopathic, 
.542. 

Coloptosis,  539. 


INDEX 


1147 


Coma,  alcoholic,  387;  apoplectic,  986,  991; 
diabetic,  429,  432;  epileptic,  1076;  sun- 
stroke, 380;  uraemic,  690. 

Combined  paralysis,  brachial,  1052;  pos- 
tero-lateral   sclerosis,    949. 

Comma  bacillus  of  Koch,  134. 

Common   duct,   obstruction   of,   564. 

Complement  fixation  test  in  pulmonary 
tuberculosis,  208;  in  syphilis,  269, 
283. 

Compressed  air  disease,  383. 

Compression  myelitis,  951. 

Compression   of   spinal  cord,  951. 

Compsomyia  macellaria,   318. 

Coneato's   disease,   598. 

Congenital  torticollis,  1046. 

Conjunctival  diphtheria,  70. 

Conjunctivitis,  acute  ulcerative,  transmit- 
ted from  rabbits,  379 ;  in  typhoid  fever, 
27. 

Constipation,  535;  in  infants,  536;  in 
tj'phoid,  treatment  of,  41. 

Consumption.  (See  tuberculosis,  pulmo- 
nary.) 

Conus  medullaris  and  cauda  equina,  lesions 
of,  959. 

Convulsions,  alcoholic,  387;  apoplectic, 
985;  epileptic,  1075;  hysterical,  1090; 
infantile,  1071;  in  brain  tumor,  1005;  in 
hemiplegia,  1001;  in  lead  poisoning,  396 ; 
in  pleurisy,  659;  in  rickets,  440;  syphi- 
litic, 277;   typhoid,  25,  26. 

Coprolalia,   1070. 

Cor  biloculare,  824. 

Cor  bovinum,  804. 

Coronary  artery,  disease,  782;  blocking, 
783,   787;   thrombosis,   787. 

Corpora  quadrigemina,  969. 

Corpus   callosum,  967. 

Corpus  striatum,  967. 

Coryza,  acute,  371. 

Costiveness,  535. 

Cough,   hysterical,   1093. 

Courvoisier  's  law,  559,  565. 

Cow  pox.      (See  vaccinia.) 

Crab  louse,  317. 

Cracked  pot  sound  in  pulmonary  tubercu- 
losis,  199. 

Cranial  nerves,   combined   paralysis,   1049. 

Craniotabes,  439. 

Creeping  eruption,  319. 

Creeping   pneumonia,   94. 

Cretinism,  865;  endemic  form,  866;  spora- 
dic form,  866. 

Criminal,  psychasthenic,   1104. 

Crossed  paralysis,  969. 

Croupous  colitis  in  lobar  pneumonia,  84. 

Cry,  hysterical,  1093. 

Cryptogenetic  septicaemia,  53. 

Cuban  itch,  322. 


Cutaneous  lesions  in  syphilis,  271. 

Cycloplegia,   1029. 

Cynobex  hebetiea,  1094. 

Cystic   duct,   obstruction   of,   563. 

Cysticercus  cellulosa?,  294;  symptoms,  cere- 
bral, 295;   ocular,  295, 

Cystinuria,  685. 

Cystitis  and  urethritis,  due  to  B.  coli,  46; 
tj-phoid,  8,  42. 


D 


Deafness  in  typhoid  fever,  27. 

Death,  sudden,  in  coronary  disease,  783. 

Deficiency  diseases,  403. 

Deglutition   pneumonia',   104. 

Delayed  resolution  in  pneumonia,  97. 

Delhi  boil,   260. 

Delirium  in  tA7)hoid  fever,  26;  treatment 
of,  41. 

Delirium  tremens,  389. 

Dementia  presenilis,  980. 

Demodex  follicularum,   316. 

Dengue,  356. 

Dercum's  disease,  442. 

Dermamyiasis  linearis  migrans  oestrosa, 
319. 

Dermatitis,  acute  exfoliating,  344;  and 
scarlet  fever,  344. 

Dermatomyositis,    1119. 

Dermocentor,  americanus,  317;  occiden- 
talis,  317;  venustus,  377. 

Dextro-cardia,  824. 

Diabetes  insipidus,  434;  pituitary  influ- 
ence,  434. 

Diabetes  mellitus,  422;  acidosis,  426,  429; 
adrenals  and  thyroids,  424;  and  heema- 
chromatosis,  444;  and  typhoid  fever,  30; 
blood  picture,  428;  carbohydrate  excess, 
422;  coma,  429,  432;  cutaneous  lesions, 
429;  diet  in,  431;  food  tables,  433; 
hereditary  influence,  425;  hypophyseal 
disturbance,  423 ;  impotence,  430 ;  in 
children,  425;  incidence,  425;  in  pulmo- 
nary tuberculosis,  210;  lietonuria,  428; 
liver  derangement,  424;  metabolism, 
425 ;  nervous  system,  423,  429 ;  pan- 
creas in,  423,  427;  pulmonary  lesions, 
429;  racial  influence,  425;  reduced  diet, 
432;  renal  lesions,  424,  426,  429;  sex 
influence,  425;  skin  lesions,  treatment, 
434;  special  sense  involvement,  430. 

Diabetic    tabes,   429. 

Diaphragm,  diseases  of,  670;  paralysis  of 
1050. 

Diarrhoja,  506;  fermentative,  516;  in 
sprue,  509;  in  typhoid,  treatment  of, 
41;   inflammatory,  .517. 

Diarrhoeal  diseases  in  children,  514;  pre- 
vention, 518. 


1148 


INDEX 


Dibothriocephalus  latus^  292. 

Dicotophyme   renale,   315. 

Dicrotism  in  typhoid  fever,  33. 

Diet,  in  broncho-pneumonia,  109 ;  in 
chronic  gastritis,  474;  in  chronic  ne- 
phritis, 700;  in  diabetes,  431;  in  diph- 
theria, 75;  in  epilepsy,  1079;  in  heart 
disease,  T91;  in  intestinal  disease  of 
children,  519;  in  lobar  pneumonia,  101; 
in  obesity,  442 ;  in  treatment  of  aneu- 
rism, 849;  in  tuberculosis,  227;  in  ty- 
phoid fever,  38. 

Dietl's  crisis,  673;   and  appendicitis,  526. 

Diffuse  and  focal  disease  of  the  brain, 
965;    diseases  of   the  spinal  cord,  957. 

Diffuse  sclerosis,  953'. 

Digitalis,  use  of,  688;  in  lobar  pneumonia, 
103. 

Dilatation,  of  colon,  541 ;  idiopathic,  542 ; 
of  duodenum,  545;  of  heart,  786;  of  the 
stomach,  477. 

Diphtheria,  61;  anaphylaxis  in,  77;  anti- 
toxin dosage,  76 ;  with  scarlet  fever, 
64;  atypical  forms,  67-8;  bacillus,  63; 
bacteriological  diagnosis  of,  72 ;  cardiac 
complications,  66;  carriers  of,  62,  63,  74; 
conjunctival,  70;  heart  involvement  in, 
66,  71;  hygienic  measures,  74;  immu- 
nity to,  62,  74;  kidney  involvement  in, 
67;  laryngeal,  69;  lung  involvement  in, 
66;  modes  of  infection,  62;  mortality 
rate,  73,.  77;  nasal,  68,  69;  neuritis  in, 
71;  diphtheria,  of  the  skin,  70;  paraly- 
sis in,  71 ;  prophylaxis,  73 ;  pharyngeal, 
67;  jjulmonary  complications,  66;  scar- 
let fever  and,  64;  Schick  reaction,  62; 
serum  disease  in,  76. 

Diphtheritic  membrane,  description  of,  65; 
otitis  media,  70. 

Diphtheritis.  {See  diphtheria)  ;  in  ty- 
phoid fever,  11. 

Diphtheroid  infections,  64,  65,  73. 

Diphtheroid  or  croupous  enteritis,  510. 

Diplococeus,  intraeellularis  meningitidis, 
112;   pneumonise,  80. 

Diplopia,   1031. 

Dipylidium  caninum,   292. 

Diseases,  bacterial,  1 ;  caused  by  cestodes, 
Teeniasis,  291;  caused  by  nematodes, 
301;  due  to  flukes,  289;  due  to  meta- 
zoan  parasites,  289;  due  to  parasitic  in- 
fusoria, 288;  due  to  physical  agents, 
380;  of  the  arteries,  833;  of  the  bile 
passages  and  gall-bladder,  553;  of  the 
blood  forming  organs,  722 ;  of  the  bron- 
chi, 610;  of  the  circulatory  system,  753; 
of  the  diaphragm,  670;  of  the  digestive 
system,  448 ;  of  the  ductless  glands,  855 ; 
of  the  dura  mater,  933 ;  of  the  efferent 
or  motor  tract,  918;   of  the  heart,  763; 


of  the  intestines,  506;  of  the  kidneys, 
671;  of  the  larynx,  605;  of  the  liver, 
545;  of  the  lungs,  627;  of  the  meninges, 
933 ;  of  metabolism,  413 ;  of  the  nerv- 
ous system,  886,  905;  of  the  nose,  604; 
of  the  omentum,  602;  of  the  oesophagus, 
463;  of  the  pancreas,  583;  of  the  para- 
thyroid glands,  872;  of  the  pericardium, 
753;  of  the  peripheral  nerves,  1014;  of 
the  peritoneum,  591 ;  of  the  pharjTix, 
456;  of  the  pia  mater,  936;  of  the  pineal 
gland,  878;  of  the  pleura,  647;  of  the 
respiratory  system,  604;  of  the  salivary 
glands,  454;  of  the  sex  glands,  879;  of 
the  spleen,  880;  of  the  stomach,  468; 
of  the  suprarenal  bodies,  855;  of  the 
tonsils,  458;  of  the  thymus  gland,  860; 
of  the  thyroid  gland,   862. 

Disinfectants  for  use  in  typhoid  fever,  37. 

Disordered  action  of  the  heart,  764. 

Distomiasis,  289;  hsemic,  290;  hepatic, 
289;  intestinal,  290;  pulmonary,  289. 

Diver 's  paralysis,  383, 

Diverticulitis,  543. 

Diverticulum  of   oesophagus,   467. 

Double  heart,  824. 

Double  pneumonia,  94. 

Double  vision,  1031. 

Dracontiasis,   313. 

Dracunculus  medinensis,   313. 

Dreyer  's  method  of  agglutination,  33. 

Drug  rashes,  345. 

Dry  mouth,  455. 

Ductless  glands,  diseases  of,  855. 

Duodenum,  dilatation  of,  545;  ulcer  of, 
481. 

Durham 's  theory  of  typhoid  reinfection, 
32. 

Dysentery,   amoebic,   237. 

Dysentery,  bacillary,  128;  agglutination, 
131;  clinical  types  of,  130;  serum  ther- 
apy, 132. 

Dyspepsia,  chronic,  471. 

Dysphagia,  in  laryngeal  tuberculosis,  202. 

Dysenergia  cerebralis  progressiva,  971. 

Dystrophia  adiposo-genitalis,  880. 


E 


Ear,  involvement  in  cerebro-spinal  fever, 
115;  in  measles,  351;  in  scarlet  fever, 
343;   in  typhoid  fever,  27. 

Echinocoecus  cyst,  295 ;  distribution  in 
the  body,  297 ;  geographical  distribution, 
297;  miiltilocular,  300;  of  kidneys,  299; 
of  liver,  297;  of  nervous  system,  300;  of 
respiratory  system,  299;  suppuration  of, 
298. 

Echokinesis,  1070, 


INDEX 


1149 


Eeholalia,  1070. 

Ectopia  cordis,  824. 

Effort  syndrome,  764. 

Eighth  nerve,  lesions  of,  1038. 

Elastic  tissue,  193. 

Elephantiasis,  312. 

Embolic  pneumonia,  97. 

Emphysema,  638;  acute  vesicular,  643; 
atrophic,  643 ;  compensatory,  638 ;  hy- 
pertrophic, 639 ;  in  pulmonary  tubercu- 
losis, 203 ;  interstitial,  643 ;  of  medias- 
tinum, 669. 

Empyema.  {See  also  pleurisy,  purulent)  ; 
in  lobar  pneumonia,  92 ;  necessitatis, 
654. 

Emprosthotonus,   in  tetanus,   145. 

Encephalitis,  acute,  1009 ;  sporadic,  of 
children,  1001;  athetosis,  1002;  post- 
hemiplegic  movements,   1002. 

Encephalitis,   epidemic,  943. 

Endemic  multiple  neuritis,  406. 

Endocarditis,  acute,  792;  embolic  process- 
es, 796;  mural  type,  795;  septic  type, 
796;  typhoid  type,  797;  vegetations, 
794;  and  typhoid  fever,  11. 

Endocarditis,  chronic  infective,  797;  fe- 
tal, S26;  in  lobar  pneumonia,  84,  92; 
syphilitic,  281;  ulcerative,  simulating 
typhoid,   35. 

Endocrine  disturbance  in  diabetes  mellitus, 
424;   glands,  diseases  of,  855. 

Enemas,  nitrate  of  silver,  513. 

Entamoeba  hystolytica,  237. 

Enteritis,  catarrhal,  506;  carbohydrate  in- 
digestion, 509;  croupous,  510;  stercoral 
ulcers,  51]  ;  ulcerative,  511. 

Entero-colitis,  517. 

Enterogenous  cyanosis,  751. 

Enteroliths,  531, 

Enteroptosis,  538. 

Eosinophilia  in   trichiniasis,   306. 

Ephemeral  fever,  372. 

Epidemic,  cerebro-spinal  meningitis.  {See 
cerebro-spinal  fever)  ;  dropsy,  408 ;  en- 
cephalitis, 943;  hfemoglobinuria,  746; 
jaundice,   373;    pneumonia,  95. 

Epilepsia  larvata,  1077. 

Epilepsy,  1073;  age  factor,  1073;  alcohol- 
ism, 388,  1074;  aura,  1075;  grand  mal, 
1075;  heredity,  1074;  Jacksonian  form, 
1077;  petit  mal,  1076;  sex,  1073;  sur- 
gical treatment,  1080. 

Epileptic  attack,  1075. 

Epistaxis,  604;  preceding  typhoid  fever, 
24. 

Erb-Goldflam's   complex,   1124. 

Ergotism,  401. 

Erysipelas,  58;  and  tuberculosis,  209;  com- 
plicating typhoid,  29;  familial  predispo- 
sition to,  59. 


Erythema,  autumnale,  320 ;  in  typhoid  fe- 
ver, 17;  nodosum  in  tuberculosis,  209; 
infectiosum,  353. 

Erythrsemia,   750. 

Erythromelalgia,  1114. 

Exophthalmic  goitre,  869. 

Exophthalmos,  870. 

External    cutaneous   nerve    lesions,    1055. 

Extra-systoles,  768. 

Eunuchs,  glandular  condition,  879. 

Eustrongylus  gigas,  315. 

Eye  involvement  in  cerebro-spinal  fever, 
115. 

Eye  lesions  in  congenital  syphilis,  275 ;  in 
gout,  419 ;  in  pulmonary  tuberculosis, 
205;  in  small  pox,  327;  in  syphilis,  272; 
in  typhoid  fever,  27. 


F 


Face,  horizontal  in  extreme  torticollis, 
1047. 

Facial  asymmetry,  in  torticollis,  1046; 
hemiatrophy,  1116;  nerve,  paralysis, 
1034;  electrical  reactions,  1036;  diplegia, 
1035;  permanent  type,  1036;  points  of 
involvement,  1034;  sensory  functions, 
1036;   spasm,   1037. 

Facial  spasm,  1037. 

Facies,  hepatic,  570 ;  Hippocratic,  in  ty- 
phoid perforation,  23 ;  in  ankylostomia- 
sis, 309;  in  Paget 's  disease,  1135;  in 
Parkinson's  disease,  1060;  in  typhoid 
fever,  14;  in  yellow  fever,  265;  leontine, 
154;  of  mouth  breathers,  461. 

Fallopian  tubes,   tuberculosis  of,   220. 

Familial  predisposition  to  erysipelas, 
59. 

Familial  spinal  muscular  atrophy,  926. 

Familial  tendency  to  haemorrhage  in  ty- 
phoid, 22;   to  asthma,  620. 

Famine  fever,  260. 

Farcy.      {See  glanders.) 

Fascolopsis  Buskii,  290. 

Fat  tape  worm,  292. 

Fatty  heart,  784. 

Fatty  liver,  580. 

Febris  recurrens.      {See  relapsing  fever.) 

Febricula,  372. 

Feet,   neuralgia  of,   1084. 

Fetal   endocarditis,    826. 

Fetor  oris,  453. 

Fetus,  tuberculosis  in,  215;  typhoid  fever 
in,   32. 

Fibrinous  bronchitis,  624. 

Fi])roid  tuberculosis.  {See  tuberculosis, 
fibroid.) 

Fibroma  molluscum,  1020. 

Fibro-sarcoma  of  brain,  1004. 


1150 


INDEX 


Fibrositis,   1120. 

Fifth  nerve  paralysis,  1032. 

Filaria  bancrofti,  311;  equina,  314;  im- 
mitis,  314;  loa,  311;  perstans,  311; 
volvulus,  314. 

Filariasis,   311. 

Fish   poisoning,   400,   401. 

Fistula  in  ano  in  tuberculosis,  209,  213. 

Fleas,  318;  as  agents  in  Leishmaniasis, 
260. 

Flies,  as  carriers  of  typhoid  infection,  1, 
6,  7,  36. 

Floating  kidney,   672. 

Flukes,   diseases  due  to,  289. 

Focal  infection,   56. 

Food  poisoning,  399. 

Food  stuffs,  contamination  of,  by  typhoid 
bacilli,  5,  6. 

Foot  and  mouth  disease,  376. 

Foreign  bodies,  in  the  bronchi,  626;  mis- 
taken for  pneumonia,  100;  in  heart, 
823;  in  intestines,  530;  in  stomach, 
496. 

"Fourth  disease,"  353. 

Fourth  nerve  paralysis,   1030. 

Fragilitas  ossium,  1136. 

Frambesia,  288. 

Freund's  theory  of  emphysema,  639. 

Friedlander 's  pneumo-bacillus,  81. 

Friedreich's  ataxia,  927. 

Froehlich's  syndrome,  441. 

Fungus  infections,   non-bacterial,   231. 

Funnel  breast  and  adenoids,  461;  in  tu- 
berculosis,  199. 

Fused  kidney,  671. 


G 


Gait,  cerebellar,  972;  in  Parkinson's  dis- 
ease, 1061. 

Gall  bladder,  acute  inflammation,  556 ;  and 
ducts,  diseases  of,  553;  atrophy  of,  564; 
calcification  of,  564;  in  acute  cholecys- 
titis, 556. 

Gall-stones,  biliary  colic,  562;  frequency 
after  typhoid,  24;  obstructing  bowel, 
566;  origin  of,  560;  physical  characters 
of,  561;  perforation,  566;  remote  effects 
of,  565. 

Galloping  consumption,  183. 

Gangrene  in  broncho-pneumonia,  106;  of 
lung,  643 ;  in  pneumonia,  98 ;  in  pulmo- 
nary tuberculosis,   203. 

Gas  bacillus  invasion  of  thorax,  664. 

Gas  poisoning,   385;    in  war,   386. 

Gastralgia,  503. 

Gastrectasis,  477;  atonic,  478;  chronic, 
478. 

Gastric,    cancer,    489;    catarrh,    468;    dila- 


tation, 477;   hypergesthesia,  503;   neuro- 
sis,   499 ;    supersecretion,    502 ;    tumors, 
non-cancerous,  495;  ulcer,  481. 
Gastritis,    acute,    468;    chronic,    471;    con- 
stipation,  476;    dietetic   treatment  474; 
flatulency,  476;  gastric  contents  in,  472; 
membranous,   470;    mycotic,  470;    phleg- 
monous,   469 ;    toxic,   470. 
Gastrodiseus  hominis,  290. 
Gastro-intestinal    fistula,    565;    symptoms, 

severe,  in  typhoid  fever,  14. 
Gastrostaxis,  497. 

General  paresis,  914;    cerebro-spinal  fluid, 
916;  cyto-diagnosis,  918;  facies  in,  916: 
prodromal  stage,  915;  second  stage,  916: 
tabo-paralysis,  916. 
Genito -urinary  system  in  pulmonary  tuber- 
culosis,  205. 
Geographical  tongue,  452. 
German  measles   (see  Rubella),  353. 
Gigantism,  876. 

Gilles  de  la  Tourette's  disease,  1069. 
Glanders,  147. 
Glioma,  963,  1003. 
Goitre,  864.      (See  thyroid  gland.) 
Gonococcus  arthritis,  127;  arthralgie,  127; 
anatomical    changes,    127;     bursal    and 
synovial  form,  127;   chronic  hydrarthro- 
sis,     127;      complications,      128;      pain- 
ful heel  of,  127;  polyarthritic,  127;  sep- 
ticsemic,  127. 
Gonococcus  infection,   125. 
Gonorrhoea,    causing    septico-pysemia,    55. 
Gout,  413;   alcohol  as  factor,  414;   articu- 
lar    changes     in,     415 ;     cardio-vascular 
manifestations,   418;    food   as   a  factor, 
414;    heredity   in,   414;    irregular   form, 
418;    mineral    waters    in,    421;    nervous 
manifestations,      418;       "poor      man's 
gout,"   414;    predisposing  factors,  414; 
urinary  disorders,  419. 
Gouty  deposits,  415;   diathesis,  418. 
Glandular  fever,  375. 
Glenard's  disease,  538. 
Glossina  palpalis,  258. 
Glossitis  in  typhoid  fever,  20. 
Glosso-labio-laryngeal        paralysis,        921; 

pharjTigeal  nerve  lesions,   1042. 
Glycosuria,   transient,   425. 
Grain   and  vegetable  poisoning,  401. 
Grand  mal,  1075. 
Graves'   disease,   869. 
Green  sickness,  725. 
Groeco's   sign,   651. 
Ground  itch,  308. 
Guinea  worm   disease,  313. 
Gull's  disease,  867. 
Gummata,  272. 

Gummatous  periarteritis,   282. 
Guy's  pill,   287. 


INDEX 


1151 


H 


Habit  spasm,  1069. 

Habitus  phthisicus,   159. 

Hfematemesis,  497;  and  hemoptysis  dif- 
ferentiated, 499;  in  portal  cirrhosis,  570. 

Hffimatoehyluria,   312. 

Haematomyelia,  962. 

Htematoporphyrin,   688. 

Hsematoporphyrinuria,   688. 

Hsematorachis,   961. 

Hematuria,  676;  caused  by  stone,  677;  es- 
sential, 676;  in  renal  tuberculosis,  218; 
traumatism,  677. 

Haemic  distomiasis,   290. 

Haemochromatosis,   444. 

Hemoglobinuria,  677;  malarial,  253;  par- 
oxysmal, 678 ;  toxic,  678 ;  treatment,  679. 

Haemopericardium,   762. 

Hsemophilia,  747. 

Hemoptysis,  629 ;  and  hematemesis  dif- 
ferentiated,   499. 

RTemoptysis,  hysterical,  1094;  in  pulmo- 
nary tuberculosis,  192,  194;  in  typhoid 
fever,  25. 

Hemorrhage,  cerebral,  982 ;  from  pancreas, 
584;  from  stomach,  497;  in  amcebiasis, 
240;  in  peptic  ulcer,  484;  intestinal  in 
typhoid  fever,  10,  22;  meningeal,  934; 
of  mesentery,  543;  typhoid,  treatment 
of,  41. 

Hemorrhagic  disease  of  the  new  born, 
746;   typhoid  fever,  31. 

Hemothorax,  662. 

Haffkine  's  serum,  in  plague,  143. 

Hair  tumor  of  the  stomach,  496. 

Hallucinosis,  acute,.  390. 

Hamburg  epidemic  of  cholera,  136. 

Harvest  bug,  316;  rash,  320. 

Hay  fever,  618. 

Head,  attitude  of,  in  progressive  muscular 
atrophy,   1046. 

Head  louse,  317. 

Head,  pressure  in,  in  hysteria,  1102. 

Headache  in  brain  tumor,  1004, 

Heart,  acceleration  of,  in  vagus  paralysis, 
1044 ;  action,  inhibition  of,  1045 ;  acute 
interstitial  myocarditis,  783;  alterna- 
tion of,  776 ;  aneurism,  822 ;  angina  pec- 
toris, 828 ;  anomalies  of  cardia  septa, 
824;  aortic  insufficiency,  802;  aortic  ste- 
nosis, 808 ;  auricular  fibrillation,  772 ; 
auricular  flutter,  771 ;  beat,  mechanical 
disorders  of,  766;  bicuspid  condition, 
825;  heart  block,  773,  774;  bradycardia, 
767;  brown  atrophy,  785;  chronic  valvu- 
lar disease,  800;  compensation  in  valvu- 
lar lesions,  801 ;  congenital  affections  of, 
824;  conseiotisness  of,  763;  coronary  ar- 
tery disease,   782 ;    cough   and  hemopty- 


sis, 791;  diet,  791;  digitalis  therapy, 
789;  dilatation  of,  779;  disease,  763; 
congenital,  symptoms,  827;  disturbances 
of  rhythm,  768;  dropsy,  790;  dyspnoea, 
790;  endocarditis,  792;  extra  systole, 
768;  tests  of,  787;  fatty,  784;  fatty 
overgrowth,  785;  fetal  endocarditis, 
826;  fragmentation  and  segmentation, 
784;  functional  tests,  787;  gastric  symp- 
toms, 790;  hypertrophy,  777;  in  diph- 
theria, 67,  71;  in  lobar  pneumonia,  84; 
insufficiency,  782;  left  ventricle  hyper- 
trophy, 777;  mitral  insufficiency,  810; 
mitral  stenosis,  778,  813;  murmurs, 
765,  778,  786,  796,  800,  805,  806, 
809,  811,  813,  815,  816,  818,  827, 
828,  837,  839,  840,  844,  845,  848, 
851,  853;  new  growths  and  parasites, 
823;  normal  mechanism  of,  766;  pain, 
763;  palpitation,  765,  790;  parenchyma- 
tous degeneration,  784;  paroxysmal 
tachycardia,  770;  patent  foramen  ovale, 
825;  pulmonary  valve  disease,  818;  re- 
nal symptoms,  791;  reserve  force  of, 
802;  right  ventricle  hypertrophy,  778; 
rupture  of,  823 ;  Schott  treatment,  792 ; 
sinus  arrhythmia,  768;  "sleep  start," 
812;  sleeplessness,  791;  sounds  in  lobar 
pneumonia,  89;  sounds  in  typhoid  fever, 
19;  special  pathological  conditions,  822 
stenosis  of  pulmonary  orifice,  818 
symptomatic  and  mechanical  disorders, 
763;  syphilis  of,  281;  tachycardia,  767 
thrombosis  of  coronary  arteries,  787 
transposition  of  arterial  trunks,  826 
tricuspid  valve  lesions,  817;  ''undefend 
ed  space, ' '  825 ;  valvular  anomalies,  825 
valvular  lesions  combined,  819 ;  valvular 
lesions,  prognosis,  820;  ventricular  pre- 
mature contractions,  769 ;  wounds  and 
foreign  bodies,  823. 

Heat  cramps,  382;   exhaustion,  380. 

Hebrews  and  diabetes,  425. 

Heel,  painful  in  gonococcus  arthritis,  127. 

Heine's  disease,  1001. 

Heine-Medin  disease,  938. 

Hemeralopia,  1023. 

Hemiplegia,  982;  alternans,  969;  in  lobar 
pneumonia,  91;  in  typhoid  fever,  27; 
spastica  cerebralis,  1001. 

Hemiplegias  of  children,  1000. 

Hepatic  abscess,  amoebic,  242;  changes  in 
typhoid  fever,  24;  cirrhosis,  567;  de- 
generation, in  typhoid  fever,  11  ;  disto- 
miasis, 289;  intermittent  fever,  564; 
vein  and  artery,  affections  of,  553. 

Hepatitis,  paludal,   247. 

Hepatization  of  lung,  in  pneumonia,  83. 

Hcpatoptosis,  539. 

Hereditary    and     familial    diseases,    923; 


1152 


INDEX 


ataxia,  927;  cerebellar  ataxia,  929;  ic- 
terus,'548;  spastic  paraplegia,  929;  tre- 
mor, 1062. 

Heroin  addiction,   392. 

Herpes,  associated  with  lobar  pneumonia, 
90;  in  cerebro-spinal  fever,  114;  in  ty- 
phoid fever,  17;  labial,  in  malaria,  251. 

Herpes  zoster,  1058 ;  complications,  1059 ; 
distribution,   1058;   in  diabetes,  429. 

Hiccough,  1050. 

Hippocratic  faeies  in  peritonitis,  593;  fin- 
gers, 206,  1134. 

Hirschsprung's  disease,  542. 

Hodgkin's  disease,  738;  latent  type,  741; 
localized  form,  740;  lymphogranuloma- 
tosis, 741 ;  lymphadenia  ossium,  741 ; 
splenomegalic  type,  741;  with  relapsing 
pyrexia,  740. 

Hoffman's  bacillus,  64. 

Homalomyia    {see   Myiasis),   318. 

Hookworm  disease,  307. 

Horse  asthma,  treatment,  623. 

Hospital  infection,  in  typhoid  fever,  5. 

Hospital  fever.     {See  typhus.) 

Hour-glass  stomach,   486. 

Hughlingg   Jackson   syndrome,   1049. 

Hunger  sense,  anomalies  of,  504. 

Huntington's  chorea,  929. 

Hutchinson's  teeth,  275. 

Hydatid  cyst,  295. 

Hydrocele,  development  of,  in  typhoid  fe- 
ver, 28. 

Hydrocephalus,  1012;  acquired  chronic, 
1013;  congenital  form,  1013;  serous 
meningitis,  1012. 

Hydronephrosis,  711;  congenital,  671;  in- 
termittent, 673. 

Hydropericardium,   762. 

Hydro-peritoneum,  600. 

Hydrophobia,  358;  distribution  of,  358; 
excitement  stage,  359;  paralytic  stage, 
359;  premonitory  stage,  359;  preventive 
inoculation,  360. 

Hydrotherapy,  in  broncho-pneumonia,  109; 
in  cerebro-spinal  fever,  117;  in  lobar 
pneumonia,  102;  in  neurasthenia,  1107; 
in  typhoid  fever,  39. 

Hydrothorax,  661. 

Hydro-ureter,  congenital,  671. 

Hymenolepis  diminuta,  292. 

Hymenolepis  nana,  292. 

Hyperacidity,  gastric,  502. 

Hypersesthesia,  gastric,  503 ;  of  the  tongue, 
453. 

Hyperchlorhydria,   502. 

Hyperpiesia,  834. 

Hyperosmia,    1022. 

Hyperplasia  of  glands  in  typhoid  fever, 
8. 

Hyperpituitarism,   875. 


Hypertension,  834;  in  nephritis,  703, 

Hyporthyroidism,  869;  basal  metabolism, 
871;  exophthalmos,  870;  Graefe's  sign, 
871;  historical  note,  869;  Stellweg's 
sign,  871;  tachycardia,  870;  tremor,  871. 

Hypertrophic  biliary  cirrhosis,  571 ;  pul- 
monary arthropathy,  1134;  stenosis  of 
pylorus,  496. 

Hypertrophy  of  pylorus,  496. 

Hypoglossal  nerve,  lesions,  1048;  cortical 
lesions,  1048;  nuclear  lesions,  1048;  pa- 
ralysis,  1048. 

Hypophyseal  tumors  {see  pituitary),  875. 

Hypophysis  cerebri,  875.  {&ee  pituitary 
body.) 

Hypopituitarism,  875. 

Hypostatic  congestion  of  lungs  in  typhoid 
fever,  25;  pneumonia,  97. 

Hypothyroidism,  865. 

Hysteria,  1087;  analytical  method,  1097; 
astasia,  1096;  Charcot's  views,  1098; 
chorea  major,  1090;  convulsive  form, 
1090;  hydrotherapy,  1100;  Freud's  view, 
1089;  globus  hystericus,  1090;  hystero- 
epilepsy,  1090;  major  forms,  1090;  mi- 
nor forms,  1090;  non-convulsive  form, 
1091;  psychotherapy,  1097;  racial  inci- 
dence, 1089;  sexual  view  of,  1088. 

Hysterical  amaurosis,  1023;  paralysis, 
1091;  peritonitis,  594. 


Ice,  containing  typhoid  bacilli,  5. 

Icterus,  545 ;    acholuric,  549  ;    gravis,   549 ; 

hereditary,    548;    in   typhoid   fever,   24; 

neonatorum,   548,  549;    syphiliticus  prse- 

eox,   272. 
Ileo-colitis,  517. 
Ileus,    gastro -mesenteric,    .530;     paralytic, 

531. 
Immunity  changes  in  tuberculosis,  161;  in 

typhoid  fever,  3. 
Immunization  in  diphtheria,  74. 
Impotence  in  diabetes,  430. 
Impulsive  tie,   1069. 
Indian  kala-azar,  259. 
Indicanuria  686. 

Indurative    mediastinopericarditis,   760. 
Inebriate,   psychasthenic,   1104. 
Infant  mortality,  and   broncho-pneumonia, 

104. 
Infantile    convulsions,     1071 ;     in    rickets, 

440;   kala-azar,   260;    scurvy,  411;    Bar- 
low's  description,   412;    prophylaxis  of, 

412. 
Infantilism,     879;     cachectic     type,     879; 

Froelich  type,  880;  hormonic  type,  880; 

idiopathic    type,    879;    pancreatic    type, 


INDEX 


1153 


880;     progeria,     880;     thyroidal     type, 
880. 

Infection,  focal,  56;  of  mouth,  453. 

Infection  of  water  in  typhoid  fever,  5. 

Infection,   terminal,  57,  95. 

Infectious  jaundice,  373. 

Inflammatory  hiccough,  1050. 

Influenza,  118;  bacteriology  of,  119;  com- 
plications, 121;  epidemic  and  endemic, 
classification,  118;  febrile  form,  120; 
gastro-intestinal  form,  120;  historical 
note,  118;  nervous  form  of,  120;  pleu- 
risy, 120;  pneumonia,  120;  respiratory 
type,  119;   simulating  typhoid  fever,  30. 

Inhalation   pneumonia,   97. 

Insolation,  380. 

Insufficiency,  cardiac,   781. 

Intercostal  neuralgia,  1084. 

Intermittent  hydrarthrosis,  1133. 

Interstitial  cells  of  testes,  879. 

Intestinal   cestodes,    291;    disease   of   chil- 
dren,     514;      indigestion,     acute,     516 
kinks,    529;    lesions   in   amcebiasis,   238 
obstruction,    528;     by    gall-stones,    531 
foreign    bodies,    530;     nature    of,    533 
sand,    542 ;     strangulation,    528 ;     strict- 
ures,    530;      symptoms     in     pulmonary 
tuberculosis,  204;   tuberculosis,  212;   tu- 
mors, 530 ;  ulcers,  cancerous,  512. 

Intestines,  tuberculosis  of,  212. 

Intoxications,  387. 

Intussusception,  528,  533. 

Ipecac,  in  amoebic  dysentery,  242. 

Iridoplegia,  1029. 

Irish  and  tuberculosis,   159. 

"Irritable  eye,"   1102. 

Irritable  heart,  764. 

Irritative  hiccough,  1050. 

Ixodiasis,    316. 


Jacksonian  epilepsy,  903,  1077. 

Jail-fever.      (See  typhus.) 

Janet's  classification  of  psychasthenics, 
1104. 

Jaundice,  545;  acholuric  hemolytic,  884; 
catarrhal,  553;  epidemic  catarrhal,  373; 
hfemolytic,  547;  hereditary,  548;  in  lo- 
bar pneumonia,  93;  in  tuberculosis  of 
liver,  214;  infectious,  373;  malignant, 
549;  obstructive,  545;  haemorrhage,  546; 
salvarsan,  548;  spirochaetal,  373;  tetra- 
chloride of  ethane,  548;  trinitrotoluene, 
548. 

.lenner's  vaccination   experiments,   331. 

•lews  and  tuberculosis,  160. 

Joints,   diseases  of,   1125. 

Joslin's   regime   in  diabetes,  431. 

Jumpers,   1070. 

Jumping  spasm,  1070. 


K 


Kahler's  disease,  681. 

Kakke,  406. 

Kala-azar.      (See  Leishmaniasis,  259.) 

Kernig's  sign,  in  cerebro-spinal  fever, 
116;  in  typhoid  fever,  25. 

Ketonuria,  688. 

Kinks,  intestinal,  530. 

Klebs-Loeffler  bacillus,  63;  bacteriological 
examination  for,  72;  morphological 
characters,  63 ;   toxins  of,  63. 

Koch,  comma  bacillus  of,  134;  work  on 
tuberculosis,  156. 

Koplik's   spots,   350. 

Korsakoff's  psychosis,  388. 

Kronig's  apical  resonance  zones,  200. 

Kidney,  amyloid  disease,  707;  circulatory 
disturbance,  674;  congenital  hydroureter, 
671;  congestion,  674;  cystic,  719 
Dietl's  crisis,  673;  diseases  of,  671 
echinococcus  cyst  of,  299 ;  fused,  671 
gummata.  of,  283;  hsematuria,  676;  le- 
sions in  diabetes  mellitus,  424;  in  diph- 
theria, 67;  lesions  in  lobar  pneumonia, 
84;  lesions  in  typhoid  fever,  11,  27; 
malformations  of,  671;  movable,  672, 
673 ;  palpable,  672 ;  perinephritic  ab- 
scess, 720;  polycystic,  719;  pyelitis, 
708;  stone  in  (see  nephrolithiasis),  713; 
tuberculosis  of,  217;  tumors  of,  717;  di- 
agnosis, 718;  physical  signs,  718;  symp- 
toms, 718;   urinary  anomalies,  675. 


Laennec's  work,  value  of,  156. 

La  Grippe.      (See  influenza.) 

Lamblia  intestinalis,   288. 

Landry's  paralysis,  948. 

Laryngeal  diphtheria,  69;  paralysis  in  ty- 
phoid fever,  25. 

Laryngismus  stridulus,  607. 

Laryngitis,  in  small-pox,  327;  in  typhoid 
fever,  24;  (Edematous,  606,  607;  spas- 
modic, 607;  syphilitic,  609;  tuberculous, 
608. 

Larynx,  involvement  in  typhoid  fever,  11; 
syphilis  of,  609;  tuberculosis  of,  608. 

Larval  pneumonia,  96. 

Latah,  1070. 

Lathyrism    (lupinosis),  401. 

Laveran,   work   of,   on   malaria,   243. 

Lead  palsy,  395. 

Lead  poisoning,  392;  arterio-sclerosis, 
396;  blue  line  in,  .394;  cerebral  symp- 
toms, 396;  colic,  394;  incidence  of,  393. 

Leishmaniasis,  definition  of,  259;  distribu- 
tion, 259;   infantile,  260. 


1154 


INDEX 


Leontiasis  ossea,  1136. 

Lepra  alba,  154. 

Leprosy,  152;  anaesthetic,  154;  clinical 
forms  of,  154;  conditions  influencing  in- 
fection, 154;  contagion,  153;  faeies  le- 
ontina,  154;  geographical  distribution, 
152;  heredity  in,  153;  historical  note, 
152;  inoculation,  153;  lepra  mutilans, 
154;  modes  of  infection,  153;  tubercu- 
lar,  154. 

Leptomeningitis,  936. 

Leptospira  icteroides,  265. 

Leptus  autumnalis,   316. 

Leucocytosis,  in  cerebro-spinal  fever,  114; 
in  pneumonia,  99. 

Leukaemia,  733;  acute  lymphatic,  736; 
association  with  other  diseases,  738; 
atypical,  737;  blood  picture,  737; 
chronic  lymphatic,  737;  lymphoid,  736; 
myeloid,  734;  aleukfemic  intervals,  736; 
blood  picture,   736 ;   priapism,  735. 

Leukiemic   retinitis,   1023. 

Leukangemia,   737. 

Leukoplakia    buccalis,    452. 

Life  insurance  and  syphilis,  287. 

Lines  atrophiege,  in  typhoid  fever,  17. 

Linguatula  rhinaria,   315. 

Linitis   plastiea,   477. 

Lipaciduria,  688. 

Lipsemia,  547;  in  diabetes,  429. 

Lipodystrophia   progressiva,    1118. 

Lipomatoses,  442 ;  cerebral,  443 ;  diffuse 
symmetrical,  443;  nodular  circumscribed, 
443. 

Lipomatous  neuritis,   1015. 

T(ips,  tuberculosis  of,  211. 

Lipuria,  428,  688. 

Lithuria,  684. 

Litten  phenomenon,  in  tuberculosis,   199. 

Little's  disease,  1000. 

Liver,  abscess  of,  574;  perforation  of  lung, 
576 ;  acute  yellow  atrophy  of,  549 ;  af- 
fections of  the  blood  vessels  of,  552; 
amoebiasis  of,  239 ;  amyloid,  581 ;  anas- 
mia  of,  552;  anomalies  in  form  and  po- 
sition, 582;  cancer,  579;  changes  in,  in 
typhoid  fever,  24;  cirrhosis,  567;  de- 
generation, in  typhoid  fever,  11;  diseases 
of,  545;  fatty  degeneration,  581;  hy- 
persemia,  552;  hydatid  cyst  of,  297;  le- 
sions of  the  portal  vein,  553;  movable, 
582;  new  growths  of,  578;  passive  con- 
gestion, 552;  primary  adenoma  of,  578; 
primary  cancer,  578  ;  sarcoma  •  of,  579 ; 
secondary  cancer,  578 ;  thrombosis  of, 
553;    tuberculosis   of,   214. 

Lobar  pneumonia  (see  pneumonia,  lobar), 
78 ;  in  typhoid  fever,  25. 

Lobstein's  disease,   1136. 


Local  infections  with  development  of  tox- 
ins, 51. 

Lockjaw.      (See  tetanus.) 

Lobular  pneumonia.  (See  pneumonia, 
broncho-.) 

Locomotor  ataxia.      (See  tabes  dorsalis.) 

Locomotor  system,  disease  of,  1119. 

Lorain  type  of  infantilism,  879. 

Louse  infection,  317;  in  transmission  of 
typhus,  48. 

Ludwig's  angina,  458. 

Lumbago,  1121. 

Lumbar  neuralgia,  1084. 

Lumbar  plexus,  paralyses,   1055. 

Lumbar  puncture,  cerebro-spinal  fever, 
116,  117;  diagnostic  aid  in  typhoid  fe- 
ver,  34. 

Lung,  abscess,  645 ;  in  pneumonia,  98 ;  cir- 
rhosis of,  202;  congestion  of,  627;  dis- 
eases of,  627;  echinococcus  cyst  of,  299; 
gangrene  of,  203,  643 ;  in  pneumonia, 
98 ;  hypostatic  congestion,  628 ;  lesions, 
in  amoebiasis,  239 ;  involvement  of,  in 
diphtheria,  66;  in  typhoid  fever,  11,  25; 
neoplasm  of,  646 ;  cedema  of,  628 ;  path- 
ology of,  in  pneumonia,  82;  syphilis  of, 
278;    tuberculosis   of,    182, 

"Lung -stones,"  189. 

Lymph  glands,  tuberculosis  of,  174. 

Lymph  scrotum,  312. 

Lymphadenitis,  mediastinal,  666. 

Lymphatic  system  in  typhoid  fever,  7, 
8,  9. 

Lymphomatous   nephritis,    28. 

Lyssa.     (See  hydrophobia.) 

Lyssophobia,   360. 


M 


Maculas  ceruleaa,  in  typhoid  fever,  17. 

Madura  disease,  235. 

Malaria,  and  lobar  pneumonia,  96 ;  com- 
plicating typhoid,  30 ;  confounded  with 
pyeemia,  55;  differentiated  from  ty- 
phoid,  85. 

Malarial  cachexia,   253. 

Malarial  fever,  242 ;  sstivo-autumnal  para- 
site, 245  ;  algid  form,  253  ;  clinical  forms 
of,  248 ;  cold  stage,  248 ;  geographical 
distribution,  243 ;  hot  stage,  248 ;  inter- 
mittent, 248,  251;  late  lesions  of,  247; 
mosquito  eradication  campaign,  255 ; 
parasites  of,  243 ;  paroxysm,  248 ;  per- 
nicious, 247,  252;  quartan,  parasite  of, 
245,  251;  quinine  treatment,  255;  re- 
lapse, 254;  remittent,  types  of,  245,  251; 
sweating  stage,  249 ;  tertian,  parasite 
of,  245. 

Malarial  nephritis,  248. 

Malarial    parasite,    development    of,    244; 


INDEX 


1155 


historical  note,  243 ;  in  man,  245 ;  with- 
in  the   mosquito,   246. 

Malarial  pneumonia,  248. 

Malignant  purpuric  fever.  {See  cerebro- 
spinal fever.) 

Mallein,  for  diagnostic  purposes,  148. 

Malta  fever,  132;  distribution  of,  133; 
goats  and,  133. 

Mammary  gland,  tuberculosis  of,  220. 

Marriage  and  syphilis,  287;  and  tubercu- 
losis, 222. 

Marie's  views  on    speech  centre,  975. 

Masque  de  femme  enceinte,  857. 

Massive   pneumonia,    94. 

Masticatory  spasm,   1033. 

Mastitis  in  pulmonary  tuberculosis,  205; 
in  typhoid  fever,  28,  42. 

Mastoid  disease,  1010. 

McBurney's  point,  524. 

Measles  (morbilli),  348;  and  membranous' 
angina,  65;  atypical,  350;  desquama- 
tion, 350. 

Meat  poisoning,  399,  400. 

Median  nerve  paralysis,  1054. 

Mediastinal  abscess,  669  ;  emphysema,  669 ; 
lymphadenitis,  666;   tumors,  667,  668. 

Mediastinitis,  669. 

Mediastinum,  diseases  of,  666.    , 

Mediterranean  fever.     {See  Malta  fever.) 

XTedullary  tumors,   1007. 

Melano-sarcoma,   579,   580. 

Melanuria,    687. 

Membranous  angina,  64;  croup,  69;  enteri- 
tis, 540;  rhinitis,  68. 

Meniere  's  syndrome,  1040. 

Meningism,  938;  in  typhoid  fever,  26. 

Meningitis,  acute,  936;  cerebro-spinal,  epi- 
demic, 110;  chronic,  938;  confused  with 
pneumonia,  100;  due  to  B.  coli,  46;  due 
to  B.  typhosus,  26;  in  lobar  pneumonia, 
84,  93;  in  typhoid  fever,  11;  tubercu- 
lous, 171,  172. 

Meningococcus,  112;   carriers  of.  111,  116. 

Meningo-myelo-encephalitis,  938. 

Mental  states  causing  diarrhoea,  507. 

Meralgia  partesthetica,    1055. 

Mercury,  inunction  method,   286. 

Merycismus,   501. 

Mesenteric  glands,  in  typhoid  fever,  10. 

Mesentery,  affections  of,  543. 

Metabolism,  basal,  in  Graves'  disease,  871; 
in  myxcedema,  867. 

Metallic    poisoning   neuritis,    1018. 

Metastatic  abscesses,  53. 

Metatarsalgia,  1084. 

Meteorism,  in  lobar  pneumonia,  93 ;  in  ty- 
phoid fever,  22. 

Methagmoglobinspmia,  751. 

Micrococcus  melitensis,  132;  parameliten- 
sis,  132;   rheumatieus,  362. 


Migraine,  1080;  ophthalmoplegic  type, 
1081. 

Migratory  pneumonia,  94. 

Mikulicz'   disease,   456. 

Miliary  fever,  375. 

Milk,  as  conveyor  of  diphtheria  bacilli,  62 ; 
of  scarlet  fever,  338;  source  of  tuber- 
culosis infection,  65;  of  typhoid  bacilli, 
5,  6. 

Milk  sickness,  374. 

Milroy's  disease,  1116. 

Mimic   spasm,   1037. 

Mitral  insufificiency,  810. 

Mitral   stenosis,   813. 

Mollites  ossium,  1137. 

Monophobia,   1102. 

Morbilli.    {See  measles.) 

Morbus  ceruleus,  827;  Gallicus,  269;  ma- 
culosus  neonatorum,  747. 

Morphia  habit,   391;   treatment,  392. 

Mortality  rate  in  lobar  pneumonia,  98. 

Morvan's  disease,   964, 

Mosquito  as  malarial  parasite  carriers, 
246;    eradication  of,   255. 

Mountain  sickness,  384, 

Mouth  breathing,  460. 

Mouth,  care  of,  in  typhoid  fever,  39. 

Movable  liver,  582. 

Mucous   colitis,   540. 

Mucous  glands,  affections  of,  454. 

Mucous   patches  in   syphilis,   272. 

Mugnet,   450. 

Multiple   cartilaginous   exostoses,   1138. 

Multiple  sclerosis,  954. 

Mumps   {see  parotitis),  354. 

Muscle  changes  in  typhoid  fever,  12. 

Muscular  dystrophy,  923 ;  Duchenne  's  type, 
925;  Landouzy-Dejerine  type,  925; 
loose  shoulders,  925;  thigh  muscle  type, 
925. 

Musculo-spiral  paralysis,  1053. 

Mussel  poisoning,  400. 

Myalgia,  1120. 

Myasthenia  gravis,  1124. 

Mycetoma,  235. 

Mycoses,  231. 

Mycosis  intestinalis,  151. 

Myelitis,  acute  ascending,  948. 

Myelitis,  cervical,  948;  diffuse,  946;  trans- 
verse, 947. 

Myelitis,  degenerative,  949. 

Myeloma,   albumosuria   in,   681. 

Myiasis,  318;  cutaneous,  319;  gastro-in- 
testinal,  319. 

Myocardial  hypertrophy,  conditions  caus- 
ing, 777. 

Myocarditis,  acute  interstitial,  783 ;  and 
typhoid  fever,  11;  functional  tests  in, 
787;  in  lobar  pneumonia,  84;  syphilitic, 
282. 


1156 


INDEX 


Myocardium  affections  of,  777;  hypertro- 
phy of,   777;   insufficiency  of,  785. 

Myoclonic  epilepsy,  932. 

Myositis,  1119;  ossificans  progressiva, 
1120. 

Myotonia,  1122. 

Myriachit,   1070. 

Mytiltoxin,   400. 

MyxoBdema,  865;   operative,  867. 


N 


Nasal  diphtheria,  68,  69. 

Necator  americanus,  307. 

Negri  bodies  in  hydrophobia,   360. 

Negro,  susceptible  to  pneumonia,  82;  to 
tuberculosis,   159. 

Nematodes,  314;    diseases  caused  by,  301. 

Neoplasms  of  liver,  578;  of  lung,  646. 

Nephritis,  acute,  692;  syphilitic,  282;  with 
typhoid   fever,    1428. 

Nephritis,   arterio-sclerotic,   700,   702,   704. 

Nephritis,  chronic  interstitial,  700;  acido- 
sis, 703;  anamia,  706;  blood  changes, 
703;  digestive  system,  703;  eye  lesions, 
704;  hypertension,  705;  myocardial  in- 
sufficiency, 706;  nervous  system,  704; 
primary  form,  700;  secondary  changes, 
704;  surgical  treatment,  707;  ursemdc 
symptoms,  706;  vaso-dilators,  706. 

Nephritis, .  chronic  parenchymatous,  697; 
diet,  700. 

Nephritis,  hereditary,   681. 

Nephritis  in  diphtheria,  71;  in  malaria, 
248;  in  scarlet  fever,  342;  in  typhoid 
fever,  28. 

Nephrolithiasis,  713;  hsematuria,  715; 
pain,  715;  pyelitis,  716;  renal  colic, 
714. 

Nephroptosis,  539,  672. 

Nephro-typhus,  28. 

Nervous  dyspepsia,  499, 

Nervous  manifestations,  in  typhoid  fever, 
13;   in  pulmonary  tuberculosis,  204. 

Nervous  system,  afferent,  diseases  of,  906; 
autonomic,  904;  cerebral  localization; 
diseases  of  the  motor  tract,  918;  ecliino- 
coccus  cyst  of,  300;  involuntary,  904; 
general  and  functional  diseases,  1059; 
involvement  in  small-pox,  327;  irritative 
lesions  of  lower  motor  segment,  901;  le- 
sions of  sensory  paths,  903;  lesions  of 
spino-muscular  segment,  900;  lesions  of 
upper  motor  segment,  902;  lower  seg- 
ment paralyses,  901;  motor  lesions,  900; 
neurone,  function  of,  886;  paralyses  of 
upper  motor  segment,  902;  para-sympa- 
thetic, 905;  reaction  of  degeneration, 
901;     segmental    skin    fields,    898,    899; 


anterior,  897;  posterior,  898;  sensory 
areas,  897;  sensory  system,  895;  sympa- 
thetic, 904;  topical  diagnosis,  900;  vege- 
tative, 904;  visceral,  904. 

Nervous  vomiting,  501. 

Neuralgia,    1082 ;    clinical   varieties,    1083. 

Neurasthenia,  1100;  after  typhoid,  27; 
anxiety,  1102;  hereditary,  1100;  hyper- 
Eesthesia,  1101;  local  symptoms,  1101; 
phobias,  1102;  pressure,  1102;  psychic 
state,  100;  rachialgia,  1103;  sexual- 
causes,  1100;  special  sense  disturbance, 
1102;    vaso-motor   disturbance,   1104. 

Neurasthenics,  personal  hygiene,   1106. 

Neuritis,.  1014;  alcoholic,  1017;  anesthe- 
sia paralyses,  1018;  angiopathic  paraly- 
sis, 1019 ;  in  lobar  pneumonia,  93 ;  me- 
tallic poisoning,  1018;  multiple,  1015; 
multiple  diphtheritic,  71;  recurring  mul- 
tiple, 1017;   typhoid,  26. 

Neuro-circulatory   asthenia,    764. 

Neuromata,  1020;  amputation,  1021;  gen- 
eralized neuro-fibromatosis,  1020 ;  plexi- 
form,    1020;     tubercula    dolorosa,    1021. 

Neurone  cell  system,  887;  degeneration 
of  886;  function  of,  886;  regeneration 
of,  886. 

Neurosis   of   the   stomach,   499,   504. 

Neurotic  children,  education,  1106;  hic- 
cougJi,   1050. 

New-born,  pneumonia  in,  95. 

New  growths  of  liver,  578;  of  lungs,  646. 

Night  blindness,  1023. 

Nile  sore,  260. 

Ninth  nerve  lesions,  1042;  and  eleventh 
nerve  involvement,   1049. 

Nocardiosis,  234. 

Nodding  spasm,  1047,  1069. 

Nodules,    subcutaneous   fibroid,   366,    1129. 

Noma,  450. 

Non-bacterial  fungus  infections,  mycoses, 
231. 

Non-cancerous  tumors  of  the  stomach,  495. 

Nose,  diseases  of,  604;  involvement  in  ce- 
rebro-spinal  fever,   116. 

Nothnagel's  syndrome,  969. 

Nystagmus,  1030. 


O 


Obesity,  440;  pituitary  influence,  441. 
Obliterating  endarteritis,  syphilitic,  282. 
Obstetrical  paralysis,  1052. 
Obstructive  jaundice.      (See  jaundice.) 
Occipital  lobe  tumors,  1006. 
Occipito-cervieal  neuralgia,  1049. 
Occupation  neuroses,  1086. 
Occupational  influence  in  tuberculosis,  160. 
Ochronosis,  444. 
Ocular  palsies,  1028, 


INDEX 


1157 


Odor  of  skin  in  typhoid  fever,  17. 

(Edema  of  legs,  hereditary,  1116;  of  lung, 
628;  of  skin,  in  typhoid  fever,  17. 

Oertel's  method  for  obesity,  442. 

(Esophageal  varices,  464. 

CEsophagismus,  465. 

(Esophagitis,   463,   465. 

(Esophago-pleuro-cutaneous  fistula,  468. 

0-]sopliagus,  cancer  of,  466;  cicatricial 
stricture,  466;  diverticula,  467;  rupture 
of,  467;  spasm  of,  465;  stricture  of, 
465;  tuberculosis  of,  212;  ulcer  of,  464. 

CEstrus  equi,   728. 

Oidiomycosis,  235. 

Oidium    albicans   in    thrush,    450. 

Olfactory  nerves,  diseases  of,  1021. 

Omentopexy,  574. 

Omentum,  diseases  of,  602. 

Open-air  treatment  of  tuberculosis,  224. 

Ophthalmia  neonatorum,  126. 

Ophthalmic   zoster,   1059. 

Ophthalmoplegic  migraine,  1082. 

Ophthalmo-reaction  in  typhoid  fever,  34. 

Ophthalmo-tuberculin  reaction,   160. 

Opisthotonus  in  hysteria,  1091;  in  tetanus, 
145. 

Oppenheim's  disease,  1124. 

Optic   aphasia,  1028. 

Optic    atrophy,    1024. 

Optic  chiasma,  lesions  of,   1025. 

Optic  nerves,  lesions  of,  1022,  1024,  1028; 
cycloplegia,  1029 ;  fourth  nerve  paraly- 
sis, 1030;  functional  disturbance  of  vi- 
sion, 1023;  general  feature  of  paralysis, 
1030;  iridoplegia,  1029;  ophthalmople- 
gia, 1031;  ptosis,  1029;  retinitis,  1022; 
1023;  sixth  nerve  paralysis,  1030; 
spasm,  1030;  third  nerve  paralysis, 
1028. 

Optic  neuritis,  1024;  in  typhoid  fever,  11, 
27. 

Optic  thalamus,  897. 

Optic  tract  and  centres,  lesions  of,  1025; 
hemianopsia,  1028;  optic  aphasia,  1028; 
Wernicke's  test,  1028. 

Optochin,  use  of,  in  pneumonia,  101. 

Oral  sepsis,  453. 

Orchitis  and  mumps,  355;  in  typhoid  fe- 
ver, 11,  28,  42;  syphilitic,  283. 

Organisms,  causing  pneumonia,  81. 

Ornithodorus  megnini,  317. 

Ornithodorus  or  Argas  moubata,  316. 

Orthotonus  in  tetanus,  145. 

Osseous  system  involvement  in  typhoid  fe- 
ver, 28,  42. 

Osteitis  deformans,  1135. 

Osteogenesis   imperfecta,   1136. 

Osteomalacia,  1137. 

Osteomyelitis,  diagnosis  of,  55;  due  to  B. 
mallei,  148. 


Osteopsathyrosis,   1136. 

Ovaries,  tuberculosis  of,  220. 

Ovum,  infection  of,  by  tubercle  bacilli,  162. 

Oxaluria,   684. 

Oxycephaly,    1138. 

Oxyuris  vermicularis,   302. 

Oysters,  as  a  source  of  typhoid  infection,  6. 


Pachymeningitis  externa,  933;  interna, 
933;  ha?morrhagic,  933;  spinal  form, 
935. 

Paget 's  disease,   1135. 

Pain,  cardiac,  805, 

Painful  heel,  1084. 

"Painful  testicle,"  1104. 

Palate,  hemiansesthesia  of,  1049;  paraly- 
sis of,  71;  tuberculosis  of,  211. 

Palato-laryngeal   paralysis,    1049. 

Palpitation,   cardiac,   765. 

Paludism.      {See  malarial   fever.) 

Pancreas,  haemorrhage,  584;  in  diabetes, 
427. 

Pancreas  in  typhoid  fever,  24;  tumors 
of,  590;  frequency,  590;  symptoms, 
590. 

Pancreatic   calculi,   591;    disease,   583. 

Pancreatic  cysts,  588;  following  inflam- 
matory conditions,  588;  not  following 
inflammatory  conditions,  588;  traumatic, 
588;   situation,  589. 

Pancreatic  insufiiciency,  583 ;  azotorrhcea, 
583;   changes  in  stools,  583. 

Pancreatic  necrosis,  584. 

Pancreatitis,   acute,   585;    chronic,   587. 

Panophthalmitis,  in  typhoid  fever,  27. 

Pantophobia,  1102. 

Pappataci  fever,  320. 

Paracentesis,  accidents  in,  659. 

Parageusia,  1043. 

Paragonimus  westermanii,  289. 

Paralysis  agitans,  1059;  gait,  1061;  ar- 
senical, 398;  bulbar,  921;  combined,  of 
cranial  nerves,  1049;  diphtheritic,  71; 
from  lead,  395;  ocular,  1028;  of  fifth 
nerve,  1032;  seventh  nerve,  1034;  tick, 
317. 

Paralytic  ileus,  531. 

Paramyoclonus  multiplex,  1123, 

Paraphasia,  975. 

Paraplegia   dolorosa,  953. 

Parasites  found  in  heart,  823. 

Parasitic  arachnida  and  ticks,  315;  flies, 
318;   insects,  317, 

Parathyroids  and  spasmophilia,  873;  dis- 
eases of,  872;   tetany  and,  873, 

Paratyphoid  fever,  43;  relative  incidence 
of,  44 


1158 


INDEX 


Paratyphoid  organisms,  differentiation  of, 

44. 
Parenchymatous  nephritis.     (See  nephritis, 

chronic   parenchymatous.) 
Parenchymatous  neuritis,   1015. 
Parkinson's   disease,   1059;    mask,   1060. 
Parosmia,  1022. 
Parotid  gland,  tumors  of,  456. 
Parotitis,    epidemic     (mumps),    354;     and 
orchitis,    355;     chronic,    455;    in    lobar 
pneumonia,  94;  in  typhoid  fever,  20,  42, 

Paroxysmal  tachycardia,  770. 

Parry's  disease,  869. 

Pathomimia,   hysterical,   1096. 

Pathophobia,  1102. 

Pediculosis,  317;   in  typhoid  fever,  17. 

Pediculus  corporis,  317;   humanus,  317. 

Peliomata,  in  typhoid  fever,  17. 

Pellagra,  405. 

Pemphigus  neonatorum  suphiliticus,   274. 

Pentastomes,   315. 

Pentastomum  constrictum,  316;  denticu- 
latum,   315;   teenioides,  315. 

Peptic  ulcer,  481;  and  cancer,  484;  and 
skin  burns,  482;  associated  diseases, 
482;  cicatrization,  483;  dyspepsia,  484; 
erosion,  483;  gastric  contents,  485; 
haemorrhage,  484;  hour-glass  stomach, 
486;  infection,  482;  jejunal,  484;  mode 
of  origin,  484;  pain,  485;  perforation, 
483,  486;  perigastric  adhesions,  483; 
Sippy  method,  487;  surgical  interfer- 
ence, 488. 

Perforation,  in  typhoid  fever,  22,  24,  42. 

Periarteritis  nodosa,   854. 

Pericarditis,  753;  acute  fibrinous,  754;  ancf 
typhoid  fever,  11,  19;  chronic  adhesive, 
760;  Brauer's  operation,  761;  pulsus 
paradoxus,  761;  in  lobar  pneumonia,  84, 
92;   tuberculous,   179. 

Pericarditis  with  effusion,  756. 

Pericardium,  adherent,  760. 

Pericardium,  diseases  of,  753;  tuberculo- 
sis of,  179. 

Perichondritis  in  typhoid  fever,  24. 

Perihepatitis,   573. 

Perinephritic   abscess,   720. 

Periodic  paralysis,  931. 

Perisigmoiditis,   543. 

Peristaltic  unrest,  500. 

Peritoneum,  ascites,  600;  diseases  of,  591; 
new  growths,  599 ;   tuberculosis  of,  180. 

Peritonitis,  acute  general,  591;  adhesive, 
598;  appendicular,  597;  chronic  hgemor- 
rhagic,  599;  due  to  B.  coli,  46;  Hippo- 
cratic  facies,  593;  in  infants,  595;  in  lo- 
bar pneumonia,  93;  in  typhoid  fever,  42; 
localized,  595;  pelvic,  597;  pneumocoe- 
cic,  594;  proliferative,  598;  subphrenic, 
595;  tuberculous,  180;  tumor  in,  181. 


Pernicious  malarial  fever,  252. 

Personal  infection   in   typhoid   fever,   5. 

Pertussis.     (See  whooping  cough.) 

Pestis  minor,  141. 

Petechial  fever.  (See  cerebro-spinal  fe- 
ver.) 

Petit  mal,   1076. 

Peyer's  glands  in  typhoid  fever,  8. 

Pfeiffer's  bacillus,  119. 

"Pfeiffer's  phenomenon,"   33. 

Phantom  tumor,  1092. 

Pharyngeal  diphtheria,  67. 

Pharyngitis,  acute,  456;  chronic,  457;  in 
typhoid  fever,  20. 

Pharynx,  circulatory  disturbances,  456; 
phlegmon  of,  458;  tuberculosis  of,  212; 
ulceration  of,  457. 

Philippine  itch,  322. 

Phlebitis,  in  typhoid  fever,  19. 

Phlebo-sclerosis,  836. 

Phlebotomous  fever,  319. 

Phlebotomy,     102,     365,     380,     788,     838, 
996. 

Phosphaturia,  686. 

Phrenic  nerve,  affections  of,  1049 ;  neu- 
ralgia, 1084. 

Phthirius  pubis,  317. 

Phthisis.      (See  tuberculosis,  pulmonary.) 

Phthisis  florida,  186. 

Pick's  disease,  760. 

Pigeon  breast  and  adenoids,  461. 

Pigmentation  of  skin,  857. 

Pin  worm,   302. 

Pineal  gland,  diseases  of,   878. 

Pituitary  body,  875;  diseases  of,  875,  876; 
description  of,  875. 

Pituitary   tumors,   1007. 

Pityriasis  versicolor  in  pulmonary  tuber- 
culosis, 205. 

Placenta,  tuberculosis  of,  220. 

Plague,  the,  139;  bubonic,  141;  geo- 
graphical distribution,  140;  historical 
note,  140;  petis  minor,  141;  pneu- 
monic, 142;  septicffimic,  142;  serum  of 
Yersin,  143 ;   spots,  142. 

Plantar  neuralgia,  1084. 

Plasmodium  falciparum,  245;  malariae, 
245;  vivax,  245. 

Pleura,  thickened,  660;  tuberculosis  of, 
178,   203. 

Pleural  complications  of  pulmonary  tuber- 
culosis, 203. 

Pleurisy,    acute,    647;     mensuration,    651 

•  acute  tuberculous,  178;  and  typhoid  fe 
ver,  11,  25;  chronic,  660;  "dry,  660 
primitive  dry,  661 ;  with  effusion,  660 
chylothorax,  656 ;  diaphragmatic,  655 
encysted,  655;  fibrinous  or  plastic,  647, 
648 ;  hajmorrhagie,  655 ;  in  lobar  pneu 
monia,   92;    interlobular,   656;    paracen- 


INDEX 


1159 


tesis,  accidents,  659 ;  purulent,  encapsu- 
lated empyema,  564;  sero-fibrinous,  648; 
tuberculous,  178,  203;  with  effusion, 
confused  with  pneumonia,  100. 

Pleurodynia,   1121. 

Pleurothotonus  in  tetanus,  145. 

Plotz,  studies  of,  on  typhus,  48. 

Plumbism,  392. 

Pneumaturia,  687. 

Pneumogastric  nerve,  1043 ;  cardiac 
branches  involvement,  1044,  1045;  distri- 
bution of,  1043  ;  gastric  branches,  1045  ; 
laryngeal  anaesthesia,  1044 ;  laryngeal 
paralysis,  1044;  laryngeal  spasm,  1044; 
pharyngeal  paralysis,  1043;  pharyngeal 
spasm,  1043;  pulmonary  branches,  1044. 

Pneumococci,  in  blood  stream,  89. 

Pneumococcic  infections,  78;  local,  110; 
other  than  pneumonia,  110;  septicajmia, 
110. 

Pneumococcus,  80;  as  normal  inhabitant, 
81;  in  septicEemia,  53;  types  of,  80;  vi- 
tality of,  81. 

Pneumoconiosis,  636. 

Pneumonia  and  pneumococcic  infections, 
78;  and  typhoid  fever,  35;  ansesthesia, 
causes  of,  97;  aspiration,  105;  broncho-, 
chronic,  106,  633 ;  fibroid  changes  in, 
106;  forms  of,  105;  gangrene  in,  106; 
hydrotherapy,  109;  inhalation,  97;  lo- 
cal applications,  109;  resolution  in,  106; 
secondary,  104,  107;  suppuration  in, 
106;  terminations  of,  106;  tuberculous, 
184;  deglutition,  104;  epidemiology  of, 
81;  in  cerebro-spinal  fever,  115;  in  ma- 
laria, 248;  incidence  of,  78;  influenzal, 
120. 

Pneumonia,  interstitial,  chronic,  633,  634, 
635;    diffuse,   633;   pleurogenous,   633. 

Pneumonia,  lobar,  78;  and  arthritis,  94, 
96;  and  malaria,  96;  and  tuberculosis, 
96;  antipneumococcic  serum,  102;  apex 
pneumonia,  94;  asthenic,  96;  ausculta- 
tion in,  88;  bacteriology  of,  80;  bleed- 
ing in,  102;  blood  picture,  89;  blood 
pressure,  89 ;  bowels,  care  of,  102 ;  car- 
diac lesions  in,  84;  cause  of  death,  99; 
central,  94;  cerebral  symptoms,  91; 
chronic,  termination,  98;  circulation  in, 
88;  circulation,  support  of,  103;  cold  in 
causation,  80;  complications  of,  92; 
convalescence,  94,  103 ;  cough,  character 
of,  86 ;  crises,  types  of,  85 ;  care  in,  103 ; 
croupous  colitis  in,  84,  93 ;  delayed 
resolution  in,  97;  diet  in,  101;  differen- 
tiation from  broncho-pneumonia,  108; 
differentiated  from  pneumonic  tubercu- 
losis, 100,  184;  digestive  disturbances, 
90;  double,  94;  dyspnoea  in,  86;  em- 
bolic, 97;  endocarditis  in,  92;  epidemic, 


95;  etiology,  79;  gangrene  of  lung,  98; 
gastric  complications,  93;  heart  sounds 
in,  89;  hemiplegia  in,  91;  historical  note, 
78;  hydrotherapy  in,  102;  hydrotherapy, 
internal,  103;  hypostatic,  97;  in  the 
aged,  95;  in  alcoholic  subjects,  95;  in 
infants,  95 ;  in  pulmonary  tuberculosis, 
203,  209;  inhalation,  97;  jaundice  in, 
93;  larval,  96;  lesions  in  other  organs, 
84 ;  leucocytosis  in,  89,  99 ;  lung  abscess 
in,  98;  lung  involvement  in,  83;  massive, 
94 ;  meningitis  in,  84,  93 ;  mensuration 
in,  87;  meteorism  in,  93;  migratory  or 
creeping,  94;  mortality  rate  in,  98; 
nervous  system  in,  103 ;  pain  in,  86 ;  pal- 
pation in,  87;  parotitis  in,  94;  percus- 
sion in,  87;  pericarditis  in,  92;  peritoni- 
tis in,  93  ;  pleurisy  in,  92 ;  postoperative, 
96;  predisposing  conditions,  79;  recur- 
rence in,  79,  94;  relapse  in,  94;  resolu- 
tion in,  83 ;  respiratory  tract,  care  of, 
103;  seasonal  influence,  80;  secondary, 
95;  skin  lesions,  90;  sputum,  86;  tem- 
perature curve  in,  85 ;  terminal,  95 ; 
toxaemia,  importance  of,  99 ;  toxic,  96 ; 
traumatic  causation,  79;  types,  death 
rate  of,  99;  typhoid,  96;  urine  in,  91; 
racial  susceptibility,  82 ;  tuberculous, 
184;    vagus,   experimental,   105. 

Pneum.onic  plague,  142. 

Pneumopericardium,   762. 

Pneumothorax,  663 ;  in  pulmonary  tuber- 
culosis, 203;  in  typhoid  fever,  25;  X-ray 
examination,  665. 

Pneumo-typhus,  25,  100. 

Podagra,  413. 

Pointing  test,  972. 

Poliomyelitis,  acute,  938;  abortive  form, 
940;  anomalous  forms,  941;  ascending 
form,  940;  bulbar  form,  941;  cerebral 
form,  941;  in  typhoid  fever,  27;  men- 
ingitic  form,  941 ;  polyneuritic  form, 
941;  spinal  fluid,  942;  spinal  form,  940; 
transverse  form,  941. 

Poliomyelitis  anterior  chronica,  918. 

Polycytheemia  vera,  750. 

Polymyositis  hfemorrhagica,  1120. 

Polyorrhomenitis,  178,  598. 

Polyserositis,  598. 

Polyuria  in  typhoid  fever,  28,  39. 

Pork  tapeworm,   291. 

Porocephalus  armillatus,  316. 

Portal  vein,  diseases  of,  553. 

Popliteal  nerve,  1056. 

Postfebrile  arthritidoa,  55. 

Post-mortem  warts,  163. 

Postoperative  pneumonia,  96. 

Post-typhoid  insanity,  43 ;  neurasthenia, 
27;  neuritis,  43;  pyelitis,  28;  septicae- 
mia and  pycTmia,  29. 


1160 


INDEX 


Posterior  spinal  sclerosis.  {See  tabes  dor- 
salis.) 

Postero-lateral  sclerosis,  primary  and  sec- 
ondary, causes,  949. 

Potato-poisoning,  402. 

Pregnancy  and  appendicitis,  527;  and  ty- 
phoid fever,  31 ;    spurious,   1092. 

Presbyophrenia,   980. 

Primary  combined  sclerosis,  949 ;  lateral 
sclerosis,  922. 

Professional  spasms,   1086. 

Prof  eta's  law,  270. 

Progressive  bulbar  paralysis,  918;  intersti- 
tial hypertrophic  neuritis,  927;  lenticu- 
lar degeneration,  930;  muscular  atro- 
phy,  918. 

Progressive  muscular  atrophy,  amyotrojjhic 
spastic  form,  920;  bulbar  paralysis,  921, 
living  skeletons,  920;  main  en  griffe, 
920;   neural  muscular  atrophy,  926. 

Prophylaxis  in  typhoid  fever,  36. 

Prostate,  tuberculosis  of,  219. 

Prostatitis,  in  typhoid  fever,  28. 

Protozoan   infections,    236. 

Pruritus  in  diabetes,  428;  in  jaundice,  546. 

"Pseudo-angina  pectoris,"   763. 

Fseudo-cyesis,   1092. 

Pseudo-diphtheria  bacillus,  64. 

Pseudohydrophobia,  360. 

Pseudo-lipoma,  443. 

Psilosis,  509. 

Psittacosis,  377. 

Psorospermiasis,    236. 

Psychasthenia,  1104. 

Psychasthenics,   classification   of,   1104. 

"Psychic  hardening,"  1106. 

Psychoanalysis  in  epilepsy,  1078;  in  hys- 
teria, 1098 ;   in  neurasthenia,  1108. 

Psychoses  in  typhoid  fever,  27. 

Psychosis   polyneuritica,   388. 

Psychotherapy  in  hysteria,  analytical  meth- 
od, 1098;  dream  analysis,  1099;  hypno- 
sis, 1097;  in  neurasthenia,  1108;  re- 
education, 1098;  suggestion,  1098. 

Ptomaine  poisoning,  399. 

Ptyalism,  451,  454. 

Pulex  irritans,   318;    penetrans,   318. 

Pulmonary  abscess,  645 ;  actinomycosis, 
232;  anthrax,  151;  apoplexy,  630;  car- 
cinoma, 646;  diseases,  627;  disease,  non- 
tuberculous,  207;  heemorrhage,  629,  631; 
infarct,  630 ;  oedema,  628 ;  orifice,  lesions 
of,  826;  severe,  in  typhoid  fever,  13;  tu- 
berculosis {see  tuberculosis,  pulmo- 
nary) ;  valve  disease,  818,  819. 

Pulse,  in  lobar  pneumonia,  88;  in  typhoid 
fever,  18;  in  yellow  fever,  266. 

Pulsus  paradoxus,  761. 

Purpura,  742 ;  arthritic,  743 ;  cachectic, 
743;   chronic,  745;  mechanical,  743;  ne- 


phritic, 704 ;  neurotic,  743 ;  rheumatica, 
744 ;  simplex,  743 ;  symptomatic,  743 ; 
toxic,  743;   visceral  lesions,  744. 

Purpura   haemorrhagica,    745. 

Purpura  variolosa,   325. 

Pustular  glanders,  329. 

PyEemia,  53 ;  gonocoecus,  126 ;  post-typhoid, 
29 ;   simulating  typhoid  fever,  35. 

Pyelitis,  682,  708;  post-typhoid,  28;  ty- 
phoid, treatment,  42. 

Pylephlebitis,    553. 

Pyloric  insufficiency,  502 ;  obstruction,  fea- 
tures of,  479;  spasm,  501;  stenosis,  con- 
genital,  496;    hypertrophic,   496. 

Pyo-cyanic  septiegemia,  53. 

Pyogenic  infections,  51;    septicaemia,  52. 

Pyuria,  28,  682,  709;  cystitis,  683;  from 
abscesses,   683;    urethritis,   683. 


Quarantine  measures  in  diphtheria,  74. 
Quincke's  disease,  1012,  1115. 
Quinine     injections     in     amcebiasis,     242; 
treatment  in  malaria,  256. 


E 


Eabies.      {See  hydrophobia.) 

Eachitis.     {See  rickets.) 

Racial  influence,  in  amoebiasis,  237;  in 
diabetes,  425 ;  in  lobar  pneumonia,  79, 
82;  in  small-pox,  321;  in  tuberculosis, 
159. 

Eag-pickers'  disease,  151. 

Eailway  brain,   1108;    spine,   1108. 

Eainey's  tube,  236. 

Eat  bite  fever,  378 

Eat  flea,  as  plague  carrier,  140. 

Eats,  as  plague  carriers,  140. 

Eaw  meat  diet  in  tuberculosis,  228. 

Eaynaud's  disease,  1111. 

"Eebound  phenomenon,"  972. 

Eectum,  syphilis  of,  281;  tuberculosis  of, 
213. 

Eedux  crepitus,  88, 

Eeflex,  gastro-colic,  541. 

Eelapsing  fever,    260;    African,   261,   271. 

Eenal  calculus  {see  nephrolithiasis)  ;  coc- 
cidiosis,  237;  diabetes,  426;  disease 
(see  kidneys)  ;  involvement  in  tj'phoid 
fever,  27;  in  diphtheria,  67;  tubercu- 
losis, 55,  217. 

Eeptile  heart,  824. 

Eesolution  in  broncho-pneumonia,  106;  de- 
layed, in  pneumonia,  97. 

Eespiration,  asynchronous,  in  lobar  pneu- 
monia, 87. 


INDEX 


1161 


Eespiratory  organs,  syphilis  of,  278;  sys- 
tem diseases  of,  604. 

Eest,  treatment  in  tuberculosis,  225. 

Eeteution  of  urine  in  typhoid  fever,  27. 

Eetro-pharyngeal    abscess,   458. 

Eeversed  peristalsis,  499. 

Eheumatic  fever,  361;  age  influence,  361; 
alkaline  treatment,  368;  as  an  acute  in- 
fectious disease,  362 ;  cardiac  lesions, 
364;  causal  organism,  362;  nervous 
complications,  365 ;  salicyl  compounds, 
use  of,  368;  seasonal  influence,  361;  sex 
influence,   361;    tonsils  in,   369. 

Eheumatic  nodules,   366. 

Ehinitis,  membranous,  68. 

Ehythmic  chorea,  1070. 

Eice  vrater  stools,  137. 

Eiekets,  436. 

Eisus  sardonicus,  145. 

Eoeky  Mountain  Spotted  fever,  377. 

Eoentgen-ray  diagnosis  in  tuberculosis, 
208. 

Eotheln.      {See  German  measles.) 

Eubella,   353. 

Eumination,  501. 


S 


Sable,  intestinal,  542. 

Saccharomycosis,  235. 

Sacral  plexus  paralyses,  1055. 

St.  Vitus 's  Dance,  1062. 

Salaam  convulsion,  1047. 

Salivary  glands,  diseases  of,  454;  tuber- 
culosis of,  211;   supersecretion,  454. 

Saltatory  spasm,  1070. 

Salvarsan,  poisoning  from,  548. 

Sarcoptes  scabiei,  316. 

Saturnine  cachexia,  394. 

Saturnism,  392. 

Scanning  speech,  953. 

Scarlet  fever,  337;  adenitis,  343;  and  diph- 
theria, 344;  and  membranous  angina, 
64;  anginose  form,  342;  arthritis  in, 
343;  atypical,  341;  cardiac  complica- 
tions, 343 ;  desquamation,  341 ;  ear  le- 
sions in,  343 ;  eruption,  339 ;  familial  in- 
fluence, 338;  hsemorrhagic  form,  341;  in- 
f ectivity,  338,  345 ;  malignant,  341 ;  ne- 
phritis in,  342,  694;  nervous  complica- 
tions, 343 ;  puerperal  {see  surgical)  ; 
septicsemic  form,  342;  serum  treatment, 
348;    surgical,   338. 

Schick   reaction,   62. 

Schistosoma  haematobium,  290;  japonicum, 
291. 

Schmidt  syndrome,  1049. 

Schonlein's  disease,  744. 

Sciatica,  1056. 

Sciatic  nerve  lesions,  105,5. 


Scleroderma,  1117. 

Sclerosis,  diffuse,  956;  miliary,  956;  mul- 
tiple, 954;   tuberose,  956.      , 

Scorbutus,  408. 

Screw-worm,  318. 

Scriveners'  palsy,   1087. 

Scrofula  {see  tuberculosis  of  the  lymphatic 
system),  174. 

Scurvy,  408;  infantile,  411;  sex  influence, 
409;  theories  of  causation,  409. 

Seasonal  influence  of  infantile  diarrhoea, 
514;  of  erysipelas,  58;  in  lobar  pneu- 
monia, 80 ;  of  rheumatic  fever,  361 ;  of 
broncho-pneumonia,  104;  of  typhoid  fe- 
ver, 3. 

Secretory  gastric  neuroses,  502. 

Secondary  infections  in  typhoid  fever,  7; 
pneumonia,  95. 

Seminal  vesicles,  tuberculosis  of,  219. 

Senile  kidney,  700;  spastic  paralysis,  951; 
tremor,  1062. 

Sensitization  to   antitoxin,  77. 

Sensory  system,   diseases  of,  906. 

Septicsjmia,,  52 ;  cryptogenetic,  53 ;  gono- 
coccus,  126;  pneumococcic,  110;  post-ty- 
phoid, 29;  progressive,  52;  streptococcic, 
52. 

Septicsemic  plague,   142. 

Septico-pysemia,  53;  causative  bacteria, 
54;  dift'erentiation  from  typhoid,  55; 
metastatic  abscess  in,  54;  skin  lesions 
in,  55;  surgical  treatment  of,  56;  vac- 
cine treatment  of,  56. 

Serous  meningitis,  in  typhoid,  26. 

Serratus  paralysis,   1053. 

Serum,  anti-tetanic,   146. 

Serum  sickness,  76. 

Serum  therapy  in  bacillary  dysentery,  132; 
cerebro-spinal  fever,  117;  in  diarrhoeal 
disease,  521;  treatment  of  scarlet  fever, 
348;  in  typhoid  fever,  40. 

Seven   day   fever,   260,   379. 

Seventh  nerve  paralyses,  1034. 

Sex  gland,  hyperfunction,  879 ;  hypofunc- 
tion,  879;  influence  in  amoebiasis,  237; 
relation  to  lobar  pneumonia,  79. 

Shaking  palsy,   1059. 

Shell  fish  poisoning,  400. 

Shiga's  bacillus,  129;  Flexner-Harris  type, 
129. 

Ship  fever  {see  typhus),  47. 

Shock  symptoms,  967. 

Shoddy  fever,  636. 

Siderodromophobia,  1102. 

Siderophobia,   1102. 

Siderosis,   636. 

Sigmoiditis,  543. 

Silicosis,  636. 

Simple  gastritis,  468. 

Sinus   arrhythmia,   768. 


1162 


INDEX 


Sippy  's  treatment  of  peptic  ulcer,  487. 

Siriasis,  380. 

Sixth  nerve   paralysis,   1030. 

Skin,  actinomycosis  of,  233 ;  diphtheria  of, 
70;  lesions  in  cerebro-spinal  fever,  114; 
in  diabetes,  429 ;  in  lobar  pneumonia,  90 ; 
in  pellagra,  404;  in  pulmonary  tubercu- 
losis, 205;  in  septico-pysemia,  55;  in  ty- 
phoid fever,  16;  odor  of,  in  typhoid  fe- 
ver, 17 ;  cedema  of,  in  typhoid  fever,  17. 

Skin  pigmentation,  in  Addison's  disease, 
857;  causes  of,  857. 

Skin  reaction  of  Von  Piquet,  160;  typhoid 
in,  38;   syphilitic  lesions,  271. 

Skoda 's   resonance,   664. 

Sleeping  sickness.      {See  trypanosomiasis.) 

Small-pox  (variola),  320;  abortive  types 
of,  326;  age  incidence,  321;  confluent 
rash,  324;  desiccation,  325;  discrete 
form  of  rash,  324;  epidemiology  of,  321; 
eruption  in,  -324;  haemorrhagic  form, 
325;  leucocytes  in,  326;  mortality  rate 
in,  328 ;  nature  of  contagion,  322 ;  nerv- 
ous system  involvement,  327;  racial  in- 
fluence, 321;  special  sense  involvement, 
327;  variola  hsemorrhagica,  323;  variola 
vera,  323. 

Smelter's  shakes,  397. 

Smoker's  tongue,  452. 

Sneezing,  as  cure  for  hiccough,   1050. 

Snuffles,   274. 

Softening  of  the  brain,  992. 

Soor,  450.' 

Sordes,  in  typhoid  fever,  20. 

Sore  throat,  456. 

Spanish-American  War,  typhoid  fever  in, 
6. 

Spasm,  1049;  in  epilepsy,  1075. 

Spasmodic  croup,  608. 

Spasmus  nutans,  1069. 

Spastic  paralysis  of  adults,  921;  second- 
ary, 923. 

Specific  infectious  diseases,   1. 

Speech  centre,  974-5. 

Spermatorrhea  in  psychasthenia,  1104. 

Spes   phthisica,    205. 

Spinal  automatism,  964. 

Spinal  cord,  anaemia,  960;  blood  vessels, 
lesions  of,  960;  congestion,  960;  com- 
pression, 951;  diffuse  and  focal  diseases 
of,  957;  embolism  and  thrombosis,  960; 
endarteritis,  960 ;  €xtrameningeal  haem- 
orrhage, 961;  focal  lesions,  957;  hasma- 
tomyelia,  962;  intrameningeal  haemor- 
rhage, 961 ;  localization  in  segments, 
891;  meningeal  tumors,  964;  transverse 
lesions,  958;  tumors,  963;  tumors  of  the 
meninges,    964;    unilateral    lesions,    958. 

Spinal  nerves,  diseases  of,  1049, 

Spine,  typhoid,   29. 


Spirillum  of  Obermeier,  261. 

SpirochEeta  ictero-hEemorrhagica,  373 ;  pal- 
lida, 269. 

Spleen,  880;  cysts  of,  882;  in  lobar  pneu- 
monia, 84;  in  typhoid  fever,  10,  24;  in- 
farct of,  882;  movable,  881;  rupture  of, 
881 ;  tuberculosis  of,  882 ;  tumors  of, 
882. 

Splenic  anaemia,  882;  fever  {see  anthrax). 

Splenomegaly,  882;  alcoholic  cirrhosis, 
885;  angemia  in,  883;  ascites,  884;  Gau- 
cher type,  884;  haemorrhagic  type,  883; 
hepatic  type,  884;  jaundice,  884;  syph- 
ilitic cirrhosis,  885;  with  haemolytic 
jaundice,  884;  with  primary  pylethrom- 
bosis,  884. 

Splenoptosis,  539,  881. 

Spondylitis  deformans,   1128. 

Sporotrichoses,  233 ;   parasite  of,  234. 

Spotted  fever.    {See  typhus.) 

Sprue,  509. 

Staphylococcus  pyogenes  in  septicemia,  53. 

Starvation  and  acidosis,  446. 

Status  epilepticus,  1076;  hystericus,  1096; 
lymphaticus,  861 ;  thymico-lymphaticus, 
861. 

Steatorrhea,  583. 

Steeple  head,  1138. 

Stegomyia  calopus  in  yellow  fever,  264; 
mosquito  and  dengue,  356. 

Steno  's  duct,  tumors,  456. 

Stenocardia,  828. 

Stenosis  of  the  bile  ducts,  559. 

Steppage  gait,  429,  1020;  in  diabetes, 
429 ;   in  lead  workers,  395. 

Sterno-mastoid  paralysis,  1045. 

Stokes-Adams  syndrome,  774. 

Stomach,  achylia,  502;  akoria,  504;  ano- 
rexia, 504;  atonic  dilatation,  478;  atony 
of,  501;  bulimia,  504:  cancer  of,  489; 
cardiospasm,  501;  dilatation  of,  477; 
chronic  dilatation  of,  478 ;  in  lobar  pneu- 
monia, 93 ;  eructations,  500 ;  gastralgia, 
503;  haemorrhage,  497;  hair  tumor,  496; 
hour-glass,  486;  hyperacidity,  502;  hy- 
permotility,  500;  motor  neuroses,  500; 
neurosis,  499 ;  non-cancerous  tumors, 
495;  pylorospasm,  501;  pyloric  obstruc- 
tion, 479 ;  secretory  neuroses,  502 ;  sen- 
sory neuroses,  503;  supersecretion,  502; 
syphilis  of,  281;  tuberculosis,  212;  ulcer 
of,  481. 

Stomatitis,  448;  aphthous,  448;  epidemic, 
376;  gangrenous,  450;  herpetic,  449; 
mercurial,  451;  parasitic,  450;  ulcera- 
tive, 449. 

Strabismus,  1031. 

Strangulation,   intestinal,   530. 

Strawberry  tongue,   340. 

Streptococcic  septicaemia,  52. 


INDEX 


1163 


Streptothiix   madurse,   235. 

Stricture  of  oesophagus,  466. 

Strongyloides   stereoralis,   315. 

Strophanthus,  use  of,  in  lobar  pneumonia, 
103. 

Struma   (see  thyroid  gland),  864. 

Submaxillary  glands,   tuberculous,   176. 

Subphrenic  peritonitis,  595. 

Succus  enteric-US,  507. 

Succussion   sounds,    665. 

Suffocative  catarrh.  (See  pneumonia,  bron- 
cho-.) 

Sulphsemoglobingemia,   752. 

Sunstroke,  380;   history  of,  380. 

Suppression  of  urine  in  typhoid  fever,  28. 

Suppuration  in  broncho-pneumonia,   106. 

Suppurative  and  ulcerative  angiocholitis, 
5'5o. 

Suprarenals,  Addison's  disease,  856;  cho- 
lin,  855;  chromaffin  system,  855;  cortex 
of,  855;  cortical  lesions  of,  859;  epine- 
phrin,  855;  hsemorrhage,  859;  hyper-  and 
hypo -function,  859;   tumors  of,  860. 

Surgical  kidney,  709. 

Surgical    scarlatina,    338. 

Sweating  sickness,  375. 

Sweats  in  typhoid  fever,  17. 

Swine  fever,  377. 

Sydenham  's  chorea,  1062. 

Sympathetic  nervous   system,   904. 

Symptomatology  of  acute  yellow  atrophy 
of  liver,  550;  of  amcEbiasis,  240;  of  an- 
thrax, 150;  of  bacillary  dysentery,  129; 
of  beri-beri,  407;  of  broncho-pneumo- 
nia, 106;  of  cerebro-spinal  fever,  113; 
of  cholera  asiatica,  137;  of  dengue,  356; 
of  diabetes  insipidus,  435;  of  diabetes 
mellitus,  427;  of  diphtheria,  67;  of  ery- 
sipelas, 59;  of  focal  infection,  57;  of 
hydrophobia,  359;  of  influenza,  119;  of 
lobar  pneumonia,  84;  of  Malta  fever, 
133;  of  measles,  349;  of  paratyphoid 
fever,  44;  of  parotitis,  354;  of  pellagra, 
404;  of  peptic  ulcer,  484;  of  pneumonia, 
82;  of  renal  tviberculosis,  218;  of  rheu- 
matic fever,  363;  of  rickets,  438;  of 
scarlet  fever,  339;  of  scurvy,  409;  of 
septieo-pysemia,  54;  of  small  pox,  323;  of 
tapeworm  infection,  292;  of  tetanus, 
145;  of  trypanosomiasis,  258;  of  tuber- 
culous meningitis,  172;  peritonitis,  ISO; 
of  typhoid  fever,  12;  of  typhus  fever, 
48;   of  whooping  cough,  123. 

Syndrome  of  Weber,  173;  suprarenal 
genital,    859. 

Syphilides,   272. 

Syphilis,  26S;  accidental  infection,  270; 
adenitis,  272;  alopecia,  272;  amyloid  de- 
generation, 273 ;  and  aortic  insufficiency, 
803;   and  life  insurance,  287;   and  mar- 


riage, 287;  and  tabes,  906;  arsphena- 
mine  treatment,  285;  arteries  in,  276, 
282;  arthritis,  272;  atrophy  of  tongue 
in,  453;  bone  lesions,  275;  cell  content, 
277;  cerebro-spinal,  276;  Colles'  law 
in,  270;  colloidal  gold  reaction,  277; 
congenital,  273 ;  cutaneous  reaction,  284 ; 
difficulty  of  administrative  measures, 
281;  early  manifestations,  274;  eye  le- 
sions, 275;  fever  in,  271;  globulin,  277; 
gummata,  270,  272;  of  lung,  278;  haemo- 
globinuria  in,  678;  haemorrhagica  neona- 
torum, 274,  746;  historical  note,  268; 
history  taking,  277;  inunction  method, 
286;  late  manifestations,  274;  latenty 
273;  meninges  in,  276;  mercurial  treat- 
ment, 286;  modes  of  infection,  270;  mu- 
cous lesions,  272;  myocarditis  in,  281; 
of  the  bones,  273;  of  circulatory  system, 
281,  282;  of  digestive  tract,  281;  of 
larynx,  609 ;  of  liver,  acquired,  280 ;  of 
liver,  delayed  congenital,  280;  congeni- 
tal, 279  ;  tertiary  lesions,  280 ;  of  pharynx, 
457;  primary  stage,  271;  of  rectum, 
281;  of  respiratory  organs,  278,  279;  of 
stomach,  281 ;  of  urinary  tract,  282 ; 
pathology,  270;  primary  lesion,  270; 
Prof  eta's  law,  270;  prophylaxis  after 
exposure,  285;  psychical  features,  277; 
pulmonary,  forms  of,  278 ;  quaternary 
stage,  273;  respiratory,  278;  coexistent 
with  tuberculosis,  279;  fibrous  interstitial 
pneumonia,  279;  rhagades,  274;  second- 
ary lesions,  270;  serum  diagnosis  of, 
284;  spinal  fluid  in,  277;  tertiary  le- 
sions, 270,  272;  therapeutic  test,  284; 
transmission  through  several  genera- 
tions, 275;  urinary,  acute  syphilitic  ne- 
phritis, 282;  visceral,  276;  Wassermann 
reaction,  277;  white  pneixmonia  of  the 
fetus,  278. 

Syphilitic  child,  development  of,  275;  cir- 
rhosis, 568,  572;  endocarditis,  282; 
myocarditis,  282  ;  orchitis,  283 ;  retinitis, 
1023;  rhinitis,  274;  tumors,  1008;  ul- 
cers of   pharjTix,   457. 

S^-philoma  of  brain,   1003. 

Syringomyelia,  963. 


Tabardillo.      (See  typhus.) 

Tabes  dorsalis,  906;  aneurism  in,  911; 
arthropathies,  911;  ataxic  stage,  909; 
bladder  symptoms,  911;  cerebro-spinal 
fluid,  911;  colloidal  gold  reaction,  911; 
Frenkel's  method  of  reeducation,  914; 
incipient  stage,  908;  loss  of  deep  re- 
flexes, 909 ;  motor  symptoms,  909 ;  ocu- 
lar symptoms,  908;  pains,  908;  paralytic 


1164 


INDEX 


stage,  911;  reflexes,  909;  Eomberg's 
sign,  909;  special  senses,  910;  sensory 
symptoms,  909;  trophic  changes,  911. 

Tabes  mesenterica,  177. 

Tabo-paralysis,  916. 

"Taches  bleuatres, "  in  typhoid  fever,  17. 

Tachycardia,   767;    pai'oxysmal,   770. 

Taenia  confusa,  292;  echinococcus,  295; 
mediocanellata,  292;  saginata,  292;  so- 
lium, 291. 

Taeniasis,   291. 

Tapeworm,  infection,  291. 

Taste,  disturbance  of,  1049. 

Tay-Sachs'  disease,  932. 

Telangiectasis,  hereditary,  604;  with  jaun- 
dice,  546. 

Temperature  chart  in  typhoid  fever,  15;  in 
typhus  fever,  50. 

Tenth  nerve  lesions,  1043. 

Terminal  infections,  57;  causative  bacte- 
ria, 58. 

Terminal  pneumonia,  95. 

Testicle,  tuberculosis  of,  127,  219. 

Tetanus,  143;  and  vaccination,  334;  anti- 
tetanic  serum,  146;  cephalic,  145;  em- 
prosthotonus  in,  145;  geographical  dis- 
tribution of,  144;  neonatorum,  145; 
opisthotonus  in,  145 ;  orthotonus  in,  145 ; 
pleurothotonus  in,  145;  postoperative, 
146;  risus  sardonicus,  145;  toxicity  of, 
144. 

Tetany,  S73;  Chvostek's  sign,  874;  Erb's 
phenomenon,  874;  in  typhoid  fever,  27; 
Trousseau's  sign,  874. 

Tetraplegia  spastica,   1000. 

Thalamic   syndrome,   967. 

Thermic  fever,  380. 

Thickened  pleura,  660. 

Third  nerve  paralysis,  1028. 

Thirst  in  diabetes,  427. 

Thomsen's  disease,  1122. 

Thorn-headed   worm,  315. 

Thornwaldt's  disease,  462. 

Thread  worm,  302. 

Thrombo-angeitis  obliterans,  838. 

Thrombosis  in  typhoid  fever,  11;  of  coro- 
nary artery,  787;   of  portal  vein,  553. 

Thrombus  formation  in  typhoid  fever,  19. 

Thrush,  450. 

Thymic  asthma,  861. 

Thymus,  atrophy  of,  861;  diseases  of,  860; 
hypertrophy  of,  860 ;  status  lymphaticus, 
861. 

Thyroid  gland,  aberrant  and  accessory, 
863;  congestion,  862;  diseases  of,  862; 
goiter,  864;  hypothyroidism,  865;  tu- 
mors of,  863;  changes  associated  with 
typhoid  fever,  20. 

Thyroiditis,  863. 

Tic,  convulsive,  1069. 


Tic  douloureux,  1083. 

Tick  fever  {see  also  relapsing  fever),  260, 
316,  377. 

Tick  paralysis,  317. 

Tinnitus  aurium,   1039. 

Tobacco  amblyopia,   1023. 

Toes,  sensitive  in  typhoid,  1084. 

Tongue,  geographical,  452;  hypersesthesia 
of,  453;  in  typhoid  fever,  20;  syphilis 
of,  281. 

Tonsillitis,  acute,  369;  chronic,  459;  defor- 
mities, 461;    suppurative,  459. 

Tonsils  and  congenital  tuberculosis,  165; 
and  rheumatic  fever^  369;  bacteriology 
of,  460. 

Torticollis,  1046;  muscles  involved  in, 
1047;    spasmodic,   1047. 

Toxemia,   typhoid,  treatment  of,  41. 

Toxic  combined  sclerosis,  949;  hiccough, 
1050;  pneumonia,  96;  tremor,  1062. 

To;xin-antitoxin  treatment  in  diphtheria,  74. 

Trachea  and  bronchi,  syphilis  of,  278. 

Tracheal  tug,  846. 

Tracheo-bronchitis,    acute,    610. 

Trance,  hysterical,  1095. 

Trapezius  paralysis,  1045. 

Trauma,  as  cause  of  lobar  pneumonia,  79; 
as  predisposing  factor  in  tuberculosis, 
160. 

Traumatic  hysteria,   1108;   neuroses,  1108. 

Treatment  of  gall-stones,  566. 

Trembles  in   cattle,   374. 

Tremor,  forms  of,  1062. 

Trench  fever,  378;  nephritis,  692. 

Treponema  pallidum,  269. 

Trichina  spiralis,   description  of,  303. 

Trichiniasis,  302;  frequency  of  infection, 
304;  modes  of  infection,  304. 

Trichocephaliasis,  314. 

Trichomonas  hominis,  288;   vaginalis,  288. 

Tricuspid  regurgitation,  817 ;  stenosis,  818. 

Trigeminal  neuralgia,  1083;  paralysis, 
1032. 

Trinitrotoluene,    548. 

Trismus,  1033. 

Trochlear  nerve,  1030. 

Tropical  sore,   260. 

Trousseau's  sign  in  tetany,  874, 

Trypanosomiasis,    257. 

Tubercle  of  brain,  1003;  bacilli,  distribu- 
tion in  the  body,  157;  in  the  blood,  ac- 
tion of,  167;  in  sputum,  diagnostic,  193; 
latency  of,  162;  soil  fruitful  for,  158; 
specific  reactions,  160;  suppuration  and, 
168. 

Tubercle,   degeneration  of,  166. 

Tuberculin,  160,  208,  227;  hypersensitive- 
ness  in  calves,  162;  reaction,  160. 

Tuberculosis,  155;  abdominal,  178;  ac- 
quired   disposition,    159;    acute   miliary, 


INDEX 


1165 


168,  180;   clinical  forms  of,  169;   diag- 
nosis of,  from  typhoid  fever,  169;  men- 
ingeal, 171-4;   pulmonary,  170;   simulat- 
ing typhoid,  35 ;  typhoid  form,  169 ;  ade- 
nitis, local,   176. 
Tuberculosis,   advice   respecting  treatment, 
231;    age   influence   in,    159;    alimentary 
canal,  lesions  of,  211;  and  typhoid  fever, 
30;    "Anlage, "    159;    and    lobar   pneu- 
monia, 96;  and  marriage,  222;   anorexia 
in,  204 ;  arguments  in  favor  of  inhalation 
infection,  164;   arterio-sclerosis  in,  210; 
asphyxial    death,     210;     asthenia,     210; 
arsenic  treatment  of,  229  ;  artificial  pneu- 
mothorax,   228;    atropine,    use    of,    230; 
blood   picture,   204;    broncho-pneumonia, 
183;    "captain   of   the   men  of   death," 
156;   cardiac   symptoms,   203;    caseation, 
nature  of,   166;    cavity  formation,   189; 
cerebral  involvement,  211;   childhood  in- 
fections, 163 ;   children,  examination  and 
care  of,   223;   chronic  fibroid,   180;    cir- 
rhosis   of    liver,    214 ;    classes    in,    225 ; 
climatic,   226;    complement   fixation  test 
in,   208;    congenital,   162;    childhood  in- 
fection of,   163 ;   inhalation  infection  in, 
163;    inoculation  of,   162;    intestinal   in- 
fection in,  165;   meningeal,  171;  tonsils 
and,  165;  contagiousness  of,  156;  cough, 
207 ;    culture   medium   for,   158 ;    cutane- 
ous inoculation,  162;  death  in,  210;  defi- 
nition of,  155;  degeneration  of  tubercle, 
166;   diarrhoea,  230;   diathesis,  159;   die- 
tetic, 227;   diffused  inflammatory  tuber- 
cle,   167;    distribution    of,    156;    distri- 
bution of  bacilli  ip.  the  body,  157;   dis- 
tribution   of    bacilli    outside    the    body, 
158;  distribution  of  lesions  in  the  body, 
166;    dried  sputum  infective,   163;   dust 
infection,     163;     dysphagia,     212;     evi- 
dence  of   healed   lesions,    224;    exercise, 
228;    experimental    infection    of    ovum, 
162;    fibroid,   202;    generalized   tubercu- 
lous   lymphadenitis,    176;     geographical 
distribution,    156;    giant   cells   in,    166; 
hepatic,    214;     hereditary    transmission, 
162;  history-taking,  208;  historical  note, 
155;  home  care,  225;  immunity  changes 
in,  161;   in  animals,  156;   in  man,  156; 
individual    prophylaxis,    223;     infection 
in,  162;  infection  by  ingestion,  165;  in- 
fection by  inhalation,   163;    inoculation, 
162;     intestinal     infection,     165;      lym- 
phatic infection,   174;    adenitis  in,  174; 
bronchial  adenitis  in,  176;   cervical  ade- 
nitis     in,      177;       general,      176;       lo- 
cal     adenitis,      176;      mesenteric      ade- 
nitis      in,        177,        181;        meningitis, 
172,      173,      174;      meningo-encephalitic 
form,  172;  mesenteric  adenitis,  177,  181; 


milk    as    a    source    of    infection,    165 ; 
modes  of  infection,  162;   mortality  rate 
of,    156 ;     mucous    membrane    infection, 
163 ;  natural  immunity  to,  159 ;  nodular 
tubercles,    166;     occupational    influence, 
160;   of  the  alimentary  canal,  211;  ileo- 
csecal  lesions,  213;   lips,  211;   of  appen- 
dix,  213;    of   bile   ducts,   214;    of  brain 
and  cord,  chronic  form,  124;   of  caecum, 
212,   213 ;   of  the  genito-urinary  system, 
215;   Fallopian  tubes,  ovaries  and  uter- 
us,   220;    heematogenous   infection,    215; 
hereditary   transmission,   215;    incidence 
of,  in  sexes,  217 ;  infection  by  extension 
from  other  organs,  126;   infection  from 
existing     areas,     215 ;      infection     from 
■without,  216;    of  the  kidneys,  217,   218, 
219;   peritoneal  infection,  216;   prostate 
and   seminal  vesicles,    219;    testes,   219; 
ureter   and  bladder,   219;    of   intestines, 
212;    of   larynx,   608;    of  liver,   214;   of 
mammary    gland,    220;     of    oesophagus, 
212;    of    palate,    211;     of    pericardium, 
179;  of  peritoneum,  180;  ascites  in,  181;' 
association    with  '  tumor,    181;    omental 
puckering  in,  181;   sacculated  exudation, 
181;    thickening  of   the   intestinal   coils, 
181;    of   pharynx,   212,   457;    of   pleura, 
178,   203;    of   rectum,    213;    of   salivary 
glands,  211;  of  serous  membranes,  178;" 
spinal    cord,    125;    of    spleen,    882;     of 
tongue,  211;  of  tonsils,  211;  of  stomach, 
212;  open-air^  224;  pathology  of  lesions, 
166;    peritonitis  in,   180;   pleural,  types 
of,    179;    pleuritic   pains,    231;    prophy- 
laxis   in,    222;    pulmonary,    182;    acute 
pneumonic,   182,   183;    and   cancer,   210; 
anorexia    in,    204;     arterio-sclerosis    in, 
210;  asphyxia,  death  by,  210;  blood  pic- 
ture in,  204 ;  brachial  plexus  involvement, 
204;   bronchopneumonie  form,   183,   185, 
187;    cardiac    hypoplasia,    209;     cardio- 
vascular symptoms,  203;   careful  history 
essential,  208;  cavity  in,  189,  191;  cere- 
bral  involvement,    death   by,    211;    cog- 
wheel rhythm  in,  200 ;   complement  fixa- 
tion   test,    208;    complications   of,    202; 
conditions   wrongly    diagnosed    as,    207; 
concurrent    infections,    209 ;     suspicious, 
207;    cutaneous   system   in,    205;    death, 
modes  of,  210;   diabetes  mellitus  in,  210; 
diagnostic  errors,  source  of,  207;   diges- 
tive tract,  204 ;  emphysema  in,  203 ;  erup- 
tive fevers  in,   209;    erysipelas  in,  209; 
erythema  nodosum  in,  209 ;   eye  lesions, 
205;   fever,  importance  of,  197;   fibroid, 
202;    fistula  in   ano,   209;    funnel  chest, 
198;   gangrene  of  lung  in,  203;   gastro- 
intestinal symptoms  in,  204;   genito-uri- 
nary  system,   205;    lunnoptysis  diagnos- 


1166 


INDEX 


tie,  207;  hEemorrhage,  death  by,  211; 
hopeful  temperament  in,  205 ;  in  infancy, 
210;  intestinal  symptoms,  204;  laryn- 
geal complications,  202;  Litten  phenom- 
enon, 199 ;  lobar  pneumonia  in,  209 ; 
mammary  gland  involvement,  205;  men- 
ingitis in,  204;  nervous  symptoms  in, 
204;  peculiarities  in  aged,  210;  periph- 
eral neuritis  in,  205 ;  physical  signs  in  di- 
agnosis, 207;  pleural  complications,  203; 
pneumonia  in,  203 ;  pneumonic  form 
symptoms,  183,  184;  pneumothorax  in, 
203;  skin  in,  205;  specific  reactions  in, 
208;  sputum  examination,  207;  symp- 
toms referable  to  other  organs,  203; 
symptoms  versus  physical  signs,  207; 
syncope,  death  by,  211;  tuberculin  test, 
208;    x-ray  diagnosis,   208. 

Tuberculosis,  pulmonary,  acute,  182-3;  in- 
fection in,  182 ;   pneumonic,  183. 

Tuberculosis,  pulmonary,  chronic,  182; 
amyloid  changes  in  organs,  191;  auscul- 
tation in,  200;  bronchial  changes,  190; 
bronchial  symptoms,  192 ;  broncho-pneu- 
monic, symptoms,  186,  188 ;  cavities  in, 
189;  cervico-axillary  involvement,  192; 
changes  in  other  organs,  190 ;  cough, 
193 ;  craeked-pot  sound,  199 ;  distribu- 
tion of  lesions,  187;  dyspnoea,  196;  ema- 
ciation in,  198;  endocarditis,  191;  gas- 
tric onset,  191;  haemoptysis,  192,  194; 
hsemoptyses,  percentage,  195 ;  laryngeal 
involvement,  191,  192;  malarial  symp- 
toms, 191;  miliary  tubercles,  188;  modes 
of  onset,  191;  nervous  symptoiQS,  192; 
pain  in,  192;  palpation  in,  199;  percus- 
sion in,  199;  pleural  involvement,  190; 
pleural  onset,  191;  pneumonia  in,  189; 
pseudo-cavernous  sounds,  201;  quiescent 
cavities,  190;  in  sanatoria,  225;  scle- 
rosis, 188;  signs  of  cavity  formation, 
201;  sputum,  193;  types  of  lesions,  188; 
vomica  in,  189 ;  Wintrich 's  sign,  201; 
racial  influence,  159;  rate,  improvement 
in,  causes,  157;  reinfection,  166;  renal, 
218;  rest,  228;  sclerosis  of  tubercle,  167; 
secondary  inflammatory  processes,  167; 
solitary  tubercle  of  liver,  182;  specific 
reactions  of  the  bacilli,  160 ;  spontaneous 
cure,  158;  sweating,  230;  testicular  in- 
fection, 219 ;  tonsillar  infection  165 ; 
tracheo-bronchial,  177;  trauma,  as  fac- 
tor, 160;  tubercle,  evolution  of,  166; 
work   of   Koch,    156. 

Tuberculin,  reaction,  160;  treatment,  160; 
types  of,  227. 

Tuberculous  adenitis,  175;  lymphadenitis, 
generalized,  176;  meningitis,  171;  peri- 
tonitis, 180;  simulating  typhoid,  35; 
pleurisy,    groups    of,    179;     pneumonia, 


differentiation  of,  108;  subject,  de- 
scribed by,  Hippocrates,  159;  ulcers  of 
pharynx,  457. 

Tufnell's  treatment  of  aneurism,  850. 

Tumor,  in  tuberculous  peritonitis,  181;   of 
brain,   1003. 

Tumors   of   kidney,   718;    of   the   stomach, 
non-cancerous,  495. 

Turpentine    stupes,    in    typhoid    fever,    41. 

Tympanites,    in    typhoid    fever,    treatment 
of,  41. 

Typhoid  baeilluria,  11,  33. 

Typhoid  carriers,   6. 

Typhoid  fever,  abortive  form  of,  30;  ab- 
dominal pain  in,  22;  agglutination  test 
in,  33;  ambulatory  form,  14,  31;  and 
endocarditis,  35;  and  membranous  an- 
gina, 65;  and  malaria,  35;  and  pneumo- 
nia, 35;  and  tuberculosis,  30;  antibodies 
in,  32;  appendicitis  in,  526;  arteritis 
in,  19;  arthritis  in,  29;  ascites  in,  24; 
association  with  other  diseases,  29;  atro- 
pin  test  (Marris)  in,  34;  baeilluria  in, 
28;  bacteria?mia  in,  36;  bathing  meth- 
ods, 39;  baths,  contraindications  to,  40; 
bed-sores  in,  17;  blood  count  in,  18; 
blood  pressure  in,  18;  bone  marrow 
changes  in,  10;  care  of  mouth  in,  39; 
carriers  of,  5;  causes  of,  2;  cholecysti- 
tis in,  42;  circulatory  changes  in,  11; 
circulatory,  failure,  treatment,  42;  cir- 
culatory system  in,  18;  cold  packs  and 
sponging,  39;  confusion  with  cerebro- 
spinal meningitis,  34;  contaminated 
dust  on  railway  tracks,  7;  contamination 
of  soil,  7;  convalescence,  management, 
43 ;  delirium  in,  26 ;  dicrotic  pulse  in, 
33 ;  diet  in,  38 ;  differentiated  from  acute 
miliary  tuberculosis,  169 ;  from  septicae- 
mia, 55;  digestive  disturbance  in,  20; 
diseases  which  simulate,  35;  disinfec- 
tants, 37;  foodstuffs,  contamination  of, 
6 ;  gall-stones  following,  24 ;  gastric  dis- 
turbance in,  20;  generative  system  in- 
volvement, 28;  grave  form  of,  31; 
haemorrhage  in,  10,  21,  22;  hsemorrhagic 
form,  31;  healing  in,  9;  heart  sounds  in, 
19 ;  hepatic  changes  in,  24 ;  hydrother- 
apy in,  39,  41 ;  immunity,  3 ;  In  the' 
aged,  31;  in  children,  31;  in  the  fetus, 
32;  in  pregnancy,  31;  incubation  period 
12 ;  influence  of  age  and  sex,  3 ;  inoeu 
lation,  3,  38 ;  intestinal  disturbances,  20 
involvement  of  nervous  system,  11;  iso 
lation  of  typhoid  bacilli  from  blood,  33 
rose  spots,  33;  from  urine  and  stools, 
33;  Kernig's  sign,  25;  kidney  involve 
ment  in,  11;  liver  degeneration  in,  11 
lobar  pneumonia  in,  25;  lumbar  punc- 
ture  as   diagnostic    aid,    34;    Maidstone 


INDEX 


1167 


epidemic,  6;  meningeal  symptoms,  26; 
mesenteric  glands  in,  10;  meteorism  in, 
22  •  milk  as  source  of  infection,  6 ;  modes 
of  conveyance,  5;  mortality  in,  35;  mor- 
tality statistics  of,  2;  muscle  changes 
in,  12.  29;  necrosis  and  sloughing  in,  9; 
nervous  manifestations,  severe,  13,  25; 
neuritis  in,  26;  odor  of  skin  in,  17;  op- 
eration necessary  in  perforation  cases, 
42;  ophthalmo-reaetion  in,  33;  orchitis 
in,  11,  28;  osseous  system  involvement, 
28;  oysters  as  a  source  of  infection, 
34;  parotitis  in,  20;  pathology  of,  7; 
perforation  of  bowel  in,  10,  22;  peri- 
carditis in,  11 ;  peritonitis,  perforative, 
in,  23;  personal  infection  in,  5;  Peyer's 
glands  in,  8;  Plymouth,  Pa.,  epidemic, 
5;  pulse  in,  18;  recrudescences,  14;  re- 
infection in,  32;  relapse  in,  32;  renal 
involvement,  27;  organs  in,  11,  24;  sea- 
sonal occurrence,  3;  secondary  infections 
in,  7;  skin  in,  16;  special  sense  disturb- 
ance, 27;  spleen  in,  10,  24;  sudden 
death  in,  36 ;  symptoms  of,  12,  20 ;  tem- 
perature, types  of,  16;  thrombus  for- 
mation in,  19 ;  thyroid  changes  in,  20 ; 
tongue  in,  20 ;  transfusion  in,  41 ;  treat- 
ment of  special  symptoms,  41;  ulcera- 
tion in,  9;  vaccine  and  serum  therapy, 
40;  water  drinking  in,  39;  patient,  iso- 
lation of,  37. 

Typhoid  pneumonia,  96. 

Tj-phoid    psychoses,    27. 

Typhoid    state,   in   pneumonia,   100. 

Typhoid  spine,  29. 

Typhoid  triple  vaccine,  38. 

Typhoid  in  skin  reaction,  38. 

Typho-malaria  a  m.isnomer,  35,  252. 

Typhus  fever,  47;  crisis  in,  49;  complica- 
tions and  sequelte;  eruption,  48;  incuba- 
tion period  of,  48 ;  louse  borne  disease, 
48;  mortality  rate  in,  50;  relation  to 
Brill's  disease,  47;  temperature  in,  49, 
50;   Weil-Felix  reaction  in,  51. 


U 


Ulcer,  diabetic,  429 ;  of  duodenum,  481 ;  of 
intestine,  511;  of  mouth,  449;  of  stom- 
ach, 481;   typhoid,  7;   tabetic,  911. 

Ulnar  nerve  paralysis,  1054. 

Unarmed  tapeworm,  292. 

Uncinariasis,  307;  distribution,  307;  his- 
torical not€,  307. 

Undulant  fever.   (See  Malta  fever.) 

Uraemia,  cerebral  symptoms,  689 ;  coma, 
690;  dyspnoea,  690;  gastro-intestinal 
symptoms,  690 ;  local  palsies,  690 ;  sto- 
matitis, 690. 


Ureter,  tuberculosis  of,  219. 

Urinary  amcebiasis,  241 ;  system,  anoma- 
lies of,  675;  tract  infections  due  to  B. 
coli,  46. 

Uterus,   tuberculosis  of,   220. 


Vaccination  and  tetanus,  334 ;  influence  of, 
on  other  diseases,  334;  irregular,  333; 
technique  of,  334 ;  transmission  of  dis- 
ease by,  334;  value  of,  335. 

Vaccinia,  331 ;  incubation  and  eruption, 
332;  nature  of,  332;  revaceination, 
333. 

Vaccine  treatment  of  erysipelas,  61;  of 
siepticEemia,  56 ;  of  typhoid  carriers,  43 ; 
of  typhoid  fever,  40 ;  of  whooping  cough, 
125. 

Vaccine,  typhoid,  37. 

Vaccines,  contamination  by  B.  tetani,  144. 

Vagabond's  disease,  317. 

Vagotonia,  905;  and  digestive  disturbance, 
1045. 

Vagus  nerve  lesions,  1043. 

Vagus  pneumonia,   experimental,   105. 

Vagus  paralysis  and  heart  acceleration, 
1044. 

Valvular  anomalies,  825;  compensation, 
801;   valve  affected,  820. 

Vaquez'    disease,   750. 

Varicella,  336. 

Variola,  320 ;  pustulosa  haemorrhagica, 
326;  vera,  323. 

Varioloid,  323,   326. 

Vaso-motor  and  trophic  disease,  1111. 

Verruca  neerogenica,  163. 

Vertigo,  auditory,  1040 ;  cardio-vascular, 
1041;  endemic  paralytic,  1042;  intra- 
cranial tumors,  1041 ;  middle  ear  dis- 
ease, 1041 ;   ocular,   1041 ;   toxic,   1041. 

Vestibular  nerve,  1040;  Meniere's  syn- 
drome,  1040;    vertigo,   1040. 

Vicarious  haemorrhage,  630. 

Villaret's   syndrome,   1049. 

Vincent's  bacillus,  64. 

Visceral  neuralgia,  1085. 

Visual  aphasia,  977. 

Vogt  syndrome,  1060. 

Volitional  tremor,  955. 

Volkmann  's  paralysis,  1055. 

Volvulus,  530. 

Vomica  in  lung,  189. 

Vomiting,  nervous,  501 ;  sickness  of  Ja- 
maica, 402. 

Von  Noorden  's  diet  for  obesity,  442_ 

Von   Pirquet   reaction,    160. 

Von  Recklinghausen's  disease,  1020;  le- 
sions of,    1020. 


1168 


IKDEX 


W 


Wall  papers  and  arsenic,  398. 

Wart-pos,  326. 

Wassermaun  test,   269,   283. 

Water,  as  entamceba  conveyor,  238;  con- 
tamination by  Bacillus  typhosus,  4,  5; 
disinfection  of,  to  prevent  typhoid,  37. 

"Water  vrhistle  noise,"  665. 

Weber's    syndrome,    173. 

Weber-Gubler  syndrome,  969. 

Weil's  disease,  373. 

Weil-Felix  reaction,  in  typhus  fever,  51. 

Weir  Mitchell 's  reeducation  -work,  1098. 

Wernicke's  hemiopic  pupillary  inaction, 
1028. 

AVet  brain,   388. 

Whipworm,  314. 

Whooping  cough,  122;  and  membranous 
angina,  65 ;  catarrhal  stage,  123 ;  compli- 
cations and  sequelee,  123 ;  paroxysmal 
stage,  123. 

Widal  test,  macroscopic  and  microscopic, 
33. 

Wilson's   disease,   930,   1060. 

Winckel's  disease,   746,   747. 

Wintrieh's  sign  in  tuberculosis,  201. 

Wool-sorters'  disease  (anthrax),  151. 

Wolves  and  hydrophobia,  359. 

Wrist-drop,  1054. 


Writer 's    cramp,    1086. 
Wry-neck,  spasmodic,  1046. 


Xanthoma  multiplex,  546. 

Xanthopsia,  546. 

Xanthrochromia,  964. 

Xerostomia,   455. 

X-ray  diagnosis  in  tuberculosis,  208. 


Yaws,  288. 

Yellow  fever,  263;  albuminuria,  266;  and 
dengue,  267;  and  malarial  fever,  267; 
black  vomit,  266;  characteristic  pulse, 
266;  differential  diagnosis,  267;  endemic 
nature  of,  265;  faeies,  265;  fever  in, 
265;  gastric  features,  266;  mental  fea- 
tures, 266;  mode  of  transmission  of,  264; 
stegomyia  calopus,  264 ;  zones  of,  264. 

Yersin,  plague  serum  of,  143. 


Zine  chills.  397. 

Zona,  1058. 

Zoster,  1058. 

(55) 


RC46 

Osier 


Os5 

19  ?0 


V 


^nrii 


ex 


